Marilyn Bulloch, PharmD, BCPS

Over 16 million Americans suffer from chronic obstructive pulmonary disease (COPD) and it is the fourth leading cause of death in the United States.

Psychiatric conditions, activity limitations, and complications from infection are all significant obstacles within this patient population. Millions of emergency department visits and thousands of hospitalizations are related to COPD, which substantially increases economic burden.

Keys to managing COPD include smoking cessation, pharmacological therapy, preventative measures, and oxygen therapy.

. Medication adherence in patients with COPD ranges from 20% to 60% in real-world studies, and 54% of patients have poor inhaler technique.

 Many factors are important when finding the right therapy for the patient: inhaler type and technique required; number of inhalations per day; and financial obtainability.

 Pharmacists can contribute to improving patients’ control of COPD and minimize complications.

A timely diagnosis of COPD leads to early intervention, in which pharmacists can play an integral role.

 Increase in spirometry testing leads to a more timely diagnosis giving way for early, pharmacist-made interventions and better quality of life.

 A health center study found referrals for spirometry testing were significantly higher in the pharmacist intervention clinic as compared to the control clinic (47.2% vs 7.7%).

 Another study of physician-referred patients showed pharmacist-conducted spirometry testing improved patient convenience, led to timely diagnosis, optimized drug therapy regimens, tailored education plans, and improved long-term management.

 Targeting patients in community pharmacies with frequent symptoms and rescue inhaler refills can lead to increased recommendations for diagnostic tools.

 A study comparing 2 community pharmacies (1 control and 1 pharmacist intervention group) showed that when pharmacists target patients with high-dose steroid and antibiotic use, treatment regimens are improved by initiating therapy and making necessary adjustments.

Pharmacist counseling in multiple settings has demonstrated superior outcomes in COPD patients. Education shown to improve outcomes include disease state background, inhaler technique, medication adherence, and self-management through lifestyle changes. An outpatient study evaluating different methods of teaching inhaler technique showed that direct pharmacist instruction resulted in significantly more accurate inhaler technique compared to reading the package insert (72.2% vs. 16.7%). Additionally, direct pharmacist instructions faired between than watching videos (11.1%), or videos combined with reading the package insert (16.7%).

Pharmacist involvement can also reduce the need for acute care. One study revealed that counseling by pharmacists in ambulatory care clinics, including a customized action plan directing patients to initiate certain therapy in the event of an exacerbation, decreased emergency department visits by 50% and hospitalizations by approximately 60% (p=0.02; p=0.01).

 Another study evaluating the impact of 2 counseling sessions by community pharmacists 1 month apart showed a 72% decrease in hospitalizations (p=0.003).

 Of note, counseling factors consistently included a focus on medication adherence and technique, which emphasizes the importance of including these components when counseling patients with COPD. Adherence can be further supported by pharmacists suggesting combination products, generic options, and patient assistance programs, as they are the primary resource to patients when it comes to addressing affordability issues.

Antibiotic stewardship in acute exacerbations of COPD is becoming an increasingly important responsibility for pharmacists as the rates of antibiotic resistance continue to rise.

 Respiratory tract infections are one of the most common causes of COPD exacerbations. Clinical guidelines recommend the use of antibiotics when cardinal symptoms (increased sputum purulence, increased sputum production, dyspnea) are present; however, a review of prescribing patterns at 2 large academic centers showed a 75% rate of inappropriate antibiotic use, the most common being fluoroquinolones (58.7%).

 Pharmacists can educate providers on proper indications for antibiotics, avoidance of unnecessary antibiotics, choosing a correct agent, and de-escalation of therapy.

Facilitating and encouraging smoking cessation is another essential duty for the pharmacist. Smoking cessation is the leading modifiable risk factor for COPD and the only proven way of slowing down disease progression.

 The benefits of smoking cessation on COPD progression are measurable within the first year of abstinence. After several years the rate of decline in lung function becomes similar to individuals who have never smoked, which is evidenced by a reduced risk of hospitalization and total mortality.

 Pharmacists can recommend individualized over-the-counter nicotine replacement therapies or pharmacologic interventions to help achieve and sustain cessation while minimizing potential untoward effects.

Lastly, as the leading provider of immunizations, it is a pharmacist’s responsibility to ensure that patients with COPD receive their pneumococcal, COVID-19, and annual influenza vaccine because COPD patients are at high risk of complications from these infections.

 For example, in a study of geriatric COPD patients followed over 3 influenza seasons, when both influenza and pneumococcal vaccines were given concomitantly, the reduction in hospitalizations for pneumonia (63%) and death (81%) were higher than for either single vaccine.

The month of November is recognized for encouraging awareness of COPD. Pharmacists have the potential to make a positive impact by screening patients, providing counseling, encouraging beneficial interventions, and helping tailor patient regimens based on personalized needs. Increasing such pharmacist-made interventions could be a breakthrough in the management of COPD, which should be a major priority for our profession.

Centers for Disease Control (CDC). Chronic Obstructive Pulmonary Disease. 2021.

Bluml BM. White paper on expanding the role of pharmacists in chronic obstructive pulmonary disease. J Am Pharm Assoc. 2011;51(2):203-11.

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of COPD Report. 2020.

Bengston LGS, Bancroft T, Schilling C. et al. Development and validation of a drug adherence index for COPD. J Manag Care Spec Pharm. 2021;27(2):198-209.

Sanaullah T, Khan S, Masoom A. et al. Inhaler use technique in chronic obstructive pulmonary disease patients: errors, practices, and barriers. Cureus. 2020 Sep;12(9).

Whitner JB, Mueller LA, Valentino AS. Pharmacist-Driven Spirometry Screening to Target High-Risk Patients in a Primary Care Setting. J Prim Care Community Health. 2019;10:2150132719889715.

Hudd TR. Emerging role of pharmacists in managing patients with chronic obstructive pulmonary disease. Am J Health Syst Pharm. 2020;77(19):1625-30.

Ottenbros S, Teichert M, de Groot R. et al. Pharmacist-led intervention study to improve drug therapy in asthma and COPD patients. Int J Clin Pharm. 2014;36: 336–344.

Axtell S, Haines S, Fairclough J. Effectiveness of Various Methods of Teaching Proper Inhaler Technique: The Importance of Pharmacist Counseling. J Pharm Pract. 2017;30(2):195-201.

Khdour MR, Kidney JC, Smyth BM, McElnay JC. Clinical pharmacy-led disease and medicine management programme for patients with COPD. Br J Clin Pharmacol. 2009;68(4):588-98.

Tommelein E, Mehuys E, Van Hees T, et al. Effectiveness of pharmaceutical care for patients with chronic obstructive pulmonary disease (PHARMACOP): a randomized controlled trial. Br J Clin Pharmacol. 2014;77(5):756-66.

Dietrich E, Klinker KP, Li J, et al. Antibiotic Stewardship for Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Am J Ther. 2019;26(4):499-501.

Wu J, Sin DD. Improved patient outcome with smoking cessation: when is it too late?. Int J Chron Obstruct Pulmon Dis. 2011;6:259-67.

Arabyat RM, Raisch DW, Bakhireva L. Influenza vaccination for patients with chronic obstructive pulmonary disease: Implications for pharmacists. Res Social Adm Pharm. 2018;14(2):162-69.

Nichol KL. The additive benefits of influenza and pneumococcal vaccinations during influenza seasons among elderly persons with chronic lung disease. Vaccine. 1999;17 Suppl 1:S91-S93.

Articles

Pharmacists have the potential to make a positive impact by screening patients, providing counseling, encouraging beneficial interventions, and helping tailor patient regimens based on personalized needs.

COPD Awareness Month: Pharmacists’ Role in Helping Patients Breathe Better

Protection against circulating influenza viruses is dependent on antibody titers to antigenically similar strains obtained via natural, or vaccine induced immunity.

 Most humans have high antibody titers against strains of influenza viruses encountered in early childhood and exposures at young ages influence how an individual reacts to antigenically distinct strains later on in life.

 indicates that adults born in the 1960s and 1970s may be less able to produce neutralizing antibodies to modern H3N2 strains, and subsequently middle aged patients may be continuously susceptible to Influenza A (H3N2) viruses.

Influenza A (H3N2) first infected humans in the late 1960s.

 They have evolved significantly in the past 5 decades. Since 2014, an antigenically drifted descendant of the first 1968 H3N2 strain known as clade 3c2.A H3N2 viruses has circulated in high levels globally. These viruses uniquely contain a key glycosylation site that shields HA antigenic site B, the major target of neutralizing antibodies. They are also capable of producing a high flu-related morbidity and mortality burden. In the 2017-18 flu season alone, these influenza viruses were responsible for more than 800,000 hospitalizations and more than 60,000 deaths in the United States.

 The fact that 2c2.A H3N2 viruses were dominate in the 2017-18 season may seem surprising because they also were the most common strains in the 2014-15 and 2016-17 seasons, and it would be reasonably expected that many people would have developed immunity against them.

The study authors collected serological samples from different aged individuals in the summer months prior to the 2017-18 influenza season.

 These investigators then characterized antibodies from patients with confirmed 3c2.A H3N2 infections prior to the 2017-18 flu season to see if antibodies would be effective in neutralizing H3N2 viruses circulating in the subsequent 2017-18 season (referred to as 3c2.A2). There were 3 amino acid substitutions seen on the HA of the 3c2.A2 H3N2 viruses compared to the HA of the 3c2.A H2N2 viruses. Over 89% of study patients aged 4 years and older had HA ELISA-reactive antibodies to 3c2.A and 3c2.A2. All but 3 of those who did not were under the age of 4 years and were thought not to have been previously exposed to H3N2 virus.

The study found that children aged 3-10 years had the highest levels of neutralizing antibodies for the viruses. It also showed that most middle-aged adults did not have detectable neutralizing antibody titers against 3c2.A or 3c2.A2 H3N2 viruses. In fact, the lowest titers were measured in patients born in 1967, a year before H3N2 introduction into human circulation. It should also be noted that there did not seem to be any significant HA antigenic changes between the 2014-15 3c2.A and 2017-18 3c2.A2 strains, which usually results in at least some immunity after exposure.

The authors contend that childhood infections that current middle-aged adults experienced in the 1960s and 1970s primed antibody responses that are reactive, but not neutralizing against modern 3c2.A H3N2 viruses. In short, people could produce non-neutralizing antibodies that could bind to the viruses’ HA but did not prevent infection.

The authors followed up on their findings by measuring HA and NA antibodies in a small sample of adults born between 1963 and 1979 before and after confirmed 3c2A H3N2 infection in the 2014-15 season.

 They found that HA ELISA antibody titers increased in serum 4-8 months after infection in most individuals, but neutralizing titers remained low. They also found that 3c2A neuraminidase (NA) antibodies increased but did not respond well to the antigenically drifted 3c2A2 NA from the 2017-18 season.

While the exact reason for the decreased immune response in middle-aged adults remains unclear, these findings suggest that this patient population may be continuously susceptible to the 3c2A H3N2 infection, even with immunization. It also provides some insight into the high infection rates of adults during seasons when H3N2 is the dominant circulating strain and why 3c2A viruses continue to circulate despite minimal to no antigenic drift. The study also raises questions about the existence of other age-related immune responses.

Further and larger studies are needed to fully evaluate immunity among different aged groups and birth years. Data from such studies could lead to a significant breakthrough in our understanding of immunity and subsequently change our influenza prevention approach.

1. Centers for Disease Control and Prevention. Immunogenicity, efficacy, and effectiveness of influenza vaccines. Accessed May 25, 2021. 

https://www.cdc.gov/flu/professionals/acip/immunogenicity.htm

2. Fonville JM et al. Antibody landscapes after influenza virus infection or vaccination. 

3. Gouma S, Kim K, Weirick ME, et al. Middle-aged individuals may be in a perpetual state of H3N2 influenza virus susceptibility. 

4. Allen JD, Ross TM. H3N2 influenza viruses in humans: viral mechanisms, evolution, and evaluation. 

5. Centers for Disease Control and Prevention. Estimated influenza illnesses, medical visits, hospitalizations, and deaths in the United states – 2017-2018 influenza season. Accessed May 25, 2021. 

https://www.cdc.gov/flu/about/burden/2017-2018.htm

While the exact reason for the decreased immune response in middle-aged adults remains unclear, these findings suggest that this patient population may be continuously susceptible to the 3c2A H3N2 infection, even with immunization. 

Ability to Produce immunity to Influenza A H3N2 Called Into Question for Certain Adults

The 2020-2021 influenza season was strikingly quiet. Cumulative positivity between September 27, 2020 and May 15, 2021 was 0.2%, a rate substantially lower than the 17% average positivity for the 3 previous seasons.

 Although some have argued that positive tests were reduced due to a lack of testing, testing for influenza in North America was consistent with previous years.2 More likely, the low infection rate is the credit of a combination of social distancing, face masks, and vaccinations.

Although the virus did not pose its usual seasonal burden, it was not eradicated. The dominant circulating influenza virus varied worldwide. In the United States, tests conducted by clinical laboratories indicate that Influenza B accounted for approximately two-thirds of infections.

 Influenza B was also dominant in China and the Middle East, while Influenza A appeared to be predominate in North Korea and Japan.

When the flu season for the northern hemisphere ends in spring, it begins for the southern hemisphere and runs through September. The southern hemisphere season is considered to precede the northern hemisphere and provided valuable insight on what to expect when flu season returns in October. The southern hemisphere, so far, is also experiencing a substantially calm flu season.

 Although clinically this may sound positive, it also makes preparing for the next flu season in the northern hemisphere more difficult.

With fewer virus specimens, experts say that it is more difficult to identify and characterize the full extent of the circulating influenza viruses’ genetic and antigenic diversity. In animals, the southern hemisphere’s 2021 vaccines have had mixed efficacy in producing antisera that recognizes, and subsequently affords protection against, circulating viruses.

 Though the match in these models seems to be stronger with the Influenza B lineages and circulating strains, there is more inconsistent efficacy with the Influenza A composition. In fact, changes in circulating Influenza A viruses, especially H3N2 strains, led experts to recommend changes to the composition of the 2021-2022 vaccine for the northern hemisphere.

The recommendations for influenza vaccine composition for Fall 2021 were released in February 2021 by the World Health Organization.

 For the second year in a row, the composition of the vaccine will depend on whether it is egg-based or cell-based or recombinant vaccine. However, the different compositions do not necessarily mean that there is a substantial difference in vaccine-produced immunity to circulating strains. According to the World Health Organization, not all viruses are optimal for the different production systems seen with egg-based vaccines versus cell or recombinant based vaccines. To accommodate this, different viruses with similar properties were selected as prototypes for timely vaccine production to ensure adequate supply by Fall 2021.

In 2021-2022, all influenza vaccines, regardless of type, will contain the same lineages of Influenza B, which are unchanged from the 2020-2021 season. This coincides with the matched protection seen in both the northern hemisphere’s 2020-2021 season and the southern hemisphere’s season so far. When lineage has been determined, most Influenza B viruses in 2020-2021 were B/Victoria/2/87 or B/Yamagata/16/88 lineage, which were closely related genetically and antigenically to the strains included in the vaccine. Quadrivalent vaccines will again include B/Washington/02/2019 (B/Victoria lineage)-like virus and B/Phuket/3073/2013 (B Yamagata lineage)-like virus. Trivalent vaccines will only contain the Victoria lineage, but the majority of available vaccines in the United States have transitioned to a quadrivalent composition.

Both strains of Influenza A for the northern hemisphere vaccines will be different from those included last season. Unlike last flu season, they will only differ by the H1N1 component rather than both strains of Influenza A. The H1N1 composition will resemble the current southern hemisphere vaccines’ H1N1 composition. Vaccines that are egg-based will include A/Victoria/2570/2019(H1N1)pdm09-like virus while cell and recombinant-based vaccines will include A/Wisconsin/588/2019 (H1N1)pdm09-like virus. The southern hemisphere’s current H3N2 component (Influenza A/Hong Kong/ 45/2019 (H3N2)-like virus in cell or recombinant-based vaccines and A/Hong Kong/2671/2019 (H3N2)-like virus) is identical to what was included in the northern hemisphere’s vaccines for 2020-2021,but appear to be producing inconsistent efficacy and protection to current circulating strains. As a result, vaccines administered in the fall will contain an updated strain of H3N2, an A/Cambodia/e0826360/2020 (H3N2)-like virus.

It is impossible to predict if the low rates of influenza in the 2020-2021 season will be repeated or serve as an isolated anomaly. The impact of the change in vaccine composition will not be known for almost another year. Eased infection control practices related to COVID-19, such as reduced face mask wearing, will also likely return influenza transmission to its usual potential. Although these measures had a noticeable contribution to the decrease in transmission of the influenza virus, the influenza vaccine remains the best way to protect against the potentially fatal virus.

It is important that patients be encouraged to receive the vaccine, even if Influenza B continues to dominate in the upcoming season, since there is a post-vaccination decline in protective antibodies. This past year has introduced the possibility that influenza season does not have to consistently produce a high health burden. The prevention strategies championed by pharmacists and other health care providers for years, vaccination and practical infection prevention practices demonstrated their capabilities in full force. While it is unlikely that all of the practices employed during the 2020-2021 season for the COVID-19 pandemic will be broadly utilized during future flu seasons, pharmacists can and should continue to champion common-sense preventative strategies such as hand hygiene, staying home when sick, and most importantly, annual influenza vaccination.

Centers for Disease Control and Prevention. FluView. Updated May 15, 2021. Accessed May 25, 2021. 

World Health Organization. Recommended composition of influenza-virus vaccines for use in the 2021-2022 northern hemisphere influenza season. Updated February 26, 2021. Accessed May 25, 2021. 

https://www.who.int/influenza/vaccines/virus/recommendations/2021-22_north/en/

Both strains of Influenza A for the northern hemisphere vaccines will be different from those included last season. 

Influenza Vaccination Updates for the 2021-2022 Season

Originally thought to be a predominantly temporary infection, a growing proportion of patients are experiencing prolonged symptoms from SARS-CoV-2 infection, or “Long COVID”.

Symptoms of Long COVID, which like COVID-19 itself, can be highly varied from patient to patient, but most commonly include fatigue, insomnia, “brain fog”, anxiety, depression, gastrointestinal symptoms, myalgia, and breathlessness.

 Some symptoms extend from the acute infection while others arise later. Researchers and medical professionals do not fully understand the pathophysiological or immunological mechanism behind this unfortunate phenomenon.

Support groups and patient care clinics have been created to help patients who suffer from lasting effects of the virus and large research studies, such as the SARS-CoV-2 Recovery Cohort though NIH, aim to provide more insight into why some patients develop Long COVID and how best to manage it.

 A recent study, not yet published in a peer-reviewed journal, may provide hope for patients via an unexpected source: vaccination.

The study, performed with help from the LongCovidSOS campaign in the United Kingdom (UK), was initially developed to determine if COVID-19 vaccines could worsen symptoms associated with Long COVID. According to the authors, there were anecdotal reports of substantial symptom improvement following vaccination, contrasting with fear that immunization might worsen Long COVID.

A cohort of patients admitted to a single UK hospital between April and May 2020 were recruited for a prospective observational study with follow-up at hospital discharge, 3 months (approximately June-July 2020), and 8 months (approximately December 2020 to January 2021). Over 80% of these patients reported at least 1 ongoing symptom associated with their COVID-19 infection. Within this group, 44 participants who received at least 1 dose of a COVID-19 vaccine were surveyed 1 month following vaccination (approximately January – February 2021) to evaluate Long COVID symptoms. Twenty-two unvaccinated patients in the observational cohort served as matched controls.

At the 8-month follow-up and prior to vaccination, symptom burden was high among all patients. Those in the soon-to-be vaccinated group reporting 159 symptoms, and 91 symptoms were reported in the unvaccinated group.1 A small, but significantly greater, improvement in symptoms occurred in vaccinated patients compared to unvaccinated patients during the same period [37 of 159 (23.2%) vs. 14 of 91 (15.4%); p=0.035].

When differences in scores across all symptoms were combined, 56.7% of individuals in the study experienced symptom improvement after 1 vaccine dose and 24.6% had no change. It is worth noting that 18.7% of patients experienced symptom deterioration which may be concerning. However, the number of patients experiencing deterioration during this period was similar between vaccinated and unvaccinated patients and it does not appear that the immunization contributed to the worsening of any symptoms.

Generally, it appears immunization may improve Long COVID symptoms, but does not appear to exacerbate or worsen them. Almost half of vaccinated patients said the improvements were permanent. Since 72% of patients were within 30 days of vaccination, it is possible that the number of patients experiencing continued symptom improvement was underestimated and follow-up studies are required to determine the long-term impact of immunization on symptom status.

In addition to physical symptom impact, vaccination was also associated with a significant improvement in wellbeing according to the Warwick and Edinburgh Mental Wellbeing scores (p=0.006). The study also suggests that mRNA vaccines may provide more symptom improvement than adenovirus vector vaccines, but the sample size is most likely too small to provide a conclusive comparison.

These study results need to be confirmed in larger studies with diverse patient populations and the mechanism of the impact requires exploration. The study is too small to draw firm associations on the benefit of COVID-19 vaccination on Long COVID symptoms.

 However, it does provide hope for patients who are suffering long after the acute COVID-19 infection resolves and introduces a potential novel role in therapy for these vaccinations beyond infection prevention.

Collins FS. NIH launches new initiative to study “Long COVID”. Updated February 23, 2021. Accessed May 21, 2021. 

https://www.nih.gov/about-nih/who-we-are/nih-director/statements/nih-launches-new-initiative-study-long-covid

Arnold DT, Milne A, Samms E, et al. Are vaccines safe in patients with Long COVID? A prospective observational study. medRxiv.2021;DOI:10.1101/2021.03.11.21253225

Centers for Disease Control and Prevention. Post-COVID Conditions. Updated April 8, 2021. Accessed May 21, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects.html

Support groups and patient care clinics have been created to help patients who suffer from lasting effects of the virus.

Vaccination May Help Reduce Symptoms of Long COVID

Each April, the National Rosacea Society (NRS) celebrates Rosacea Awareness Month in an effort to increase public awarenss of a condition that affects approximately 16 million people in the United States. Throughout April, the NRS hosts a variety of activities with a goal of educating patients who are experiencing the symptoms of the condition, but not yet diagnosed with Rosacea, to seek evaluation and effective management.

Rosacea is most commonly seen in fair skined individuals, but has been diagnosed in patients of all ethnicities and backgrounds. Women experience symptoms more often than men and symptoms usually appear after the age of 30.

In 2018, the NRS focus will be around new classification standards recently published, the first update to these standards since 2002 and only the second set of classfication standards ever released by the Society. The 2002 classifications focused on common morphologic groupings into subtypes, while the 2017 version emphasizes individual phenotypes based on observable characterisits resulting from environmental of genetic factors. In order to be diagnosed with rosacea, patients should have either fixederythema in the facial center that has a characteristic pattern or phymatous changes such as skin thickening, fibrosis, patulous follicles, rhinophyma (a large red bulbous nose), or glandular hyperplasia. Centrofacial redness intensity may be consistent or may periodically increase and is the most common sign of rosacea.

It is important to rule out other causes of these symptoms, including drug-induced causes such as corticosteroid-induced rosacea or drugs causing lupus erythematosus, before the diagnosis of rosacea is made. These cutanous signs usually appear with at least one diagnositic feature, but the presence of two or more major phenotypes can also be considered diagostic for the condition.

Major phenotypes, or features, listed in the new standard include:

 primarily in the centrofacial area. These should be distinguished from comedones which should be credited to an acne process rather than rosacea. Patients may also experience nodules

 that is frequent and usually prolonged.  Erythema from flushing may be less visually apparent in patients with darker skin tones, but these patients may report subjectively expericing this symptom

 which are widened venules that redlines or patterns on the skin, often in clusters.

, especially lid margin telangiectasis, scleritis, sclerokeratitis, spade-shaped infiltrates in the cornea, or redness on the conjunctiva between the eyelids. 

The 2017 standards also list multiple secondary phenotypes that may occur in patients. These signs and symptoms may include:

, usually on erythematous skin with or without scales.

 that accompanies of follows extended erythema or flusing due to post-capillar extravasation during inflamation and may persist for several days.

 that are not exclusive to rosacea, such as burning, stinging, photosensitivity, foreign object sensation, conjunctivitis, or 'honey crust' and cylindrical collarette accumulation at the eyelash bases.

Diagnosis and subsequent treatment can have a tremendouns impact on patients' quality of life. Untreated or undertreated rosacea has been linked to depression and anxiety. Trigger avoidance, laser therapy, or topical or oral medications directed at symptoms (i.e. clonidine for flushing, antiinflammatories, or artificial tears for occular symptoms ) are all potential treatment options, depending on the severity of the rosacea. Pharmacists who suspect that a patient may be suffering from rosacea should refer them to the primary care physician for evaluation.

Rosacea Awareness Month. National Rosacea Society. 

Gallo RL, Granstein RD, Kang S, et al. Standard classification and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee. 

Rosacea Awareness Month to Highlight New Standard Classification and Pathophysiology of This Widely Misunderstood Disorder [news release]. Barrington, IL. National Rosacea Society. February 1, 2018. 

www.rosacea.org/press/rosacea-awareness-month-highlight-new-standard-classification-and-pathophysiology-widely

Rosacea Treatment Algorithms. National Rosacea Society. 

www.rosacea.org/physicians/treatmentalgorithms

In 2018, the National Rosacea Society's focus will be around new classification standards.

New Classification Standards Will Highlight National Rosacea Month

 gaining so much attention due to its severity, it is important to understand and choose the best treatment option for each patient. The CDC currently recommends treating the flu with a neuriminidase inhibitor (NAI), such as oral oseltamivir (Tamiflu), inhaled zanamivir (Relenza), or IV peramivir (Rapivab).

They recommend against the use of adamantanes, such as amantadine and rimantidine, due to their high level of resistance in the past few years.

The NAIs work by preventing NA formation, which leads to a reduction in viral replication by inhibition of release of the virus from infected cells.

While it is ideal to treat the infection within 48 hours of symptoms, even treatment with an antiretroviral after 4 to 5 days of onset has shown to reduce severe outcomes in both inpatient and outpatient settings.

compared patients with influenza who were treated versus those untreated, and found all patients treated with an NAI, even if it was initiated up to 5 days after symptom onset, were more likely to survive (p<0.05 for each day through day 5 of treatment, with 58% of patients surviving in the untreated group, 89% survival if the patient was treated on day 1 after onset of symptoms, 84% on day 2, 76% on day 3 , 73% on day 4, and 72% survivial on day 5).

In a retrospective cohort study conducted in critically ill children diagnosed with influenza, ages 1-21, those treated with oseltamivir had an approximately 18% shorter duration of hospital stay than those not given oseltamivir (p=0.02).

Another member of the NAI family, zanamivir, is often forgotten, but it is a strong alternative to oseltamivir treatment. In a head to head study in outpatient-treated influenza patients, the difference in efficacy and adverse events between patients using zanamivir vs oseltamivir was not significant, showing that either one could be appropriately used in treating influenza patients on an outpatient basis.

 However, due to lack of data in severely ill hospitalized patients, only oseltamivir is currently recommended for these patients.

Comparing these two therapies’ cost, it is important to note the significant difference between them. Zanamivir costs about $65 without insurance for a full course of treatment, while oseltamivir costs roughly $130 for a full course.

 This difference in price is significant, and should be considered in areas where zanamivir is readily accessible.

Since oseltamivir is such a popular choice for treatment, it is important to recognize ways to handle its common adverse event. Oral oseltamivir is known to cause GI upset. It is important to inform patients that symptoms such as nausea and vomiting have shown to be lessened when taken with food.

 If patients, especially children, have difficulty swallowing this medication due to taste or swallowing considerations, it is appropriate to mix the contents of a capsule or the dose of the liquid with about a spoonful of thick, sweetened syrup, such as chocolate syrup.

 Mix directly before administration, draw it up in a syringe, and administer the full dose.

With so many patients using oseltamivir, there has been concern for resistance. Current CDC data for the week ending February 24, 2018 shows a 1% resistance rate with oseltamivir and peramivir for influenza A strain H1N1 pdm09, but a zero percent resistance rate for these drugs with another strand of influenza A.

 There is no resistance reported thus far for zanamivir, and no resistance for any drug regarding influenza B.

 One trial that studied resistance patterns for oseltamivir showed that resistance was much more frequent in ages 1-5 as compared with the combined older age groups, when treated within 48 hours of onset.

There is also data showing antiviral utility for influenza prophylaxis. The decision on whether to administer antivirals for prophylaxis should depend on the exposed person’s risks for influenza complications, type and duration of exposure, recommendations from local or public health authorities, and, perhaps most importantly, clinical judgement.

Jackson RJ et al. found in a systematic review that oseltamivir is an effective influenza prophylactic agent when used in healthy adults and at-risk elderly patients, and zanamivir was effective in the same populations as well as post-exposure prophylaxis in elderly patients. The amantadines had very limited data supporting their use for influenza prophylaxis.

  Types of exposure will primarily refer to a variety of different degrees of close contact, which include droplet exposure via coughing or sneezing, contact with an infectious patient, or small particle aerosols in close proximity to the infectious patient. In general, prophylaxis with antivirals following exposure should be used only if they can can be started within 48 hours of that exposure. Local public health authorities should also be able to provide additional information with regard to use of prophylaxis in times of antiviral medication shortage or whether efforts should be focused on treatment versus prophylaxis.

Preexposure prophylaxis with antivirals has also shown to be effective, but should be reserved for patients who are at very high risk for influenza-related complications who cannot otherwise be protected during times of a high risk of exposure.

 Residents of nursing homes or long-term facilities are at a high risk of developing influenza related complications and may experience severe and fatal illness during an influenza outbreak. It is recommended by the CDC that all nursing home residents and healthcare personnel be vaccinated as soon as the influenza vaccine becomes available for that season, and, during an influenza outbreak, all eligible residents in the entire long-term care facility should receive prophylaxis. It is also recommended that prophylaxis within the long-term care facility should be given for at least two weeks and continuing for at least seven days after the last known case was identified. The drugs of choice for prophylaxis in this patient population is oseltamivir or zanamivir, and zanamivir should be used if a oseltamivir-resistant strain in suspected.

 However, researchers showed that amantadine chemoprophylaxis initiated five or more days following an influenza outbreak resulted in longer duration of outbreaks, greater incidence of outbreaks, and higher case-fatality rates in long-term care facilities. This study showed that prophylaxis within the nursing homes or long-term care facilities can be critical for the health and safety of the residents.

 Ease of administration should be considered when making prophylaxis decisions, especially in this population.

Zanamivir can be an effective agent for prophylaxis, but researchers found that 20% of long-term care facility residents found difficulties with the inhalation product and only about 3% of each dose was absorbed in patients who were not able to adequately use the inhaled product. Nausea and vomiting is still associated with oseltamivir in this setting, but it was found to be less common in older patients compared to younger adults.

 Both oseltamivir and zanamivir can be effective agents when used prophylactically, but it is imperative that all patient factors be considered when making treatment decisions.

Overall, antivirals have many uses during the influenza season and beyond. Not only are there a variety of products available to treat the flu, there are also options to use these agents as prophylaxis to prevent an outbreak in various populations. In addition, these agents have been shown to decrease the severity of flu symptoms and hospital stays, even if the virus is caught late and treatment is initiated outside of the ideal window. There are three agents available to combat the flu, and they have proved to be life saving this year in many different venues of use.

Influenza Antiviral Medications: Summary for Clinicians. Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases (NCIRD): January 9, 2018. 

https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm

Njoku, JC. Influenza. Pharmacotherapy: A Pathophysiologic Approach, 10e Eds. Joseph T. DiPiro, et al. New York, NY: McGraw-Hill, , 

http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861§ionid=146071550

Louie JK, Yang S, Acosta M, Yen C, Samuel MC, et al. (2012) Treatment With Neuraminidase Inhibitors for Critically Ill Patients With Influenza A (H1N1)pdm09, 

Coffin SE ,Leckerman K, Keren R, et. al. (2011). Oseltamivir Shortens Hospital Stays of Critically Ill Children Hospitalized with Seasonal Influenza: A Retrospective Cohort Study. 

http://doi.org/10.1097/INF.0b013e318232ede9

Tuna N, Karabay O, YahyaoÄŸlu, M (2012). Comparison of efficacy and safety of oseltamivir and zanamivir in pandemic influenza treatment. 

https://www.goodrx.com/tamiflu?drug-name=tamiflu

Opening and mixing tamiflu capsules with liquids. US Department of health and human services: centers for disease control and prevention. 

https://www.cdc.gov/h1n1flu/antivirals/09_208940-A_JILES_Tamiflu_InstrSHEET5_WEB.pdf

Weekly U.S. Influenza Surveillance Report. Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases (NCIRD): February 9, 2018. 

Lina B, Boucher C, Osterhaus A, et. al. (2018). Five years of monitoring for the emergence of oseltamivir resistance in patients with influenza A infections in the Influenza Resistance Information Study.

https://www.ncbi.nlm.nih.gov/pubmed/29265727

Jackson RJ, Cooper KL, Tappenden P, et al. Oseltamivir, zanamivir, and amantadine in the prevention of influenza: A systematic review. 

Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities. Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases (NCIRD): March 28, 2017. 

https://www.cdc.gov/flu/professionals/infectioncontrol/ltc-facility-guidance.htm

 Rubin MS, Nivin B, Ackelsberg J. Effect of timing of amantadine chemoprophylaxis on severity of outbreaks of influenza a in adultlong-term care facilities. 

McGeer A, Sitar DS, Tamblyn SE, et al. Use of antiviral prophylaxis in influenza outbreaks in long term care facilities. 

With this year's strain of influenza gaining so much attention, due to its severity, it is important to understand and choose the best treatment option for any patient.