Karen Berger, PharmD

With all the talk about COVID-19 vaccines and flu season approaching, it is almost easy to forget the importance of the pneumonia vaccine. The good news is that pneumonia vaccinations are increasing. According to the National Health Interview Survey, from 2000-2018

percentage of adults aged 65 to 74 years who had ever received pneumonia vaccine increased from 48% to 64.8%,

percentage of adults aged 75 to 84 years who had ever received pneumonia vaccine increased from 59.5% to 74.9%, and

percentage of adults 85 years and older who had ever received pneumonia vaccine increased from 56.4% to 76.3%.

Pneumonia is a lung infection involving 1 or both lungs. Pneumonia causes the air sacs of the lungs to fill with pus or fluid. Symptoms vary in severity, depending on factors such as cause of the infection, the patient’s age, and other medical conditions. Bacteria (usually Streptococcus pneumoniae in the United States) are the most common cause of pneumonia, which can occur on its own or secondary to a viral infection. Pneumonia may be viral or fungal. Fungal pneumonia occurs more often in patients who are immunocompromised or have other chronic health problems.

The CDC’s Advisory Committee on Immunization Practice (ACIP) recommends vaccination to prevent pneumococcal disease (any illness caused by S pneumoniae). There are 2 vaccines available in the United States

pneumococcal conjugate vaccine (PCV) 13 (Prevnar 13; Pfizer)—pneumococcal conjugate vaccine for intramuscular (IM) or subcutaneous injection; prevents pneumonia caused by Spneumoniae serotypes 1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F, and 33F8 

ACIP recommends the following for pneumococcal vaccination

PCV13 for all children under 2 years, individuals 2 or older with certain medical conditions, and adults 65 or older who are not immunocompromised and do not have a cerebrospinal fluid leak or cochlear implant

PPSV23 for all adults 65 or older, individuals aged 2 to 64 years with certain medical conditions, and adult smokers aged 19 to 64 years

Regimens vary based on individual circumstances. For adults 65 and older who are not immunocompromised and do not have a cerebrospinal fluid leak or cochlear implant, a standard regimen is 1 dose of PCV13 first, followed by 1 dose of PPSV23 at least 1 year later.

Pneumococcal vaccine 20-valent (Prevnar 20; Pfizer) was approved by the FDA in June 2021 and is anticipated to be available in August 2021. The ACIP is expected to meet in October to review recommendations for vaccination.

Globally, pneumonia kills more children younger than 5 each year than any other infectious disease.

 About 50,000 individuals die due to pneumonia each year; most are adults.

Pharmacists have the resources and knowledge to provide vaccines to patients who need them. What are some ways we can help get the word out to our patients? Bruce Kneeland is an independent pharmacy specialist based in Prescott, Arizona, and host of the popular 

podcast. He has helped independent pharmacies for over 40 years.

Kneeland is a longtime advocate of pharmacy immunizations. Kneeland acknowledged that some pharmacists may be apprehensive about conflicts with physicians. He recommends finding ways to assure physicians that the goal is not to steal patients but to provide a critical service

that pharmacists are qualified to deliver. “Reach out to key physicians in your immediate area and let them know you’re vaccinating,” Kneeland said. “Explain that you are trained, have the infrastructure to support vaccine administration, and you look forward to cooperating with them to help people get the vaccines they need.”

Pharmacists may also contact their key technology partners to find out how they can identify who needs a specific vaccination by accessing their state’s Immunization Information System, Kneeland said. From there, pharmacists can approach targeted patients with a quick consult in person, asking, “Have you gotten your pneumonia shot yet?”

According to Kneeland, patients often require time to consider the need for vaccination. Pharmacists should not be discouraged if a patient visits the pharmacy 2 or 3 times before agreeing to receive the vaccine. Pharmacists can also send text messages, emails, or snail mail to targeted patients about the importance of the pneumonia vaccine, suggesting that they ask to speak with the pharmacist on their next visit. 

Importantly, pharmacists should become comfortable talking to patients who may be in a hurry or are unsure why they need a particular vaccine, Kneeland said. Keeping up with available vaccines and new ones on the market helps pharmacists stay current and able to address patients’ questions Kneeland also suggests setting up a designated area for vaccine administration in the pharmacy.

Bridget Hanna, CPhT, a marketing consultant for independent pharmacies in the United States and Canada, noted that pharmacists can utilize various marketing platforms and resources to develop a successful plan for promoting the pneumonia vaccine. “To effectively educate patients on these topics, you need to create content on multiple platforms,” Hanna explained.

“Social media is an extremely effective way to deliver your message to multiple target audiences. You need to create different forms of content to provide information on the vaccine,” Hanna said.

She suggests live videos, educational posts, webinar events, and links to the pharmacy’s website or to a PDF with important information. Hanna also recommends strategically placed in-store signage, printed material, newsletters, bag stuffers, and email marketing. “This brings awareness to the vaccine and lets patients know that your pharmacy can provide a solution by vaccinating patients,” she explained.

Keeping the community and patients updated, educated, and supported is of utmost importance. “The more you communicate with your patients and community with this information, the more you build trust and loyalty, resulting in long-term retention,” she added.

Articles

Pharmacists can promote vaccinations to at-risk individuals. 

Getting Patients Immunized Against Pneumonia Is Important

Given the popularity of cannabidiol (CBD), patients are curious about this natural remedy, asking more questions than ever. We consulted 4 pharmacists knowledgeable about CBD for advice on counseling patients. Our experts are:

, PharmD, ND, MBA, RPh, owner of Owensboro Family Pharmacy and Wellness in Owensboro, Kentucky, and certified endocannabinoid specialist

, RPh, CEO of MyCureAll, based in Fair Lawn, New Jersey

, PharmD, owner of Alpine Apothecary in Whitefish, Montana

, PharmD, owner of Malley’s Compounding Pharmacy in Richland, Washington

Our experts recommend that pharmacists advise patients to discuss CBD use with their health care providers before starting it. Here are some of the most frequently asked patient questions and our experts’ answers.

: Patients will typically ask how CBD works and whether it will really help with pain, inflammation, [gastrointestinal] issues, anxiety, etc. We explain that CBD works by allowing the cannabinoids their body makes [eg, (anandamide) AEA and (2-arachidonoylglycerol) 2-AG] to stay in their body longer and that it helps to strengthen the endocannabinoid system [ECS]. The ECS is a system that functions to bring the body back into balance and to decrease inflammation. It reduces inflammation by decreasing proinflammatory chemicals (eg, cytokines and chemokines) and helping the immune system become better at recognizing what it should attack (ie, T-cell upregulation). If they have a symptom that is due to inflammation…it should help.

: As a pharmacist who is a certified endocannabinoid specialist, I love providing education and counseling my patients on the benefits and effective use of CBD. When a patient [is deciding] what product to try, I ask what they are interested in using it for. If they have pain in the wrist, elbow, or knee, or skin conditions, we will start using a balm or topical product. If they have pain in multiple joints, autoimmune conditions, inflammatory diseases, or mental health issues such as anxiety, I recommend using an oil or capsule.

: Match your intention with the application. Topical applications are great for localized support of your muscles and joints. Oral and under-the-tongue formulations are better for systemic absorption and support of your whole body. Supporting your sleep with CBD is a great way to start and then adjust when or if necessary.

: Patients often ask about the dose they should use, how long it takes to work, and how they should use it. I advise starting low and going slow. I recommend a starting dose of 15 mg once or twice daily, explaining that the timing of effectiveness typically depends on the state of their endocannabinoid system. If they have had illness or pain that the body has tried to bring back into balance for a while, it typically takes longer for the full benefit to show. I recommend [for the patient to try] the product for at least 10 days and to increase the dose every 3 days if needed. For oils and tinctures, I advise them to hold it under the tongue for at least 30 seconds, but 1 minute is usually best.

For capsules, I let them know that it takes longer for the effects to kick in, because they must wait for the stomach to empty. We discuss how oils have the fastest absorption rates, because there are a lot of blood vessels under the tongue. For my patients [who are] taking antacids, [proton pump inhibitors], have gastroparesis, or any condition of the gut that makes me question the intestinal permeability and function, I recommend the oils, because bioavailability will differ in edibles or capsules depending on how the gut is functioning.

: Remind the patient to consult a professional when adjusting, because more is not always better. Switching up routes or sites may be more beneficial. Teaching patients to read and understand a label is also crucial. Product labeling isn’t always standard or clear, so advising consumers to pay attention and understanding things like mg per bottle vs mg per serving becomes important. Serving sizes can be listed as per ml or per dropperful, and those distinctions can make a difference and often lead to confusion with consumers.

: More is not always better. Once someone has found an effective dose… taking more can either decrease the effect, increase [adverse] effects [AEs], or provide no further benefits. In my experience, most patients take between 10 and 40 mg daily in divided doses every 12 hours. 

Is it safe to purchase CBD from anywhere?

: I recommend that patients only purchase CBD from a reputable source, because some preparations can become contaminated with fungus, which may be especially harmful to patients with a compromised immune system. If the patient needs to take a drug test, [they] should always ask for the certificate of analysis when purchasing CBD to ensure the product is [tetrahydrocannabinol] THC free. 

: Verify your product with the certificate of analysis, and never buy from a company that doesn’t provide lot-specific analysis that is conducted by a third-party lab.

: I always ask the patient whether they are in a profession where they are drug tested or in pain management. If so, I recommend a product that is THC free. I always recommend THC-free CBD for children. We discuss that products can have the legal limit of THC, and although that amount will not cause any psychoactive [AEs], the urine test limit is so low that they can still fail a drug test for THC.

: In my experience, the most common adverse events [AEs] of CBD are tiredness and drowsiness, dry mouth, dizziness and lightheadedness, and changes in appetite. I recommend taking the first dose in the evening and not doing anything else for the day until one knows how they respond to the CBD. We often forget that most accidents happen in the home. With any prescription, over-the-counter [OTC] medicine, or supplement that might affect cognition, I recommend that one does not do tasks around the house where they could hurt themselves afterward until they have adjusted to the medication.

: We educate that the ECS is a different system than the central nervous system and that added sedation is not a concern. As far as CBD AEs, clinically we have had patients say they would become drowsy, which can be mitigated by decreasing the dose and checking the product to make sure it doesn’t have melatonin or other ingredients. We have had a few patients say the oil caused mild stomach discomfort, to which we suggest taking it with food and allowing it to sit under the tongue for 30 to 60 seconds.

: CBD is a strong inhibitor of both cytochrome P450 3A4 (CYP3A4) and cytochrome P450 2D6 (CYP2D6). CBD may increase levels of:

macrolide antibiotics (azithromycin, erythromycin, clarithromycin)

calcium channel blockers (verapamil, diltiazem)

benzodiazepines (lorazepam, diazepam, alprazolam, clonazepam)

erectile dysfunction drugs (sildenafil, tadalafil, vardenafil, avanafil)

certain statins (atorvastatin and simvastatin)

CYP2D6 metabolizes many antidepressants, so CBD may increase levels of these drugs in the patient’s body:

selective serotonin reuptake inhibitors (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline)

tricyclic antidepressants (amitriptyline, nortriptyline)

β-blockers (atenolol, metoprolol, propranolol, bisoprolol)

Levels of opioids, such as oxycodone, codeine, hydrocodone, morphine, or tramadol, increase when CBD is introduced.

: CBD can have potential drug interactions with prescription medications. Some of these drug interactions may cause increased AEs of either the medication or the CBD. Other times the drug interaction may cause an increased level of the medication or the CBD. It is vital for the patient to inform the pharmacist and medical provider about CBD usage. Another valuable tool for screening for drug interactions includes an interaction checker, such as on drugs.com, which helps screen for interactions between cannabis, CBD, and THC and prescription drugs.

 Retail CBD comes from the hemp plant and has no high or psychoactive effect. When given with THC, CBD inhibits the psychoactive effects of THC.

: We counsel our patients that although CBD can help with a wide variety of symptoms, it may not be their miracle or silver bullet and solve every problem they have. It can help decrease inflammation, but the source of the inflammation is the root cause, and we should work to correct the source.

 As medical professionals, it is very important to ensure collaboration with other caretakers of the patient. Informed and shared decision-making is a must. We need to ensure ongoing monitoring and adapting the treatment plan as needed.

, PharmD, graduated from the University of Pittsburgh School of Pharmacy, and her experience includes chain and independent pharmacy as well as medical writing and reviewing.

How to discuss CBD and answer questions frequently asked by patients 


Boosting Confidence in CBD Counseling 

Pharmacists can save lives by counseling patients on naloxone use, although it may be a difficult topic to address. If you are not experienced in naloxone counseling, where do you begin? Drug Topics® interviewed experts on how to best approach patients about naloxone, an opioid antagonist medication that is used to reverse an opioid overdose.

Ellen R. Cohn, PhD, CCC-SLP, AASHA-F, who is an adjunct professor of communications at the University of Pittsburgh in Pennsylvania and an adjunct professor at the University of Maryland Global Campus, reminds pharmacists to maintain eye contact, convey caring, and be direct and calm. She suggests telling the patient: “The medication you are taking could put you at risk. It would be good to have an antidote on hand.” If the pharmacist is anxious about discussing this sensitive topic, the patient can pick up on their anxiety, she said. Cohn acknowledges that the topic may be difficult, but it will become second nature over time. “The more one delivers the message, the easier it will be,” she said.


Amanda McQuillan, PharmD, BCPS, BCPP, is a pharmacist in Pittsburgh. “You have to approach the subject like any other,” she said. “For example, does it make you feel awkward counseling a [patient with diabetes] on healthy food options or educating someone on an EpiPen? If you feel uncomfortable, they obviously will, too. Your anxiety about the topic will come across as being judgmental, and that never goes well when counseling a patient,” she said. In a situation where she thinks the patient may feel o ended, McQuillan reviews all the possible ways the patient can accidentally overdose, such as when starting a new medication or when they have an acute respiratory illness. She also asks if the patient has any children in their home who could come across the medication. “It’s really a public safety measure for everyone,” she said.


Rebecca Bouse, PharmD, pharmacy manager at Walmart Pharmacy in Newcastle, Oklahoma, approaches counseling with an “open mind and one of care to the patient and their family, [including] children and pets,” who may accidentally ingest the patient’s medication. After introducing herself, Bouse lets the patient know that she would like to discuss safe medication use and risk. “I also ask permission to speak openly and candidly. Empathy is key, and I place myself in their shoes and think about how difficult it must be to have to take opiate medication for their health condition,” she said. Bouse suggests listening with an open mind and letting the patient talk freely.

“There is already a stigma attached to opiates, and often patients feel judged [about their] treatment with opiate medications even before the conversation starts,” she said. Bouse then o ers to check the price of naloxone HCl nasal spray (Narcan; Emergent BioSolutions) with insurance or a discount card. Bouse and her colleagues document conversations in the patient profile. “We never force a patient to obtain Narcan. It’s always a choice. And more times than not, they opt out. It’s not a failure. It just may take several times or talking to various family members for the justification to make sense,” she said.

Elizabeth VanSlyke, PharmD, BCPS, begins naloxone counseling by saying, “We have an initiative to provide naloxone to any patient on opioids— no matter the dose—and this is a standard of care.” By starting this way, “I think this helps, so people don’t feel singled out,” she said. VanSlyke encourages the patient to bring their spouse or another close friend or family member for training. She finds that using the word “poisoning” is better accepted by patients than “overdose.” VanSlyke emphasizes that the risk of overdose or poisoning is present and possible. “I normally tell patients that typically the naloxone never gets used, [it] expires, and they dispose of it and get a new one, but it is a protective factor that we would much rather have in place and available on the small chance it is needed, versus needing it and not having it,” she said.

Crystal D. Choi, PharmD, MS, MEd, is a pharmacist at CVS in Las Vegas, Nevada. She reminds pharmacists that many patients who take opioids are older adults, so there could be polypharmacy and drug interactions. “Mix-ups are a distinct possibility. If the patient, or someone else, takes the opiate medication by accident, or maybe they double a dose because they forgot they already took it, having the naloxone gives them a layer of protection,” she explained. Choi also considers younger patients who have children in the home. “For those patients, I point out that if a child takes their medication, naloxone could prevent an accidental overdose.

This line of reasoning is effective for parents picking up prescriptions for teen and young adult children, as well,” she said. “I also bring up the potential for drug interactions... and remind them that having it in the home is just a precaution. I let them know that naloxone is like an EpiPen. They can use it to save another person who needs it if the situation arises.” 

McQuillan compares naloxone to a fire extinguisher. “Nobody anticipates setting a fire, but if there is one, you defi - nitely want a fire extinguisher, you want to know where it is located and how to use it, and, naturally, you are also going to call for help by calling 911,” she explained. Bouse uses an open-ended style of questioning. She asks patients questions such as, “What risks do you think there are with taking opiate medications?” and “What are the risks associated with adding other medications that can have additive depressant effects or adding medications that have a stimulant effect?”

She acknowledges to the patient that all the various medications have a valid place in therapy. However, there are also risks associated with each treatment that can cause unexplained respiratory depression, up to and including sudden death in extreme cases. Bouse tries to avoid the word “overdose,” as most patients will automatically assume that it would never happen to them. She also compares taking opiates to driving a car— each has inherent risks. “Those risks go up with speeding, taking benzodiazepines, and so on,” she said. 

When a patient gets naloxone, Choi takes it out of the box and shows the patient how to use it and where the directions are. She suggests that the patient teach other adults in the home.

“It’s just like CPR [cardiopulmonary resuscitation] or the EpiPen—a lifesaving measure—and they should be familiar with it before actually facing a situation where they have to use it,” Choi said. VanSlyke reminds patients to always carry naloxone, “just like an EpiPen, because if the naloxone is at home and the patient is not and something happens, it isn’t going to [do] any good.” VanSlyke also tells patients that more than 1 dose of naloxone may be needed. And if the patient regains consciousness, caregivers should stay with the patient until help arrives—do not cancel the ambulance.

Naloxone education often requires difficult but necessary conversations
with patients.

How to Tactfully Handle Naloxone Counseling

Constipation is one common condition where pharmacists can provide assistance to patients.

As knowledgeable and accessible health care professionals, pharmacists are in a unique position to help patients with acute constipation with OTC medication selection or referral to a physician if necessary.

We talked to 2 pharmacists to see how they address the most common questions around constipation. Of course, since each patient has a different medical history, before making a recommendation, ask the patient about medical conditions and medications they take, including prescription, OTC, and vitamins.

1. What is the best OTC medication for constipation in adults?

Jill Caracci, PharmD, is a pharmacist at Sterling Pharmacy in Independence, Missouri.

She explained that the OTC treatment of choice for adults varies depending on the cause. “In idiopathic constipation, [constipation not due to diet, medications, medical conditions, pregnancy, or activity level] I would suggest an osmotic agent such as polyethylene glycol (MiraLAX; Bayer). Mix 17 grams of the polyethylene glycol in 8 ounces of water and drink daily,” she said.

However, if the patient’s constipation is associated with pregnancy, Caracci suggests a fiber product such as psyllium husk (Metamucil; Procter and Gamble).

For opioid-induced constipation, Caracci recommends a combination stool softener/stimulant laxative such as Senna-S, or bisacodyl (Dulcolax; Boehringer Ingelheim Pharmaceuticals Inc) with docusate sodium (Colace; Pharmacal Corporation).

2. I need to go right away. What should I take?

Sara Shelley, PharmD, is the pharmacy manager at Corner Drug Co. in Woodland, California. For quick relief in adult patients, Shelley recommends a Fleet enema. However, if the patient does not want to use an enema, “a bisacodyl suppository or oral magnesium citrate are suitable alternatives,” she said.

What is a good OTC medication for my child’s constipation?

Caracci suggests consulting the child’s pediatrician in this case. For those who have received a green light from the pediatrician to treat constipation, she suggests a glycerin suppository (Pedia-Lax), especially for small children. "They are generally well-tolerated and often produce results within 30 minutes,” she said. For those children who are older or will not tolerate a suppository, Caracci recommends polyethylene glycol with weight-based dosing.

4. What dietary measures will help my constipation?

“Fiber and water are your friends!” Shelley said. “Increasing your fiber intake, decreasing intake of highly processed foods, and staying adequately hydrated can help constipation.” She recommends increasing dietary intake of high fiber foods, such as fruits, vegetables, whole grains, beans, and nuts.

Shelley advises slowly introducing a fiber supplement like psyllium husk or wheat dextrin (Benefiber; GlaxoSmithKline) for patients who need help getting enough fiber. She also reminds patients that beverages containing caffeine, such as coffee and soda, are dehydrating, so drink sparingly, if at all, when constipated.

5. What warning signs would alert you to something more serious than just general constipation?

Shelley advises her patients to seek medical attention right away if their stools are dark/bloody and tarry, or if they have severe abdominal pain, a distended abdomen, unintentional weight loss, or vomiting. If the patient has general constipation, she recommends contacting the doctor if dietary modifications and OTC medications haven’t helped in 4 or 5 days.

6. How long should I try to treat my constipation before seeing a doctor?

In the absence of warning signs mentioned above or known causes of constipation, Caracci suggests consulting the doctor “if there has been no improvement with OTC treatment after 5 days.”

Ten high-fiber foods to help constipation:

Recommend increasing consumption as tolerated as well as increasing water intake.

10 High-Fiber Foods to Help Constipation

We talked to 2 pharmacists to see how they address the most common questions around constipation.