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Ruth Carrico, PhD, DNP, APRN, discussed declining influenza and COVID-19 vaccination rates and how it has created a looming threat for public health officials.

Q&A: Understanding the Cause of Declining Vaccination Rates Amidst Flu Season

The FDA has mandated that companies participating in the Opioid Analgesic Risk Evaluation and Mitigation Strategy program provide pre-paid mail-back envelopes for unused or expired opioid medications.

FDA Expands OA REMS, Mandates Mail-Back Envelopes for Opioid Analgesics

Ruth Carrico, PhD, DNP, APRN, discussed the importance of annual vaccination and overall health awareness and literacy during the winter flu season.

Q&A: The Importance of Vaccine Literacy, Uptake During Flu Season

In case you missed it, this week we had stories about PBMs' threat to independent pharmacies, the risks and benefits of AI in pharmacy, pharmacists' role in hormonal prescribing, and more.

Weekend ICYMI: October 28 to November 1

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Hospital readmissions constitute one of the most significant problems in healthcare. Medication therapy management is one way to reduce the problem.

MTM cuts hospital readmissions

journal explores issues within pharmacy, from the impact advocacy can have in community pharmacies to staffing shortages across multiple sectors within pharmacy. This month’s issue also explored the importance of disease awareness months and how they are opportunities to maximize valued care. Check out a preview of this month’s issue here.

download the PDF of the Total Pharmacy August 2024 issue here

Don’t get left behind: Sign up today for our 

 and get the latest drug information, industry trends, and patient care tips delivered straight to your inbox.

See what’s trending in pharmacy with a preview of the Total Pharmacy August issue.

Total Pharmacy

In This Issue: Total Pharmacy August 2024

Combining sodium glucose co-transporter 2 inhibitors (SGLT2is) with glucagon-like peptide-1 receptor agonists (GLP-1RAs) may offer additional protection against cardiovascular and kidney disease in patients with type 2 diabetes (T2D), according to the results of a new meta-analysis published in 

 and presented at the 61st European Renal Association Congress in Stockholm, Sweden.

Separately, SGLT2is and GLP-1RAs have demonstrated cardiovascular benefits. However, little clinical literature has focused on outcomes associated with using the medicines together. Due to the growing prevalence of GLP-1RAs in the 

 and obesity landscape, accelerated by an increasing number of indications for the agent class, this is a crucial area for further study.

The SGLT2 Inhibitor Meta-analysis Cardio-Renal Trialists’ Consortium (SMART-C) is the largest assessment of outcomes for the combined therapeutic use of SGLT2is and GLP-1RAs. The study gathered data from 12 large-scale, placebo-controlled trials of SGLT2is involving 73,238 patients with diabetes. Of these, 3065 were already receiving GLP-1RAs.

Overall, SGLT2is lowered the risk of major adverse cardiovascular events by 11% and hospitalization for heart failure or cardiovascular death by 23% compared to placebo. Notably, this benefit was seen regardless of whether patients were also taking GLP-1RAs.

When used together with GLP-1RAs, SGLT2is reduced the risk of chronic kidney disease progression by 33% and slowed the annual loss of kidney function by nearly 60%.

The study found no additional safety concerns when SGLT2is were used in combination with GLP-1RAs.

Study Reveals Robust Benefits of Semaglutide in Protecting Against Kidney, CV Events in Patients With T2D

Current meta-analysis results build off positive results of the landmark FLOW trial (

). Published earlier in May, results of the international, double-blind, randomized, placebo-controlled phase 3 trial spotlighted semaglutide’s effectiveness in lowering the risk of kidney failure, decelerating worsening kidney function, and protecting against the risk of cardiovascular events and death, in patients with T2D.

“SGLT2 inhibitors have clear protective effects against heart failure and chronic kidney disease, while GLP-1 receptor agonists can reduce the risk of heart attack, stroke, and also kidney disease—as recently demonstrated in the landmark FLOW trial,” said Brendon Neuen, lead author, clinical associate professor, senior research fellow at The George Institute for Global Health, and director of kidney trials at Sydney’s Royal North Shore Hospital, in a news release.

 “Our findings support using this combination to further improve outcomes in patients with type 2 diabetes who meet guideline recommendations for both therapies.”

Elevated glucose from diabetes can damage blood vessels in the heart and kidneys, increasing the risk of 

 and kidney disease. In fact, diabetes is the most common cause of chronic kidney disease.

Moreover, estimates predicting that T2D prevalence will more than double in the next 30 years, surpassing 1 billion global cases by 2050, further strengthen the need for research into diabetes care.

 According to Neuen in an interview with 

 conducted over email, the current study offers valuable insights for developing global treatment strategies for the condition.

"These findings, which represent the largest and most comprehensive evaluation of the combined use of SGLT2i and GLP-1RA, provides the clearest evidence yet that combined use of both medicines can further reduce cardiovascular and kidney disease," said Neuen. "We anticipate that these findings will inform how people with diabetes are treated worldwide, including influencing major clinical practice guidelines.

Although current results suggest that using SGLT2is and GLP-1RAs in tandem may offer robust protection against cardiovascular and kidney disease, further research is needed to fully understand the long-term effects of the combination therapy.

Pharmacy practice is always changing. Stay ahead of the curve: Sign up for our 

 and get the latest drug information, industry trends, and patient care tips, straight to your inbox.

1. Apperloo E, Neuen BL et al. Efficacy and safety of sodium glucose co-transporter 2 inhibitors with and without glucagon-like peptide-1 receptor agonists: A SMART-C collaborative meta-analysis of randomised controlled trials. 

. 2024. doi: 10.1016/S2213-8587(24)00183-9

2. Massaro L. Study reveals robust benefits of semaglutide in protecting against kidney, CV events in patients with T2D. 

https://www.drugtopics.com/view/study-reveals-robust-benefits-of-semaglutide-in-protecting-against-kidney-cv-events-in-patients-with-t2d

3. Combining popular diabetes drugs offers complementary heart and kidney benefits. News release. The George Institute for Global Health. July 9, 2024. Accessed July 10, 2024. 

https://www.georgeinstitute.org/media-releases/combining-popular-diabetes-drugs-offers-complementary-heart-and-kidney-benefits

4. Mayo Clinic Staff. Chronic kidney disease. Fact sheet. Accessed July 8, 2024. 

https://www.mayoclinic.org/diseases-conditions/chronic-kidney-disease/symptoms-causes/syc-20354521

5. Klein HE. Diabetes prevalence expected to double globally by 2050. 

https://www.ajmc.com/view/diabetes-prevalence-expected-to-double-globally-by-2050

When used together, sodium glucose co-transporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) were able to lower the risk of major adverse cardiovascular events and kidney disease by 11% and 33%, respectively.

Clinical

SGLT2i, GLP-1RA Combination Therapy Offers Robust Protection Against Cardiovascular, Kidney Disease

We know the prescription drug supply chain is complex, shaping medication pricing in complicated ways. As prescription costs continue to rise, and insurance coverage fluctuates, cash-pay prescriptions have emerged as a viable option for many people seeking affordable medication.

Most prescriptions are available as generics. By offering these at wholesale prices plus a slight markup, cash pricing circumvents insurance complexities and offers competitive rates.

The trend has significant implications for both patients and pharmacies, so let’s explore the benefits and the strategies available to independent pharmacies for effectively managing cash pricing.

Understanding Trends in Cash-Pay Prescriptions

Cash-pay prescriptions refer to medications purchased directly by patients without the involvement of insurance coverage. It’s not difficult to understand why this payment method is gaining traction:

With increasing out-of-pocket expenses and high deductibles, many patients are seeking ways to mitigate the financial burden of prescription medications. Cash-pay prescriptions can offer substantial savings, especially for generic medications, compared to insurance copays or deductibles.

Despite efforts to expand healthcare coverage, a significant portion of the population remains uninsured or underinsured, leading them to opt for cash payments for their prescriptions.

Cash-pay prescriptions allow patients to choose where to fill their prescriptions, providing greater flexibility in selecting pharmacies based on convenience and pricing. Without the need to navigate insurance bureaucracy or wait for pre-authorization, patients can obtain their medications more quickly and easily through cash-pay options.

The proliferation of price comparison tools and online pharmacies has empowered consumers to seek out the best deals for their medications, often leading them to cash-pay options. Cash pricing provides clarity regarding the actual cost of medications, eliminating the confusion often associated with insurance copays, deductibles, and formularies.

It’s important to note that cash-pay prescriptions may not be feasible for individuals with chronic conditions requiring expensive medications, as the out-of-pocket costs can become higher than insurance copays.

Cash Pricing Strategies for Independent Pharmacies

As the demand for cash-pay prescriptions grows, pharmacies face an increasing need for accurate, up-to-date, competitive cash pricing. To effectively manage this new demand within an already heavy workload, independent pharmacies should consider leveraging new technology.

, some of which use AI to suggest pricing at the point of adjudication. These solutions can lessen the burden of keeping complex pricing tables updated to market conditions, and they often provide revenue uplift potential compared to a store’s current pricing.

When selecting an automated cash-pricing program, pharmacies should consider these key factors:

: Look for a program that allows customization to tailor pricing strategies based on factors such as location, demand fluctuations, and competitive landscape. The ability to adjust pricing parameters according to specific business goals and market conditions is essential for optimizing profitability.

: Choose a program that seamlessly integrates with existing pharmacy management systems to ensure smooth implementation and workflow efficiency. Integration capabilities enable real-time data synchronization, minimizing manual intervention and streamlining pricing updates.

: A robust algorithmic framework that incorporates varied data, advanced analytics, and machine learning techniques enhances pricing precision and effectiveness.

: Look for a solution that enables you to see the numbers: dashboards to visualize impact/ROI, multi-location reporting, a tool to check prices in advance, and full pricing visibility across locations.

: Assess the program’s ability to accommodate multi-location operations and any future growth and expansion. A scalable solution can adapt to evolving business needs, accommodate increased transaction volumes, and support many locations without compromising performance or reliability.

: Seek a provider that offers comprehensive support services, including training, technical assistance, and ongoing maintenance. Access to knowledgeable support staff and resources facilitates successful program adoption and troubleshooting, ensuring optimal usage and maximizing return on investment.

Cheek and Scott Pharmacy of Florida has found the RxCash+ program 

 for their pharmacy’s cash pricing. Pharmacy owner Joey Chamberlain sat down to share his experience on a recent 

As the landscape of prescription medication pricing continues to evolve amidst rising healthcare costs and shifting insurance coverage, cash-pay prescriptions are likely here to stay. Automated pricing programs allow independent pharmacies to navigate this new terrain with agility and precision.

Optimizing cash pricing ensures their competitiveness and enhances patient satisfaction – proving yet again that independent pharmacies remain resilient in the face of change, serving their communities with excellence and affordability.

Explore what to look for in a solution to effectively manage cash pricing.

Navigating Cash-Pay Prescriptions at NCPA 2024: A Guide for Pharmacies 

Leveraging US Prescription Market Insights to Drive Pharmacy Innovation

 Solutions Summit, held virtually on October 19, Scott Biggs, Director of Supplier Services at IQVIA, discussed various pharmacy trends including the US Use of Medicine Report, retail pharmacy performance, booming medications like GLP-1s, and much more. Keeping their hand on the pulse of pharmacy, the team at IQVIA and InterLink AI put together this presentation to also help independent pharmacists stay ahead of the curve.

“We know that there are a lot of challenges out there in this industry,” said Biggs. “In the end, all these challenges that we’re facing impact the patients.” From drug shortages and issues surrounding biosimilars to DSCSA stabilization and DIR fees, everyday patients may not understand the common challenges pharmacies face. Furthermore, patients don’t understand how pharmacy challenges—when they’re not addressed—fall onto them and ultimately impact their overall health outcomes.

Every Spring, IQVIA presents the US Health Services Utilization Index. Biggs touched on his company’s resource and how it helps pharmacists understand the prescriptions they fill in the pharmacy to a fuller capacity. He used the US Health Services Utilization Index to dive deep into trends within pharmacy, from vaccine uptake to GLP-1 medications.

Check out Biggs’ presentation titled “Leveraging US Prescription Market Insights to Drive Pharmacy Innovation” from the Fall 2024 

 Solutions Summit. Learn more about pharmacy trends, how to stay more on top of them, and how data and technology can translate to more revenue at the pharmacy counter.

Total Pharmacy Solutions Summit Fall 2024: Innovating with Cutting-Edge Technology

Scott Biggs, Director of Supplier Services at IQVIA, discussed pharmacy trends within the industry and how pharmacists can stay ahead of them.

How Participating in Pharma-Sponsored Programs Can Benefit Your Pharmacy

At the Fall 2024 Total Pharmacy Solutions Summit, held virtually on October 19, A.J. Lipka, Business Development Lead of Network Growth at Outcomes, led a discussion titled “How Participating in Pharma-Sponsored Programs Can Benefit Your Pharmacy.” In order to drive medication adherence and keep their patients informed regarding their respective complications, Lipka and his Outcomes team believe programs to keep pharmacists educated and informed regarding medications is key to the delivery of valued care.

“These are programs that you can run in your pharmacy that are specifically designed to drive adherence or awareness to patients of your pharmacy. They run at no cost to you as they are sponsored by the pharma manufacturers,” said Lipka when introducing the pharma-sponsored programs that Outcomes offers to all pharmacists.

He opened up his presentation by offering attendees a snapshot of the health care industry. The ongoing shortage of physicians, Lipka said, is expected to reach 120,000 by 2030. Furthermore, 38% of patients said their physicians don’t listen to their patients’ concerns and 35% said they don’t get enough time with their physicians during medical visits.

As a way of reestablishing the patient-provider relationship, navigating shorter attention spans spurred on by technology, and much more, Outcomes’ pharma-sponsored programs are designed to address an ever-evolving health care—and more specifically, pharmacy—landscape. Check out Lipka’s presentation and learn about how you can go above and beyond as a pharmacist.

A.J. Lipka, Business Development Lead of Network Growth at Outcomes, discussed the impact of pharmacy-sponsored programming.

Even outside of respiratory virus season, vaccination is an important tool to decrease rates of vaccine-preventable diseases. In part 2 of his immunization presentation, David Ha, PharmD, BCIDP, infectious diseases manager at Stanford Health Care, presented at the National Community Pharmacists Association 2024 Annual Meeting and Expo, reviewed the latest CDC Advisory Committee on Immunization Practices (ACIP) updates on vaccines for meningococcal disease, human papillomavirus, and tetanus, diphtheria, and pertussis, among others.

According to data from the CDC, 2023 had the highest rate of cases of 

 in adults since 2014, man of which were driven by bacterial strains that compose serogroup Y. In adolescents, meningococcal disease cases associated with serogroups ACWY have decreased due to routine vaccination, but cases due to serogroup B remain similar—and college students are at the highest risk for serogroup B meningococcal disease.

In October 2023, a pentavalent meningococcal vaccine targeting serogroups ABCW and Y (Penbraya) was approved by the FDA for use in individuals aged 10 to 25 years. Other meningococcal vaccines are available as well: a quadrivalent vaccine targeting serogroups ACWY (Menveo and MedQuadfi), and a vaccine targeting serogroup B (Bexsero and Trumenba).

“One of the unfortunate challenges with meningococcal B vaccination is, this vaccine—as opposed to the quadrivalent [vaccine]—is not quite as immunogenic,” Ha said. “You get protection for maybe 2 years or so after vaccination, so it really is ideal to time that second dose as close as possible to when [patients] are matriculating into college.”

“I would highly recommend checking your local college websites; in my home state, for example, all state schools require Men B vaccination,” Ha said. State public health websites should also provide this information. “These are great resources if you’re trying to push the marketing of Men B vaccination, because it’s really important that we get future students vaccinated—ideally on time—for their matriculation.”

While human papillomavirus (HPV) vaccine recommendations have stayed largely the same, there have been “really great data” around the outcomes of this vaccine.

“[The HPV vaccine] is one of the most effective vaccines that we have to date,” Ha explained. “It is highly immunogenic, especially if you give it at a young age; the earlier you give it, the better.” Clinical outcomes, he added, have been “fantastic.” Looking at data from sequential cohorts of vaccinated patients, “we’re seeing lower and lower and lower rates of vaccine-type HPV, which has led to reduced pre-cancer incidence rates and reduced cervical cancer incidence rates in the United States,” Ha said.

With only one vaccine available—a 9-valent HPV vaccine (Gardasil-9), ACIP recommendations have remained unchanged. Gardasil-9 should be administered in a 2-dose series in adolescents aged 9 to 14 years, with the first dose ideally at age 11 or 12. The second dose should be administered 6 to 12 months later, but if more than 5 months have passed, a third dose should be administered. For those catching up—including adolescents and young adults aged 15 to 26 years, a 3-dose series administered at months 0, 1to 2, and 6 is recommended.

Patient-Level Interventions Can Increase HPV Vaccination Rates in Communities | IDWeek 2024

Although the vaccine is more effective if given earlier, there is an option for adults aged 27 to 45 to catch up. Using shared clinical decision making, a 3-dose series can be considered for adults at high risk—for example, those with new sex partners or those with limited prior sexual exposure. If patients in this population previously received a bivalent or quadrivalent vaccine (Cervarix or Gardasil, respectively, discontinued in 2016 and 2017), the vaccination series may be completed with the 9-valent vaccine. Perhaps most importantly for this age group, prior HPV infection does not preclude these individuals from vaccination.

There are 2 clades of Mpox currently circulation: Clade I, which is responsible for ongoing outbreaks in countries such as the Democratic Republic of Congo, and Clade II, which has continued to circulate at low levels in the US.

“[Mpox] is one of the more under-recognized, and more limited, [vaccines] in terms of access,” Ha said. “it’s a very important vaccine, and maybe only about 25% of patients in the US who are indicated for the vaccine have actually received it.” For pharmacists who care for patient populations where Mpox vaccination would make sense, Ha recommended incorporating routine Mpox vaccination as part of practice.

“I’ve personally seen a couple of cases of Mpox, and it can be quite severe,” Ha added. “I can’t underscore enough for really all of these [diseases]—but for Mpox in particular—the importance of vaccination those who it is indicated for.” This list includes individuals with known exposure to someone diagnosed with mpox; gay, bisexual, or other men who have sex with a partner who has more than 1 sex partner or a new diagnosis of a sexually transmitted infection; individuals who have sex at commercial sex venues or locations where mpox transmission is occurring; or those who have a sex partner with any of the previous risks.

The Smallpox and Monkeypox vaccine, live, non-replicating (Jynneos) is the only vaccine available to vaccinate against Mpox. For Clade II—currently endemic in the US—a 2-dose series of Jynneos protected against both severe disease and hospitalization, with approximately 86% effectiveness with 2 doses and approximately 75% effectiveness with 1 dose. For Clade I, Jynneos is “likely to be effective.”

There has been a massive spike in Dengue virus cases this year, especially in Puerto Rico, American Samoa, the Marshall Islands, the US Virgin Islands, Micronesia, and Palau. “Paired with the fact that our dengue vaccine, [dengue tetravalent vaccine, live; Dengvaxia] has been discontinued—and so the supply that we have access to now is being…distributed on a limited basis to these areas [with transmission],” Ha explained that there is no end in sight for the current 

Dengvaxia was initially approved in May 2019 for children and adolescents aged 9 to 16 years, and recently discontinued by Sanofi Pasteur due to lack of demand. Additionally, Takeda withdrew their company’s FDA application for a dengue vaccine.

A second immunization session focused on updates in meningococcal disease, HPV, and Mpox.

Derek McFerran, PharmD

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