RSV Vaccines in Older Adults

Special guests Lauren B. Angelo, PharmD, MBA from the Rosalind Franklin University of Medicine and Science and Jean-Venable “Kelly” R. Goode, PharmD, BCPS, FAPhA, FCCP from the Virginia Commonwealth University School of Pharmacy join us to talk about respiratory syncytial virus (RSV) vaccines.

Listen in as they review new RSV vaccine recommendations in adults age 60 years and older.  

You’ll also hear practical advice from panelists on TRC’s Editorial Advisory Board:

• Reid B. Blackwelder, MD, FAAFP, Associate Dean of Graduate and Continuing Medical Education and Professor of Family Medicine at East Tennessee State University
• Stephen Carek, MD, CAQSM, DipABLM, Clinical Assistant Professor of Family Medicine, Prisma Health/USC-SOMG Family Medicine Residency Program at the USC School of Medicine Greenville
• Andrea Darby Stewart, MD, Associate Director, Honor Health Family Medicine Residency Program and Clinical Professor of Family, Community & Occupational Medicine at the University of Arizona College of Medicine - Phoenix
• Anthony A. Donato, Jr., MD, MHPE, Associate Program Director, Tower Health System Internal Medicine Residency Program and Professor of Medicine at the Drexel University College of Medicine

For the purposes of disclosure, Dr. Angelo reports relevant financial relationships [vaccines] with Moderna (honorarium); Pfizer (speakers bureau). Dr. Goode reports relevant financial relationships [vaccines] with Merck, Pfizer, Sanofi, Valneva (honorarium).

The other speakers have nothing to disclose. All relevant financial relationships have been mitigated.

TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist’s Letter or Prescriber’s Letter account and look for the title of this podcast in the list of available CE courses.

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Transcript

Narrator 0:06

Welcome to Medication Talk, the official podcast of TRC Healthcare, Homopharmacist Letter, Prescribers Letter, RX Advanced, and the most trusted clinical resources. On today's episode, we'll listen in as our expert panel reviews new RSV vaccine recommendations in adults aged 60 years and older. Our guests today are Dr. Lauren B. Angelo from the Rosalind Franklin University of Medicine and Science and Dr. Kelly R. Good from the Virginia Commonwealth University School of Pharmacy. You'll also hear practical advice from panelists on TRC's editorial advisory board. Dr. Reed Blackwelder from East Tennessee State University. Dr. Stephen Carrick from the USC School of Medicine Greenville. Dr. Andrea Darby Stewart from the University of Arizona College of Medicine Phoenix. And Dr. Anthony Donato from the Tower Health System. This podcast is an extract from TRC's Emerging Recommendations panel webinar. Each month, experts and frontline providers discuss current medication therapy topics and practical recommendations to include TRC's letter articles. The full webinar originally aired on August 21st, 2023.

CE Narrator 1:12

And now, the CE information.

Narrator 1:17

This podcast offers continuing education credit for pharmacists' physicians and nurses. Please log into your pharmacist letter or prescriber's letter account and look for the title of this podcast in the list of available CE courses. For the purposes of disclosure, Dr. Angelo reports relevant financial relationships by receiving an honorarium from Moderna and participating on the Speaker's Bureau for Pfizer. Dr. Good reports relevant financial relationships by receiving an honorarium from Merck, Pfizer, Sonofi, and Valneva. The other speakers you'll hear have nothing to disclose. All relevant financial relationships have been mitigated. Now, let's join TRC editor, Dr. Jennifer Neiman, and start our discussion.

Jennifer Nieman 2:00

We're talking about this topic now because you're going to get questions about the first vaccines to prevent respiratory synstitial virus in older adults. And I do want to say offhand here, just to start the discussion, that the FDA did also today approve them, just one of them, the Abrezvo brand for use in pregnancy. But tonight's discussion is going to just focus on their use in older adults. And so, Kelly, would you mind getting us started off with some background about what is RSV and its typical symptoms and what is the usual RSV season?

Jean-Venable “Kelly” R. Goode 2:38

Yes, certainly. So RSV is an RNA virus, and there is one serotype of RSV, but it is classified into two strains, A and B. And it's spread through respiratory droplet, just like some of our other respiratory viruses. Usually the clinical presentation is similar to other respiratory, so you have rhinoa, you might have nasal congestion, cough, sneezing, but you can lead to a lower respiratory illness, bronchiolitis, which can cause significant morbidity mortality, especially in infants and older adults. The usual season is October to May, kind of peaking in that December-February time frame. But as Lauren mentioned a little while ago, our sort of viruses and respiratory has changed with COVID-19, right? With masking. So in the seasonal pattern is not the same. We had little to no activity in 2020. And then in our 2021-22 and 2022-23, we saw a much earlier RSV season peaking much, much earlier than that sort of December, February. So that's why this year, when we look at starting to vaccinate with RSV, we're starting as the vaccine becomes available because we're just not sure what that pattern is going to look and continuing to vaccinate through the RSV season because we're not sure what that pattern is going to look like.

Jennifer Nieman 4:04

Okay. Yes. Thank you for that clarification. That's and I'm going to actually get back to some of the dosing in a little bit because that is a question I think that's still a little bit unclear. And one question I also had was so I think a lot of patients are going to be a little wary of possibly getting the recommendation for three vaccines this year. So one of the questions I anticipate they might ask is if most patients have mild symptoms, why do we have RSV vaccines coming out? And who are they going to be, you know, most likely to benefit?

Jean-Venable “Kelly” R. Goode 4:38

Yeah, so even though you can have mild symptoms, it can cause significant morbid mortality that that's very sort of in line with influenza virus. So you know, 2 million symptomatic illnesses per year, 100 over 170,000 hospitalizations, and 14,000 deaths per year. And so when you look at that data in that very old population, which is where we see recommendations for the vaccine, and then the infants, where we're we're getting some movement in that infant space and protection for infants, or where we can have serious disease and mortality. So that's why it's important, and it's sort of this triple um demic with the RSV influenza and COVID all sort of converging. And so you don't really want to get all three, you don't want to get and have that. So I think that it's still important, especially in patients who might be at higher risk, to make sure that they're vaccinated.

Jennifer Nieman 5:33

So you said something very interesting, Kelly, when you mentioned you kind of made a connection with the numbers of flu. If I were to add wording in there that this morbidity and mortality data is similar to many flu seasons, would you consider that accurate? Because I think that would be that would probably resonate with a lot of patients if we were to describe that to them.

Jean-Venable “Kelly” R. Goode 5:55

Yeah, I mean, when you think about flu, I mean, but our flu seasons are are always different, right? We can have a a low of you know 3,000 deaths up to 43,000 deaths per year. So, but it is, you know, pretty similar in line and crosses over what we would might see in a normal normal influence of vaccine season.

Jennifer Nieman 6:15

Okay, that's really that's that's good to know. And you know, Andy, I actually have a question for you. When you've seen patients hospitalized with RSV, can you comment on what the usual clinical course of these patients is and and are they hard to treat?

Anthony A. Donato 6:33

You know, for me they they look a whole lot like the flu. They're setting off patients that have underlying lung disease, and they they look all the world like those patients. So I can't tell you I could even clinically distinguish them from those types of conditions. The sicker they are, the the harder the time they have with it.

Jennifer Nieman 6:52

Okay. And which patients have you seen that are at higher risk of having severe infections from RSV in general?

Anthony A. Donato 6:59

The underlying bad cardiopulmonary disease, more the pulmonary than the cardiac is what I've seen. Now, I for the record, I don't take care of any kids, and I'm sure my family practice colleagues see this much more than I do from that. But for for old people, it's it's almost the same people that get flu, that get sick.

Jennifer Nieman 7:15

Okay. And that is helpful too, to kind of put that parallel out there. Okay. So Kelly, I kind of want to move on about the new vaccines themselves. And so what are the new options? And then what what patients are they approved for?

Jean-Venable “Kelly” R. Goode 7:32

Yeah, so we have two options. One um is an adjuvant vaccine, and one is sort of two strains, and it's a ribsio and a rexy. And so they were FDA approved for adults 60 years and older, and ACIP, and they're both single doses 0.5 mls, one dose, and they were approved by ACIP for individuals 60 years and over under shared clinical decision making. The patients that we just discussed that have that are at higher risk with those chronic morbidities, diabetes, COPD, people in long-term care facilities are very old individuals or people who would sort of fall under that shared clinical decision making. And it's important to understand that pharmacists are healthcare providers that can help patients with that shared clinical decision making.

Jennifer Nieman 8:26

Okay, yes. And I think that's a really good point because I think a lot of this is when you have patients coming in and having three possible vaccines recommended, how can we help them decide this? And so one of the questions I also anticipate coming from a lot of practitioners in general, and that I've gotten throughout writing this article, and this can be either for Kelly or Lauren, whichever you wants to jump in, but do you have a preference one over the other vaccine? And if so, you know, is what what drives that preference if there is one?

Jean-Venable “Kelly” R. Goode 9:01

So I personally don't have a preference. They have very similar efficacy and very similar adverse effect profiles. When you look at the efficacy piece, you want to think about the fact that you know, some of the trials were underpowered for some of our oldest adults, so those 75 and over, and they were really underpowered to show efficacy against our RCB hospitalization. But they both have very similar efficacy, very similar second season profiles. So they studied into the second season with both vaccines and very similar safety profiles with the vaccines. So if you're going to stock a vaccine, one of them, I would choose one, keep one versus having two, and then you won't have the errors that could potentially happen because they are done a little bit, um reconstitute a little bit differently and done differently, which could confuse people if you have the two vaccines.

Jennifer Nieman 9:51

Okay. And so, Lauren, I wondered if you could also then help us comment a little bit. I think it was briefly mentioned just a moment ago, but how effective are these vaccines? And which patients were they studied?

Lauren B. Angelo 10:05

So I do want to comment that this is really early on, um, looking at these vaccines and the data and some of the trials. And I think we're gonna get more information as the seasons unfold over the next couple of years. And Kelly's point, you know, and trying to pick one over the other, we just we're not in a place to do that. You know, there's no comparative data, and again, we don't have a lot of data to begin with. And so what was presented to the FDA, what was presented to ACIP in order to make those recommendations really was looking at individuals 60 years of age and older, and for the most part, getting one dose and then evaluating mostly in season one, who was getting RSV associated lower respiratory tract disease, which again is what we're looking at. We're not looking at are you getting RSV or not? It's what is happening when you get infected and are you getting that lower respiratory tract infection? And Kelly gave some good examples of what those look like in terms of bronchiolitis, pneumonia. And then looking at if you had a lower respiratory tract infection, was it what did you need medical attention as a result of ending up in either the ER or urgent care? But we really don't have data going beyond that and looking at the hospitalization. So I think that's to come. So really just looking at that season one. So you get one dose and how did it fare in season one? Both of them are around about 80 to 85 percent in terms of vaccine efficacy. I think season two data, we had some interim data, it was a little bit too soon, looking at the combo of the seasons, um, erx bees trials, they did have a second dose given 12 months after the first dose, but really not seeing a huge change or benefit by giving that second dose, which sort of lends to the recommendations that we're talking about when we're saying right now we're just gonna give one dose and give it as soon as you have vaccine available.

Jennifer Nieman 11:58

And that brings me to another question that's pretty much related. So the recommendations are they say one dose. And so I've been still bidding getting questions from people that they that ask, is it gonna be one dose annually, or is that still kind of up in the air? Can you comment on that for us, Lauren? Sure.

Lauren B. Angelo 12:18

I I don't think we know. I think right now it's just one dose. We need more data to say does a second dose have value and at what time point would we give that second dose? Again, just looking at some very early on data that was presented, that second dose given 12 months later didn't have really much benefit over just giving one dose. So I think it's a wait and watch and and and see how all this unfolds.

Jennifer Nieman 12:45

Okay. And related to that, let you know, you mentioned that the season goes possibly up until May. But if you have a patient that comes in, say, you know, that late in the season or even later than that, and they have not received the RSV vaccine, would you still offer it to them if it happens to be off-season or would you wait until it's during the next season? Uh vaccinate.

Lauren B. Angelo 13:07

You know, you're saying off-season, Jenny, but we don't even know what off-season is because it's been so uh, you know, kind of erratic. And COVID-19 really disrupted a lot of that. And so the CDC's recommendation, as well as I think ours, is vaccinate as soon as you have available. But if you've got someone later in the spring or even next summer, still vaccinate just because we don't know you know when when the different peaks will occur.

Jennifer Nieman 13:32

Okay, that's good clarification too. So, Andrea, I know that you do a great job educating your patients. And so how in the world do you discuss vaccine efficacy with your patients? For example, how do you make them understand when a vaccine efficacy is 85%? How do you help them understand that so that when you're using that in clinical decision making, it's a useful statistic to them?

Andrea Darby Stewart 13:59

So I, you know, I percentages are hard for patients. If you know we had a number needed to treat to reduce your risk for getting RSV, that would be a lovely number to give to them because it just is, I think it's a little bit more accessible in terms of their numerical processing skills. But I really just try and even take it away from numbers, right? If I can reduce your risk for getting something that's gonna make you, you know, cough for you know four to six weeks and really disrupt your life and potentially reduce your risk for hospitalization or for other bad outcomes, then I that that's kind of the tactic that I'll use. And it really depends on the patient in front of me, how long I've known them, what I know is important to them in terms of their likelihood to accept a vaccine and you know, talking about their ability to infect others, their ability to, you know, continue their normal daily activities, the things that they enjoy are generally ways that I can help people come alongside the need for vaccinations against flu, COVID, RS, and hopefully now RSV.

Jennifer Nieman 15:03

Okay. That's really helpful. And Lauren, I want to step back to you for a second because with the shared decision-making approach, how can we help practitioners kind of have a rule of thumb as to which patients might benefit most from the vaccine?

Lauren B. Angelo 15:19

Sure, I think we have to go back to those high-risk groups. So we know we're we're dealing with folks who are 60 years of age and older, and so whenever someone's in front of you, you already be thinking, okay, RSV vaccine, and then that's when that conversation needs to happen around risk versus benefit. And so looking at those medical conditions that we know increase a person's risk for severe disease or ending up in the hospital or even dying from RSV. And so lung disease, you know, anything that we we deal with when we're talking respiratory and then cardiovascular disease was huge as well. And so really looking at patients with heart failure, coronary artery disease. And then even though immunocompromised patients weren't part of the studies that were shared with the FDA or ACIP, they are recommending that patients who are immunocompromised in that age group be vaccinated as well. And then going down the list, we've got patients with diabetes, kidney, liver disease, hematologic disorders. But and then the last line that the ACIP gives us is really any other underlying conditions that you think might increase the patient's risk. And so, you know, that's where those conversations are important and really helping patients to evaluate their risk factors. And there may be situations, your frail patients, advanced age, living in long-term care facilities or nursing homes, again, that might lend itself to having a higher risk for severe outcomes. And so those are going to be the groups that you're really going to try to try to target in those conversations and really convincing them that you know this would be an important vaccine for them to receive.

Jennifer Nieman 16:55

Perfect. That's really good clarification there. And I'm really glad that you brought up the immunocompromised patients because I think that is a a group that there have been quite a few questions about. And I wondered, Reed, if you are managing a patient who's immunocompromised, how are you going to talk with them about getting this vaccine?

Reid B. Blackwelder 17:15

Well, I think a lot of it I've I've been having some in the chat discussion about just the key aspect of trust with the physician-patient relationship. And so patients are seeing you already have some trust and just being able to say, look, you know you've got a disease that has challenges. I often ask people things before I tell them. You know, what's your awareness of your increased risk to uh bad problems? What do you know about the flu? What have you heard about RSV? Because uh, before I tell people things, I really just want to know where they're coming from because that'll help me spend my time wisely. And then I think just being able to say, you know, one of the most important things is keeping you keeping you from getting really sick and getting in the hospital because everything gets worse then. And it's just a it's a typical conversation that, especially in primary care, we have every day with patients about a lot of different things. So, you know, I think that's kind of the approach that I would take.

Jennifer Nieman 18:10

Okay, and that that's really helpful too. And I'm trying to move us along a little bit because I want to get to that co-administration piece, but we need to also talk about side effects. And so, Lauren, I know that there were a handful of inflammatory neurologic events that occurred and some rare cases of new onset atrial fibrillation. But overall, what would you tell patients about the side effects of these vaccines?

Lauren B. Angelo 18:37

In terms of just overall tolerability across the general population that was studied, we aren't seeing a lot of serious adverse effects. It's what we're expecting from vaccines. So a sore arm, maybe mild, you know, muscle pains, swelling at the site, maybe fever. You might see with an adjuvante vaccine that could be a little bit higher. Again, we don't have comparative data between the two vaccines, but that's something, you know, when we see adjuvened vaccines, we might expect that due to that reactogenicity profile of adjuvenated vaccines. With respect to serious adverse effects, um they're pretty mild and pretty rare. And so we're only looking at about a handful of patients in those trials, about 4% across the board for both. But you brought up inflammatory neurologic events, and Kelly, I've heard you talk about these too, so feel free to chime in when we're dealing with these. But there are two kind of unique and unexpected adverse events with these vaccines, AFib and inflammatory neurologic events. And so with atrial fibrillation in particular, each manufacturer had reported 10 events in their intervention group and four in the control or placebo groups. These were 30 days after vaccination. So again, not enough to really pause on these vaccines, but it was just something that was noted in these trials. And the same thing with inflammatory neurologic events or Yambrae syndrome, GBS. There were some cases reported, six cases across both studies that looked at this. So while concerning, it is very rare, it's just something we're gonna continue to watch and monitor as we enter, you know, kind of our first round of vaccines in RSV season.

Jennifer Nieman 20:23

Okay, that's great clarification. And I want to step back for a second. We're just getting a ton of audience questions, and a really good one just came up and it talks about targeted patients basically. So the question is should grandparents get the RSV vaccine, just like is recommended for pertussis. So if a grandparent gets the RSV vaccine, will it lower the risk of infecting a new grandchild? What do you think about that? Any of the panelists who might want to jump in. Or Kelly or Lauren, do you have a specific recommendation related to that?

Lauren B. Angelo 20:56

I was going to say, in theory, we hope that would be the case and that we're decreasing shedding and spread of the virus, but I don't know that we know enough yet. And when we're looking at protestants in particular, I think there was enough data to show by vaccinating others around a young infant who's who's too young to be vaccinated, that we are providing that protective effect. I think with RSV, I think that all still remains to be determined, but I'll defer to others if there's data out there I'm not aware of.

Andrea Darby Stewart 21:27

I wouldn't say that there's data, but I would say that that would be a discussion point that I might consider, including we don't know the answer to this question. Theoretically, this could help reduce the risk for other people in your vicinity, including your grandkids becoming ill.

Jennifer Nieman 21:43

That's really good wording, Andrea. I really like that. Theoretically, it can help, and I think that's that's really helpful wording. Okay. And I do want to jump in and talk about cost before we can move on. And so I just want to make sure that we have this correct. Kelly, it appears That I've been reading that Medicare Part D is going to cover these vaccines. Do we know anything about Part B and how will all of this coverage affect patients who are between 60 and 64 or where they can get these vaccines?

Jean-Venable “Kelly” R. Goode 22:16

So that is correct. That all new vaccines that are covered under Medicare are covered under Medicare Part D. That's been put in, that's the way the law works. So they wouldn't be the only vaccines that are under B are the ones that are already B already there, your flu, your influenza, your influenza, and your pneumococcal, and then some vaccines for patients on dialysis. But so it would be part D, which means that for our family practitioners here on the call, it's sometimes harder to offer those vaccines for their Medicare patients in their offices because of how the payment is done through the Medicare Part D. But it would be at no copay, but it's they're not going to be covered under Part B. For commercial payer for that 60 to 64. So under the new ACA Act, right, all vaccines have to be covered at no copay. So they would be covered for your commercial patients as well for that 60 to 64. The question really becomes what's going to happen for that patient that's uninsured and does it have the ability to pay pay for the vaccine. It will potentially be covered under a vaccines for adults program, but not all states have that. We don't have a national vaccine for adults program, so it is going to be difficult for patients to get access to this, but mostly it's going to be in a pharmacy for those Medicare Part D patients and patients who have have commercial insurance.

Jennifer Nieman 23:46

Okay. So that's mostly good news. But Stephen, you know, you and I were back and forth a little bit about the Part B coverage. So how will that affect what you do and the conversations you might have in the clinic?

Stephen Carek 24:00

Yeah, sort of cluster this vaccine, the same conversations that I have about getting shame grips or getting their tetanus shots for especially for basement in Medicare. So we probably won't have these in stock in our clinic as it's been mentioned, just because of the cost of upkeep and then the unintended billing that may go be passed on to the patient when they can get it covered at a commercial pharmacy. So just continuing to have these conversations, you know, trying to direct instructions. If we have the patient wishes to get it, just give them the available resources, locations. We're fortunate in our clinic, we have a pharmacy right across the hall from a clinic where they have these vaccines and get them as they're leaving the visit. So that hopefully reduces some of the barrier that we'll see. I think the big thing though is that we wish this was something that we could give in the clinic, wish that we could get uh a clearer uh sort of uh a billing and reimbursement pathways to get these vaccines covered, regardless of insurance status. But hopefully we can reduce some of these barriers so the patients will get them.

Jennifer Nieman 24:59

Okay. Well, I need to move on. I can't believe we're almost out of time here. And we have just had a million questions about co-administration. And so, Lauren, can patients get the flu COVID-19 and RSV RSV vaccines all at the same time at the same visit?

Lauren B. Angelo 25:15

The answer is yes. When we follow the CDC and ACIP guidance, um, they are saying that yes, you can vaccinate with all three, and you might see patients in in clinic or in the pharmacies looking to get them. But the advice is if you are giving multiple vaccines, give them in different limbs. If you have to give them in the same limb, make sure you are separating them by an inch apart. Those vaccines that tend to be more reactogenic, so something that might be higher dose or adjuvanted, we might see more local reactions or more reactogenicity with those particular vaccines. So it's just something to keep in mind based on what you stock in the pharmacies or in your clinics and what you're counseling patients to expect.

Jennifer Nieman 25:58

Okay. And another great question we got was if if you have a patient who needs the flu vaccine and also the RSV vaccine, would you avoid giving them both the adjuvented brands or forms of that vaccine? Or do you think it matters, or we do we do we even know?

Lauren B. Angelo 26:14

We don't know and we don't have that guidance yet, and so I don't want to give one an answer one way or the other. I don't know if the clinicians on here have experience with that and what they would do, but we really don't know for sure when giving two different adjuvants if that's going to be a problem or not. Just to point out, um, the adjuvante RSV vaccine is the same adjuvant that's in the Shingritz vaccine. So, you know, whether that matters or not, we don't know. But it's just an interesting fact. I can think about the adjuvant used.

Jennifer Nieman 26:44

And I think it was about half as much as in the Shingritz. I I read that somewhere if that is also accurate, accurate. So it's a little bit less adjuvant. And I guess the one big question that I'm, you know, I'm even talking to my own parents who qualify for all three of these, and they've they are kind of resistant. They don't want to go in and get them all three at once. So what if you have other patients that come in? And I guess this could be a question for hey, Andrea, what if you want if a patient just wants one or two of these? Which one or two are you going to recommend? And then how do you keep track of them to come back for the third one if they are willing?

Andrea Darby Stewart 27:21

Well, I my rank order is gonna be get your COVID vaccine, then your flu vaccine, then your RSV vaccine if everybody, if if people want to do this one or two at a time. And in terms of keeping track of them to come back in, um, you know, I can certainly set reminders up, certainly let them know that they can come in with respect to RSV, since our office won't be offering it. I've confirmed that as of today. I will have a prescription that's sent out there to the pharmacy if they are able to obtain it there. And I'm hoping my pharmacy colleagues will do a good job of tracking my patients down and reminding them to come and get that vaccine too.

Jennifer Nieman 27:57

Does anyone have any other comments about the combination vaccine? I actually saw some experts that recommended, you know, just giving two at once. I'm like, no, if you have them there and they're willing to get all three, is there any reason why you wouldn't give all three at one time while you have them captive? Do Reed or Steven, do you have any comments on that as far as if you have a patient who is willing to get all three, is that okay?

Reid B. Blackwelder 28:22

Yes. Yes.

Jennifer Nieman 28:24

And that's definitely preferred, is it not? Yes.

Andrea Darby Stewart 28:27

We give babies like five, six vaccines at a time. I don't know why all of these adults are so freaked out. They bring their children and grandchildren in and they let them, their little legs get punctured, and yet they can't get their own vaccines. It just makes me crazy.

Anthony A. Donato 28:44

Yeah, they give you like 12 at once in the military, and you just say thank you and move on.

Jennifer Nieman 28:50

That is a really good point about kids, for sure. Wow, this has been a fantastic discussion and some really interesting topics.

Narrator 29:00

We hope you enjoyed and gained practical insights from listening into this discussion. Now that you've listened, pharmacists, physicians, and nurses can receive CE credit. Just log into your pharmacist letter or prescribers letter account and look for the title of this podcast in the list of available CE courses. You'll also be able to access and print out additional materials on this topic, like charts and other quick reference tools from the pharmacist letter and prescribers letter websites. If you're not yet a pharmacist letter or prescribers letter subscriber, find out more about our product offerings at TRCHealthcare.com. Be sure to follow or subscribe, rate, and review this show in your favorite podcast app. It helps spread the word about our show and is a great way for you to let us know how we're doing. You can also reach out to provide feedback or make suggestions by emailing us at contact us at trchealthcare dot com. Thanks for listening to Medication Talk.