Archive for January, 2015

New Pneumonia Vaccine Guidelines for Patients Over 65

Friday, January 23, 2015 // News, Vaccines

These recommendations have been in the works for a long time. What the CDC didn’t mention is that Medicare hasn’t decided whether to pay for the PCV13 vaccine or not. Patients anxious to get the vaccine are getting confusing information from pharmacies. Some are trying to give them the PPSV23 when the ask for the PCV13 which goes by the brand name Prevnar. Until the dust settles, I’m not ordering any.

The Advisory Committee on Immunization Practices (ACIP) recommends that the 13-valent pneumococcal conjugate vaccine (PCV13,Prevnar) and the 23-valent pneumococcal polysaccharide vaccine (PPSV23,Pneumovax) should be routinely administered in series to all adults who are at least 65 years of age, the CDC announced last week.

Adults in this age group who have not previously received a pneumococcal vaccine or who do not know their vaccination history should receive a dose of PCV13, followed by a dose of PPSV23 6 to 12 months later. The 2 vaccines should not be administered together, and the minimum acceptable interval between them is 8 weeks, the ACIP said.

Adults in this age group who have previously received 1 or more doses of PPSV23 should receive a dose of PCV13 if they not already done so. This dose should be given at least 1 year after the most recent PPSV23 dose was received. Patients in whom another dose of PPSV23 is indicated should receive it 6 to 12 months after PCV13 and 5 or more years after the most recent dose of PPSV23.

The recommendations were published in the Sept. 19 Morbidity and Mortality Weekly.


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Friday, January 23, 2015 // Medication, News

Vicodin (hydrocodone/APAP) a potent pain killer has been changed by the Federal government from a Class III drug for which a prescription can be written or called in to a special prescription which can’t be called in and has to be written on a special prescription. This is in an effort to reduce abuse of prescription drugs. There is also a reduction in the number of days for which a prescription can be written. It goes from 180 days to 90 days. A prescription for it will now necessitate a trip to the doctor’s office.

We’ll see how this plan works. It will be challenging for patients with chronic conditions which necessitate the regular use of this medication.


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Stress Testing

Friday, January 23, 2015 // News

Stress testing may be useful to screen for heart disease, assess exercise tolerance and blood pressure response to exercise, but the American College of Cardiology does not recommend doing it in patients at low risk for coronary artery disease because a positive test, which may indicate underlying heart disease, is more likely to be a false positive in these individuals.  The patient may then have to go through additional testing to prove what isn’t wrong with them.  It may be useful in stratifying risk is patients who have multiple risk factors for heart disease.  I will continue to utilize it in those select individuals.


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Flu Vaccine

Friday, January 23, 2015 // Flu, News

Most patients have received their flu vaccine by now. Unfortunately, it’s not a great match with the strain that is circulating now as the following article from Journal Watch outlines, but it is all we have available and offers some protection.


Flu Vaccine Not a Perfect Match to Circulating Viruses

By Kelly Young Edited by André Sofair, MD, MPH, and William E. Chavey, MD, MS Roughly half of the circulating influenza A (H3N2) viruses collected in the U.S. early this flu season are antigenically different from the H3N2 virus included in this year’s vaccine, prompting CDC officials to remind healthcare providers about using neuraminidase inhibitors to treat and prevent influenza. H3N2 has been present in about 90% of influenza-positive tests this flu season. Years with high H3N2 activity tend to see higher flu morbidity and mortality. The World Health Organization recommended components for the Northern Hemisphere vaccine in February. Antigenically drifted H3N2 viruses were detected in March and became more prevalent in September, too late to change the vaccine. “They’re different enough that we’re concerned that protection from vaccination … may be lower than we usually see,” CDC Director Tom Frieden told reporters on Thursday.The CDC is still recommending that people get vaccinated against the flu because it provides partial protection and the B strains are well matched. But Frieden said that if clinicians suspect influenza in high-risk patients, they should start neuraminidase inhibitor treatment without waiting for confirmatory test results. – See more here.

I was very surprised by the recommendation of the Tamiflu-like medications (neuraminidase inhibitors) given recent articles on their lack of efficacy. Again, from Journal Watch.


Tamiflu, Relenza Data Show Little Clinical Benefit Against Flu
By Joe Elia

The neuraminidase inhibitors oseltamivir (Tamiflu) and zanamivir (Relenza) have only marginal benefits in the treatment and prevention of influenza, a series of BMJ articles concludes. Investigators reviewed documents submitted to regulatory agencies concerning both drugs. Tamiflu data showed it reduced symptom duration by roughly 17 hours but made no difference in hospital admissions or rates of carefully defined pneumonia. Tamiflu increased nausea and vomiting. As prophylaxis, it greatly reduced symptomatic (but not asymptomatic) cases. The Relenza analysis similarly showed a modest reduction in symptom duration (14 hours) and no effect on pneumonia. As prophylaxis, it acted like Tamiflu and had fewer side effects. Editorialists observe that the analyses show “with greater clarity than ever” that the current system for drug regulation is broken. And one commented that, given these results, “it is difficult to conceive that many patients would actively seek treatment.”. NEJM Journal Watch Infectious Diseases associate editor Stephen Baum wrote: “Clean out your medicine cabinet: these reviews call into question the drugs’ efficacy and side effects, as well as the ways in which data were selectively used to promote them.” – See more here

Still, most people who are sick would gladly shorten their sickness by 17 hours. If you have headache, fever and a cough you can call, email or text. Make sure to do it in the first 48 hours. It is not considered good medical practice to prescribe medications for people who are not your patients. It is also a big liability to prescribe drugs with potential side effects for people with whose medical history you are not familiar.. For those reasons I don’t call in Tamiflu for non patients, and recommend calling their physician.



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New Associate: Dr. Jennifer Wallace

Friday, January 23, 2015 // News

When I opened this practice 12 years ago, I designed the space for two physicians. I felt confident that I would locate someone who would be a good match. That didn’t happen, I got used to the quiet along with the patients and staff and I didn’t actively seek another physician. Now, I have finally identified someone who is a good fit. I worked with Dr. Jennifer Wallace in my old practice and she has agreed to come on board starting in the spring of 2015. Dr. Wallace graduated from Texas A+M. She received her medical degree from the University of Texas Health Science Center at San Antonio and did her residency there in Internal Medicine. She is board certified in Internal Medicine. She is married, is a stepmother and plays the piano.

She is currently accepting new patients so if you wish to refer a friend or family member to Dr. Wallace, you can call Sieglinde at 210-822-2004. Her email address is [email protected]. Forms are available on this page. She will start April 1st. No fooling. I think having another physician in the office will improve coverage when I am out of town and will allow us to take care of more of our existing patients, families and friends than we would otherwise have been able to.



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