Article

I had the opportunity to experience first-hand acute postoperative pain management in both the United States and Saudi Arabia. In this article, I discuss some of the differences in how postop pain is managed in each location, potential reasons for these differences, how they may impact patients over time, and the psychiatrist’s role in raising awareness about the hazards of overprescribing analgesic medications.

Vast differences in postop opioid prescribing

From personal observation and literature review, I was appalled by the amount of oxycodone tablets patients are typically discharged home with after a surgical procedure in the United States. Depending on the extent of the surgical procedure, opioid-naïve patients were routinely discharged with 40 to 120 tablets of oxycodone 5 mg. A ventral hernia repair or laparotomy was on the high end of how much oxycodone was provided, and a laparoscopic cholecystectomy or inguinal hernia repair was on the low end. At least one study has supported this observation, finding a wide variation and excessive doses of opioids prescribed postop.¹ Notably, among opioids obtained by postsurgical patients, 42% to 71% of all tablets went unused.² Nevertheless, prescribing in this manner became the standard for postop pain management—possibly in an effort to maximize patient satisfaction on surveys. Additionally, marketing and promotion by the pharmaceutical industry appears to have considerably amplified the prescription, sales, and availability of opioids.³

Signing those prescriptions always left a bad taste in my mouth out of concern for the potential for initiating chronic opioid use.⁴ Personally, I would prescribe the lowest reasonable number of narcotic tablets for my patients, along with acetaminophen and ibuprofen, knowing that nonsteroidal anti-inflammatory drugs are sufficient for treating postop pain and will decrease opioid requirements, therefore minimizing opiate-induced adverse events.⁵ Overtreatment of pain with narcotics as first-line therapy is particularly problematic when treating postop pain in children after minor procedures, such as an umbilical hernia repair.Allowing children to resort to a narcotic analgesic agent as a first-line therapy had the potential to develop into an opioid use disorder (OUD) later in life if environmental factors tipped the scales.⁶

In the hospital in Saudi Arabia where I initially trained, surgery residents were not permitted to prescribe narcotics. The standard of care was to discharge patients with acetaminophen and ibuprofen. In cases where there was an indication for pain treatment with narcotics, stringent regulations were in place. For example, in my experience, which is corroborated by one study,⁶ special “narcotic forms” are required in the Middle East. In most of these countries, access to these forms is restricted.⁷ Moreover, pharmacists would only accept this special form when attested to by the surgery consultant (the equivalent of an attending physician in the United States). These consultants would typically write a prescription for 9 to 15 oxycodone 5 mg tablets. Patients receiving such medications were closely watched and followed up in the surgery clinic 3 to 5 days after discharge. Patients were also required to fill out a form detailing their contact information, including their home address and national ID number, to be able to pick up their prescription. Furthermore, apart from 2 Middle East countries, opioids were only available from hospital pharmacies, which were independent of the general hospital pharmacy in location and staff training.⁸

The psychiatrist’s role

Adapting similar stringent practices for prescribing narcotics in the United States might reduce 1 risk factor for OUD in postop patients. Surgeons attempt to provide the best care by maximizing analgesia, but psychiatrists see firsthand the consequences of overprescribing, and play a direct role in managing patients’ OUDs. As psychiatrists, we have a duty to continue to raise awareness and alert other clinicians about the hazards of overprescribing narcotic analgesic agents.

I had the opportunity to experience first-hand acute postoperative pain management in both the United States and Saudi Arabia. In this article, I discuss some of the differences in how postop pain is managed in each location, potential reasons for these differences, how they may impact patients over time, and the psychiatrist’s role in raising awareness about the hazards of overprescribing analgesic medications.

Vast differences in postop opioid prescribing

From personal observation and literature review, I was appalled by the amount of oxycodone tablets patients are typically discharged home with after a surgical procedure in the United States. Depending on the extent of the surgical procedure, opioid-naïve patients were routinely discharged with 40 to 120 tablets of oxycodone 5 mg. A ventral hernia repair or laparotomy was on the high end of how much oxycodone was provided, and a laparoscopic cholecystectomy or inguinal hernia repair was on the low end. At least one study has supported this observation, finding a wide variation and excessive doses of opioids prescribed postop.¹ Notably, among opioids obtained by postsurgical patients, 42% to 71% of all tablets went unused.² Nevertheless, prescribing in this manner became the standard for postop pain management—possibly in an effort to maximize patient satisfaction on surveys. Additionally, marketing and promotion by the pharmaceutical industry appears to have considerably amplified the prescription, sales, and availability of opioids.³

Signing those prescriptions always left a bad taste in my mouth out of concern for the potential for initiating chronic opioid use.⁴ Personally, I would prescribe the lowest reasonable number of narcotic tablets for my patients, along with acetaminophen and ibuprofen, knowing that nonsteroidal anti-inflammatory drugs are sufficient for treating postop pain and will decrease opioid requirements, therefore minimizing opiate-induced adverse events.⁵ Overtreatment of pain with narcotics as first-line therapy is particularly problematic when treating postop pain in children after minor procedures, such as an umbilical hernia repair.Allowing children to resort to a narcotic analgesic agent as a first-line therapy had the potential to develop into an opioid use disorder (OUD) later in life if environmental factors tipped the scales.⁶

In the hospital in Saudi Arabia where I initially trained, surgery residents were not permitted to prescribe narcotics. The standard of care was to discharge patients with acetaminophen and ibuprofen. In cases where there was an indication for pain treatment with narcotics, stringent regulations were in place. For example, in my experience, which is corroborated by one study,⁶ special “narcotic forms” are required in the Middle East. In most of these countries, access to these forms is restricted.⁷ Moreover, pharmacists would only accept this special form when attested to by the surgery consultant (the equivalent of an attending physician in the United States). These consultants would typically write a prescription for 9 to 15 oxycodone 5 mg tablets. Patients receiving such medications were closely watched and followed up in the surgery clinic 3 to 5 days after discharge. Patients were also required to fill out a form detailing their contact information, including their home address and national ID number, to be able to pick up their prescription. Furthermore, apart from 2 Middle East countries, opioids were only available from hospital pharmacies, which were independent of the general hospital pharmacy in location and staff training.⁸

The psychiatrist’s role

Adapting similar stringent practices for prescribing narcotics in the United States might reduce 1 risk factor for OUD in postop patients. Surgeons attempt to provide the best care by maximizing analgesia, but psychiatrists see firsthand the consequences of overprescribing, and play a direct role in managing patients’ OUDs. As psychiatrists, we have a duty to continue to raise awareness and alert other clinicians about the hazards of overprescribing narcotic analgesic agents.

I had the opportunity to experience first-hand acute postoperative pain management in both the United States and Saudi Arabia. In this article, I discuss some of the differences in how postop pain is managed in each location, potential reasons for these differences, how they may impact patients over time, and the psychiatrist’s role in raising awareness about the hazards of overprescribing analgesic medications.

Vast differences in postop opioid prescribing

From personal observation and literature review, I was appalled by the amount of oxycodone tablets patients are typically discharged home with after a surgical procedure in the United States. Depending on the extent of the surgical procedure, opioid-naïve patients were routinely discharged with 40 to 120 tablets of oxycodone 5 mg. A ventral hernia repair or laparotomy was on the high end of how much oxycodone was provided, and a laparoscopic cholecystectomy or inguinal hernia repair was on the low end. At least one study has supported this observation, finding a wide variation and excessive doses of opioids prescribed postop.¹ Notably, among opioids obtained by postsurgical patients, 42% to 71% of all tablets went unused.² Nevertheless, prescribing in this manner became the standard for postop pain management—possibly in an effort to maximize patient satisfaction on surveys. Additionally, marketing and promotion by the pharmaceutical industry appears to have considerably amplified the prescription, sales, and availability of opioids.³

Signing those prescriptions always left a bad taste in my mouth out of concern for the potential for initiating chronic opioid use.⁴ Personally, I would prescribe the lowest reasonable number of narcotic tablets for my patients, along with acetaminophen and ibuprofen, knowing that nonsteroidal anti-inflammatory drugs are sufficient for treating postop pain and will decrease opioid requirements, therefore minimizing opiate-induced adverse events.⁵ Overtreatment of pain with narcotics as first-line therapy is particularly problematic when treating postop pain in children after minor procedures, such as an umbilical hernia repair.Allowing children to resort to a narcotic analgesic agent as a first-line therapy had the potential to develop into an opioid use disorder (OUD) later in life if environmental factors tipped the scales.⁶

In the hospital in Saudi Arabia where I initially trained, surgery residents were not permitted to prescribe narcotics. The standard of care was to discharge patients with acetaminophen and ibuprofen. In cases where there was an indication for pain treatment with narcotics, stringent regulations were in place. For example, in my experience, which is corroborated by one study,⁶ special “narcotic forms” are required in the Middle East. In most of these countries, access to these forms is restricted.⁷ Moreover, pharmacists would only accept this special form when attested to by the surgery consultant (the equivalent of an attending physician in the United States). These consultants would typically write a prescription for 9 to 15 oxycodone 5 mg tablets. Patients receiving such medications were closely watched and followed up in the surgery clinic 3 to 5 days after discharge. Patients were also required to fill out a form detailing their contact information, including their home address and national ID number, to be able to pick up their prescription. Furthermore, apart from 2 Middle East countries, opioids were only available from hospital pharmacies, which were independent of the general hospital pharmacy in location and staff training.⁸

The psychiatrist’s role

Adapting similar stringent practices for prescribing narcotics in the United States might reduce 1 risk factor for OUD in postop patients. Surgeons attempt to provide the best care by maximizing analgesia, but psychiatrists see firsthand the consequences of overprescribing, and play a direct role in managing patients’ OUDs. As psychiatrists, we have a duty to continue to raise awareness and alert other clinicians about the hazards of overprescribing narcotic analgesic agents.

Pregnancy apps are more popular as patients use the internet to seek information about pregnancy and childbirth.¹ Research has shown that over 50% of pregnant patients download apps focused on pregnancy, with an average of 3 being tried.² This is especially true during the COVID-19 pandemic, when patients seek information but may want to minimize clinical exposures. Other research has shown that women primarily use apps to monitor fetal development and to obtain information on nutrition and antenatal care.³

We identified apps and rated their contents and features.⁴ To identify the apps, we performed a Google search to mimic what a patient may do. We scored the identified apps based on what has been shown to make apps successful, as well as desired functions of the most commonly used apps. The quality of the applications was relatively varied, with many of the apps (60%) not having comprehensive information for every stage of pregnancy and no app attaining a perfect score. However, the top 3 apps had near perfect scores of 15/16 and 14/16, missing points only for having advertisements and requiring an internet connection.

The table details these top 3 recommended pregnancy apps, along with a detailed shortened version of the APPLICATIONS scoring system, APPLI (App comprehensiveness, Price, Platform, Literature Used, Other special features). We hope this column will help you feel comfortable in helping patients use pregnancy apps, should they ask for recommendations.

Pregnancy apps are more popular as patients use the internet to seek information about pregnancy and childbirth.¹ Research has shown that over 50% of pregnant patients download apps focused on pregnancy, with an average of 3 being tried.² This is especially true during the COVID-19 pandemic, when patients seek information but may want to minimize clinical exposures. Other research has shown that women primarily use apps to monitor fetal development and to obtain information on nutrition and antenatal care.³

We identified apps and rated their contents and features.⁴ To identify the apps, we performed a Google search to mimic what a patient may do. We scored the identified apps based on what has been shown to make apps successful, as well as desired functions of the most commonly used apps. The quality of the applications was relatively varied, with many of the apps (60%) not having comprehensive information for every stage of pregnancy and no app attaining a perfect score. However, the top 3 apps had near perfect scores of 15/16 and 14/16, missing points only for having advertisements and requiring an internet connection.

The table details these top 3 recommended pregnancy apps, along with a detailed shortened version of the APPLICATIONS scoring system, APPLI (App comprehensiveness, Price, Platform, Literature Used, Other special features). We hope this column will help you feel comfortable in helping patients use pregnancy apps, should they ask for recommendations.

Pregnancy apps are more popular as patients use the internet to seek information about pregnancy and childbirth.¹ Research has shown that over 50% of pregnant patients download apps focused on pregnancy, with an average of 3 being tried.² This is especially true during the COVID-19 pandemic, when patients seek information but may want to minimize clinical exposures. Other research has shown that women primarily use apps to monitor fetal development and to obtain information on nutrition and antenatal care.³

We identified apps and rated their contents and features.⁴ To identify the apps, we performed a Google search to mimic what a patient may do. We scored the identified apps based on what has been shown to make apps successful, as well as desired functions of the most commonly used apps. The quality of the applications was relatively varied, with many of the apps (60%) not having comprehensive information for every stage of pregnancy and no app attaining a perfect score. However, the top 3 apps had near perfect scores of 15/16 and 14/16, missing points only for having advertisements and requiring an internet connection.

The table details these top 3 recommended pregnancy apps, along with a detailed shortened version of the APPLICATIONS scoring system, APPLI (App comprehensiveness, Price, Platform, Literature Used, Other special features). We hope this column will help you feel comfortable in helping patients use pregnancy apps, should they ask for recommendations.

Immune checkpoint inhibitors in combination with chemotherapy are part of standard treatment for patients with advanced gastroesophageal adenocarcinoma. However, not all patients benefit from immunotherapy addition. Programmed death-ligand 1 (PD-L1) expression has emerged as a useful, yet imperfect, biomarker for identifying patients who are most likely to benefit from the addition of immunotherapy. There is a need to better identify patients with higher chances of responding to these therapies, as well as a need to augment the activity that we are seeing with current approaches. Tumor mutational burden (TMB) has been previously identified as a predictive biomarker of response to immunotherapy. It is not widely used in clinical practice when treating patients with upper gastrointestinal cancers though, and it has not been extensively evaluated in this disease.

The study by Lee and colleagues evaluated the association between TMB and pembrolizumab response in patients treated in the phase 3 KEYNOTE-62 study. This was a prespecified exploratory analysis, which included 306 of 763 patients, based on TMB data availability. Although there was association between high TMB (cut-off defined as 10 mut/Mb), the benefit from pembrolizumab was most pronounced in patients with microsatellite-unstable tumors. When the analysis was limited to microsatellite-stable tumors with high TMB, the signal was attenuated and was only detected when immunotherapy was combined with chemotherapy.

Ultimately, although TMB is a predictive biomarker of response to immunotherapy, it is unlikely to significantly alter our approach to treatment of upper gastrointestinal cancers, especially when PD-L1 testing and microsatellite testing are more readily available and do not require more time- and resource-consuming next-generation sequencing when selecting first-line treatments.

Perioperative chemotherapy plays a critical role in the management of patients with early-stage gastric cancer. In the United States, perioperative FLOT (5-fluorouracil, oxaliplatin, and docetaxel) chemotherapy is the standard approach to this disease, with four cycles administered before and four cycles administered after resection.

In Korea, adjuvant chemotherapy is typically used, with 1 year of S-1 chemotherapy or 6 months of CAPOX (capecitabine/oxaliplatin) chemotherapy used most frequently. Kim and colleagues analyzed whether a shorter duration of chemotherapy (either S-1 or CAPOX) had similar outcomes. In a retrospective analysis of 20,552 patients, which included 13,614 patients who received S-1 and 6938 patients who received CAPOX, overall survival was worse in those patients who received a shorter duration of adjuvant treatment. Although this study is not directly applicable to how we approach treatment of early-stage gastric cancer in the United States, it does suggest that any modification in the duration of perioperative chemotherapy should be evaluated in prospective clinical trials, similarly to recent investigations regarding the duration on adjuvant chemotherapy in colon cancer.

Immune checkpoint inhibitors in combination with chemotherapy are part of standard treatment for patients with advanced gastroesophageal adenocarcinoma. However, not all patients benefit from immunotherapy addition. Programmed death-ligand 1 (PD-L1) expression has emerged as a useful, yet imperfect, biomarker for identifying patients who are most likely to benefit from the addition of immunotherapy. There is a need to better identify patients with higher chances of responding to these therapies, as well as a need to augment the activity that we are seeing with current approaches. Tumor mutational burden (TMB) has been previously identified as a predictive biomarker of response to immunotherapy. It is not widely used in clinical practice when treating patients with upper gastrointestinal cancers though, and it has not been extensively evaluated in this disease.

The study by Lee and colleagues evaluated the association between TMB and pembrolizumab response in patients treated in the phase 3 KEYNOTE-62 study. This was a prespecified exploratory analysis, which included 306 of 763 patients, based on TMB data availability. Although there was association between high TMB (cut-off defined as 10 mut/Mb), the benefit from pembrolizumab was most pronounced in patients with microsatellite-unstable tumors. When the analysis was limited to microsatellite-stable tumors with high TMB, the signal was attenuated and was only detected when immunotherapy was combined with chemotherapy.

Ultimately, although TMB is a predictive biomarker of response to immunotherapy, it is unlikely to significantly alter our approach to treatment of upper gastrointestinal cancers, especially when PD-L1 testing and microsatellite testing are more readily available and do not require more time- and resource-consuming next-generation sequencing when selecting first-line treatments.

Perioperative chemotherapy plays a critical role in the management of patients with early-stage gastric cancer. In the United States, perioperative FLOT (5-fluorouracil, oxaliplatin, and docetaxel) chemotherapy is the standard approach to this disease, with four cycles administered before and four cycles administered after resection.

In Korea, adjuvant chemotherapy is typically used, with 1 year of S-1 chemotherapy or 6 months of CAPOX (capecitabine/oxaliplatin) chemotherapy used most frequently. Kim and colleagues analyzed whether a shorter duration of chemotherapy (either S-1 or CAPOX) had similar outcomes. In a retrospective analysis of 20,552 patients, which included 13,614 patients who received S-1 and 6938 patients who received CAPOX, overall survival was worse in those patients who received a shorter duration of adjuvant treatment. Although this study is not directly applicable to how we approach treatment of early-stage gastric cancer in the United States, it does suggest that any modification in the duration of perioperative chemotherapy should be evaluated in prospective clinical trials, similarly to recent investigations regarding the duration on adjuvant chemotherapy in colon cancer.

Immune checkpoint inhibitors in combination with chemotherapy are part of standard treatment for patients with advanced gastroesophageal adenocarcinoma. However, not all patients benefit from immunotherapy addition. Programmed death-ligand 1 (PD-L1) expression has emerged as a useful, yet imperfect, biomarker for identifying patients who are most likely to benefit from the addition of immunotherapy. There is a need to better identify patients with higher chances of responding to these therapies, as well as a need to augment the activity that we are seeing with current approaches. Tumor mutational burden (TMB) has been previously identified as a predictive biomarker of response to immunotherapy. It is not widely used in clinical practice when treating patients with upper gastrointestinal cancers though, and it has not been extensively evaluated in this disease.

The study by Lee and colleagues evaluated the association between TMB and pembrolizumab response in patients treated in the phase 3 KEYNOTE-62 study. This was a prespecified exploratory analysis, which included 306 of 763 patients, based on TMB data availability. Although there was association between high TMB (cut-off defined as 10 mut/Mb), the benefit from pembrolizumab was most pronounced in patients with microsatellite-unstable tumors. When the analysis was limited to microsatellite-stable tumors with high TMB, the signal was attenuated and was only detected when immunotherapy was combined with chemotherapy.

Ultimately, although TMB is a predictive biomarker of response to immunotherapy, it is unlikely to significantly alter our approach to treatment of upper gastrointestinal cancers, especially when PD-L1 testing and microsatellite testing are more readily available and do not require more time- and resource-consuming next-generation sequencing when selecting first-line treatments.

Perioperative chemotherapy plays a critical role in the management of patients with early-stage gastric cancer. In the United States, perioperative FLOT (5-fluorouracil, oxaliplatin, and docetaxel) chemotherapy is the standard approach to this disease, with four cycles administered before and four cycles administered after resection.

In Korea, adjuvant chemotherapy is typically used, with 1 year of S-1 chemotherapy or 6 months of CAPOX (capecitabine/oxaliplatin) chemotherapy used most frequently. Kim and colleagues analyzed whether a shorter duration of chemotherapy (either S-1 or CAPOX) had similar outcomes. In a retrospective analysis of 20,552 patients, which included 13,614 patients who received S-1 and 6938 patients who received CAPOX, overall survival was worse in those patients who received a shorter duration of adjuvant treatment. Although this study is not directly applicable to how we approach treatment of early-stage gastric cancer in the United States, it does suggest that any modification in the duration of perioperative chemotherapy should be evaluated in prospective clinical trials, similarly to recent investigations regarding the duration on adjuvant chemotherapy in colon cancer.

CHEST Physician presents the 2022 edition of Pulmonology Data Trends (click to view the digital edition). This special issue provides updates on hot topics in pulmonology through original infographics and visual storytelling. 

Inside this issue:

• Comorbidities, Racial Disparities, and Geographic Differences in Asthma
  Navitha Ramesh, MD, FCCP
• Post-COVID-19 Effects
  Viren Kaul, MD, FCCP, FACP
• New Pathogens, COVID-19, and Antibiotic Resistance in the Field of Pneumonia
  Marcos I. Restrepo, MD, MSc, PhD, FCCP
• COPD Characteristics and Health Disparities
  Muhammad Adrish, MD, MBA, FCCP
• Reducing Tuberculosis Globally and the Impact of COVID-19
  Patricio Escalante, MD, MSc, FCCP and Paige K. Marty, MD
• New Treatment Pathways for Cystic Fibrosis
  David Finklea, MD
• Risk Assessment in Pulmonary Arterial Hypertension
  Sandeep Sahay, MD, MSc, FCCP, ATSF
• Rising Incidence of Bronchiectasis and Associated Burdens
  Anne E. O'Donnell, MD, FCCP
• ILD: Diagnostic Considerations and Socioeconomic Barriers
  Daniel Dilling, MD, FCCP, FACP, FAST
• Advances in Lung Cancer Diagnostics and Treatment
  Eric S. Edell, MD, FCCP

CHEST Physician presents the 2022 edition of Pulmonology Data Trends (click to view the digital edition). This special issue provides updates on hot topics in pulmonology through original infographics and visual storytelling. 

Inside this issue:

• Comorbidities, Racial Disparities, and Geographic Differences in Asthma
  Navitha Ramesh, MD, FCCP
• Post-COVID-19 Effects
  Viren Kaul, MD, FCCP, FACP
• New Pathogens, COVID-19, and Antibiotic Resistance in the Field of Pneumonia
  Marcos I. Restrepo, MD, MSc, PhD, FCCP
• COPD Characteristics and Health Disparities
  Muhammad Adrish, MD, MBA, FCCP
• Reducing Tuberculosis Globally and the Impact of COVID-19
  Patricio Escalante, MD, MSc, FCCP and Paige K. Marty, MD
• New Treatment Pathways for Cystic Fibrosis
  David Finklea, MD
• Risk Assessment in Pulmonary Arterial Hypertension
  Sandeep Sahay, MD, MSc, FCCP, ATSF
• Rising Incidence of Bronchiectasis and Associated Burdens
  Anne E. O'Donnell, MD, FCCP
• ILD: Diagnostic Considerations and Socioeconomic Barriers
  Daniel Dilling, MD, FCCP, FACP, FAST
• Advances in Lung Cancer Diagnostics and Treatment
  Eric S. Edell, MD, FCCP

CHEST Physician presents the 2022 edition of Pulmonology Data Trends (click to view the digital edition). This special issue provides updates on hot topics in pulmonology through original infographics and visual storytelling. 

Inside this issue:

• Comorbidities, Racial Disparities, and Geographic Differences in Asthma
  Navitha Ramesh, MD, FCCP
• Post-COVID-19 Effects
  Viren Kaul, MD, FCCP, FACP
• New Pathogens, COVID-19, and Antibiotic Resistance in the Field of Pneumonia
  Marcos I. Restrepo, MD, MSc, PhD, FCCP
• COPD Characteristics and Health Disparities
  Muhammad Adrish, MD, MBA, FCCP
• Reducing Tuberculosis Globally and the Impact of COVID-19
  Patricio Escalante, MD, MSc, FCCP and Paige K. Marty, MD
• New Treatment Pathways for Cystic Fibrosis
  David Finklea, MD
• Risk Assessment in Pulmonary Arterial Hypertension
  Sandeep Sahay, MD, MSc, FCCP, ATSF
• Rising Incidence of Bronchiectasis and Associated Burdens
  Anne E. O'Donnell, MD, FCCP
• ILD: Diagnostic Considerations and Socioeconomic Barriers
  Daniel Dilling, MD, FCCP, FACP, FAST
• Advances in Lung Cancer Diagnostics and Treatment
  Eric S. Edell, MD, FCCP

Inside this issue:

• The Impact of COVID-19 on Colorectal Cancer Screening Programs
  Rachel B. Issaka, MD, MAS
• Early Onset Colorectal Cancer: Trends in Incidence and Screening
  Aasma Shaukat, MD, MPH, AGAF
• Diversity in the Gastroenterology Workforce and its Implications for Patients
  Sandra M. Quezada, MD, MS, AGAF
• Trends in Surveillance and Management of Dysplasia in IBD
  Joseph D. Feuerstein, MD, AGAF
• Environmental Factors in IBD: Diet and Stress
  Ashwin Ananthakrishnan, MBBS, MPH
• Evolving Therapeutic Goals in Crohn’s Disease Management
  Ryan Ungaro, MD, MS
• Switching to Disposable Duodenoscopes: Risks and Rewards
  Rajesh N. Keswani, MD, MS
• Increasing Surveillance Programs and Expanding Treatment Options in HCC
  Amit Singal, MD, MS
• Achalasia Remains a Challenging Disorder for the Community Gastroenterologist
  Benson T. Massey, MD

Inside this issue:

• The Impact of COVID-19 on Colorectal Cancer Screening Programs
  Rachel B. Issaka, MD, MAS
• Early Onset Colorectal Cancer: Trends in Incidence and Screening
  Aasma Shaukat, MD, MPH, AGAF
• Diversity in the Gastroenterology Workforce and its Implications for Patients
  Sandra M. Quezada, MD, MS, AGAF
• Trends in Surveillance and Management of Dysplasia in IBD
  Joseph D. Feuerstein, MD, AGAF
• Environmental Factors in IBD: Diet and Stress
  Ashwin Ananthakrishnan, MBBS, MPH
• Evolving Therapeutic Goals in Crohn’s Disease Management
  Ryan Ungaro, MD, MS
• Switching to Disposable Duodenoscopes: Risks and Rewards
  Rajesh N. Keswani, MD, MS
• Increasing Surveillance Programs and Expanding Treatment Options in HCC
  Amit Singal, MD, MS
• Achalasia Remains a Challenging Disorder for the Community Gastroenterologist
  Benson T. Massey, MD

Inside this issue:

• The Impact of COVID-19 on Colorectal Cancer Screening Programs
  Rachel B. Issaka, MD, MAS
• Early Onset Colorectal Cancer: Trends in Incidence and Screening
  Aasma Shaukat, MD, MPH, AGAF
• Diversity in the Gastroenterology Workforce and its Implications for Patients
  Sandra M. Quezada, MD, MS, AGAF
• Trends in Surveillance and Management of Dysplasia in IBD
  Joseph D. Feuerstein, MD, AGAF
• Environmental Factors in IBD: Diet and Stress
  Ashwin Ananthakrishnan, MBBS, MPH
• Evolving Therapeutic Goals in Crohn’s Disease Management
  Ryan Ungaro, MD, MS
• Switching to Disposable Duodenoscopes: Risks and Rewards
  Rajesh N. Keswani, MD, MS
• Increasing Surveillance Programs and Expanding Treatment Options in HCC
  Amit Singal, MD, MS
• Achalasia Remains a Challenging Disorder for the Community Gastroenterologist
  Benson T. Massey, MD

Research on psoriatic arthritis (PsA) published over the past month has highlighted the effect of disease on patients and provided insights into clinical management. Because of the heterogeneous nature of PsA, assessing disease activity is difficult. A blood biomarker for disease activity would be useful. C-reactive protein (CRP) is a commonly used and well-established marker of inflammation in general. However, CRP does not reflect PsA disease activity itself. In a cross-sectional study, Gialouri and colleagues evaluated the association between CRP and PsA disease activity. CRP status (CRP  ≤  0.5 mg/dL [normal] and CRP > 0.5  mg/dL [increased]) was not associated with any of the clinical disease activity (clinical Disease Activity Index for Psoriatic Arthritis [cDAPSA] or minimal disease activity [MDA]) or patient-reported outcomes measures (Patient Global, Patient Pain, Health Assessment Questionnaire-Disability Index [HAQ-DI] or EuroQol [EQ-5D]). Among patients with normal CRP levels, a substantial proportion (45.9%) were not in MDA (thus, an indicator of active disease) while 76.7% of patients with elevated CRP were not in MDA. Therefore, an elevated CRP may indicate active PsA, but a normal CRP is not a reliable indicator of disease state in PsA.

Gender differences in PsA are increasingly being recognized as important. In a real-world survey of 2270 PsA patients (1047 women) from Europe and the United States, Gossec and colleagues demonstrated that, despite similar disease duration, disease presentation, and biologic use, women had worse quality-of-life, disability, and physical functioning scores, a greater degree of work activity impairment, and higher pain and fatigue scores compared with men. Thus, it is increasingly clear that PsA affects women differently from men. Interventions for the holistic management of PsA should be tailored according to the patient's gender for optimal outcomes.

Despite major advances in the treatment of adult PsA, the treatment options for children with PsA (juvenile PsA [JPsA]) are limited. Anti–tumor necrosis factor (TNF) agents are the only currently approved advanced therapy. Brunner and colleagues conducted a treatment-withdrawal, phase 3 study including 86 biologic-naive patients with active enthesitis-related arthritis (n = 52) or JPsA (n = 34) who were randomly assigned to receive secukinumab or placebo.

This study demonstrated that, compared with placebo, secukinumab was associated with a significant delay in disease flare and a higher proportion of patients achieving juvenile idiopathic arthritis American College of Rheumatology 30 response at week 104. This study provides evidence that secukinumab, a safe and effective therapy used in adult psoriatic disease, may provide similar benefits in JPsA, especially in patients who either have not responded to or have contraindications to treatment with anti-TNF agents.

Finally, because skin disease predates joint disease in almost 90% of PsA patients, identifying predictors for the development of joint disease is of considerable interest. It is hoped that identifying such predictors will help dermatologists and primary care physicians stratify management such that those at higher risk are carefully followed up for early diagnosis or even preventive therapy.

To identify such predictors, Ogdie and colleagues conducted a prospective study of 1489 patients with psoriasis and no prior diagnosis of PsA from the CorEvitas Psoriasis registry. They demonstrated that 10% of patients with psoriasis developed PsA after 2 years. Psoriasis Epidemiology Screening Tool (PEST, a brief screening questionnaire for PsA) and body mass index (BMI) were important factors predicting the development of PsA. Although the incidence of PsA in this cohort is higher than that reported from other studies, the study indicates that PEST and BMI should be important factors that predict PsA and should be variables in any prediction model.

Research on psoriatic arthritis (PsA) published over the past month has highlighted the effect of disease on patients and provided insights into clinical management. Because of the heterogeneous nature of PsA, assessing disease activity is difficult. A blood biomarker for disease activity would be useful. C-reactive protein (CRP) is a commonly used and well-established marker of inflammation in general. However, CRP does not reflect PsA disease activity itself. In a cross-sectional study, Gialouri and colleagues evaluated the association between CRP and PsA disease activity. CRP status (CRP  ≤  0.5 mg/dL [normal] and CRP > 0.5  mg/dL [increased]) was not associated with any of the clinical disease activity (clinical Disease Activity Index for Psoriatic Arthritis [cDAPSA] or minimal disease activity [MDA]) or patient-reported outcomes measures (Patient Global, Patient Pain, Health Assessment Questionnaire-Disability Index [HAQ-DI] or EuroQol [EQ-5D]). Among patients with normal CRP levels, a substantial proportion (45.9%) were not in MDA (thus, an indicator of active disease) while 76.7% of patients with elevated CRP were not in MDA. Therefore, an elevated CRP may indicate active PsA, but a normal CRP is not a reliable indicator of disease state in PsA.

Gender differences in PsA are increasingly being recognized as important. In a real-world survey of 2270 PsA patients (1047 women) from Europe and the United States, Gossec and colleagues demonstrated that, despite similar disease duration, disease presentation, and biologic use, women had worse quality-of-life, disability, and physical functioning scores, a greater degree of work activity impairment, and higher pain and fatigue scores compared with men. Thus, it is increasingly clear that PsA affects women differently from men. Interventions for the holistic management of PsA should be tailored according to the patient's gender for optimal outcomes.

Despite major advances in the treatment of adult PsA, the treatment options for children with PsA (juvenile PsA [JPsA]) are limited. Anti–tumor necrosis factor (TNF) agents are the only currently approved advanced therapy. Brunner and colleagues conducted a treatment-withdrawal, phase 3 study including 86 biologic-naive patients with active enthesitis-related arthritis (n = 52) or JPsA (n = 34) who were randomly assigned to receive secukinumab or placebo.

This study demonstrated that, compared with placebo, secukinumab was associated with a significant delay in disease flare and a higher proportion of patients achieving juvenile idiopathic arthritis American College of Rheumatology 30 response at week 104. This study provides evidence that secukinumab, a safe and effective therapy used in adult psoriatic disease, may provide similar benefits in JPsA, especially in patients who either have not responded to or have contraindications to treatment with anti-TNF agents.

Finally, because skin disease predates joint disease in almost 90% of PsA patients, identifying predictors for the development of joint disease is of considerable interest. It is hoped that identifying such predictors will help dermatologists and primary care physicians stratify management such that those at higher risk are carefully followed up for early diagnosis or even preventive therapy.

To identify such predictors, Ogdie and colleagues conducted a prospective study of 1489 patients with psoriasis and no prior diagnosis of PsA from the CorEvitas Psoriasis registry. They demonstrated that 10% of patients with psoriasis developed PsA after 2 years. Psoriasis Epidemiology Screening Tool (PEST, a brief screening questionnaire for PsA) and body mass index (BMI) were important factors predicting the development of PsA. Although the incidence of PsA in this cohort is higher than that reported from other studies, the study indicates that PEST and BMI should be important factors that predict PsA and should be variables in any prediction model.

Research on psoriatic arthritis (PsA) published over the past month has highlighted the effect of disease on patients and provided insights into clinical management. Because of the heterogeneous nature of PsA, assessing disease activity is difficult. A blood biomarker for disease activity would be useful. C-reactive protein (CRP) is a commonly used and well-established marker of inflammation in general. However, CRP does not reflect PsA disease activity itself. In a cross-sectional study, Gialouri and colleagues evaluated the association between CRP and PsA disease activity. CRP status (CRP  ≤  0.5 mg/dL [normal] and CRP > 0.5  mg/dL [increased]) was not associated with any of the clinical disease activity (clinical Disease Activity Index for Psoriatic Arthritis [cDAPSA] or minimal disease activity [MDA]) or patient-reported outcomes measures (Patient Global, Patient Pain, Health Assessment Questionnaire-Disability Index [HAQ-DI] or EuroQol [EQ-5D]). Among patients with normal CRP levels, a substantial proportion (45.9%) were not in MDA (thus, an indicator of active disease) while 76.7% of patients with elevated CRP were not in MDA. Therefore, an elevated CRP may indicate active PsA, but a normal CRP is not a reliable indicator of disease state in PsA.

Gender differences in PsA are increasingly being recognized as important. In a real-world survey of 2270 PsA patients (1047 women) from Europe and the United States, Gossec and colleagues demonstrated that, despite similar disease duration, disease presentation, and biologic use, women had worse quality-of-life, disability, and physical functioning scores, a greater degree of work activity impairment, and higher pain and fatigue scores compared with men. Thus, it is increasingly clear that PsA affects women differently from men. Interventions for the holistic management of PsA should be tailored according to the patient's gender for optimal outcomes.

Despite major advances in the treatment of adult PsA, the treatment options for children with PsA (juvenile PsA [JPsA]) are limited. Anti–tumor necrosis factor (TNF) agents are the only currently approved advanced therapy. Brunner and colleagues conducted a treatment-withdrawal, phase 3 study including 86 biologic-naive patients with active enthesitis-related arthritis (n = 52) or JPsA (n = 34) who were randomly assigned to receive secukinumab or placebo.

This study demonstrated that, compared with placebo, secukinumab was associated with a significant delay in disease flare and a higher proportion of patients achieving juvenile idiopathic arthritis American College of Rheumatology 30 response at week 104. This study provides evidence that secukinumab, a safe and effective therapy used in adult psoriatic disease, may provide similar benefits in JPsA, especially in patients who either have not responded to or have contraindications to treatment with anti-TNF agents.

Finally, because skin disease predates joint disease in almost 90% of PsA patients, identifying predictors for the development of joint disease is of considerable interest. It is hoped that identifying such predictors will help dermatologists and primary care physicians stratify management such that those at higher risk are carefully followed up for early diagnosis or even preventive therapy.

To identify such predictors, Ogdie and colleagues conducted a prospective study of 1489 patients with psoriasis and no prior diagnosis of PsA from the CorEvitas Psoriasis registry. They demonstrated that 10% of patients with psoriasis developed PsA after 2 years. Psoriasis Epidemiology Screening Tool (PEST, a brief screening questionnaire for PsA) and body mass index (BMI) were important factors predicting the development of PsA. Although the incidence of PsA in this cohort is higher than that reported from other studies, the study indicates that PEST and BMI should be important factors that predict PsA and should be variables in any prediction model.

As always, several provocative publications on colorectal cancer (CRC) have found their way into the medical literature. I will be discussing two of these in my Clinical Edge Journal Scan commentary for the month of October.

The first article, by Kennecke and colleagues, examines the role of neoadjuvant chemotherapy for early rectal cancer. We have been inundated with data showing that organ preservation is achievable in cases of node-positive rectal cancer with neoadjuvant chemoradiotherapy and chemotherapy (total neoadjuvant treatment [TNT] approach). As such, it stands to reason that organ preservation should also be achievable in cases of early, node-negative rectal cancer.

NEO was a single-arm, phase 2 trial examining the role of neoadjuvant chemotherapy only in early rectal cancer. In it, 58 patients with clinical T1-T3ab N0 low-to-mid rectal adenocarcinoma (proficient mismatch repair status) eligible for endoscopic resection were treated with 3 months of mFOLFOX6 (5-fluorouracil, leucovorin, and oxaliplatin) or CAPEOX (capecitabine and oxaliplatin). Those with evidence of tumor regression proceeded to transanal resection.

The primary endpoint was a protocol-specified organ preservation rate, defined as the proportion of patients with tumor downstaging to ypT0/T1 N0/X and who avoided radical surgery. Thirty-three (33) of the 58 patients were successfully downstaged, resulting in a protocol-specified organ preservation rate of 57% (90% CI 45-68). Of note, this treatment had no radiation at all and only used chemotherapy. Of the remaining 23 patients, 13 declined total mesorectal excision (TME) and went into observation. Of the 10 patients who underwent TME, seven had no histopathologic evidence of residual disease. The 1- and 2-year locoregional relapse-free survival rates were 98% (95% CI 86-100) and 90% (95% CI 58-98), respectively, and there were no metastatic recurrences or deaths. Although this is a small study, the results are enormously encouraging, suggesting that organ preservation not only can be achieved in early-stage rectal cancer, but also can be accomplished using only chemotherapy, further reducing morbidity to patients.

The second study I want to discuss was conducted by Ciardiello and colleagues and concerns the KRAS^G12C mutation in colorectal cancer. This mutation is targetable in lung cancer and has led to the approval of sotorasib for the treatment of advanced KRAS^G12C non–small-cell lung cancer . Unfortunately, previous studies of these inhibitors in advanced KRAS^G12C colorectal cancer have yielded disappointing results.

This study looked retrospectively at 6952 cases of metastatic colorectal cancer across Italy. A total of 256 cases (3.7%) demonstrated the KRAS^G12C mutation. Of those, 111 met inclusion criteria and were included in the analysis. Of note, this mutation was associated with a poor response to first-line chemotherapy (38.7%), with a median progression-free survival of 9 months (95% CI 7.5-10.5 months). Median overall survival was 21 months (95% CI 17.4-24.6 months). There was little difference between first-line oxaliplatin-containing regimens compared with those containing irinotecan. Triplet therapy (folinic acid, fluorouracil, oxaliplatin, and irinotecan; FOLFOXIRI) was associated with an objective response rate of 56.3% with a progression-free survival of 13 months and median overall survival of 32 months, suggesting that triplet therapy might be a better approach for these patients when they are identified. This study is important because it corroborates and builds upon data reported in smaller studies demonstrating the general resistance of KRAS^G12C metastatic colorectal cancer to chemotherapeutic treatments.

As always, several provocative publications on colorectal cancer (CRC) have found their way into the medical literature. I will be discussing two of these in my Clinical Edge Journal Scan commentary for the month of October.

The first article, by Kennecke and colleagues, examines the role of neoadjuvant chemotherapy for early rectal cancer. We have been inundated with data showing that organ preservation is achievable in cases of node-positive rectal cancer with neoadjuvant chemoradiotherapy and chemotherapy (total neoadjuvant treatment [TNT] approach). As such, it stands to reason that organ preservation should also be achievable in cases of early, node-negative rectal cancer.

NEO was a single-arm, phase 2 trial examining the role of neoadjuvant chemotherapy only in early rectal cancer. In it, 58 patients with clinical T1-T3ab N0 low-to-mid rectal adenocarcinoma (proficient mismatch repair status) eligible for endoscopic resection were treated with 3 months of mFOLFOX6 (5-fluorouracil, leucovorin, and oxaliplatin) or CAPEOX (capecitabine and oxaliplatin). Those with evidence of tumor regression proceeded to transanal resection.

The primary endpoint was a protocol-specified organ preservation rate, defined as the proportion of patients with tumor downstaging to ypT0/T1 N0/X and who avoided radical surgery. Thirty-three (33) of the 58 patients were successfully downstaged, resulting in a protocol-specified organ preservation rate of 57% (90% CI 45-68). Of note, this treatment had no radiation at all and only used chemotherapy. Of the remaining 23 patients, 13 declined total mesorectal excision (TME) and went into observation. Of the 10 patients who underwent TME, seven had no histopathologic evidence of residual disease. The 1- and 2-year locoregional relapse-free survival rates were 98% (95% CI 86-100) and 90% (95% CI 58-98), respectively, and there were no metastatic recurrences or deaths. Although this is a small study, the results are enormously encouraging, suggesting that organ preservation not only can be achieved in early-stage rectal cancer, but also can be accomplished using only chemotherapy, further reducing morbidity to patients.

The second study I want to discuss was conducted by Ciardiello and colleagues and concerns the KRAS^G12C mutation in colorectal cancer. This mutation is targetable in lung cancer and has led to the approval of sotorasib for the treatment of advanced KRAS^G12C non–small-cell lung cancer . Unfortunately, previous studies of these inhibitors in advanced KRAS^G12C colorectal cancer have yielded disappointing results.

This study looked retrospectively at 6952 cases of metastatic colorectal cancer across Italy. A total of 256 cases (3.7%) demonstrated the KRAS^G12C mutation. Of those, 111 met inclusion criteria and were included in the analysis. Of note, this mutation was associated with a poor response to first-line chemotherapy (38.7%), with a median progression-free survival of 9 months (95% CI 7.5-10.5 months). Median overall survival was 21 months (95% CI 17.4-24.6 months). There was little difference between first-line oxaliplatin-containing regimens compared with those containing irinotecan. Triplet therapy (folinic acid, fluorouracil, oxaliplatin, and irinotecan; FOLFOXIRI) was associated with an objective response rate of 56.3% with a progression-free survival of 13 months and median overall survival of 32 months, suggesting that triplet therapy might be a better approach for these patients when they are identified. This study is important because it corroborates and builds upon data reported in smaller studies demonstrating the general resistance of KRAS^G12C metastatic colorectal cancer to chemotherapeutic treatments.

As always, several provocative publications on colorectal cancer (CRC) have found their way into the medical literature. I will be discussing two of these in my Clinical Edge Journal Scan commentary for the month of October.

The first article, by Kennecke and colleagues, examines the role of neoadjuvant chemotherapy for early rectal cancer. We have been inundated with data showing that organ preservation is achievable in cases of node-positive rectal cancer with neoadjuvant chemoradiotherapy and chemotherapy (total neoadjuvant treatment [TNT] approach). As such, it stands to reason that organ preservation should also be achievable in cases of early, node-negative rectal cancer.

NEO was a single-arm, phase 2 trial examining the role of neoadjuvant chemotherapy only in early rectal cancer. In it, 58 patients with clinical T1-T3ab N0 low-to-mid rectal adenocarcinoma (proficient mismatch repair status) eligible for endoscopic resection were treated with 3 months of mFOLFOX6 (5-fluorouracil, leucovorin, and oxaliplatin) or CAPEOX (capecitabine and oxaliplatin). Those with evidence of tumor regression proceeded to transanal resection.

The primary endpoint was a protocol-specified organ preservation rate, defined as the proportion of patients with tumor downstaging to ypT0/T1 N0/X and who avoided radical surgery. Thirty-three (33) of the 58 patients were successfully downstaged, resulting in a protocol-specified organ preservation rate of 57% (90% CI 45-68). Of note, this treatment had no radiation at all and only used chemotherapy. Of the remaining 23 patients, 13 declined total mesorectal excision (TME) and went into observation. Of the 10 patients who underwent TME, seven had no histopathologic evidence of residual disease. The 1- and 2-year locoregional relapse-free survival rates were 98% (95% CI 86-100) and 90% (95% CI 58-98), respectively, and there were no metastatic recurrences or deaths. Although this is a small study, the results are enormously encouraging, suggesting that organ preservation not only can be achieved in early-stage rectal cancer, but also can be accomplished using only chemotherapy, further reducing morbidity to patients.

The second study I want to discuss was conducted by Ciardiello and colleagues and concerns the KRAS^G12C mutation in colorectal cancer. This mutation is targetable in lung cancer and has led to the approval of sotorasib for the treatment of advanced KRAS^G12C non–small-cell lung cancer . Unfortunately, previous studies of these inhibitors in advanced KRAS^G12C colorectal cancer have yielded disappointing results.

This study looked retrospectively at 6952 cases of metastatic colorectal cancer across Italy. A total of 256 cases (3.7%) demonstrated the KRAS^G12C mutation. Of those, 111 met inclusion criteria and were included in the analysis. Of note, this mutation was associated with a poor response to first-line chemotherapy (38.7%), with a median progression-free survival of 9 months (95% CI 7.5-10.5 months). Median overall survival was 21 months (95% CI 17.4-24.6 months). There was little difference between first-line oxaliplatin-containing regimens compared with those containing irinotecan. Triplet therapy (folinic acid, fluorouracil, oxaliplatin, and irinotecan; FOLFOXIRI) was associated with an objective response rate of 56.3% with a progression-free survival of 13 months and median overall survival of 32 months, suggesting that triplet therapy might be a better approach for these patients when they are identified. This study is important because it corroborates and builds upon data reported in smaller studies demonstrating the general resistance of KRAS^G12C metastatic colorectal cancer to chemotherapeutic treatments.

Interleukin (IL)–6 is known to be of great importance in the pathogenesis of rheumatoid arthritis (RA) owing to its role in the inflammatory response. Current IL-6-directed therapies in RA, namely sarilumab and tocilizumab, target the receptor. In a double-blind randomized controlled trial with both placebo and active comparators, Smolen and colleagues evaluated the efficacy of olokizumab, which directly binds and inhibits the activity of IL-6, in combination with methotrexate, in the treatment of people with RA. Patients were treated with methotrexate alone or in combination with adalimumab or olokizumab, and clinical outcomes were evaluated after 12 weeks, a relatively short time frame. Olokizumab was noninferior to adalimumab in terms of the proportion of patients achieving an American College of Rheumatology 20 response, with similar rates of serious adverse events, the most common of which was infection. Though this study included patients from across the globe, the percentage of Black and Asian patients was relatively low and thus may affect the generalizability of this study to a US population; the numbers of patients in each group was also relatively small. These results certainly warrant larger-scale and longer studies to evaluate olokizumab's efficacy.

For those patients with RA who achieve sustained disease remission, the question of medication tapering has been raised as a possible strategy for minimizing risks for therapy. Using insurance database information, Birkner and colleagues performed a prospective cohort study of over 400 patients in Germany. Using shared decision-making between patients and their rheumatologists, two groups of patients were followed: 237 people who elected to remain on therapy and 200 who decided to taper medication. Of note, similar proportions of patients in both groups were taking conventional and biologic disease-modifying antirheumatic drug (DMARD) monotherapy, but more patients in the tapering group were taking a combination therapy with both. Flares and loss of remission were more common in the continuation group, a difference that did not persist after adjusting for patient risk characteristics. Overall, results from this "real-world" study were consistent with prior studies and support the possibility of tapering with flare in a subset of patients. Although the authors address the potential for selection bias in terms of patients "assigned" to each group, this can also be viewed as part of the shared decision-making in determining the appropriateness of tapering therapy in individual patients.

Because people receiving rituximab have experienced more severe COVID-19, studies aimed at enhancing the protection of these patients are of current interest. Of note, in a follow-up to a prior observational study by van der Togt and colleagues on the response to COVID-19 vaccines in people with RA being treated with rituximab, they looked at responses to the third (booster) dose of the COVID-19 vaccine. Only about 20% of patients treated with rituximab developed a humoral response to a third vaccine dose, as defined by immunoglobulins (Ig; total, IgG, and IgM) against SARS-CoV-2. Patients treated with 200 mg rituximab had a higher response rate than did those treated with 500 mg or 1000 mg, though this difference was not statistically significant. The study lacked a control arm of people being treated with other DMARD and also did not measure B-cell counts, COVID-19, or outcomes. Reassuringly, those patients who did have a positive humoral response to the first two vaccine doses tended to maintain a humoral response to the third, regardless of rituximab dose or timing.

Interleukin (IL)–6 is known to be of great importance in the pathogenesis of rheumatoid arthritis (RA) owing to its role in the inflammatory response. Current IL-6-directed therapies in RA, namely sarilumab and tocilizumab, target the receptor. In a double-blind randomized controlled trial with both placebo and active comparators, Smolen and colleagues evaluated the efficacy of olokizumab, which directly binds and inhibits the activity of IL-6, in combination with methotrexate, in the treatment of people with RA. Patients were treated with methotrexate alone or in combination with adalimumab or olokizumab, and clinical outcomes were evaluated after 12 weeks, a relatively short time frame. Olokizumab was noninferior to adalimumab in terms of the proportion of patients achieving an American College of Rheumatology 20 response, with similar rates of serious adverse events, the most common of which was infection. Though this study included patients from across the globe, the percentage of Black and Asian patients was relatively low and thus may affect the generalizability of this study to a US population; the numbers of patients in each group was also relatively small. These results certainly warrant larger-scale and longer studies to evaluate olokizumab's efficacy.

For those patients with RA who achieve sustained disease remission, the question of medication tapering has been raised as a possible strategy for minimizing risks for therapy. Using insurance database information, Birkner and colleagues performed a prospective cohort study of over 400 patients in Germany. Using shared decision-making between patients and their rheumatologists, two groups of patients were followed: 237 people who elected to remain on therapy and 200 who decided to taper medication. Of note, similar proportions of patients in both groups were taking conventional and biologic disease-modifying antirheumatic drug (DMARD) monotherapy, but more patients in the tapering group were taking a combination therapy with both. Flares and loss of remission were more common in the continuation group, a difference that did not persist after adjusting for patient risk characteristics. Overall, results from this "real-world" study were consistent with prior studies and support the possibility of tapering with flare in a subset of patients. Although the authors address the potential for selection bias in terms of patients "assigned" to each group, this can also be viewed as part of the shared decision-making in determining the appropriateness of tapering therapy in individual patients.

Because people receiving rituximab have experienced more severe COVID-19, studies aimed at enhancing the protection of these patients are of current interest. Of note, in a follow-up to a prior observational study by van der Togt and colleagues on the response to COVID-19 vaccines in people with RA being treated with rituximab, they looked at responses to the third (booster) dose of the COVID-19 vaccine. Only about 20% of patients treated with rituximab developed a humoral response to a third vaccine dose, as defined by immunoglobulins (Ig; total, IgG, and IgM) against SARS-CoV-2. Patients treated with 200 mg rituximab had a higher response rate than did those treated with 500 mg or 1000 mg, though this difference was not statistically significant. The study lacked a control arm of people being treated with other DMARD and also did not measure B-cell counts, COVID-19, or outcomes. Reassuringly, those patients who did have a positive humoral response to the first two vaccine doses tended to maintain a humoral response to the third, regardless of rituximab dose or timing.

Interleukin (IL)–6 is known to be of great importance in the pathogenesis of rheumatoid arthritis (RA) owing to its role in the inflammatory response. Current IL-6-directed therapies in RA, namely sarilumab and tocilizumab, target the receptor. In a double-blind randomized controlled trial with both placebo and active comparators, Smolen and colleagues evaluated the efficacy of olokizumab, which directly binds and inhibits the activity of IL-6, in combination with methotrexate, in the treatment of people with RA. Patients were treated with methotrexate alone or in combination with adalimumab or olokizumab, and clinical outcomes were evaluated after 12 weeks, a relatively short time frame. Olokizumab was noninferior to adalimumab in terms of the proportion of patients achieving an American College of Rheumatology 20 response, with similar rates of serious adverse events, the most common of which was infection. Though this study included patients from across the globe, the percentage of Black and Asian patients was relatively low and thus may affect the generalizability of this study to a US population; the numbers of patients in each group was also relatively small. These results certainly warrant larger-scale and longer studies to evaluate olokizumab's efficacy.

For those patients with RA who achieve sustained disease remission, the question of medication tapering has been raised as a possible strategy for minimizing risks for therapy. Using insurance database information, Birkner and colleagues performed a prospective cohort study of over 400 patients in Germany. Using shared decision-making between patients and their rheumatologists, two groups of patients were followed: 237 people who elected to remain on therapy and 200 who decided to taper medication. Of note, similar proportions of patients in both groups were taking conventional and biologic disease-modifying antirheumatic drug (DMARD) monotherapy, but more patients in the tapering group were taking a combination therapy with both. Flares and loss of remission were more common in the continuation group, a difference that did not persist after adjusting for patient risk characteristics. Overall, results from this "real-world" study were consistent with prior studies and support the possibility of tapering with flare in a subset of patients. Although the authors address the potential for selection bias in terms of patients "assigned" to each group, this can also be viewed as part of the shared decision-making in determining the appropriateness of tapering therapy in individual patients.

Because people receiving rituximab have experienced more severe COVID-19, studies aimed at enhancing the protection of these patients are of current interest. Of note, in a follow-up to a prior observational study by van der Togt and colleagues on the response to COVID-19 vaccines in people with RA being treated with rituximab, they looked at responses to the third (booster) dose of the COVID-19 vaccine. Only about 20% of patients treated with rituximab developed a humoral response to a third vaccine dose, as defined by immunoglobulins (Ig; total, IgG, and IgM) against SARS-CoV-2. Patients treated with 200 mg rituximab had a higher response rate than did those treated with 500 mg or 1000 mg, though this difference was not statistically significant. The study lacked a control arm of people being treated with other DMARD and also did not measure B-cell counts, COVID-19, or outcomes. Reassuringly, those patients who did have a positive humoral response to the first two vaccine doses tended to maintain a humoral response to the third, regardless of rituximab dose or timing.

Dual-physician marriages are becoming increasingly common. The estimated median age of first marriage has been increasing; the US Census Bureau reported a median age of 30.4 years for men and 28.6 years for women in early 2021.¹ According to the Association of American Medical Colleges 2020 Matriculating Student Questionnaire, the median age at matriculation for medical students was 23 years (N=16,956), and 92.4% (N=15,932) reported their marital status as single and never legally married.² Thus, it is likely that the majority of physicians get married at some point during medical school or residency training. A survey of over 10,000 physicians in more than 29 specialties showed that 24% of female physicians and 15% of male physicians are married to other physicians.³

Challenges

There are common challenges to all dual-career households, including coordinating demanding career schedules that compete with each other, balancing childrearing with career advancement, and harmonizing economic and personal goals. However, there are challenges that can be amplified in and unique to dual-physician marriages.

The Couples Match—Medical students, trainees, and even physicians in later stages of their careers may have less autonomy over their schedules compared to professionals in other fields. An early obstacle that many dual-physician marriages must overcome is navigating the National Resident Matching Program as a couple. The number of individuals participating as a couple in the 2022 Main Residency Match was 2444, and the postgraduate year 1 (PGY-1) match rate for individuals participating as a couple was 93.7%. The overall PGY-1 match rate for MD seniors in the United States was 92.9%.⁴ Thus, entering the match as a couple does not necessarily pose a disadvantage to successfully matching, but these statistics may be misleading. When applicants participate in the Match as a couple, their rank order lists form pairs of program choices that are processed by the matching algorithm to match the couple to the most preferred pair of programs on their rank order lists where each partner has been offered a position. Although many couples coordinate their rank order lists geographically, there is no guarantee that the couple will actually match together in the same city, let alone in the same time zone. Also, the statistics do not take into account if an individual in the couple is only partially matched (eg, if one applicant matches to a preliminary year position but not to an advanced dermatology position). The couples’ Match is only available to partners in the same application cycle, and couples that are not in sync may be more restricted when applying for residency positions.

Lack of Synchronization—Dual-physician couples are challenged to achieve synchronization not only in their day-to-day lives but also over the course of their careers. After matching to residency, the dual-physician couple faces additional scheduling stressors during training. Varied demanding patient schedules and competing call schedules may take a toll on the ability to spend time together. Coordination between both training programs to ensure weekend schedules and vacations are aligned can be helpful to try to maximize time together. If the couple’s education is staggered, their training schedules may not align when proceeding to fellowship or starting off with a new job as an attending. It is not uncommon for couples in medicine to be long-distance for a period of time, and partners may find themselves sacrificing ideal positions or self-restricting application to certain programs or jobs to secure a position near a partner who is already in training in a certain geographic location.

Domestic Work-Life Balance—Juxtaposing 2 highly demanding careers in the same household can be associated with certain tensions, as the weight of household and childrearing responsibilities as well as professional productivity and advancement is divided by the couple. In a 2008 survey of the American College of Surgeons on burnout, work-home conflict, and career satisfaction, surgeons in dual-physician relationships experienced a recent career conflict with their domestic partner and a work-home conflict more often than surgeons whose partners were working nonphysicians.⁵ The hours worked between men and women in dual-physician families differed according to a national sample of 9868 physicians in dual-physician relationships. The study showed that weekly hours worked by women with children were lower than among those without children, whereas similar differences were not observed among men.⁶ It is not understood if this suggests that women in dual-physician families work fewer hours due to the pressures of historical gender norms and increased household responsibilities. A 1988 survey of female physicians (N=382) in which 247 respondents indicated that they had domestic partners showed that women physicians whose partners also were physicians (n=91) were more than twice as likely to interrupt their own careers for their partners’ careers compared to female physicians whose partners were not physicians (n=156)(25% vs 11%, respectively). In contrast, the male partners who were not physicians were significantly more likely to interrupt their careers than male partners who were physicians (41% vs 15%, respectively, P<.05).⁷

Divorce—There have been mixed reports on the incidence of divorce in physicians compared to the general population, but studies suggest that physicians’ marriages tend to be more stable than those of other societal groups.⁸ Of 203 respondents of a survey of female physician members of the Minnesota Medical Association who were or had been married to another physician, 11.3% (22/203) were divorced, and medicine was reported to play a role in 69.6% of those separations.⁹ A retrospective analysis of nationally representative surveys by the US Census showed that divorce among physicians is less common than among non–health care workers and several other health professions.¹⁰

Rewards

The benefits of medical marriages are multifold and include increased job satisfaction, stability, financial security, shared passions, and mutual understanding. Common passions and interests form the foundation for many relationships, which is true for the dual-physician marriage. In a 2009 study, Perlman et al¹¹ performed qualitative interviews with 25 physicians and their partners—10 of which were in dual-physician relationships—about the challenges and strengths of their relationships. A key theme that emerged during the interviews was the acknowledgment of the benefits of being a physician to the relationship. Participants discussed both the financial security in a physician marriage and the security that medical knowledge adds to a relationship when caring for ill or injured family members. Other key themes identified were relying on mutual support in the relationship, recognizing the important role of each family member, and having shared values.¹¹

Financial Security—The financial security attributed to being in a medical marriage was highlighted in a series of interviews with physicians and their spouses.¹¹ A cross-sectional survey of a random sample of physicians showed that both men and women in dual-physician families had lower personal incomes than physicians married to nonphysicians. However, men and women in dual-physician families had spouses with higher incomes compared to spouses of physicians married to nonphysicians. Thus, the total family incomes were substantially higher in dual-physician households than the family incomes of physicians married to nonphysicians.¹²

Satisfaction—Dual-physician marriages benefit from a shared camaraderie and understanding of the joys and sacrifices that accompany pursuing a career in medicine. Medical spouses can communicate in mutually understood medical jargon. Compared to physicians married to nonphysicians, a statistically significant difference (P<.001) was found in physicians in dual-physicians families who more frequently reported enjoyment in discussing work with their spouses and more frequently reported satisfaction from shared work interests with their spouses.¹²

Final Thoughts

From the start of medical training, physicians and physicians-in-training experience unique benefits and challenges that are compounded in distinctive ways when 2 physicians get married. In an era where dual-physician marriage is becoming more common, it is important to acknowledge how this can both enrich and challenge the relationship.

Acknowledgment—The author thanks her husband Joshua L. Weinstock, MD (Camden, New Jersey), for his contribution to this article and their marriage.

Dual-physician marriages are becoming increasingly common. The estimated median age of first marriage has been increasing; the US Census Bureau reported a median age of 30.4 years for men and 28.6 years for women in early 2021.¹ According to the Association of American Medical Colleges 2020 Matriculating Student Questionnaire, the median age at matriculation for medical students was 23 years (N=16,956), and 92.4% (N=15,932) reported their marital status as single and never legally married.² Thus, it is likely that the majority of physicians get married at some point during medical school or residency training. A survey of over 10,000 physicians in more than 29 specialties showed that 24% of female physicians and 15% of male physicians are married to other physicians.³

Challenges

There are common challenges to all dual-career households, including coordinating demanding career schedules that compete with each other, balancing childrearing with career advancement, and harmonizing economic and personal goals. However, there are challenges that can be amplified in and unique to dual-physician marriages.

The Couples Match—Medical students, trainees, and even physicians in later stages of their careers may have less autonomy over their schedules compared to professionals in other fields. An early obstacle that many dual-physician marriages must overcome is navigating the National Resident Matching Program as a couple. The number of individuals participating as a couple in the 2022 Main Residency Match was 2444, and the postgraduate year 1 (PGY-1) match rate for individuals participating as a couple was 93.7%. The overall PGY-1 match rate for MD seniors in the United States was 92.9%.⁴ Thus, entering the match as a couple does not necessarily pose a disadvantage to successfully matching, but these statistics may be misleading. When applicants participate in the Match as a couple, their rank order lists form pairs of program choices that are processed by the matching algorithm to match the couple to the most preferred pair of programs on their rank order lists where each partner has been offered a position. Although many couples coordinate their rank order lists geographically, there is no guarantee that the couple will actually match together in the same city, let alone in the same time zone. Also, the statistics do not take into account if an individual in the couple is only partially matched (eg, if one applicant matches to a preliminary year position but not to an advanced dermatology position). The couples’ Match is only available to partners in the same application cycle, and couples that are not in sync may be more restricted when applying for residency positions.

Lack of Synchronization—Dual-physician couples are challenged to achieve synchronization not only in their day-to-day lives but also over the course of their careers. After matching to residency, the dual-physician couple faces additional scheduling stressors during training. Varied demanding patient schedules and competing call schedules may take a toll on the ability to spend time together. Coordination between both training programs to ensure weekend schedules and vacations are aligned can be helpful to try to maximize time together. If the couple’s education is staggered, their training schedules may not align when proceeding to fellowship or starting off with a new job as an attending. It is not uncommon for couples in medicine to be long-distance for a period of time, and partners may find themselves sacrificing ideal positions or self-restricting application to certain programs or jobs to secure a position near a partner who is already in training in a certain geographic location.

Domestic Work-Life Balance—Juxtaposing 2 highly demanding careers in the same household can be associated with certain tensions, as the weight of household and childrearing responsibilities as well as professional productivity and advancement is divided by the couple. In a 2008 survey of the American College of Surgeons on burnout, work-home conflict, and career satisfaction, surgeons in dual-physician relationships experienced a recent career conflict with their domestic partner and a work-home conflict more often than surgeons whose partners were working nonphysicians.⁵ The hours worked between men and women in dual-physician families differed according to a national sample of 9868 physicians in dual-physician relationships. The study showed that weekly hours worked by women with children were lower than among those without children, whereas similar differences were not observed among men.⁶ It is not understood if this suggests that women in dual-physician families work fewer hours due to the pressures of historical gender norms and increased household responsibilities. A 1988 survey of female physicians (N=382) in which 247 respondents indicated that they had domestic partners showed that women physicians whose partners also were physicians (n=91) were more than twice as likely to interrupt their own careers for their partners’ careers compared to female physicians whose partners were not physicians (n=156)(25% vs 11%, respectively). In contrast, the male partners who were not physicians were significantly more likely to interrupt their careers than male partners who were physicians (41% vs 15%, respectively, P<.05).⁷

Divorce—There have been mixed reports on the incidence of divorce in physicians compared to the general population, but studies suggest that physicians’ marriages tend to be more stable than those of other societal groups.⁸ Of 203 respondents of a survey of female physician members of the Minnesota Medical Association who were or had been married to another physician, 11.3% (22/203) were divorced, and medicine was reported to play a role in 69.6% of those separations.⁹ A retrospective analysis of nationally representative surveys by the US Census showed that divorce among physicians is less common than among non–health care workers and several other health professions.¹⁰

Rewards

The benefits of medical marriages are multifold and include increased job satisfaction, stability, financial security, shared passions, and mutual understanding. Common passions and interests form the foundation for many relationships, which is true for the dual-physician marriage. In a 2009 study, Perlman et al¹¹ performed qualitative interviews with 25 physicians and their partners—10 of which were in dual-physician relationships—about the challenges and strengths of their relationships. A key theme that emerged during the interviews was the acknowledgment of the benefits of being a physician to the relationship. Participants discussed both the financial security in a physician marriage and the security that medical knowledge adds to a relationship when caring for ill or injured family members. Other key themes identified were relying on mutual support in the relationship, recognizing the important role of each family member, and having shared values.¹¹

Financial Security—The financial security attributed to being in a medical marriage was highlighted in a series of interviews with physicians and their spouses.¹¹ A cross-sectional survey of a random sample of physicians showed that both men and women in dual-physician families had lower personal incomes than physicians married to nonphysicians. However, men and women in dual-physician families had spouses with higher incomes compared to spouses of physicians married to nonphysicians. Thus, the total family incomes were substantially higher in dual-physician households than the family incomes of physicians married to nonphysicians.¹²

Satisfaction—Dual-physician marriages benefit from a shared camaraderie and understanding of the joys and sacrifices that accompany pursuing a career in medicine. Medical spouses can communicate in mutually understood medical jargon. Compared to physicians married to nonphysicians, a statistically significant difference (P<.001) was found in physicians in dual-physicians families who more frequently reported enjoyment in discussing work with their spouses and more frequently reported satisfaction from shared work interests with their spouses.¹²

Final Thoughts

From the start of medical training, physicians and physicians-in-training experience unique benefits and challenges that are compounded in distinctive ways when 2 physicians get married. In an era where dual-physician marriage is becoming more common, it is important to acknowledge how this can both enrich and challenge the relationship.

Acknowledgment—The author thanks her husband Joshua L. Weinstock, MD (Camden, New Jersey), for his contribution to this article and their marriage.

Dual-physician marriages are becoming increasingly common. The estimated median age of first marriage has been increasing; the US Census Bureau reported a median age of 30.4 years for men and 28.6 years for women in early 2021.¹ According to the Association of American Medical Colleges 2020 Matriculating Student Questionnaire, the median age at matriculation for medical students was 23 years (N=16,956), and 92.4% (N=15,932) reported their marital status as single and never legally married.² Thus, it is likely that the majority of physicians get married at some point during medical school or residency training. A survey of over 10,000 physicians in more than 29 specialties showed that 24% of female physicians and 15% of male physicians are married to other physicians.³

Challenges

There are common challenges to all dual-career households, including coordinating demanding career schedules that compete with each other, balancing childrearing with career advancement, and harmonizing economic and personal goals. However, there are challenges that can be amplified in and unique to dual-physician marriages.

The Couples Match—Medical students, trainees, and even physicians in later stages of their careers may have less autonomy over their schedules compared to professionals in other fields. An early obstacle that many dual-physician marriages must overcome is navigating the National Resident Matching Program as a couple. The number of individuals participating as a couple in the 2022 Main Residency Match was 2444, and the postgraduate year 1 (PGY-1) match rate for individuals participating as a couple was 93.7%. The overall PGY-1 match rate for MD seniors in the United States was 92.9%.⁴ Thus, entering the match as a couple does not necessarily pose a disadvantage to successfully matching, but these statistics may be misleading. When applicants participate in the Match as a couple, their rank order lists form pairs of program choices that are processed by the matching algorithm to match the couple to the most preferred pair of programs on their rank order lists where each partner has been offered a position. Although many couples coordinate their rank order lists geographically, there is no guarantee that the couple will actually match together in the same city, let alone in the same time zone. Also, the statistics do not take into account if an individual in the couple is only partially matched (eg, if one applicant matches to a preliminary year position but not to an advanced dermatology position). The couples’ Match is only available to partners in the same application cycle, and couples that are not in sync may be more restricted when applying for residency positions.

Lack of Synchronization—Dual-physician couples are challenged to achieve synchronization not only in their day-to-day lives but also over the course of their careers. After matching to residency, the dual-physician couple faces additional scheduling stressors during training. Varied demanding patient schedules and competing call schedules may take a toll on the ability to spend time together. Coordination between both training programs to ensure weekend schedules and vacations are aligned can be helpful to try to maximize time together. If the couple’s education is staggered, their training schedules may not align when proceeding to fellowship or starting off with a new job as an attending. It is not uncommon for couples in medicine to be long-distance for a period of time, and partners may find themselves sacrificing ideal positions or self-restricting application to certain programs or jobs to secure a position near a partner who is already in training in a certain geographic location.

Domestic Work-Life Balance—Juxtaposing 2 highly demanding careers in the same household can be associated with certain tensions, as the weight of household and childrearing responsibilities as well as professional productivity and advancement is divided by the couple. In a 2008 survey of the American College of Surgeons on burnout, work-home conflict, and career satisfaction, surgeons in dual-physician relationships experienced a recent career conflict with their domestic partner and a work-home conflict more often than surgeons whose partners were working nonphysicians.⁵ The hours worked between men and women in dual-physician families differed according to a national sample of 9868 physicians in dual-physician relationships. The study showed that weekly hours worked by women with children were lower than among those without children, whereas similar differences were not observed among men.⁶ It is not understood if this suggests that women in dual-physician families work fewer hours due to the pressures of historical gender norms and increased household responsibilities. A 1988 survey of female physicians (N=382) in which 247 respondents indicated that they had domestic partners showed that women physicians whose partners also were physicians (n=91) were more than twice as likely to interrupt their own careers for their partners’ careers compared to female physicians whose partners were not physicians (n=156)(25% vs 11%, respectively). In contrast, the male partners who were not physicians were significantly more likely to interrupt their careers than male partners who were physicians (41% vs 15%, respectively, P<.05).⁷

Divorce—There have been mixed reports on the incidence of divorce in physicians compared to the general population, but studies suggest that physicians’ marriages tend to be more stable than those of other societal groups.⁸ Of 203 respondents of a survey of female physician members of the Minnesota Medical Association who were or had been married to another physician, 11.3% (22/203) were divorced, and medicine was reported to play a role in 69.6% of those separations.⁹ A retrospective analysis of nationally representative surveys by the US Census showed that divorce among physicians is less common than among non–health care workers and several other health professions.¹⁰

Rewards

The benefits of medical marriages are multifold and include increased job satisfaction, stability, financial security, shared passions, and mutual understanding. Common passions and interests form the foundation for many relationships, which is true for the dual-physician marriage. In a 2009 study, Perlman et al¹¹ performed qualitative interviews with 25 physicians and their partners—10 of which were in dual-physician relationships—about the challenges and strengths of their relationships. A key theme that emerged during the interviews was the acknowledgment of the benefits of being a physician to the relationship. Participants discussed both the financial security in a physician marriage and the security that medical knowledge adds to a relationship when caring for ill or injured family members. Other key themes identified were relying on mutual support in the relationship, recognizing the important role of each family member, and having shared values.¹¹

Financial Security—The financial security attributed to being in a medical marriage was highlighted in a series of interviews with physicians and their spouses.¹¹ A cross-sectional survey of a random sample of physicians showed that both men and women in dual-physician families had lower personal incomes than physicians married to nonphysicians. However, men and women in dual-physician families had spouses with higher incomes compared to spouses of physicians married to nonphysicians. Thus, the total family incomes were substantially higher in dual-physician households than the family incomes of physicians married to nonphysicians.¹²

Satisfaction—Dual-physician marriages benefit from a shared camaraderie and understanding of the joys and sacrifices that accompany pursuing a career in medicine. Medical spouses can communicate in mutually understood medical jargon. Compared to physicians married to nonphysicians, a statistically significant difference (P<.001) was found in physicians in dual-physicians families who more frequently reported enjoyment in discussing work with their spouses and more frequently reported satisfaction from shared work interests with their spouses.¹²

Final Thoughts

From the start of medical training, physicians and physicians-in-training experience unique benefits and challenges that are compounded in distinctive ways when 2 physicians get married. In an era where dual-physician marriage is becoming more common, it is important to acknowledge how this can both enrich and challenge the relationship.

Acknowledgment—The author thanks her husband Joshua L. Weinstock, MD (Camden, New Jersey), for his contribution to this article and their marriage.

To the Editor:

In a 2010 landmark paper, researchers reported that the Preexposure Prophylaxis Initiative (iPrEx) trial demonstrated that once-daily pre-exposure prophylaxis (PrEP) with emtricitabine plus tenofovir disoproxil fumarate, which was approved by the US Food and Drug Administration (FDA) and packaged together as Truvada (Gilead Sciences, Inc), achieved a 44% reduction in the incidence of HIV infection compared to the placebo arm of the study (64/1248 HIV infections in the placebo group vs 36/1251 in the intervention group).¹ Subsequently, the US Department of Health and Human Services proposed an initiative to reduce new HIV infections by 90% by 2030.² The Centers for Disease Control and Prevention estimates that 1.1 million Americans have an indication for PrEP, yet only approximately 400,000 individuals currently take PrEP.^3,4

Increasing awareness of PrEP and its indications is essential because PrEP exerts its greatest benefit when used broadly. Awareness among primary care and infectious disease physicians was reported at 76%⁵; awareness among other medical specialists remains unknown. Awareness of PrEP among dermatologists is important because dermatologists play an important role in the diagnosis and treatment of many sexually transmitted infections (STIs), which are a risk factor for transmission of HIV. As providers who treat STIs, dermatologists are in a prime position to educate patients about PrEP, refer them for treatment, and prescribe the regimen. We conducted a survey to assess dermatologists’ knowledge about and attitudes toward PrEP. We also provide a brief summary of prescribing information about common PrEP regimens to fill in the knowledge gap among dermatologists as a way to promote its utilization.

An electronic survey was distributed to 486 members of the Association of Professors of Dermatology based in the United States using the web-based survey application REDCap. The study was approved by the New York University Grossman School of Medicine (New York, New York) institutional review board. Eighty-one anonymous survey responses were completed and returned (response rate, 16.6%). Data were analyzed using descriptive statistics.

The mean age (SD) of respondents was 39.1 (9.7) years; 49.4% (40/81) were male; and 74.1% (60/81) were attending physicians, with a mean (SD) of 9.4 (8.6) years of practice. Clinical practices were predominantly from the northeast (46.9% [38/81]) and mostly in an academic setting (74.1% [60/81]). As shown in Table 1, most surveyed dermatologists reported being aware of PrEP (93.8% [76/81]), but a minority (42.0% [34/81]) were familiar with indications for its use; even fewer (4.9% [4/81]) were current prescribers. Referral to other physicians for PrEP was reported by 58.0% (47/81) of respondents.

Despite respondents’ awareness of PrEP as a preventive measure (93.8% [76/81]) and their willingness to prescribe it (67.9% [55/81]), many reported being largely unfamiliar with its indications (58.0% [47/81]) and uncomfortable discussing its adverse effects (72.8% [59/81]), conducting appropriate laboratory monitoring (84.0% [68/81]), and refilling existing prescriptions (77.8% [63/81]). Respondents’ lack of education about PrEP was a barrier to prescribing (51.9% [42/81] to 59.3% [48/81]) and explains why a small minority (4.9% [4/81]) currently prescribe the regimen.

Our study sought to characterize current clinical knowledge about and practice patterns of PrEP among dermatologists. Dermatologists often encounter patients who present with an STI, which is a risk factor for HIV infection, but our survey respondents reported several barriers to utilizing PrEP. The difference in the degree of respondents’ willingness to prescribe PrEP (67.9%) and those who self-identified as prescribers (4.9%) suggests a role for dermatologists in prescribing or discussing PrEP with their patients—albeit a currently undefined role.

The results of our study suggested that half (41/81) of dermatologists believe that PrEP prescription is out of their scope of practice, likely due to a combination of scheduling, laboratory monitoring, and medicolegal concerns. For dermatologists who are interested in being PrEP prescribers, our results suggested that closing the knowledge gap around PrEP among dermatologists through training and education could improve comfort with this medication and lead to changes in practice to prevent the spread of HIV infection.

PrEP is indicated for HIV-negative patients who have HIV-positive sexual partners, utilize barrier protection methods inconsistently, or had a diagnosis of an STI in the last 6 months.⁶ In 2012, the FDA approved once-daily use of emtricitabine plus tenofovir for primary prevention of HIV infection. Post hoc analysis of iPrEx trial data revealed that once-daily PrEP taken regularly had a 92% to 100% protective effect against HIV.⁷

Regrettably, real-world uptake of PrEP has been slower than desired. The most recent data (2021) show that nearly 1 million individuals worldwide take PrEP; however, this represents only approximately one-third of those eligible.⁸ Utilization is notably lower among Black and Latino populations who stand to gain the most from PrEP given their higher risk of contracting HIV compared to their White counterparts.⁹ As such, improving access to PrEP through expanded provider awareness is essential to decrease the risk for HIV infection and transmission.

Emtricitabine plus tenofovir is safe and well tolerated; more common adverse effects are headache, nausea, vomiting, rash, and loss of appetite. Tenofovir likely decreases bone mineral density, even in HIV-negative patients¹⁰; mineralization seems to recover after the medication is discontinued.¹¹ Rarely, tenofovir can increase the level of creatinine and hepatic transaminases; a recent report on its long-term side effects has shown small nonprogressive decreases in glomerular filtration rate.¹² Monitoring kidney function is a component of prescribing PrEP (Table 2).

In 2019, emtricitabine plus tenofovir was reformulated with tenofovir alafenamide; the new combination regimen received FDA approval for once-daily PrEP under the brand name Descovy (Gilead Sciences, Inc). The new formulation results in a lower blood concentration of tenofovir and has been reported to present less of a risk for bone and kidney toxicity.^13,14

Notably, emtricitabine plus tenofovir alafenamide might accumulate faster in peripheral lymphatic tissue than emtricitabine plus tenofovir disoproxil fumarate. This property has led to a new regimen known as “on-demand PrEP,” which follows a 2-1-1 dosing regimen: Patients take a double dose 2 to 24 hours before sexual activity, 1 dose on the day of sexual activity, and 1 dose the day after sexual activity.¹⁵ Because some patients at risk for HIV infection might not be consistently sexually active, on-demand PrEP allows them to cycle on and off the medication. Barriers to implementing on-demand PrEP include requiring that sexual activity be planned and an adverse effect profile similar to daily-use PrEP.¹⁶

The FDA recently approved a long-acting, once-monthly combination injectable PrEP of cabotegravir and rilpivirine.¹⁷ The long duration of action of this PrEP will benefit patients who report problems with medication adherence.

Our study demonstrates low frequency in prescribing patterns of PrEP among dermatologists and suggests that an addressable barrier to such prescribing is the lack of knowledge on how to prescribe it safely, which warrants further clinical investigation. We summarize an approach to prescribing PrEP in Table 2. Our study was limited by a small sample of mostly academic dermatologists and selection bias, which may diminish the generalizability of findings. A study of a larger, more representative group of dermatologists likely would show different prescribing patterns and degrees of knowledge about PrEP. Research is needed to study the impact of educational interventions that aim to increase both knowledge and prescribing of PrEP among dermatologists.

To the Editor:

In a 2010 landmark paper, researchers reported that the Preexposure Prophylaxis Initiative (iPrEx) trial demonstrated that once-daily pre-exposure prophylaxis (PrEP) with emtricitabine plus tenofovir disoproxil fumarate, which was approved by the US Food and Drug Administration (FDA) and packaged together as Truvada (Gilead Sciences, Inc), achieved a 44% reduction in the incidence of HIV infection compared to the placebo arm of the study (64/1248 HIV infections in the placebo group vs 36/1251 in the intervention group).¹ Subsequently, the US Department of Health and Human Services proposed an initiative to reduce new HIV infections by 90% by 2030.² The Centers for Disease Control and Prevention estimates that 1.1 million Americans have an indication for PrEP, yet only approximately 400,000 individuals currently take PrEP.^3,4

Increasing awareness of PrEP and its indications is essential because PrEP exerts its greatest benefit when used broadly. Awareness among primary care and infectious disease physicians was reported at 76%⁵; awareness among other medical specialists remains unknown. Awareness of PrEP among dermatologists is important because dermatologists play an important role in the diagnosis and treatment of many sexually transmitted infections (STIs), which are a risk factor for transmission of HIV. As providers who treat STIs, dermatologists are in a prime position to educate patients about PrEP, refer them for treatment, and prescribe the regimen. We conducted a survey to assess dermatologists’ knowledge about and attitudes toward PrEP. We also provide a brief summary of prescribing information about common PrEP regimens to fill in the knowledge gap among dermatologists as a way to promote its utilization.

An electronic survey was distributed to 486 members of the Association of Professors of Dermatology based in the United States using the web-based survey application REDCap. The study was approved by the New York University Grossman School of Medicine (New York, New York) institutional review board. Eighty-one anonymous survey responses were completed and returned (response rate, 16.6%). Data were analyzed using descriptive statistics.

The mean age (SD) of respondents was 39.1 (9.7) years; 49.4% (40/81) were male; and 74.1% (60/81) were attending physicians, with a mean (SD) of 9.4 (8.6) years of practice. Clinical practices were predominantly from the northeast (46.9% [38/81]) and mostly in an academic setting (74.1% [60/81]). As shown in Table 1, most surveyed dermatologists reported being aware of PrEP (93.8% [76/81]), but a minority (42.0% [34/81]) were familiar with indications for its use; even fewer (4.9% [4/81]) were current prescribers. Referral to other physicians for PrEP was reported by 58.0% (47/81) of respondents.

Despite respondents’ awareness of PrEP as a preventive measure (93.8% [76/81]) and their willingness to prescribe it (67.9% [55/81]), many reported being largely unfamiliar with its indications (58.0% [47/81]) and uncomfortable discussing its adverse effects (72.8% [59/81]), conducting appropriate laboratory monitoring (84.0% [68/81]), and refilling existing prescriptions (77.8% [63/81]). Respondents’ lack of education about PrEP was a barrier to prescribing (51.9% [42/81] to 59.3% [48/81]) and explains why a small minority (4.9% [4/81]) currently prescribe the regimen.

Our study sought to characterize current clinical knowledge about and practice patterns of PrEP among dermatologists. Dermatologists often encounter patients who present with an STI, which is a risk factor for HIV infection, but our survey respondents reported several barriers to utilizing PrEP. The difference in the degree of respondents’ willingness to prescribe PrEP (67.9%) and those who self-identified as prescribers (4.9%) suggests a role for dermatologists in prescribing or discussing PrEP with their patients—albeit a currently undefined role.

The results of our study suggested that half (41/81) of dermatologists believe that PrEP prescription is out of their scope of practice, likely due to a combination of scheduling, laboratory monitoring, and medicolegal concerns. For dermatologists who are interested in being PrEP prescribers, our results suggested that closing the knowledge gap around PrEP among dermatologists through training and education could improve comfort with this medication and lead to changes in practice to prevent the spread of HIV infection.

PrEP is indicated for HIV-negative patients who have HIV-positive sexual partners, utilize barrier protection methods inconsistently, or had a diagnosis of an STI in the last 6 months.⁶ In 2012, the FDA approved once-daily use of emtricitabine plus tenofovir for primary prevention of HIV infection. Post hoc analysis of iPrEx trial data revealed that once-daily PrEP taken regularly had a 92% to 100% protective effect against HIV.⁷

Regrettably, real-world uptake of PrEP has been slower than desired. The most recent data (2021) show that nearly 1 million individuals worldwide take PrEP; however, this represents only approximately one-third of those eligible.⁸ Utilization is notably lower among Black and Latino populations who stand to gain the most from PrEP given their higher risk of contracting HIV compared to their White counterparts.⁹ As such, improving access to PrEP through expanded provider awareness is essential to decrease the risk for HIV infection and transmission.

Emtricitabine plus tenofovir is safe and well tolerated; more common adverse effects are headache, nausea, vomiting, rash, and loss of appetite. Tenofovir likely decreases bone mineral density, even in HIV-negative patients¹⁰; mineralization seems to recover after the medication is discontinued.¹¹ Rarely, tenofovir can increase the level of creatinine and hepatic transaminases; a recent report on its long-term side effects has shown small nonprogressive decreases in glomerular filtration rate.¹² Monitoring kidney function is a component of prescribing PrEP (Table 2).

In 2019, emtricitabine plus tenofovir was reformulated with tenofovir alafenamide; the new combination regimen received FDA approval for once-daily PrEP under the brand name Descovy (Gilead Sciences, Inc). The new formulation results in a lower blood concentration of tenofovir and has been reported to present less of a risk for bone and kidney toxicity.^13,14

Notably, emtricitabine plus tenofovir alafenamide might accumulate faster in peripheral lymphatic tissue than emtricitabine plus tenofovir disoproxil fumarate. This property has led to a new regimen known as “on-demand PrEP,” which follows a 2-1-1 dosing regimen: Patients take a double dose 2 to 24 hours before sexual activity, 1 dose on the day of sexual activity, and 1 dose the day after sexual activity.¹⁵ Because some patients at risk for HIV infection might not be consistently sexually active, on-demand PrEP allows them to cycle on and off the medication. Barriers to implementing on-demand PrEP include requiring that sexual activity be planned and an adverse effect profile similar to daily-use PrEP.¹⁶

The FDA recently approved a long-acting, once-monthly combination injectable PrEP of cabotegravir and rilpivirine.¹⁷ The long duration of action of this PrEP will benefit patients who report problems with medication adherence.

Our study demonstrates low frequency in prescribing patterns of PrEP among dermatologists and suggests that an addressable barrier to such prescribing is the lack of knowledge on how to prescribe it safely, which warrants further clinical investigation. We summarize an approach to prescribing PrEP in Table 2. Our study was limited by a small sample of mostly academic dermatologists and selection bias, which may diminish the generalizability of findings. A study of a larger, more representative group of dermatologists likely would show different prescribing patterns and degrees of knowledge about PrEP. Research is needed to study the impact of educational interventions that aim to increase both knowledge and prescribing of PrEP among dermatologists.

To the Editor:

In a 2010 landmark paper, researchers reported that the Preexposure Prophylaxis Initiative (iPrEx) trial demonstrated that once-daily pre-exposure prophylaxis (PrEP) with emtricitabine plus tenofovir disoproxil fumarate, which was approved by the US Food and Drug Administration (FDA) and packaged together as Truvada (Gilead Sciences, Inc), achieved a 44% reduction in the incidence of HIV infection compared to the placebo arm of the study (64/1248 HIV infections in the placebo group vs 36/1251 in the intervention group).¹ Subsequently, the US Department of Health and Human Services proposed an initiative to reduce new HIV infections by 90% by 2030.² The Centers for Disease Control and Prevention estimates that 1.1 million Americans have an indication for PrEP, yet only approximately 400,000 individuals currently take PrEP.^3,4

Increasing awareness of PrEP and its indications is essential because PrEP exerts its greatest benefit when used broadly. Awareness among primary care and infectious disease physicians was reported at 76%⁵; awareness among other medical specialists remains unknown. Awareness of PrEP among dermatologists is important because dermatologists play an important role in the diagnosis and treatment of many sexually transmitted infections (STIs), which are a risk factor for transmission of HIV. As providers who treat STIs, dermatologists are in a prime position to educate patients about PrEP, refer them for treatment, and prescribe the regimen. We conducted a survey to assess dermatologists’ knowledge about and attitudes toward PrEP. We also provide a brief summary of prescribing information about common PrEP regimens to fill in the knowledge gap among dermatologists as a way to promote its utilization.

An electronic survey was distributed to 486 members of the Association of Professors of Dermatology based in the United States using the web-based survey application REDCap. The study was approved by the New York University Grossman School of Medicine (New York, New York) institutional review board. Eighty-one anonymous survey responses were completed and returned (response rate, 16.6%). Data were analyzed using descriptive statistics.

The mean age (SD) of respondents was 39.1 (9.7) years; 49.4% (40/81) were male; and 74.1% (60/81) were attending physicians, with a mean (SD) of 9.4 (8.6) years of practice. Clinical practices were predominantly from the northeast (46.9% [38/81]) and mostly in an academic setting (74.1% [60/81]). As shown in Table 1, most surveyed dermatologists reported being aware of PrEP (93.8% [76/81]), but a minority (42.0% [34/81]) were familiar with indications for its use; even fewer (4.9% [4/81]) were current prescribers. Referral to other physicians for PrEP was reported by 58.0% (47/81) of respondents.

Despite respondents’ awareness of PrEP as a preventive measure (93.8% [76/81]) and their willingness to prescribe it (67.9% [55/81]), many reported being largely unfamiliar with its indications (58.0% [47/81]) and uncomfortable discussing its adverse effects (72.8% [59/81]), conducting appropriate laboratory monitoring (84.0% [68/81]), and refilling existing prescriptions (77.8% [63/81]). Respondents’ lack of education about PrEP was a barrier to prescribing (51.9% [42/81] to 59.3% [48/81]) and explains why a small minority (4.9% [4/81]) currently prescribe the regimen.

Our study sought to characterize current clinical knowledge about and practice patterns of PrEP among dermatologists. Dermatologists often encounter patients who present with an STI, which is a risk factor for HIV infection, but our survey respondents reported several barriers to utilizing PrEP. The difference in the degree of respondents’ willingness to prescribe PrEP (67.9%) and those who self-identified as prescribers (4.9%) suggests a role for dermatologists in prescribing or discussing PrEP with their patients—albeit a currently undefined role.

The results of our study suggested that half (41/81) of dermatologists believe that PrEP prescription is out of their scope of practice, likely due to a combination of scheduling, laboratory monitoring, and medicolegal concerns. For dermatologists who are interested in being PrEP prescribers, our results suggested that closing the knowledge gap around PrEP among dermatologists through training and education could improve comfort with this medication and lead to changes in practice to prevent the spread of HIV infection.

PrEP is indicated for HIV-negative patients who have HIV-positive sexual partners, utilize barrier protection methods inconsistently, or had a diagnosis of an STI in the last 6 months.⁶ In 2012, the FDA approved once-daily use of emtricitabine plus tenofovir for primary prevention of HIV infection. Post hoc analysis of iPrEx trial data revealed that once-daily PrEP taken regularly had a 92% to 100% protective effect against HIV.⁷

Regrettably, real-world uptake of PrEP has been slower than desired. The most recent data (2021) show that nearly 1 million individuals worldwide take PrEP; however, this represents only approximately one-third of those eligible.⁸ Utilization is notably lower among Black and Latino populations who stand to gain the most from PrEP given their higher risk of contracting HIV compared to their White counterparts.⁹ As such, improving access to PrEP through expanded provider awareness is essential to decrease the risk for HIV infection and transmission.

Emtricitabine plus tenofovir is safe and well tolerated; more common adverse effects are headache, nausea, vomiting, rash, and loss of appetite. Tenofovir likely decreases bone mineral density, even in HIV-negative patients¹⁰; mineralization seems to recover after the medication is discontinued.¹¹ Rarely, tenofovir can increase the level of creatinine and hepatic transaminases; a recent report on its long-term side effects has shown small nonprogressive decreases in glomerular filtration rate.¹² Monitoring kidney function is a component of prescribing PrEP (Table 2).

In 2019, emtricitabine plus tenofovir was reformulated with tenofovir alafenamide; the new combination regimen received FDA approval for once-daily PrEP under the brand name Descovy (Gilead Sciences, Inc). The new formulation results in a lower blood concentration of tenofovir and has been reported to present less of a risk for bone and kidney toxicity.^13,14

Notably, emtricitabine plus tenofovir alafenamide might accumulate faster in peripheral lymphatic tissue than emtricitabine plus tenofovir disoproxil fumarate. This property has led to a new regimen known as “on-demand PrEP,” which follows a 2-1-1 dosing regimen: Patients take a double dose 2 to 24 hours before sexual activity, 1 dose on the day of sexual activity, and 1 dose the day after sexual activity.¹⁵ Because some patients at risk for HIV infection might not be consistently sexually active, on-demand PrEP allows them to cycle on and off the medication. Barriers to implementing on-demand PrEP include requiring that sexual activity be planned and an adverse effect profile similar to daily-use PrEP.¹⁶

The FDA recently approved a long-acting, once-monthly combination injectable PrEP of cabotegravir and rilpivirine.¹⁷ The long duration of action of this PrEP will benefit patients who report problems with medication adherence.

Our study demonstrates low frequency in prescribing patterns of PrEP among dermatologists and suggests that an addressable barrier to such prescribing is the lack of knowledge on how to prescribe it safely, which warrants further clinical investigation. We summarize an approach to prescribing PrEP in Table 2. Our study was limited by a small sample of mostly academic dermatologists and selection bias, which may diminish the generalizability of findings. A study of a larger, more representative group of dermatologists likely would show different prescribing patterns and degrees of knowledge about PrEP. Research is needed to study the impact of educational interventions that aim to increase both knowledge and prescribing of PrEP among dermatologists.