Declines in cognitive function often occur as adults age and can include memory loss.

 Pharmacists can support the brain health and well-being of older adults in the community setting by understanding age-related cognitive function changes and the dietary supplement options available that can promote healthy brain activity.

 is an OTC brain health supplement clinically shown to be safe and to improve memory and support brain function, such as mild memory loss associated with aging.

Apoaequorin, the Unique Ingredient of Prevagen

Neuronal calcium dysregulation is an established contributor to age-related deficits in learning and memory.

 Apoaequorin is a calcium-binding protein found in luminescent jellyfish (

) and is the unique ingredient of Prevagen. Calcium-binding proteins play an important role in the regulation of intracellular calcium homeostasis integral to neuronal cell function.

 It has been proposed that age-related declines in the expression and concentration of intracellular calcium-binding proteins and their altered distribution throughout the central nervous system may contribute to cognitive decline, as well as enhance susceptibility to neuronal cell damage and death.

Given the role of calcium-binding proteins in the pathophysiology of age-related neurocognitive decline, there may be benefits to the administration of the exogenous form of apoaequorin.

Results from several animal studies support the hypothesis that apoaequorin treatment may be neuroprotective.

 In a study of aged canines, apoaequorin treatment improved memory- and performance-related behaviors, including measures of learning and attention.

 As apoaequorin treatment modified markers of cognitive decline in preclinical studies, Prevagen was further investigated in an in-human clinical trial.

The Madison Memory Study was a randomized, double-blinded, placebo-controlled trial that investigated the effects of Prevagen on cognitive performance in adults with self-reported memory and cognitive concerns.

 The trial enrolled a generally healthy population of 218 adults aged 40 to 91 years, without a history of neurologic or cognitive illness. Participants were randomized (3:2) to receive one 10-mg capsule of Prevagen or placebo daily for 90 days. A total of 211 participants completed the study.

At baseline, participants were stratified into distinct cohorts based on their level of self-reported cognitive impairment as measured via the Ascertain Dementia 8 (AD8) screening tool. The AD8 is a validated, interview-based, 8-question screening tool that differentiates those with cognitive changes attributed to normal aging from those with early signs of dementia.

 An AD8 score of 2 was used as a cutoff value to identify the populations with normal cognitive function (AD8 0-1) and very mildly impaired cognitive function (AD8 0-2) from those with higher levels of impairment (AD8 3-8). Because Prevagen is a dietary supplement intended for healthy, nondemented individuals, results from participants in the AD8 0-1 and AD8 0-2 cohorts are most relevant to the efficacy of the product.

To assess the effect of Prevagen compared with placebo, changes in cognitive function were quantitively assessed at baseline and at 8-, 30-, and 90-day time points using tests from the Cogstate Research battery, a widely used and validated tool to assess verbal and visual learning, memory and working memory, executive functioning, and psychomotor function and attention via
computer-based maze learning and recall tasks.

 Although no statistically significant results were observed over the entire study population, the Prevagen-treated participants in the AD8 0-1 and AD8 0-2 cohorts achieved statistically significant improvement in the Cogstate mean test scores measuring aspects of cognitive function compared with the placebo treatment group (

As a result of the findings, it was concluded that dietary supplementation with Prevagen enhances cognitive function among healthy adults with normal cognitive aging or very mild impairment.

The unique ingredient in Prevagen, apoaequorin, has undergone extensive safety testing for toxicity and allergenicity. In human clinical trials, apoaequorin was well tolerated for up to 90 days.

 In animal safety studies, apoaequorin was found to be safely consumed in doses much higher than the recommended dosage (4000 to 16,000 times the recommended daily amount of Prevagen Regular Strength) and without adverse effects when taken orally.

 Apoequorin is not a known allergen and is not likely to be cross-reactive with any known allergens. In a separate safety study, apoaequorin exhibited a digestibility profile similar to those of other nonallergic dietary proteins, without any significant risk of allergic reactivity when ingested orally.

 OTC national survey, Prevagen is the number-1 pharmacist-recommended memory support brand among pharmacists who recommend memory support products. If asked for a recommendation, pharmacists can provide information about Prevagen’s safety, efficacy, and clinically tested ingredient. In a clinical trial, a subgroup of adults with mild, age-related cognitive impairment taking just 1 Prevagen a day, over 90 days, achieved improvements in measurements related to memory.

As with any new dietary supplement, pharmacists can be a helpful resource for information and can answer questions regarding the use of Prevagen. Prevagen is available in Regular Strength (10 mg) and Extra Strength (20 mg) dosages as a once-daily oral capsule or chewable tablet. Note that it is recommended to take Prevagen for 90 days to fully gauge its effectiveness. In addition to recommending Prevagen, pharmacists can provide education on lifestyle choices that can promote cognitive health, such as regular physical and social activity.

These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.

Harada CN, Natelson Love MC, Triebel KL. Normal cognitive aging. 

. 2013;29(4):737-752. doi:10.1016/j.cger.2013.07.002

Nikoletopoulou V, Tavernarakis N. Calcium homeostasis in aging neurons. 

. 2012;3:200. doi:10.3389/fgene.2012.00200

Calvo-Rodriguez M, Hernando-Pérez E, López-Vázquez S, et al. Remodeling of intracellular Ca2+ homeostasis in rat hippocampal neurons aged in vitro.

. 2020;21(4):1549. doi:10.3390/ijms21041549

Fairless R, Williams SK, Diem R. Calcium-binding proteins as determinants of central nervous system neuronal vulnerability to disease. 

. 2019;20(9):2146. doi:10.3390/ijms20092146

Detert JA, Adams EL, Lescher JD, et al. Pretreatment with apoaequorin protects hippocampal CA1 neurons from oxygen-glucose deprivation. 

. 2013;8(11):e79002. doi:10.1371/journal.pone.0079002

Adams EL, Ehlers VL, Michels SC, et al. Orally administered apoaequorin protects neurons from oxygen-glucose deprivation. Presented at: Society for Neuroscience Annual Meeting; November 9-13, 2013; San Diego, CA. Accessed October 4, 2021.

Ehlers VL, Adams EL, Fettinger NB, et al. The neurotherapeutic effects of the calcium binding protein apoaequorin. Poster presented at: Society for Neuroscience Annual Meeting; November 15-19, 2014; Washington, DC. Accessed October 4, 2021.

Hochstetter EL, Detert JA, Lescher JD, Moyer JR Jr. Apoaequorin protects neurons from ischemia and alters cytokine mRNA levels in rat hippocampus. Poster presented at: Society for Neuroscience Annual Meeting; October 13-17, 2012; New Orleans, LA. Accessed October 4, 2021.

Smies CW, Moyer JR. Neuroprotective effects of apoaequorin on ischemic stroke. Poster presented at: Society for Neuroscience Annual Meeting; October 19-23, 2019; Chicago, IL. Accessed October 4, 2021.

Milgram NW, Landsberg G, Merrick D, Underwood MY. A novel mechanism for cognitive enhancement in aged dogs with the use of a calcium-buffering protein. 

. 2015;10(3):217-222. doi:10.1016/j.jveb.2015.02.003

Moran DL, Underwood MY, Gabourie TA, Lerner KC. Effects of a supplement containing apoaequorin on verbal learning in older adults in the community. 

Lerner KC. Clinical Trial Synopsis QB-0011: Madison Memory Study: a randomized, double-blinded, placebo-controlled trial of apoaequorin in community-dwelling, older adults. Published August 1, 2016. Accessed October 4, 2021. 

Galvin JE, Roe CM, Powlishta KK, et al. The AD8: a brief informant interview to detect dementia. 

. 2005;65(4):559-564. doi:10.1212/01.wnl.0000172958.95282.2a

Moran DL, Marone PA, Bauter MR, Soni MG. Safety assessment of apoaequorin, a protein preparation: subchronic toxicity study in rats. 

. 2013;57:1-10. doi:10.1016/j.fct.2013.02.047

Bauter MR, Mendes O. Subchronic toxicity of lyophilized apoaequorin protein powder in Sprague-Dawley rats.

. 2018;2:1-15. doi:10.1177/2397847318756905

Moran DL, Tetteh AO, Goodman RE, Underwood MY. Safety assessment of the calcium-binding protein, apoaequorin, expressed by Escherichia coli. 

. 2014;69(2):243-249. doi:10.1016/j.yrtph.2014.04.004

Articles

A Pharmacists' Guide to Recommending Prevagen®

Please see Important Safety Information throughout this article. Please see full Prescribing Information for 

As an integral part of the health care team, pharmacists are well positioned to work with providers and patients along their treatment journey by supporting access to prescribed medications, like the Digihaler

Guidelines set forth by the 2021 Global Initiative for Asthma (GINA) recommend assessing inhaler technique and inhaler use to help guide treatment decision-making by employing an assessment cycle that includes 3 stages: assess, adjust, and review response.

 However, assessing patient inhaler use can be difficult. Information regarding inhaler use is primarily based on patient-reported information and dose counters.

 Self-reporting may not be an accurate measure of use of inhaled therapy (eg, may not capture overuse and underuse of medication).

 There may be errors associated with incorrect timing of inhaler use (eg, missed doses, overuse of inhaler) and poor inhalation techniques.

 Patients may not know their inhaler technique needs improvement and may misperceive their disease severity.

To help guide decision-making, it is important for health care providers to understand key information regarding how patients are using their inhaler, such as inspiratory flow, frequency of inhaler use, and if they are missing doses of their maintenance medication.

Digihaler is the first and only family of breath-actuated digital inhalers with built-in sensors that provide objective data on patient inhaler events.

 These built-in sensors can track how often and how well the inhalers are used, as measured by inspiratory flow. Inhaler use is recorded as an event when the cap is opened or a patient inhales. Data on usage and inspiratory flow can be sent directly to the Digihaler app via Bluetooth

 wireless technology, giving patients the ability to share their inhaler use information with their providers, if desired (

Although connection to the Digihaler app is required for transmission of data, it is not required to deliver medicine from the inhaler. Once connected, the objective data provided, may be used to help inform treatment decisions. There is no evidence the use of Digihaler

 technology leads to improved clinical outcomes, including safety and effectiveness.

When patients or their caregivers come to the pharmacy to pick up their newly prescribed Digihaler inhaler, it is important for pharmacists to dispense as written, as the provider intended, and recognize its ability to capture objective data. Pharmacists can provide an overview of the Digihaler technology and explain its ability to capture objective data. As with any prescription medication, cost may be a concern for some patients

; they may need pharmacists’ help to address financial barriers and provide information to support Digihaler affordability with the Digihaler Savings Program (available to commercial patients regardless of coverage).


During counseling, pharmacists can also give instructions for how to set up their Digihaler device to capture objective data by: 1) downloading the app; 2) setting up a profile; and 3) scanning the inhaler’s QR code (to register the inhaler with the app).

There are 3 product inhalers (with 7 total SKUs) in the Digihaler family. ProAir

-agonist (SABA) inhaler, and the other 2 products are maintenance inhalers. AirDuo

 inhalation powder is a combination inhaled corticosteroid (ICS)/long-acting β

 inhalation powder is a digital ICS monotherapy inhaler.

 The Digihaler family of inhalers do not require washing, shaking, or priming.

INDICATIONS AND IMPORTANT SAFETY INFORMATION FOR 

 Inhalation Powder is indicated inpatients≥4 years of age for the treatment or prevention of bronchospasm with reversible obstructive airway disease and in patients≥4 years of age for the prevention of exercise-induced bronchospasm.

 ProAir Digihaler Inhalation Powder is contraindicated in patients with hypersensitivity to albuterol or patients with a severe hypersensitivity to milk proteins. Rare cases of hypersensitivity reactions, including urticaria, angioedema, and rash have been reported after the use of albuterol sulfate. There have been reports of anaphylactic reactions in patients using inhalation therapies containing lactose

ARMONAIR® DIGIHALER® AND AIRDUO® DIGIHALER®

 (fluticasonepropionate) inhalation powder is indicated for the maintenance treatment of asthma as prophylactic therapy in patients 12 years of age and older.

 ArmonAir Digihaler is not indicated for the relief of acute bronchospasm.

 (fluticasone propionate and salmeterol) inhalation powder is indicated for the treatment of asthma in patients aged 12 years and older. AirDuo Digihaler is only for patients uncontrolled on an inhaled corticosteroid (ICS) or whose disease severity clearly warrants an ICS/Long-acting beta

 AirDuo Digihaler is not indicated for the relief of acute bronchospasm.

 ArmonAir Digihaler and AirDuo Digihaler are contraindicated in:
-Primary treatment of status asthmaticus or other acute episodes of asthma requiring intensive measures
-Patients with known severe hypersensitivity to milk proteins or any ingredients of ArmonAir Digihaler or AirDuo Digihaler

 For providers, access to Digihaler objective data may allow for more personalized conversations during patient visits and help inform data-driven treatment decisions (

Each Digihaler contains a built-in electronic module that detects, records, and stores data on inhaler events, including peak inspiratory flow rate (L/min), for transmission to the mobile app, where inhaler events are categorized. Inspiratory flow rates are categorized in the app as good (> 45 L/min), fair (30-45 L/min), low or no inhalation (< 30 L/min), and exhalation or possible air vent block.

 Tracking these inspiratory flow rates over time may help providers 

establish a baseline, access patients’ trends, and help identify if inhaler technique might need improvement.

The Digihaler family of inhalers record objective inhaler use data (inhaler use is recorded as an event when the cap is opened or a patient inhales). Inhaler events can be viewed as daily and monthly reports on the Digihaler app for the connected Digihaler.

If a patient chooses to share this information with their provider, seeing when and how often patients use their SABA inhalers may help providers 

assess if patients’ events are increasing (eg, increased frequency of SABA inhaler use).

 Additionally, data on maintenance inhaler events may help 

assess whether patients are taking their medication as prescribed.

IMPORTANT SAFETY INFORMATION FOR PROAIR®

 ProAir Digihaler can produce paradoxical bronchospasm that may be life-threatening. Discontinue ProAir Digihaler and institute alternative therapy if paradoxical bronchospasm occurs
•

 Need for more doses of ProAir Digihaler than usual may be a marker of acute or chronic deterioration of asthma and requires reevaluation of treatment, such as possible need for anti-inflammatory treatment, e.g., corticosteroids
•

 ProAir Digihaler alone may not be adequate to control asthma in many patients. Early consideration should be given to adding anti-inflammatory agents, e.g., corticosteroids
•

: ProAir Digihaler, like other beta-adrenergic agonists, can produce clinically significant cardiovascular effects in some patients, as measured by heart rate, blood pressure, and/or symptoms. If such effects occur, the drug may need to be discontinued. ProAir Digihaler, like all sympathomimetic amines, should be used with caution in patients with cardiovascular disorders, especially coronary insufficiency, cardiac arrhythmias, and hypertension
•

: Fatalities have been reported in association with excessive use of inhaled sympathomimetic drugs in patients with asthma

IMPORTANT SAFETY INFORMATION FOR ARMONAIR® 

DIGIHALER® AND AIRDUO® DIGIHALER® CONTINUED

Serious Asthma-Related Events – Hospitalizations, Intubations, Death

: Use of a LABA as monotherapy (without an ICS) for asthma is associated with an increased risk of asthma-related death. Available data from controlled clinical trials also suggest that use of LABA as monotherapy increases the risk of asthma-related hospitalization in pediatric and adolescent patients. These findings are considered a class effect of LABA monotherapy. When LABA are used in fixed-dose combination with ICS (such as AirDuo Digihaler), data from large clinical trials do not show a significant increase in the risk of serious asthma-related events (hospitalizations, intubations, death) compared with ICS alone

Deterioration of Disease and Acute Episodes

: AirDuo Digihaler should not be initiated in patients during rapidly deteriorating or potentially life-threatening episodes of asthma. ArmonAir Digihaler and AirDuo Digihaler are not indicated for the relief of acute bronchospasm. An inhaled, short-acting beta

-agonist, not ArmonAir Digihaler or AirDuo Digihaler, should be used to relieve acute symptoms such as shortness of breath 

Pharmacists can provide eligible commercially insured patients with information regarding the Digihaler Savings Program, including full terms and conditions for eligibility restrictions at 

. The program is available to all eligible commercially insured patients, regardless of formulary status, and can be used for the entire Digihaler

 family of inhalers. Eligible commercially insured patients may pay as little as $20 for their prescription with the Digihaler Savings Program. Instructions are available with each card to assist pharmacists when processing the card.

IMPORTANT SAFETY INFORMATION FOR PROAIR® 

 may occur after administration of albuterol sulfate, as demonstrated by rare cases of urticaria, angioedema, rash, bronchospasm, anaphylaxis, and oropharyngeal edema. Hypersensitivity reactions including anaphylaxis, angioedema, pruritus, and rash have been reported with the use of therapies containing lactose, an inactive ingredient in ProAir Digihaler.
•

 ProAir Digihaler, like all sympathomimetic amines, should be used with caution in patients with convulsive disorders, hyperthyroidism, or diabetes mellitus; and in patients who are unusually responsive to sympathomimetic amines.
•

 As with other beta-agonists, ProAir Digihaler may produce significant hypokalemia in some patients. The decrease is usually transient, not requiring supplementation
•

In controlled studies in patients 12 years of age and older, adverse events that occurred in≥1% and >placebo included back pain (2% vs 1%), pain (2% vs <1%), gastroenteritis viral (1% vs <1%), sinus headache (1% vs <1%), and urinary tract infection (1% vs <1%). In controlled studies in patients 4 to 11 years of age, adverse events that occurred in≥ 2% and > placebo included nasopharyngitis (2% vs 1%), oropharyngeal pain (2% vs 1%), and vomiting (3% vs 1%)

IMPORTANT SAFETY INFORMATION FOR ARMONAIR® DIGIHALER® AND AIRDUO® DIGIHALER® CONTINUED

Avoid Excessive Use and Avoid Use with Other Long acting Beta

: AirDuo Digihaler should not be used more often than recommended, at higher doses than recommended, or in conjunction with other medicines containing LABA, as an overdose may result. Clinically significant cardiovascular effects and fatalities have been reported in association with excessive use of inhaled sympathomimetic drugs.
Patients using AirDuo Digihaler should not use another medicine containing a LABA (e.g., salmeterol, formoterol fumarate, arformoterol tartrate, indacaterol) for any reason
•

 has occurred in patients treated with ArmonAir Digihaler or AirDuo Digihaler. Advise patients to rinse the mouth with water without swallowing following inhalation
•

Immunosuppression and Risks of Infections

: Patients who use corticosteroids, such as found in AirDuo Digihaler and ArmonAir Digihaler are at risk for potential worsening of existing tuberculosis; fungal, bacterial, viral, or parasitic infections; or ocular herpes simplex. A more serious or even fatal course of chickenpox or measles may occur in susceptible patients. Use with caution in patients with the above because of the potential for worsening of these infections
•

Transferring Patients from Systemic Corticosteroid Therapy

: Particular care is needed for patients who have been transferred from systemically active corticosteroids to ICS because deaths due to adrenal insufficiency have occurred in patients with asthma during and after transfer from systemic corticosteroids to less systemically available ICS. Taper patients slowly from systemic corticosteroids if transferring to ArmonAir Digihaler or AirDuo Digihaler

Pharmacists have an important opportunity to help patients understand features of the Digihaler app and how to get 

 Pharmacists can ensure that patients understand that the data capture works only if the patient downloads the app and syncs the device.

For patients who may need assistance with connecting their device to the app on their smartphone, pharmacists can walk them through these 3 steps:

 for a summary of information that can be used to help pharmacists prepare for counseling sessions with patients and their caregivers regarding their prescription for a Digihaler product.

Additional resources to support pharmacists during counseling are available from 

IMPORTANT SAFETY INFORMATION FOR PROAIR® DIGIHALER® CONTINUED

 Other short-acting sympathomimetic bronchodilators should not be used concomitantly with ProAir Digihaler
-

: Beta-adrenergic-receptor blocking agents not only block the pulmonary effect of beta-agonists, such as ProAir Digihaler, but may produce severe bronchospasm in asthmatic patients. Therefore, patients with asthma should not normally be treated with beta-blockers
-

: Caution is advised in the coadministration of beta-agonists with non-potassium sparing diuretics (such as loop or thiazide diuretics). Consider monitoring potassium levels
-

 Carefully evaluate the serum digoxin levels in patients whoare currently receiving digoxin and ProAir Digihaler
-

Monoamine Oxidase Inhibitors or Tricyclic Antidepressants

: ProAir Digihaler should be administered with extreme caution to patients being treated with these agents, or within 2 weeks of discontinuation of these agents, because the action of albuterol on the cardiovascular system may be potentiated. Consider alternative therapy

 may occur with high doses of ICS, including fluticasone propionate, or at the recommended dose in susceptible individuals. If such changes occur, discontinue ArmonAir Digihaler or AirDuo Digihaler slowly
•

Drug Interactions with Strong Cytochrome P450 3A4 Inhibitors

: The use of strong cytochrome P450 3A4 (CYP3A4) inhibitors (e.g., ritonavir, ketoconazole) with ArmonAir Digihaler or AirDuo Digihaler is not recommended because increased systemic corticosteroid adverse effects may occur; increased cardiovascular adverse effects may also occur with AirDuo Digihaler
•

Paradoxical Bronchospasm and Upper Airway Symptoms

: Paradoxical bronchospasm may occur. if bronchospasm occurs treat immediately with an inhaled, short-acting bronchodilator discontinue AirDuo Digihaler or ArmonAir Digihaler and institute alternative therapy
•

Hypersensitivity Reactions, Including Anaphylaxis

: Immediate hypersensitivity reactions (e.g., urticaria, angioedema, rash, bronchospasm, hypotension), including anaphylaxis, may occur after administration of ArmonAir Digihaler or AirDuo Digihaler. Discontinue ArmonAir Digihaler or AirDuo Digihaler if such reactions occur
•

Cardiovascular and Central Nervous System Effects

: The salmeterol component of AirDuo Digihaler, can be associated with excessive beta-adrenergic stimulation which could present as the following symptoms: seizures, angina, hypertension or hypotension, tachycardia with rates up to 200 beats/min, arrhythmias, nervousness, headache, tremor, palpitation, nausea, dizziness, fatigue, malaise, and insomnia. Use with caution in patients with cardiac arrhythmias, hypertension, coronary insufficiency. Drug may need to be discontinued in certain patients.
•

: Decreases in BMD have been observed with long-term administration of products containing ICS. Patients with major risk factors for decreased bone mineral content, such as prolonged immobilization, family history of osteoporosis, or chronic use of drugs that can reduce bone mass (e.g., anticonvulsants, oral corticosteroids) should be monitored and treated with established standards of care when using ArmonAir Digihaler or AirDuo Digihaler
•

: ICS may cause a reduction in growth velocity, Patients should be maintained on the lowest dose of inhaled corticosteroid that effectively controls their asthma. Monitor growth of pediatric patients receiving ArmonAir Digihaler and AirDuo Digihaler.
•

: Long-term use of ICS, including fluticasone propionate, a component of ArmonAir Digihaler and AirDuo Digihaler, may increase the risk for cataracts or glaucoma. Regular eye exams should be considered
•

Eosinophilic Conditions and Churg-Strauss Syndrome

: Systemic eosinophilic conditions, such as Churg-Strauss syndrome, may occur when using ArmonAir Digihaler or AirDuo Digihaler. Be alert to eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, and/or neuropathy
•

: Use AirDuo Digihaler with caution in patients with convulsive disorders, thyrotoxicosis, diabetes mellitus, ketoacidosis, and in patients who are unusually responsive to sympathomimetic amines
•

: Beta-adrenergic agonist medicines may produce significant hypokalemia in some patients, possibly through intracellular shunting, which has the potential to produce adverse cardiovascular effects. Decrease in serum potassium are usually transient, not requiring supplementation. Be alert to hypokalemia and hyperglycemia in patients using AirDuo Digihaler
•

Adverse Reactions with ArmonAir Digihaler

: Most common adverse reactions (greater than or equal to 3%) are: upper respiratory tract infection, nasopharyngitis, oral candidiasis, headache, and cough
•

: Most common adverse reactions (greater than or equal to 3%) include nasopharyngitis, oral candidiasis, headache, cough and back pain

Global Initiative for Asthma. GINA Global Strategy for Asthma Management and Prevention, 2021. https://www.ginasthma.org. Updated April 26, 2021. Accessed on May 17, 2021. https://ginasthma.org/wp-content/uploads/2021/04/21_04_26-GINA-COVID-19-and-asthma.pdf

Patel M, Perrin K, Pritchard A, et al. Accuracy of patient self-report as a measure of inhaled asthma medication use. 

Sulaiman I, Seheult J, MacHale E, et al. Irregular and ineffective: a quantitative observational study of the time and technique of inhaler use. 

Sastre J, Fabbri LM, Price D, et al. Insights, attitudes, and perceptions about asthma and its treatment: a multinational survey of patients from Europe and Canada.

 2016;9:13. Published 2016 May 4. doi:10.1186/s40413-016-0105-4

Sanchis J, Gich I, Pedersen S; Aerosol Drug Management Improvement Team (ADMIT). Systematic review of errors in inhaler use: has patient technique improved over time? 

AirDuo Digihaler. Prescribing information. Teva Respiratory, LLC; July 2019. Accessed June 2, 2021. https://www.digihaler.com/globalassets/airduo_digihaler/airduo_digihaler_pi.pdf

ArmonAir Digihaler. Prescribing information. Teva Respiratory, LLC; February 2020. Accessed June 2, 2021. https://www.digihaler.com/globalassets/armonair_digihaler/armonair_digihaler_pi.pdf

ProAir Digihaler. Prescribing information. Teva Respiratory, LLC; September 2020. Accessed June 2, 2021. https://www.digihaler.com/globalassets/proair_digihaler/proair_digihaler_pi.pdf

Khassawneh BY, Al-Ali MK, Alzoubi KH, et al. Handling of inhaler devices in actual pulmonary practice: metered-dose inhaler versus dry powder inhalers. 

Using Digihaler® Technology in the Community Pharmacy in Patients With Asthma

In an effort to increase equitable access to COVID-19 vaccination across the United States, the White House launched the Federal Retail Pharmacy Program for COVID-19 Vaccination in February 2021.

 This program gives eligible individuals the ability to receive COVID-19 vaccinations at more than 40,000 participating pharmacy locations across the nation.

 Most Americans live within 5 miles of a pharmacy, which makes pharmacies readily accessible in diverse communities and positions them as critical players in the federal COVID-19 vaccination strategy.

Americans seeking COVID-19 vaccination may enter the pharmacy with hesitation or questions regarding the available vaccines; therefore, pharmacists can prepare for conversations that can help their community understand the importance of vaccination and support their informed decision to be vaccinated.

PHARMACISTS AS COVID-19 VACCINE ADVOCATES

 for a summary of resources available from the CDC website to support pharmacists in their roles as vaccine advocates.

As of July 2021, 3 COVID-19 vaccines were authorized for use under an Emergency Use Authorization and recommended by the CDC Advisory Committee on Immunization Practices in the United States to prevent COVID-19: Pfizer-BioNTech, Moderna, and Janssen (Johnson & Johnson) COVID-19 vaccines.

Pharmacists have an opportunity to educate the community regarding the risks and benefits of each vaccine, provide information relating to vaccine safety and efficacy, explain the benefits of high vaccination effectiveness, and answer questions about how the vaccines were developed.

 If asked whether vaccines were tested in all populations, pharmacists can explain that the clinical trials recruited a diverse mix of participants. It is important to be specific and provide the percentages of people included in the trials who had underlying health conditions, were from communities of color, and were older adults.

 Education should be offered in plain language and tailored to the individual’s level of health literacy.

As defined by the CDC, vaccine confidence is “the trust that patients, parents, or providers have in recommended vaccines; providers who administer vaccines; and processes and policies that lead to vaccine development, licensure, manufacturing, and recommendations for use.”

 Pharmacists can strengthen confidence by starting conversations about vaccines, providing a strong recommendation, and addressing myths and hesitancy.

Capturing public attention about vaccines is the first step in facilitating conversations with interested individuals. Signage about the availability of COVID-19 vaccines at the pharmacy placed on the building’s exterior can encourage individuals to inquire about more information from the pharmacist.

 Store employees should be encouraged to direct customers to the pharmacy section to discuss questions and concerns about COVID-19 vaccinations.

Pharmacies can encourage vaccination through social media posts that include facts about how the vaccines were developed and answers to commonly asked questions (eg, side effects and immunity).

 This can be a useful way to disseminate COVID-19 vaccine information to individuals who do not frequent a pharmacy and to those who are hesitant about receiving a vaccine.

As another opportunity to engage in conversations about vaccines, pharmacists can identify patients with chronic medical conditions that are associated with high risk for severe COVID-19 (eg, heart conditions, cerebrovascular disease, lung conditions, diabetes mellitus) at prescription pickup and educate them on the importance of vaccination.

Pharmacists can use approaches that will facilitate effective communication, such as listening to each individual’s perspective without making assumptions and responding in an empathetic and nonjudgmental manner. Starting with an open-ended question such as “

What would you think about receiving a COVID-19 vaccination today?

” can be effective in initiating a conversation. Messages should be clear, complete, and accurate to build trust in the vaccines and those who administer them.

Hearing testimonials can be encouraging to those considering vaccination. Pharmacists can put individuals at ease by openly sharing their own personal experiences with vaccination, including that they received the vaccine, why they chose to get vaccinated, and why they encourage others to do the same.

Pharmacists can emphasize how important it was to them to protect themselves and their families, coworkers, and communities. It is important that pharmacists convey a willingness to continue discussions and answer additional questions.

Pharmacists can make a strong, effective recommendation by saying, “

I strongly recommend you get vaccinated. The vaccine will help protect you from getting COVID-19. If you still get infected after you get vaccinated, the vaccine may prevent serious illness. By getting vaccinated, you can also help protect people around you.

” Recommendations can be tailored to the individual’s unique circumstance (eg, medical vulnerability, exposure risk at home or work).

Addressing misinformation and vaccine hesitancy

By sharing credible and accurate information, pharmacists can proactively address and mitigate the spread and harm of misinformation regarding COVID-19 vaccination. Key facts to share include that COVID-19 vaccines cannot give people COVID-19, people who have already gotten sick with COVID-19 may still benefit from getting vaccinated, and getting vaccinated can help prevent getting sick with COVID-19. Pharmacists can also proactively explain side effects and provide information on the vaccines' safety and efficacy.

In response to the COVID-19 pandemic, viral vector-based and messenger RNA (mRNA)–based vaccines have been developed.

 Pharmacists can prepare to answer questions regarding the differences in vaccine types available. As an important message to convey, pharmacists should note that neither type of vaccine interacts with or integrates into a person’s DNA in any way.

A viral vector-based vaccine uses a modified virus as a vector to deliver genetic material into human cells. Once inside human cells, the cell’s machinery uses the gene to produce/express a harmless piece of the virus, or antigen, and display it on cell surfaces. The presence of the antigen triggers an immune response in which antibodies are produced to help prepare the body to respond when it encounters the real infection in the future, for example,
COVID-19.

Viral vector-based vaccines are also being studied as potential alternatives to common seasonal influenza vaccines. Due to the continuous antigenic drift of seasonal viruses, influenza vaccines need to be updated nearly each year to effectively target the specific strains in circulation. In addition, seasonal influenza vaccines do not protect against antigenically specific pandemic influenza viruses that typically have viral subtypes for which people do not have corresponding antibodies. Viral vector vaccines for influenza may address these challenges.

mRNA-based vaccines have been studied for decades. They can be developed in a laboratory using readily available materials and produced relatively quickly in larger amounts than for traditional vaccines.

mRNA is a single-stranded copy of DNA that travels from a cell’s nucleus to ribosomes in the cytoplasm, where it is translated into proteins. A vaccine based on mRNA technology does not use inactivated virus, attenuated virus, or any other kind of virus but instead includes a sequence of nucleoside-modified mRNA encoding viral antigens. This technology helps the body to produce the viral antigen itself, against which the body mounts an immune response.

 This allows the body to generate an antibody response, and to retain the information in memory immune cells with the goal of attacking the virus, for example the COVID-19 virus, if the vaccinated individual is exposed.

Advancements in mRNA technology can offer a different approach to personalized medicine and help innovate the development of future vaccines.

As COVID-19 vaccination providers, pharmacists are well positioned to address vaccine hesitancy, improve immunization rates, and build vaccine confidence in diverse communities. The resources provided in the 

 can be used to help pharmacists initiate conversations about COVID-19 vaccination and prepare a strong, effective recommendation.

Fact sheet: President Biden announces increased vaccine supply, initial launch of the federal retail pharmacy program, and expansion of FEMA reimbursement to states. Statements and releases. The White House. Published February 2, 2021. Accessed June 7, 2021.

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