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CASE 4: VACCINE NEEDS IN HEART FAILURE A 65-year-old woman is interested in learn- ing more about the pneumococcal vaccine. Her cardiologist men- tioned she should be immunized at her last checkup, but did not explain why this type of vaccine would be indicated for her. She has a significant car- diac history, including a myocardial infarction 2 years ago (which required her to undergo coronary artery bypass graft surgery), heart failure with an ejection fraction of 45%, hyper- tension, and dyslipidemia. According to her pharmacy profile, she takes numerous medications, including antihypertensive, antiplatelet, diuretic, and antilipemic medications. What recommendations or education on the use of the pneumococcal vaccine should the phar- macist offer? ANSWER Streptococcus pneumonia is the bacteria respon- sible for causing pneumococcal disease, an infection caused by contact with infectious respiratory droplets. Individuals at risk for developing disseminated disease if infected with this organism, include those who are immunocompromised, have functional or anatomic asplenia, smoke or have asthma, or have other heart, lung, liver, or kidney diseases. 5 Based on this patient's age, she is eligible to receive the pneumococcal poly- saccharide vaccine (PPSV23), and the pneumococcal conjugate vaccine (PCV13). If she has never received a pneumococcal vaccine, current recommendations from the Advisory Committee on Immunization Practices suggest administering PCV13 first, and PPSV23 6 to 12 months later. 6 Based on the patient's extensive cardiac history, she may have received PPSV23 prior to 65 years of age; encourage her to check with her other health care providers, and in her medical records, to determine if this is the case. If she has already been immunized with 1 dose of PPSV23 prior to 65 years of age, she should receive PCV13 at least 1 year after PPSV23, with a second dose of PPSV23 administered at least 8 weeks after PCV13 and at least 5 years after the first dose of PPSV23. 6 CASE 3: HERBAL SUPPLEMENTS FOR CHOLESTEROL REDUCTION An 84-year-old man would like information on natural options for lowering cholesterol. In a recent senior health publication, he recalls reading about the ben- efits of several natural products that can lower cho- lesterol levels without AEs on liver function, muscle tissue, and the kidneys. He has been taking a "statin" for several years and would like to stop taking it, if an equally effective and safer option is available. He reports having a significant medical history, including atrial fibrillation and osteoporosis, for which he takes a combination of diltiazem and aspirin, along with once-weekly alendronate, respectively. What advice would be reasonable to share with this patient? ANSWER Numerous herbal remedies, vitamins, and dietary supplements have been touted to be effective for low- ering elevated cholesterol levels; these supplements include niacin, beta-glucan and beta-sitosterol, garlic, psyllium, soy, red rice yeast, and omega-3 fatty acids. 3 In many cases, although the use of these agents seems promising for reducing elevated cholesterol levels, evidence is often limited. Therefore, more research is necessary to definitively determine the effectiveness of these options. This patient should be informed that many supplements marketed for a natural approach to lowering cholesterol levels may have AEs and could interact with other medications the patient is taking. Inform the patient that "natural" products are not necessarily safe, especially considering the patient's medical comorbidities and use of concomitant medica- tions. If the patient is determined to use an alternative to statin therapy, encourage him to discuss the matter with his cardiologist before changing his medication regimen on his own. If the patient wants to offset the potential toxicities associated with statin use, supple- mentation with ubiquinone or coenzyme Q10 may reduce the risk of statin-induced myopathy; although clinical trial results regarding this are mixed, and clini- cal data are limited, these supplements are generally inexpensive and well-tolerated. 4 Coenzyme Q10 may enhance the blood pressure–lowering effects of dil- tiazem; if the patient decides to use this supplement, he should be instructed on self-monitoring his blood pressure. 4 GOT AN INTERESTING QUESTION REGARDING OTC MEDICATIONS? Contact the authors at otccasestudies@pharmacy.rutgers.edu and share the details. Your case could be featured in an upcoming column! For references, go to PharmacyTimes.com/ publications/issue. MORE @ PHARMACY TIMES.COM OTC FOCUS CASE STUDIES 28 PharmacyTimes.com December 2015