April 2018
Shingrix - A New Vaccine For Shingles

I wrote about this novel vaccine when it was under study two or 3 years ago.  At that time I indicated to the readers this looked like a "game changer".  As of January of this year the Centers for Disease Control recommend it for the prevention of shingles and post-herpetic neuralgia. I have been reviewing the studies and looking into the cost and availability of the product. Here is a bullet summary of the relevant concerns.
  • It is recommended by the CDC for individuals 50 and up.
  • It is not a live attenuated virus thus not contraindicated in immunosuppressed patients.
  • It is far superior for preventing shingles-97% in the 50-69 years age group and 91% in the 70 years and up group.
  • It is recommended even if you had the prior Zostavax vaccine or shingles itself.
  • It is two injections, the second is given 2-6 months after the first.
  • It has a far higher incidence of local reaction and pain than Zostavax; the reaction is similar to the local reaction to the tetanus shot (pain and swelling).
  • Pharmacies can provide this vaccine and will likely be set up to file the cost to insurances and Medicare Part D (if you have this).
  • Many insurers will endorse it and payment for it- you will need to check with your carrier.
  • Medicare Part D is the Medicare payer for this -copays will vary based upon plans.
  • For those interested in getting the vaccine in the office we will be providing the 2 injection series for $300. 
  • I am not a Medicare or insurance contracted provider and thus won't be submitting claims to plans.
This new vaccine is not part of our membership program.  If you want us to send a prescription to your retail pharmacist so you may get the vaccine, simply portal message us the request or ask at your next appointment.  If you wish for us to arrange the vaccine in the office please inform us the same way. We should be able to get product within a week of requesting. 

Generic Dispensary Service
Generics, Bioequivalence and Our Dispensary Service- Demand for our dispensing service is very high!

January of 2017 our interest poll for using our generic dispensing program included approximately 58 respondents. This last March we filled 256 separate prescriptions.  The staff will agree this has become a significant part of our daily tasks and services for our patients. I am sure many of the readers have seen my   facebook posts and   twitter comments revealing how suddenly everyone is figuring out we are getting scammed on generic prices when using our insurance companies or Medicare part D to help us pay for our medications.  

Several factors led to my decision to offer this value added service to the practice including: efficiency, reduction of delays in medication use, the desire to maintain control of my prescribing preferences (experience) and very importantly - saving patients money and time!

I recently read a good article reviewing the issue of equivalence between generic medications and name branded products. In order for a generic equivalent product to be approved for sale in the US market,stringent requirements must be met for the medication to be deemed bioequivalent. The rate and extent of absorption of the generic product must be closely similar to the reference name brand product. Essentially to meet this criteria the generic medication has to stay within the range of peak and total bioavailability of the name brand with a 90% confidence interval throughout the total time of absorption.  This is both a reasonable and high standard.

Whenever we start a new medication, generic or otherwise, the clinical outcome should be consistent with this background of bioequivalence. This is why we document our vital signs and measure relevant labs when monitoring treatment plans. 

I see no reason for us not to continue to use and benefit from the generic dispensing program. Is is so refreshing for the doctor and the patient to be in the driver's seat of medication use and preferences.  Leaving the insurance system out of this decision process allows continuity of treatment and avoids the unforeseen costs and outcomes of forced medication changes. Historically these generic changes are requested simply to improve profitability for the insurance companies. 

A Tasty Vegetarian Dish
Recipe From Blue Apron- One Pan Udon Stir-Fry with Vegetables and Peanuts 

In order to help us with meal planning Margaret and I recently started using Blue Apron for 3 meals of the week.  This past week we found this recipe to be quite delicious.  I would recommend a whole grain udon (Japanese) noodle to improve nutritional content and fiber.  The recipe came with fresh (soft noodles).  If you get boxed dry noodles you will need to boil them prior to making this recipe.

Serves two. 

  • 1/2 lb fresh or cooked Udon noodles
  • 2 scallions
  • 2 cloves of garlic
  • 1 large carrot
  • 3-4 small sweet peppers
  • 1/2 normal sized cabbage
  • 3-4 tablespoons roasted peanuts
  • 1 inch piece of ginger
  • 2 tablespoons sesame oil
  • 2 tablespoons soy glaze 
  • 3 tablespoons sweet chili sauce 
Prep the ingredients: 
  • wash and dry all produce
  • remove stems and core of peppers; cut lengthwise into quarters 
  • thinly slice the scallion separating white ends from the greens 
  • roughly chop garlic and ginger
  • in a bowl combine peppers, garlic, ginger and sliced white scallion bottoms
  • cut out and discard core of cabbage, slice or coarsely grate the cabbage
  • peel and grate the carrot 
  • chop the peanuts 
Make the sauce:
  • combine soy glaze,sesame oil,chili sauce and 1/3 cup of water
Start the stir-fry:
  • in a large pan or wok heat 1 tablespoon olive oil (2 won't hurt) on medium-high heat
  • add the prepared bowl of pepper mixture, stirring occasionally for 2-3 minutes
  • add sliced cabbage and stir occasionally another 2-3 minutes
Finish the stir-fry:
  • to the cooking vegetables add the sauce and fresh (or prior boiled and drained) noodles 
  • cook and stir for 2-3 minutes until thoroughly heated and combined
  • turn off the heat and add the grated carrots
  • Divide in two servings and garnish with chopped peanuts and sliced green scallion tops
  • Enjoy!

Raymond Kordonowy MD 

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