516 - New Vaccine Roundup, 2023 Beers Criteria®, Getting Found

From the ACIP of the CDC

1)  New Vaccine Roundup!

The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) has been busy in the last few months recommending new vaccines. There is a lot of change happening in the vaccine world, so having the link to the Adult and Child/Adolescent schedules readily available can help you keep up to date; the more so now because the ACIP has begun publishing official addenda (adult, child/adolescent) to the schedule. These addenda will now be the official source of timely ACIP recommendations (rather than publishing them in the MMWR), so that insurance coverage will kick in faster, and providers can be notified of vaccine changes prior to the new print schedule’s release every February.

The newest additions to the schedule to know about:

·         Novavax – Novavax (NVX-CoV2373, 5µg antigen + 50µg Matrix-M adjuvant) is the only currently-produced non-mRNA vaccine against COVID-19. It has been authorized (under an Emergency Use Authorization) by the US Food and Drug Administration (FDA) and recommended by ACIP for patients 12 years and older to prevent COVID-19. Patients who have never received ANY COVID-19 vaccine should get 2 doses (separated by 3 weeks). Immunocompromised patients may receive an additional dose 8 weeks after their last dose (whether Novavax or mRNA). Patients who have had any COVID-19 vaccination in the past should get a single dose this season, at least 2 months after their last COVID-19 vaccination.

·         PCV20 – Both PCV20 (Prevnar 20) and PCV15 (Vaxneuvance) have been approved by the ACIP for ages 19 and above for the age-related and condition-related pneumococcal vaccine recommendations. For the adults, using PCV15 requires that you also use PPSV23 (usually 1 year later) to complete the vaccination series, whereas PCV20 is used alone. Both PCV20 and PCV15 have now been approved to replace PCV13 in the child/adolescent schedule. For routine age-based pneumococcal vaccination for children without additional risk factors, either PCV20 or PCV15 can be used alone in place of PCV13. For children with risk conditions, PCV20 or PCV15 can be used, but if PCV15 is used, PPSV23 should be given 8 weeks after the last recommended PCV dose.

·         RSV vaccine (Abrysvo) – The ACIP has approved the RSV vaccination for pregnant people between 32- and 36-weeks’ gestation in order to prevent RSV-related hospitalizations (57% efficacy), severe disease (69% efficacy) and healthcare visits (51% efficacy) in their infants over the first six months of life. In the phase 3 trials, preterm labor was more common in the vaccinated group (who were vaccinated between 24 and 36 weeks), but this difference did not reach statistical significance. The ACIP recommendation designed their recommendation to avoid this risk of preterm birth at lower gestational age by starting their recommendation at 32 weeks. The CDC is monitoring this vaccination closely through their usual mechanisms – the Vaccine Adverse Events Reporting System (VAERS) and the Vaccine Safety Datalink (VSD).

John’s Comments: 

The Novavax and PCV20 (our currently supported PCV option at Carilion) are relatively easy adjustments. The recommendation for RSV vaccination during pregnancy is similar to the Tdap vaccine recommendation in that it’s given to the mother to protect the newborn child (as both passive immunity and to prevent transmission from an ill mother). Primary care clinicians who do not do maternity care themselves should coordinate and support vaccination efforts during pregnancy for the health of mothers and babies.

References:

·         Interim Clinical Considerations for Use of COVID-19 Vaccines | CDC. Published October 5, 2023. Accessed October 12, 2023. Link

·         ACIP Updates: Recommendations for the Use of 20-Valent Pneumococcal Conjugate Vaccine in Children ― US, 2023. 

          Accessed October 12, 2023. Link

·         Healthcare Providers: RSV Vaccination for Pregnant People | CDC. Published September 29, 2023. Accessed October 12, 2023. Link

From the American Geriatrics Society (AGS) Guidelines

2)  2023 Beers Criteria^® For Medication Use in Older Adults

In May of this year, the American Geriatrics Society (AGS) released a 2023 update of the Beers Criteria for potentially inappropriate medication (PIM) use in older adults.  The previous update was in 2019.  The intention of the AGS Beers Criteria is to: (1) reduce older adults' exposure to PIMs by improving medication selection; (2) educate clinicians and patients; and (3) serve as a tool for evaluating the quality of care, cost, and patterns of drug use in older adults.

The criteria are designed to be applied by practicing clinicians to adults > 65 in all ambulatory, acute, and institutionalized settings of care, except hospice and end-of-life care settings.  Whenever and wherever used, the Beers Criteria are intended to be applied thoughtfully and in a manner that supports, rather than replaces, shared clinical decision-making.

The expert panel organized the criteria into the same five general categories that were used in the 2019 update:

1.     Medications considered as potentially inappropriate;
2.     Medications potentially inappropriate in patients with certain diseases or syndromes;
3.     Medications to be used with caution;
4.     Potentially inappropriate drug–drug interactions); and
5.     Medications whose dosages should be adjusted based on renal function.

Some notable recommendations include (abridged):

•  Potentially inappropriate medications (generally avoid):  first generation antihistamines, medications with strong anticholinergic properties, nitrofurantoin, aspirin for primary prevention, warfarin, rivaroxaban (Xarelto), non-selective alpha-blockers for HTN, first and second generation anti-psychotics, barbiturates, benzodiazepines, non-benzodiazepine hypnotics (“z-drugs”), testosterone (unless symptomatic hypogonadism), oral estrogens, short-acting sliding scale insulin, sulfonylureas, PPIs for > 8 weeks (unless high-risk), non-Cox-2-selective NSAIDS chronically (if necessary, use with PPI), skeletal muscle relaxants.
• Potentially inappropriate medications with certain diseases:  heart failure (NSAIDS, non-dihydropyridine CCBs), dementia (anti-cholinergics, benzodiazepines, “z-drugs”, antipsychotics
• Drugs to be used with caution: dabigatran (Pradaxa), SSRIs, SNRIs, mirtazapine, SGL2-inhibitors, nitrofurantoin, trimethoprim-sulfamethoxazole, tramadol, diuretics
• Potentially inappropriate drug-drug interactions: Do not use: opioids with benzodiazepines, more than one medication with anticholinergic properties, 3 or more CNS active agents
• Medications whose dosages should be adjusted based on renal function:  Antibiotics (ciprofloxacin, nitrofurantoin, and trimethoprim-sulfamethoxazole if eGFR < 30), NSAIDS (<30), H-2 blockers (<50 for famotidine, cimetidine, nizatidine), gabapentin (<60)

Mark’s Comments:

The list under the first bullet is like a “who’s who” of medications that show up on the medication list of many elderly patients.  The challenge for many of us is that deprescribing appears to be a lot more difficult than prescribing in the first place.  Particularly worrisome is how many of those medications negatively impact cognitive function.  When we feel prescribing these medications is necessary and appropriate (and the AGS acknowledges there are times when that is the case), at the least we should regularly be looking for opportunities to be sure we’re prescribing the lowest necessary dose and not continuing any potentially harmful medications without a conversation with the patient (and/or family) and documenting the outcome of that dialogue.    

References:

·         AGS Beers Criteria Update Expert Panel.  American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults.  First published 04 May, 2023. Link:   Pocket Guide and Mobile App

From PeerRxMed ( www.PeerRxMed.org )

3)  Having the Courage to Get Found

The essence of the PeerRxMed process is regularly and intentionally connecting with other colleagues in order to support each other in the challenging times, celebrate with each other in the good times, and travel alongside each other in the times in between.  To do so requires both vulnerability and receptivity.  Neither of these are qualities that many physicians (or humans for that matter) find easy to express.

So, when a colleague in our midst courageously models this in a way that is accessible, it provides a “teachable moment” for us all.  Over the past few weeks one of our beloved Geriatricians here in Roanoke, Brian Unwin, who is also nationally known for his teaching excellence, was diagnosed with a yet unidentified GI mass that was concerning enough that he underwent a Whipple procedure on Wednesday (with some initially hopeful news regarding the cause).

What has been most notable for me about Brian’s healthcare journey has been the openness (CaringBridge), faith-fullness, optimism, courage, and even humor with which he has shared.  For those who know him, this does not come as a total surprise.  He has always been one who is willing to push a bit against the prevailing status quo and conventional wisdom of our profession. 

At the same time, for anyone, let alone a colleague, to be this open regarding hardship and tragedy still seems extraordinary, as it is not what most of us have seen modeled, nor is it likely what most of our normal instincts would have us do.  Withdrawal into “hiding” would be more the norm.  In his modeling of greater openness, I have found myself inspired and am left with an even deeper understanding of what “help-seeking” and connection might look like when one is facing a personal crisis.   

In an e-mail that he sent last month when he was first hospitalized, Brian closed with the sentiments below.  I would encourage you to read the brief story "Get Found" that he references.  In doing so, be ready for your heart to open a bit wider, and perhaps yearn for more “sardines friends.”     

We’re much better together,

“Cyndy and I won't be facing this in a 'shy and hard to reach' fashion. We feel loved and supported, and the company and spirit you share truly lifts us …. Take a moment to read "Get Found", from Robert Fulghum's book All I Really Need to Know I Learned in Kindergarten.  We will be approaching this challenge ahead by playing sardines.  . 

Join us.

I (we) love you all,

Brian”

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org