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Our Practice Newsletter : By Pharmacists For Pharmacists, issue 20 Ziemczonek, Adrian; Domanski, Nicole; Lee, Min Joo 2020-11

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2020-11-16, 10:45 AMOur Practice: Issue 20, November 2020Page 1 of 7…nvoke-Our-Practice&utm_term=Our-Practice%3A-Issue-20%2C-NovembIssue 20, November 2020 | View Online CORONAVIRUS (COVID-19) and UBC’s response: Information and FAQs here. FEATURE ARTICLEAddressing Vaccine Hesitancy BY: ADRIAN ZIEMCZONEK, BSC(PHARM), RPH Visit our website | Read past issues of Our Practice 2020-11-16, 10:45 AMOur Practice: Issue 20, November 2020Page 2 of 7…nvoke-Our-Practice&utm_term=Our-Practice%3A-Issue-20%2C-Novemb  Vaccines prevent millions of deaths worldwide every year, and have saved moreCanadian lives than any other medical intervention in the last 50 years.1 Despiteoverwhelming scientific evidence of vaccine benefits, up to 20-30% of Canadianshave wavering or uncertain views on vaccination, which may be a factor in outbreaksof vaccine preventable diseases in Canada.2,3 The World Health Organization defines vaccine hesitancy as the “delay inacceptance or refusal of vaccines despite availability of vaccination services.” Asdepicted in Figure 1, vaccine beliefs and attitudes vary across the spectrum, from fullacceptance to complete refusal of all vaccines. Vaccine hesitant individuals aresomewhere in the middle of this continuum, with attitudes and opinions that canchange over time or vary depending on the vaccine. These individuals should not beconfused with “anti-vaxxers” who are people with strong anti-vaccination convictionsand make up an estimated 5-10% of the population.3 Figure 1: Spectrum of Vaccine Acceptance 2020-11-16, 10:45 AMOur Practice: Issue 20, November 2020Page 3 of 7…nvoke-Our-Practice&utm_term=Our-Practice%3A-Issue-20%2C-Novemb Vaccine hesitant people tend to be misinformed, express reluctance towardvaccines, and often have difficulty articulating specific concerns.4 Their mostcommonly expressed barriers and concerns are related to side effects, fear of thevaccine causing the disease itself, and lack of perceived necessity.5 Our team at the Pharmacists Clinic prioritizes our role as vaccine educators for allpeople, and particularly for those who are vaccine hesitant. Our Approach Below are considerations and strategies we have found helpful in our practice. Leverage our position as a trusted resource. Canadians identify health careproviders (HCPs) as their most trusted source for vaccine information and advice,and direct recommendations from an HCP drive acceptance. 2,6 At our clinic, weensure we are current on vaccine information (including the latest circulatingrumours) and ready to discuss vaccines with patients. Be proactive. We ask all patients about their vaccination status, rather than wait forthem to voluntarily express interest in a vaccine. Screening for vaccination statushas been incorporated into all of our clinical documentation templates, to serve as aroutine reminder for clinicians and students that this is a vital component of apatient’s health history. Have reliable information on hand. We have links at our fingertips (on ourworkstations) so we can print off the latest vaccine recommendations and reliablesources of vaccine information for patients. We used to pre-print information butfound it went out of date and we were wasting paper. We have also developed avaccine assessment algorithm to quickly and confidently identify immunizationopportunities. Ask patients about their beliefs and values. During our first appointment, we askpatients about any preferences, beliefs or values they hold regarding their health ormedications, including vaccinations. Establishing these preferences sets the tone forthe remainder of the appointment and helps tailor our messaging when vaccine2020-11-16, 10:45 AMOur Practice: Issue 20, November 2020Page 4 of 7…nvoke-Our-Practice&utm_term=Our-Practice%3A-Issue-20%2C-Novembhesitancy is expressed. Offer a vaccine consultation. Any patient with questions about vaccines is offereda one-on-one vaccine consultation with a pharmacist. These appointments areintended primarily to have an open discussion and address a patient’s questions andconcerns related to vaccines, not necessarily to administer a vaccine. Make vaccinations easy and convenient for patients. We know that one of themain reasons for vaccine hesitancy is inconvenience in accessing vaccinationservices. We keep a number of publicly funded vaccines on-hand and administerdoses whenever the opportunity presents itself (i.e. following a vaccine consultation). As trusted and accessible HCPs, we are relentless advocates for improved publicawareness and the utilization of vaccines. However, we respect and work withpatients where they are at in terms of beliefs, values and attitudes towards vaccines.Our goal is not just to get vaccines in arms. We also strive to support vaccinehesitant people in shifting their thinking and taking a step toward greater vaccinationacceptance. References1. Immunize BC (2020). Why vaccinate? [online] Available at: [Accessed Oct 1, 2020]2. Dubé E, Bettinger JA, Fisher WA, Naus M, Mahmud SM, Hilderman T. Vaccine acceptance, hesitancy and refusal in Canada:Challenges and potential approaches. Can Commun Dis Rep. 2016;42(12):246-251.3. Dubé E, Laberge C, Guay M, Bramadat P, Roy R, Bettinger J. Vaccine hesitancy: an overview. Hum Vaccin Immunother.2013;9(8):1763-17734. Hagood EA, Mintzer Herlihy S. Addressing heterogeneous parental concerns about vaccination with a multiple-source model: aparent and educator perspective. Hum Vaccin Immunother. 2013;9(8):1790-1794. doi:10.4161/hv.248885. Shen SC, Dubey V. Addressing vaccine hesitancy: Clinical guidance for primary care physicians working with parents. Can FamPhysician. 2019;65(3):175-181.6. Violette R, Pullagura GR. Vaccine hesitancy: Moving practice beyond binary vaccination outcomes in community pharmacy. CanPharm J (Ott). 2019;152(6):391-394. >  CASE STUDYTaking a break from bisphosphonates:Treatment decisions after 10 years of therapyBY: NICOLE DOMANSKI, BSC, PHARMD, RPH, ACPR and MIN JOO LEE, BHSC, ENTRY-TO-PRACTICEPHARMD CANDIDATE, 2021 2020-11-16, 10:45 AMOur Practice: Issue 20, November 2020Page 5 of 7…nvoke-Our-Practice&utm_term=Our-Practice%3A-Issue-20%2C-NovembAn 86-year-old female was referred to the Pharmacists Clinic by her physician forour input on deprescribing her bisphosphonate after 10 years of continuous therapy.She is currently taking alendronate 70mg once weekly for osteoporosis, apixaban5mg po BID for atrial fibrillation, citalopram 10mg daily for depression, calcium500mg daily, and vitamin D 1000IU daily. Her social history is non-contributory. The patient started alendronate in 2010 after falling from standing height andsustaining a wrist fracture. With no previous history of hip or vertebral fracture, shereceived a bone mineral density (BMD) scan, which returned a T-score of -2.3(interpretation: osteopenia). Despite no history of glucocorticoid use or rheumatoidarthritis, her FRAX Fracture Risk Assessment Tool score revealed moderate risk(10-20%) of major osteoporosis-related fracture in the next 10 years and thealendronate was started. Since then, the patient has had no falls or clinical fractures.A repeat T-score done this year was -2.8 (interpretation: osteoporosis). Bisphosphonates are the mainstay of osteoporosis treatment, however the optimalduration of treatment is a matter of controversy. There is a concern that long-termtreatment may increase bone fragility and escalate the risk of two rare but seriousadverse events: osteonecrosis of the jaw (ONJ; 1 case in 100,000 person-years)and atypical femur fracture (AFF; 2 to 78 cases in 100,000 person-years).1,2 2020-11-16, 10:45 AMOur Practice: Issue 20, November 2020Page 6 of 7…nvoke-Our-Practice&utm_term=Our-Practice%3A-Issue-20%2C-NovembThe concept of a “drug holiday”, usually recommended after three to five years oftreatment, may mitigate the risks of long-term exposure.2 However, seeing how thebenefits far outweigh the risks, many patients continuing bisphosphonate therapywithout holiday for up to 10 years.3 Unfortunately, the benefit of continuing treatmentis uncertain since bisphosphonate use has not been studied beyond 10 years.4,5 The Canadian Agency for Drugs and Technologies in Health (CADTH) recentlypublished a report summarizing the evidence on bisphosphonate treatmentduration.5 In the report, only the 2017 National Osteoporosis Guideline Group(NOGG) mentioned treatment beyond 10 years.5 Unfortunately, the NOGGrecommendation was that “There is no evidence to guide decisions beyond 10 yearsof treatment and management options in such patients should be considered on anindividual basis.”5 Various groups have taken this recommendation from NOGG and adapted it basedon clinical consensus. In particular, one UK group suggests a two-year treatmentbreak after 10 years of bisphosphonate therapy to minimize the risk of ONJ andAFF.4 This recommendation is reiterated by other authors, who additionally state thattherapy should be reinstated right away if significant loss of BMD or a fractureoccurs within the two-year treatment break.6 Clear recommendations for continuing bisphosphonates beyond 10 years oftreatment are still lacking. In our case, we recommended that alendronate can bediscontinued given that the patient does not present with typical “high risk” factors(no fractures while on therapy; no oral glucocorticoids). We suggested continuousreassessment of risk factors and repeating a BMD scan in two years. AlthoughFRAX could be repeated as well, this calculator is only validated in treatment-naïvepatients so results in other patients need to interpreted with caution.4 As pharmacists in the care of patients approaching 10 years of bisphosphonatetherapy, we engage in shared decision making with the patient and their health careteam around continuing or stopping therapy. We also optimize calcium and vitamin Dsupplementation, advise on treatment for smoking cessation, identify medicationsassociated with an increased falls risk and investigate therapeutic alternatives tospare patients from long-term glucocorticoid use, all of which impact the risk offractures once bisphosphonate therapy is stopped. The Fracture Risk Assessment Tool (FRAX) can be found here. References1. Ma S, Goh EL, Jin A, et al. Long-term effects of bisphosphonate therapy: perforations, microcracks and mechanical properties.SciRep. 2017;7:43399. Published 2017 Mar 6. doi:10.1038/srep433992020-11-16, 10:45 AMOur Practice: Issue 20, November 2020Page 7 of 7…nvoke-Our-Practice&utm_term=Our-Practice%3A-Issue-20%2C-NovembNoteEach case study has been peer reviewed and qualifies as a non-accredited learning activity (CE-Plus) within theannual professional development requirement for licensure by the College of Pharmacists of British Columbia.Your ResponsibilityThe recommendations in this case are based on the views of our clinicians after careful consideration of the bestavailable evidence and needs of a specific patient. As a health care professional, you will assess each of your casesbased on the patient’s unique circumstances and in consultation with the patient and their care team.If you would like to discuss one of your patients with us please contact the Clinic team.  Images: Justin Lee Ohata, UBC Pharm Sci      This email was sent to you by UBC Faculty of Pharmaceutical Sciences2405 Wesbrook Mall, Vancouver BC V6T 1Z3 | Update your email preferences or unsubscribe here  2. Brown JP, Morin S, Leslie W, et al. Bisphosphonates for treatmentof osteoporosis: expected benefits, potential harms, and drugholidays. Can Fam Physician. 2014;60(4):324-333.3. Ro C, Cooper O. Bisphosphonate drug holiday: choosing appropriate candidates. Curr Osteoporos Rep. 2013;11(1):45-51.doi:10.1007/s11914-012-0129-94. Derbyshire Joint Area Prescribing Committee. Bisphosphonate length of treatment in osteoporosis: Guidance on treatment break. Published January 2014/Updated June 2019. Accessed October 30, 2020.5. Marchand D, Loshak H. Duration of Bisphosphonate Treatment for Patients with Osteoporosis: A Review of Clinical Effectivenessand Guidelines. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; October 4, 2019.6. Diab DL, Watts NB. Bisphosphonate drug holiday: who, when and how long.Ther Adv Musculoskelet Dis. 2013;5(3):107-111. doi:10.1177/1759720X13477714> 


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