A 65 y/o patient with type II diabetes presents to your clinic for a routine appointment and refills on her metformin, lisinopril, and simvastatin. Her labs, including her HgbA1C, are current and all look good. You've refilled her medications through the computer. She's current on her annual foot and eye exam. She has a current mammogram and PAP on file.

Is there anything else you need to do for her during this visit?

Of course, there is or we wouldn't have a Pearl!

IMMUNIZATIONS!

This is flu season and all patients over age 50 should have their ANNUAL flu shot, especially ones with chronic diseases such as diabetes. An annual flu shot is the best defense against influenza. Even if an immunized patient gets the flu, it should be a milder clinical course. Elderly patients have the highest mortality from influenza compared to other age groups. Ninety percent (90%) of the deaths related to influenza occur in elderly patients over age 65. Other groups who should receive an annual flu shot include all patients over age 50, residents of long-term care facilities, health care workers, children over 6 months of age receiving chronic aspirin therapy, children over 6 months with chronic diseases, and pregnant women in the 2nd or 3rd trimester.

According to the CDC, up to 75% of persons at high risk for influenza or who die from pneumonia and influenza may have received care in a physician's office during the previous year. One study indicated that all persons who died from pneumonia or influenza and did not reside in a nursing home, had at least one medical visit during the previous year (another MISSED opportunity!). Annual flu shots are required because 1) the immunity from the flu shot rarely extends past 12 months and 2) each year the formulation is different due to antigenic drift and antigenic shift.

An average of less than 20% of persons in high-risk groups receive influenza vaccine each year. More effective strategies for delivering vaccine to high-risk persons, their health care providers, and household contacts are needed. Persons for whom the vaccine is recommended can be identified and immunized in a variety of settings. We should NOT let people out of our hospitals or clinics without getting them their annual flu shot, esp at this time of the year! Although not perfect, an annual flu shot is STILL your best defense against influenza.

The injectable flu vaccine is a KILLED vaccine so you CANNOT get the flu from the flu shot (a common misperception). The intranasal flu vaccine is a live, attenuated vaccine and all the cautions regarding live vaccines apply to it. Both the injectable flu vaccine AND the intranasal vaccine is grown in eggs. Anaphylactic reactions to eggs or egg products is a contraindication to either vaccine. A general rule of thumb is if someone can eat eggs, they can receive the flu vaccine. Indications for the live intranasal vaccine are only for patients between ages of 5 and 49 years, without a history of Guillian Barre syndrome or any kind immunosuppression or deficiency.

Pneumococcal vaccine - most of the same patients who require a flu shot should have a pneumococcal vaccine. Pneumococcal disease causes 40,000 deaths a year, despite antibiotic therapy. The current 23 valent vaccine contains 23 different serotypes responsible for 88% of all invasive pneumococcal disease. Current recommendations is for everyone over the age of 65 to get the pneumococcal vaccine - one 0.5ml IM dose. Persons aged 65 years and older should be administered a second dose of pneumococcal vaccine if they received the vaccine more than 5 years previously, and were less than 65 years of age at the time of the first dose. The vaccine is (overall) 60-70% effective in preventing invasive pneumococcal disease.

Since both of these vaccines are killed vaccines, flu vaccine and pneumococcal vaccine can be given together. The intranasal vaccine (live vaccine) and the pneumococcal vaccine can be given together as well.

Diphtheria-tetanus (dT) vaccine status should also be checked. A booster dose should be given every year to maintain immunity. In the case of a dirty wound or unknown tetanus vaccination history, vaccine and tetanus immunoglobulin (in addition to good wound care and appropriate ABX) should be used. Tetanus vaccine is almost 100% effective in preventing tetanus. Diphtheria is often thought of as a pediatrics-only disease. There is a fair number of cases, esp in children who have not, for one reason or another, completed their DTaP series. Diphtheria can be seen in adults as well so keep this in mind (see previous Pearl).

Have a happy and safe Thanksgiving!

This Pearl is meant for academic and educational purposes only. This Pearl is meant to raise important points regarding the safe and cost-effective pharmacotherapy of patients. It is not meant to be the definitive reference for the treatment or prophylaxis of various diseases. Although every effort is taken to ensure this Pearl is correct and factual, errors may occur. The Pharmacoeconomic Center assumes no liability for incorrect information or harm that may occur from the use of the information included in this Pearl.