Should patients with diabetes receive an influenza vaccine yearly?

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1 My Background Tomorrow s Prevention, Today Margaret Robinson, PharmD Virginia Commonwealth University Community Pharmacy Residency Program Hometown: New Kent, VA Virginia Tech Bachelors of Science, Human Nutrition, Food, and Exercise 2011 MCV/VCU School of Pharmacy PharmD 2015 National Diabetes Statistics Report, 2014 In the U.S. population, 29.1 million people (9.3%) have diabetes Only 21 million are diagnosed 1.7 million new cases in 2012 Prediabetes: 37% of U.S. adults >20 years old Medications: Insulin only: 2.9 million Insulin + oral medications: 3.1 million Oral medication only: 11.9 million receive an influenza vaccine yearly? diabetes report web.pdf receive a pneumococcal vaccine? receive the hepatitis B vaccine series? 1

2 Pharmacist Objectives receive a zoster vaccine? Develop a list of appropriate vaccines for Explain the importance of immunizations for Recommend additional preventive care services for Technician Objectives Advocate the importance of immunizations for Assist pharmacist in connecting patients to preventive services Based on discussions with patients and their profile, collaborate with the pharmacist and patient to determine which vaccines are appropriate United States Immunization Statistics Influenza Vaccine 2014 >65 years: 69.1% years: 43.6% years: 29.3% October 26, % of Virginians >6 months Pneumococcal Vaccine years: 20% >65 years: 61.3% Hepatitis B Vaccine in diabetes years: 28.6% 2014 National Health Interview Survey. CDC estimates.htm Vaccine recommendations for patients with Type 1 and Type 2 diabetes According to the CDC Yearly influenza Pneumococcal Hepatitis B Influenza Vaccine Patients with diabetes should receive an inactivated influenza vaccine yearly Influenza Vaccine contains: A/California/7/2009 (H1N1)pdm09 like virus A/Switzerland/ /2013 (H3N2) like virus B/Phuket/3073/2013 like virus B/Brisbane/60/2008 like virus (Quadrivalent) 2

3 Trade Name Manufacturer Antigens Age Indication Fluzone Sanofi Pasteur Trivalent/Quadrivalent 6 mo of age Fluzone ID Sanofi Pasteur Quadrivalent* yrs of age Fluzone High- Dose Sanofi Pasteur Trivalent >65 yr of age Fluvirin Novartis Trivalent 4 yr of age Fluarix GlaxoSmithKline Trivalent/Quadrivalent >3 yr of age FluLaval GlaxoSmithKline Quadrivalent 18 yr of age Afluria CSL Biotherapies Trivalent 9 yr of age yrs via jet Flucelvax (cell culture-based) FluBlok (recombinant) Novartis Trivalent >18 yr of age Protein Sciences Trivalent >18 yr of age FluMist Medimmune Quadrivalent 2 49 yrs of age Adapted from the APhA Immunization Certificate Program Pneumococcal Vaccine Protection against the most serious strains of pneumococcal 2 types of pneumococcal vaccines 23 (PPSV23): Polysaccharide vaccine Long chain sugar molecule Stimulates B cells with T cell independent response No booster effect Prevnar13 (PCV13): Conjugate vaccine T cell dependent response Increased immunogenicity Antibody booster effect vaccines Pneumococcal vaccine schedule Age 2 64 with diabetes 23 Pneumococcal vaccine schedule Age >65 years with diabetes No history of pneumococcal vaccine Prevnar 13 After 1 year, 23 Diabetes 23 Received 23 before age 65 At least 1 year later Prevnar 13 After 1 year 23 (must be >5 years since previous 23 ) Received 23 at age 65 or later After 1 year Prevnar recs/vacc specic/pneumo.html recs/vacc specic/pneumo.html Hepatitis B May be spread through sharing diabetes equipment Meters Insulin pens Lancets Age 19 59: Receive the 3 dose Hepatitis B series: 0, 1 month, 6 months Age 60+: Recommend discussion with physician to determine risk conditions.html What other vaccines should be considered? Tetanus, diptheria and pertussis Tdap: once as an adult Td: every 10 years 2013: 17.2% of adults received Tdap vaccine Zoster vaccine: After age 60 Helps to protect against shingles vac/health conditions/diabetes.html 3

4 Timing Between Immunizations >2 inactivated vaccines Inactivated Vaccines + Live vaccines Same day Any time before or after Same day Any time before or after >2 live vaccines Same day >4 weeks apart Additional Complication Prevention Measures CDC Dental Visit Patients with diabetes have increased risk of periodontitis Gum disease poor blood glucose control Recommend a check up every 6 months Oral hygiene Brush teeth at least twice daily Floss with diabetes/treatment and care/oral health and hygiene/diabetes and oralhealth.html Foot examinations Neuropathy Type 1: screen 5 years after diagnosis Type 2: screen at diagnosis Monofilament test Annual comprehensive foot examination Self exams Check feet daily for wounds and changes Cut toenails Use lotion for dry feet to prevent cracking Kidney Function Evaluation At least annually Lab Urinary Albumin Spot test Estimated glomerular filtration rate Serum Creatinine Normal Value < 2 mg/l >90 ml/min/1.73m mg/dl Eye exams Type 1 diabetes in adults: Initial dilated and comprehensive eye exam within 5 years of onset Type 2 diabetes: Initial dilated and comprehensive eye exam shortly after diagnosis Signs of retinopathy: repeat annually No signs of retinopathy: repeat every 2 years Wear protective glasses when in the sun 4

5 Inactivated Influenza Immunizations Annually* Check ups At diagnosis* After 65 Dental Every six months Prevnar After 65 Feet Annually Hepatitis B 3dose series if <60 years old* Kidney Annually Tdap Once as an adult Td booster every 10 years Eye Annually to every 2 years Zoster After 60 *Specific recommendation for Self Care Oral Health Brush teeth at least twice daily Floss Feet Eye Check feet daily Use lotion Cut toenails Wear protective eyeglasses when in the sun 5