Doug Brunk

SAN DIEGO – A simple intervention of initial warfarin dose capping in hospitalized patients aged 85 years and older led to significant reductions in supratherapeutic INRs without a significant change in length of stay, a single-center study showed.

“We’re excited to see if these results are reproducible,” Jonathan Falsetta, PharmD, said at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “We do feel that it may represent an important step forward in warfarin safety in a vulnerable patient population.”

Doug Brunk/MDEdge News

A review of current medical literature revealed a lack of well-validated recommendations regarding warfarin initiation in older patients, so Dr. Falsetta and his associates set out to create their own dose-capping recommendation. This involved limiting the initial dose of warfarin to 2.5 mg or less for hospitalized patients aged 85 years and older.

“We wanted this to be applicable to patients regardless if they were warfarin naïve or if they had been on warfarin prior to admission,” he said.

Before the roll out, clinical pharmacists and pharmacy residents conducted provider education on the initial dose capping protocol. Providers could order initial doses that exceeded 2.5 mg with valid clinical reasoning. Outcomes of interest were dosing protocol compliance and post-intervention analysis of INRs in this patient population. The pre-intervention period spanned from Nov. 1, 2014 through Oct. 31, 2015, while the post-intervention period spanned from Nov. 1, 2015 through Oct. 31, 2017. Dr. Falsetta reported data from 768 patients.

Between the pre-intervention and post-intervention periods, compliance with dose capping rose from 38.5% to 64.2% (P less than .001), the supratherapeutic INR rate dropped from 20.9% to 13.3% (P= .004), and the length of hospital stay in hours rose from a mean of 145.8 to a mean of 155.8, which was not statistically significant (P= .13).

Following the post-intervention period, the number of peak INRs in the 1 to 2 range rose by 15% and the number of peak INRs in the 2 to 3 range rose by 6%. At the same time, the number of peak INRs in the 3 to 4 range fell by 6%, the number of peak INRs in the 4 to 5 range fell by 36%, and the number of peak INRs in the 5 and greater range fell by 53%. These INR percentages represent relative increases and/or decreases.

“This was a relatively simple intervention that resulted in significant reductions in supratherapeutic INRs,” Dr. Falsetta said.

The researchers also observed that there was less IV vitamin K use after the dose capping intervention. “We can’t say for sure that this was tied to the intervention, but it was interesting, and it is something for us to take a look at, as well as roll this out in future iterations,” he said. “We are on the cusp of rolling this out at some of the tertiary sites within our health care system, and some of the community sites as well.”

He acknowledged certain limitations of the study, including its single-center design, relatively small sample size, and lack of clinical endpoints. “I’d like to be able to tie this to something like reduced bleeding events,” Dr. Falsetta said. “I think that’s something we need to explore in the future.”

Dr. Falsetta reported having no financial disclosures.

[email protected]

SOURCE: Falsetta J et al. THSNA 2018.

SAN DIEGO – A simple intervention of initial warfarin dose capping in hospitalized patients aged 85 years and older led to significant reductions in supratherapeutic INRs without a significant change in length of stay, a single-center study showed.

“We’re excited to see if these results are reproducible,” Jonathan Falsetta, PharmD, said at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “We do feel that it may represent an important step forward in warfarin safety in a vulnerable patient population.”

Doug Brunk/MDEdge News

A review of current medical literature revealed a lack of well-validated recommendations regarding warfarin initiation in older patients, so Dr. Falsetta and his associates set out to create their own dose-capping recommendation. This involved limiting the initial dose of warfarin to 2.5 mg or less for hospitalized patients aged 85 years and older.

“We wanted this to be applicable to patients regardless if they were warfarin naïve or if they had been on warfarin prior to admission,” he said.

Before the roll out, clinical pharmacists and pharmacy residents conducted provider education on the initial dose capping protocol. Providers could order initial doses that exceeded 2.5 mg with valid clinical reasoning. Outcomes of interest were dosing protocol compliance and post-intervention analysis of INRs in this patient population. The pre-intervention period spanned from Nov. 1, 2014 through Oct. 31, 2015, while the post-intervention period spanned from Nov. 1, 2015 through Oct. 31, 2017. Dr. Falsetta reported data from 768 patients.

Between the pre-intervention and post-intervention periods, compliance with dose capping rose from 38.5% to 64.2% (P less than .001), the supratherapeutic INR rate dropped from 20.9% to 13.3% (P= .004), and the length of hospital stay in hours rose from a mean of 145.8 to a mean of 155.8, which was not statistically significant (P= .13).

Following the post-intervention period, the number of peak INRs in the 1 to 2 range rose by 15% and the number of peak INRs in the 2 to 3 range rose by 6%. At the same time, the number of peak INRs in the 3 to 4 range fell by 6%, the number of peak INRs in the 4 to 5 range fell by 36%, and the number of peak INRs in the 5 and greater range fell by 53%. These INR percentages represent relative increases and/or decreases.

“This was a relatively simple intervention that resulted in significant reductions in supratherapeutic INRs,” Dr. Falsetta said.

The researchers also observed that there was less IV vitamin K use after the dose capping intervention. “We can’t say for sure that this was tied to the intervention, but it was interesting, and it is something for us to take a look at, as well as roll this out in future iterations,” he said. “We are on the cusp of rolling this out at some of the tertiary sites within our health care system, and some of the community sites as well.”

He acknowledged certain limitations of the study, including its single-center design, relatively small sample size, and lack of clinical endpoints. “I’d like to be able to tie this to something like reduced bleeding events,” Dr. Falsetta said. “I think that’s something we need to explore in the future.”

Dr. Falsetta reported having no financial disclosures.

[email protected]

SOURCE: Falsetta J et al. THSNA 2018.

SAN DIEGO – A simple intervention of initial warfarin dose capping in hospitalized patients aged 85 years and older led to significant reductions in supratherapeutic INRs without a significant change in length of stay, a single-center study showed.

“We’re excited to see if these results are reproducible,” Jonathan Falsetta, PharmD, said at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “We do feel that it may represent an important step forward in warfarin safety in a vulnerable patient population.”

Doug Brunk/MDEdge News

A review of current medical literature revealed a lack of well-validated recommendations regarding warfarin initiation in older patients, so Dr. Falsetta and his associates set out to create their own dose-capping recommendation. This involved limiting the initial dose of warfarin to 2.5 mg or less for hospitalized patients aged 85 years and older.

“We wanted this to be applicable to patients regardless if they were warfarin naïve or if they had been on warfarin prior to admission,” he said.

Before the roll out, clinical pharmacists and pharmacy residents conducted provider education on the initial dose capping protocol. Providers could order initial doses that exceeded 2.5 mg with valid clinical reasoning. Outcomes of interest were dosing protocol compliance and post-intervention analysis of INRs in this patient population. The pre-intervention period spanned from Nov. 1, 2014 through Oct. 31, 2015, while the post-intervention period spanned from Nov. 1, 2015 through Oct. 31, 2017. Dr. Falsetta reported data from 768 patients.

Between the pre-intervention and post-intervention periods, compliance with dose capping rose from 38.5% to 64.2% (P less than .001), the supratherapeutic INR rate dropped from 20.9% to 13.3% (P= .004), and the length of hospital stay in hours rose from a mean of 145.8 to a mean of 155.8, which was not statistically significant (P= .13).

Following the post-intervention period, the number of peak INRs in the 1 to 2 range rose by 15% and the number of peak INRs in the 2 to 3 range rose by 6%. At the same time, the number of peak INRs in the 3 to 4 range fell by 6%, the number of peak INRs in the 4 to 5 range fell by 36%, and the number of peak INRs in the 5 and greater range fell by 53%. These INR percentages represent relative increases and/or decreases.

“This was a relatively simple intervention that resulted in significant reductions in supratherapeutic INRs,” Dr. Falsetta said.

The researchers also observed that there was less IV vitamin K use after the dose capping intervention. “We can’t say for sure that this was tied to the intervention, but it was interesting, and it is something for us to take a look at, as well as roll this out in future iterations,” he said. “We are on the cusp of rolling this out at some of the tertiary sites within our health care system, and some of the community sites as well.”

He acknowledged certain limitations of the study, including its single-center design, relatively small sample size, and lack of clinical endpoints. “I’d like to be able to tie this to something like reduced bleeding events,” Dr. Falsetta said. “I think that’s something we need to explore in the future.”

Dr. Falsetta reported having no financial disclosures.

[email protected]

SOURCE: Falsetta J et al. THSNA 2018.

SAN DIEGO – An estimated 41% of patients who experienced a venous thromboembolism (VTE) fear another clot often or almost all the time. In addition, about 25% report abnormal levels of anxiety, and 12% have abnormal depression scores.

Those are key findings from a large survey that set out to estimate the number of bleeding harms and emotional harms experienced by a U.S. population of adults who have experienced a VTE.

Doug Brunk/MDedge News

“There is emerging research in Europe that shows high levels of stress and anxiety in people who have a thrombosis event,” lead study author Michael Feehan, PhD, said in an interview at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “We interviewed people around the country and found that a lot of them were living with fear, anxiety, and distress. We did a projective exercise and asked, ‘If VTE was an animal, what would it be?’ Many responded with snakes and bears, hostile things. Snakes came up a lot. Snakes can be dormant, and then they can suddenly come out and bite you. That was the kind of language they were using.”

In what he said is the largest study of its kind, Dr. Feehan, a psychologist in the College of Pharmacy at the University of Utah, Salt Lake City, and his associates conducted an online survey of 907 patients aged 18 and older who had experienced a VTE event in the previous 24 months.

The survey was administered in May 2016 and excluded patients with cancer-related VTE. It took about 30 minutes to complete and included questions about the bleeding harms that have occurred since their VTE diagnosis, such as nosebleeds or a cut difficult to control, excessive bruising, vomiting blood, bloody urine, and blood in stools. It also included standardized measures of anxiety, depression, cognitive function, and ratings on eight items of current distress, feeling tense, anxious, confused, depressed, afraid, angry, frustrated, or annoyed.

Self-reported bleeding events included excessive bruising (45%), bleeding from cuts difficult to control (33%), and epistaxis (16%). As for emotional harm, 41% of respondents lived in fear of getting another clot “often” or “almost all the time,” while 25% experienced abnormally high levels of anxiety, and 12% experienced abnormally high levels of depression.

A multivariate structural equation model revealed the following principal factors significantly associated with a composite latent variable of emotional harm: poor health literacy, younger age, the lack of perceived self-control over one’s health, history of medical mistakes in care, and overt barriers to health care access such as transportation limitations and financial limitations (P less than .05 for all associations).

“If you’re working with patients who believe they don’t have any control over their own care, or if they’re younger or have other disease states, or if they have difficulty getting to and from the hospital, all of those things contribute to elevated emotional harms,” Dr. Feehan said. “That level of emotional harm is clinically relevant.”

After the research team shared the study results with staff of the university’s thrombosis services, clinicians started changing how they interview patients. “For example, instead of asking just ‘Have you experienced any VTE symptoms?’ they now ask things like, ‘How are you feeling?’ or ‘How are things going for you living with the disease?’” Dr. Feehan noted. “Then, patients might say, ‘I’m actually quite worried.’ Such questions can help patients open up about how they feel and foster a better relationship with their provider. A better relationship with their provider might help them feel more in control.”

The study was supported by Pfizer Independent Grants for Learning & Change, Bristol-Myers Squibb Independent Medical Education, the Joint Commission, the National Eye Institute, and an unrestricted grant from Research to Prevent Blindness. Dr. Feehan disclosed that he has consulted for Pfizer in the past.

[email protected]

SOURCE: Feehan et al. THSNA 2018, Poster 75.

SAN DIEGO – An estimated 41% of patients who experienced a venous thromboembolism (VTE) fear another clot often or almost all the time. In addition, about 25% report abnormal levels of anxiety, and 12% have abnormal depression scores.

Those are key findings from a large survey that set out to estimate the number of bleeding harms and emotional harms experienced by a U.S. population of adults who have experienced a VTE.

Doug Brunk/MDedge News

“There is emerging research in Europe that shows high levels of stress and anxiety in people who have a thrombosis event,” lead study author Michael Feehan, PhD, said in an interview at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “We interviewed people around the country and found that a lot of them were living with fear, anxiety, and distress. We did a projective exercise and asked, ‘If VTE was an animal, what would it be?’ Many responded with snakes and bears, hostile things. Snakes came up a lot. Snakes can be dormant, and then they can suddenly come out and bite you. That was the kind of language they were using.”

In what he said is the largest study of its kind, Dr. Feehan, a psychologist in the College of Pharmacy at the University of Utah, Salt Lake City, and his associates conducted an online survey of 907 patients aged 18 and older who had experienced a VTE event in the previous 24 months.

The survey was administered in May 2016 and excluded patients with cancer-related VTE. It took about 30 minutes to complete and included questions about the bleeding harms that have occurred since their VTE diagnosis, such as nosebleeds or a cut difficult to control, excessive bruising, vomiting blood, bloody urine, and blood in stools. It also included standardized measures of anxiety, depression, cognitive function, and ratings on eight items of current distress, feeling tense, anxious, confused, depressed, afraid, angry, frustrated, or annoyed.

Self-reported bleeding events included excessive bruising (45%), bleeding from cuts difficult to control (33%), and epistaxis (16%). As for emotional harm, 41% of respondents lived in fear of getting another clot “often” or “almost all the time,” while 25% experienced abnormally high levels of anxiety, and 12% experienced abnormally high levels of depression.

A multivariate structural equation model revealed the following principal factors significantly associated with a composite latent variable of emotional harm: poor health literacy, younger age, the lack of perceived self-control over one’s health, history of medical mistakes in care, and overt barriers to health care access such as transportation limitations and financial limitations (P less than .05 for all associations).

“If you’re working with patients who believe they don’t have any control over their own care, or if they’re younger or have other disease states, or if they have difficulty getting to and from the hospital, all of those things contribute to elevated emotional harms,” Dr. Feehan said. “That level of emotional harm is clinically relevant.”

After the research team shared the study results with staff of the university’s thrombosis services, clinicians started changing how they interview patients. “For example, instead of asking just ‘Have you experienced any VTE symptoms?’ they now ask things like, ‘How are you feeling?’ or ‘How are things going for you living with the disease?’” Dr. Feehan noted. “Then, patients might say, ‘I’m actually quite worried.’ Such questions can help patients open up about how they feel and foster a better relationship with their provider. A better relationship with their provider might help them feel more in control.”

The study was supported by Pfizer Independent Grants for Learning & Change, Bristol-Myers Squibb Independent Medical Education, the Joint Commission, the National Eye Institute, and an unrestricted grant from Research to Prevent Blindness. Dr. Feehan disclosed that he has consulted for Pfizer in the past.

[email protected]

SOURCE: Feehan et al. THSNA 2018, Poster 75.

SAN DIEGO – An estimated 41% of patients who experienced a venous thromboembolism (VTE) fear another clot often or almost all the time. In addition, about 25% report abnormal levels of anxiety, and 12% have abnormal depression scores.

Those are key findings from a large survey that set out to estimate the number of bleeding harms and emotional harms experienced by a U.S. population of adults who have experienced a VTE.

Doug Brunk/MDedge News

“There is emerging research in Europe that shows high levels of stress and anxiety in people who have a thrombosis event,” lead study author Michael Feehan, PhD, said in an interview at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “We interviewed people around the country and found that a lot of them were living with fear, anxiety, and distress. We did a projective exercise and asked, ‘If VTE was an animal, what would it be?’ Many responded with snakes and bears, hostile things. Snakes came up a lot. Snakes can be dormant, and then they can suddenly come out and bite you. That was the kind of language they were using.”

In what he said is the largest study of its kind, Dr. Feehan, a psychologist in the College of Pharmacy at the University of Utah, Salt Lake City, and his associates conducted an online survey of 907 patients aged 18 and older who had experienced a VTE event in the previous 24 months.

The survey was administered in May 2016 and excluded patients with cancer-related VTE. It took about 30 minutes to complete and included questions about the bleeding harms that have occurred since their VTE diagnosis, such as nosebleeds or a cut difficult to control, excessive bruising, vomiting blood, bloody urine, and blood in stools. It also included standardized measures of anxiety, depression, cognitive function, and ratings on eight items of current distress, feeling tense, anxious, confused, depressed, afraid, angry, frustrated, or annoyed.

Self-reported bleeding events included excessive bruising (45%), bleeding from cuts difficult to control (33%), and epistaxis (16%). As for emotional harm, 41% of respondents lived in fear of getting another clot “often” or “almost all the time,” while 25% experienced abnormally high levels of anxiety, and 12% experienced abnormally high levels of depression.

A multivariate structural equation model revealed the following principal factors significantly associated with a composite latent variable of emotional harm: poor health literacy, younger age, the lack of perceived self-control over one’s health, history of medical mistakes in care, and overt barriers to health care access such as transportation limitations and financial limitations (P less than .05 for all associations).

“If you’re working with patients who believe they don’t have any control over their own care, or if they’re younger or have other disease states, or if they have difficulty getting to and from the hospital, all of those things contribute to elevated emotional harms,” Dr. Feehan said. “That level of emotional harm is clinically relevant.”

After the research team shared the study results with staff of the university’s thrombosis services, clinicians started changing how they interview patients. “For example, instead of asking just ‘Have you experienced any VTE symptoms?’ they now ask things like, ‘How are you feeling?’ or ‘How are things going for you living with the disease?’” Dr. Feehan noted. “Then, patients might say, ‘I’m actually quite worried.’ Such questions can help patients open up about how they feel and foster a better relationship with their provider. A better relationship with their provider might help them feel more in control.”

The study was supported by Pfizer Independent Grants for Learning & Change, Bristol-Myers Squibb Independent Medical Education, the Joint Commission, the National Eye Institute, and an unrestricted grant from Research to Prevent Blindness. Dr. Feehan disclosed that he has consulted for Pfizer in the past.

[email protected]

SOURCE: Feehan et al. THSNA 2018, Poster 75.

SAN DIEGO – Among children with types 1 and 2 von Willebrand disease (VWD), a higher proportion of boys than girls reported ever having a bleeding episode and using more treatment products. But the trend did not continue among children with type 3 disease.

Those are some of the key findings from a never-before-published analysis of surveillance data from the Centers for Disease Control and Prevention presented by Karon Abe, PhD, during a poster session at the biennial summit of the Thrombosis & Hemostasis Societies of North America.

Doug Brunk/MDedge News

Nearly two-thirds of children (65%) were non-Hispanic, 17% were Hispanic, 8% were black, and the remainder were from other ethnicities. In addition, 40% of the children had no family history of a bleeding disorder.

The median age of first bleed was lower among children with type 3 VWD, compared with other VWD types, and was lower among boys than girls with type 1 VWD (36 months vs. 48 months, respectively; P less than .001) and type 3 VWD (9 months vs. 12 months; P = .04), Dr. Abe reported.

A higher proportion of boys than girls reported ever having a bleeding episode among children with type 1 VWD (78% vs. 73%; P = .01) and type 2 VWD (90% vs. 75%; P = .01), but not among children with type 3 VWD (97% vs. 96%; P = .77).

A higher prevalence of treatment-product use was reported among children with type 3 VWD, compared with those with the other VWD types (a mean of 95% vs. 79% and 71% among types 2 and 1, respectively). A significantly higher prevalence of the use of treatment product was seen among boys than girls with type 1 VWD (73% vs. 68%, P = .03) and type 2 VWD (87% vs. 72%, P =.01), but not type 3 VWD (94% vs. 96%, P = .87).

The most common sites of the first bleed among all patients regardless of gender or VWD type were epistaxis and oral cavity bleeding.

“To our surprise, the boys were showing more bleeding and were receiving more product than the females,” Dr. Abe said in an interview. “This is a fairly large population.”

Multivariate regression analysis revealed independent associations between the following patient characteristics and ever having a bleed among children with type 1 VWD: male gender (adjusted odds ratio, 1.23); being aged 7-9 years at registration, compared with being aged 2-6 years (aOR, 1.5); being black (aOR, 1.7); being Asian, Native Hawaiian or Pacific Islander (aOR, 2.4), being Hispanic (aOR, 2.8), and being some other race/ethnicity (aOR, 1.8). However, family history of a bleeding disorder was protective (aOR, 0.721).

Dr. Abe said she hopes that the findings will raise awareness and help physicians to educate families about bleeding symptoms and intervene to treat bleeding episodes appropriately. She and her associates are planning to compare the data with Community Counts, “so it’s more up to date,” she said.

Dr. Abe reported having no financial disclosures.

[email protected]

SOURCE: Abe K et al. THSNA 2018, Poster 145.

SAN DIEGO – Among children with types 1 and 2 von Willebrand disease (VWD), a higher proportion of boys than girls reported ever having a bleeding episode and using more treatment products. But the trend did not continue among children with type 3 disease.

Those are some of the key findings from a never-before-published analysis of surveillance data from the Centers for Disease Control and Prevention presented by Karon Abe, PhD, during a poster session at the biennial summit of the Thrombosis & Hemostasis Societies of North America.

Doug Brunk/MDedge News

Nearly two-thirds of children (65%) were non-Hispanic, 17% were Hispanic, 8% were black, and the remainder were from other ethnicities. In addition, 40% of the children had no family history of a bleeding disorder.

The median age of first bleed was lower among children with type 3 VWD, compared with other VWD types, and was lower among boys than girls with type 1 VWD (36 months vs. 48 months, respectively; P less than .001) and type 3 VWD (9 months vs. 12 months; P = .04), Dr. Abe reported.

A higher proportion of boys than girls reported ever having a bleeding episode among children with type 1 VWD (78% vs. 73%; P = .01) and type 2 VWD (90% vs. 75%; P = .01), but not among children with type 3 VWD (97% vs. 96%; P = .77).

A higher prevalence of treatment-product use was reported among children with type 3 VWD, compared with those with the other VWD types (a mean of 95% vs. 79% and 71% among types 2 and 1, respectively). A significantly higher prevalence of the use of treatment product was seen among boys than girls with type 1 VWD (73% vs. 68%, P = .03) and type 2 VWD (87% vs. 72%, P =.01), but not type 3 VWD (94% vs. 96%, P = .87).

The most common sites of the first bleed among all patients regardless of gender or VWD type were epistaxis and oral cavity bleeding.

“To our surprise, the boys were showing more bleeding and were receiving more product than the females,” Dr. Abe said in an interview. “This is a fairly large population.”

Multivariate regression analysis revealed independent associations between the following patient characteristics and ever having a bleed among children with type 1 VWD: male gender (adjusted odds ratio, 1.23); being aged 7-9 years at registration, compared with being aged 2-6 years (aOR, 1.5); being black (aOR, 1.7); being Asian, Native Hawaiian or Pacific Islander (aOR, 2.4), being Hispanic (aOR, 2.8), and being some other race/ethnicity (aOR, 1.8). However, family history of a bleeding disorder was protective (aOR, 0.721).

Dr. Abe said she hopes that the findings will raise awareness and help physicians to educate families about bleeding symptoms and intervene to treat bleeding episodes appropriately. She and her associates are planning to compare the data with Community Counts, “so it’s more up to date,” she said.

Dr. Abe reported having no financial disclosures.

[email protected]

SOURCE: Abe K et al. THSNA 2018, Poster 145.

SAN DIEGO – Among children with types 1 and 2 von Willebrand disease (VWD), a higher proportion of boys than girls reported ever having a bleeding episode and using more treatment products. But the trend did not continue among children with type 3 disease.

Those are some of the key findings from a never-before-published analysis of surveillance data from the Centers for Disease Control and Prevention presented by Karon Abe, PhD, during a poster session at the biennial summit of the Thrombosis & Hemostasis Societies of North America.

Doug Brunk/MDedge News

Nearly two-thirds of children (65%) were non-Hispanic, 17% were Hispanic, 8% were black, and the remainder were from other ethnicities. In addition, 40% of the children had no family history of a bleeding disorder.

The median age of first bleed was lower among children with type 3 VWD, compared with other VWD types, and was lower among boys than girls with type 1 VWD (36 months vs. 48 months, respectively; P less than .001) and type 3 VWD (9 months vs. 12 months; P = .04), Dr. Abe reported.

A higher proportion of boys than girls reported ever having a bleeding episode among children with type 1 VWD (78% vs. 73%; P = .01) and type 2 VWD (90% vs. 75%; P = .01), but not among children with type 3 VWD (97% vs. 96%; P = .77).

A higher prevalence of treatment-product use was reported among children with type 3 VWD, compared with those with the other VWD types (a mean of 95% vs. 79% and 71% among types 2 and 1, respectively). A significantly higher prevalence of the use of treatment product was seen among boys than girls with type 1 VWD (73% vs. 68%, P = .03) and type 2 VWD (87% vs. 72%, P =.01), but not type 3 VWD (94% vs. 96%, P = .87).

The most common sites of the first bleed among all patients regardless of gender or VWD type were epistaxis and oral cavity bleeding.

“To our surprise, the boys were showing more bleeding and were receiving more product than the females,” Dr. Abe said in an interview. “This is a fairly large population.”

Multivariate regression analysis revealed independent associations between the following patient characteristics and ever having a bleed among children with type 1 VWD: male gender (adjusted odds ratio, 1.23); being aged 7-9 years at registration, compared with being aged 2-6 years (aOR, 1.5); being black (aOR, 1.7); being Asian, Native Hawaiian or Pacific Islander (aOR, 2.4), being Hispanic (aOR, 2.8), and being some other race/ethnicity (aOR, 1.8). However, family history of a bleeding disorder was protective (aOR, 0.721).

Dr. Abe said she hopes that the findings will raise awareness and help physicians to educate families about bleeding symptoms and intervene to treat bleeding episodes appropriately. She and her associates are planning to compare the data with Community Counts, “so it’s more up to date,” she said.

Dr. Abe reported having no financial disclosures.

[email protected]

SOURCE: Abe K et al. THSNA 2018, Poster 145.

SAN DIEGO – The incidence of polypharmacy among patients on warfarin therapy appears to peak at age 75, with close to 10 concurrent active prescriptions on average, results from a single-center study showed.

“Beware of polypharmacy with these patients,” Alan Jacobson, MD, said in an interview at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “Anticoagulation tends to be a high-risk area. If you don’t treat, people have strokes. If you treat, they can have bleeds. Warfarin is the number one drug that gets older patients into the ER and admitted. We know that warfarin has a lot of drug-drug interactions.”

Doug Brunk/ Frontline Medical News

SOURCE: Jacobson M et al. THSNA 2018. Poster 2.

SAN DIEGO – The incidence of polypharmacy among patients on warfarin therapy appears to peak at age 75, with close to 10 concurrent active prescriptions on average, results from a single-center study showed.

“Beware of polypharmacy with these patients,” Alan Jacobson, MD, said in an interview at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “Anticoagulation tends to be a high-risk area. If you don’t treat, people have strokes. If you treat, they can have bleeds. Warfarin is the number one drug that gets older patients into the ER and admitted. We know that warfarin has a lot of drug-drug interactions.”

Doug Brunk/ Frontline Medical News

SOURCE: Jacobson M et al. THSNA 2018. Poster 2.

SAN DIEGO – The incidence of polypharmacy among patients on warfarin therapy appears to peak at age 75, with close to 10 concurrent active prescriptions on average, results from a single-center study showed.

“Beware of polypharmacy with these patients,” Alan Jacobson, MD, said in an interview at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “Anticoagulation tends to be a high-risk area. If you don’t treat, people have strokes. If you treat, they can have bleeds. Warfarin is the number one drug that gets older patients into the ER and admitted. We know that warfarin has a lot of drug-drug interactions.”

Doug Brunk/ Frontline Medical News

SOURCE: Jacobson M et al. THSNA 2018. Poster 2.

SAN DIEGO – The use of direct oral anticoagulants were not significantly different from warfarin for safety and efficacy in cases of postoperative atrial fibrillation following coronary artery bypass grafting, according to results from a single-center study.

In fact, patients who took rivaroxaban and apixaban had significantly shorter postoperative lengths of stay, which suggests a potential for reduced hospital stay-related costs. “There are several different niche populations for which the DOACs have not been studied,” one of the study authors, Ammie J. Patel, PharmD, said in an interview at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “This provides the opportunity for institutions and hospitals to study the use of these drugs in non-traditional ways.”

Dr. Patel, of Temple University, Philadelphia, said that postoperative atrial fibrillation occurs in about 30% of patients following CABG and that new-onset postoperative atrial fibrillation after CABG has been linked to a 21% increase in relative mortality.

Noting that patients with planned major surgery were excluded from RE-LY, ROCKET AF, ARISTOTLE, and other pivotal clinical trials of DOACs, she and her research mentor, Rachael Durie, PharmD, retrospectively evaluated the safety and efficacy of DOACs in 285 cases of new-onset postoperative atrial fibrillation following CABG performed at Jersey Shore University Medical Center, Neptune, N.J., between July 1, 2014, and June 30, 2016. They hypothesized that using DOACs in this patient population might offer advantages over warfarin, including rapid onset and earlier hospital discharge, fewer drug interactions, and no coagulation monitoring.

[email protected]

SOURCE: Patel AJ et al. THSNA 2018. Poster 64.

SAN DIEGO – The use of direct oral anticoagulants were not significantly different from warfarin for safety and efficacy in cases of postoperative atrial fibrillation following coronary artery bypass grafting, according to results from a single-center study.

In fact, patients who took rivaroxaban and apixaban had significantly shorter postoperative lengths of stay, which suggests a potential for reduced hospital stay-related costs. “There are several different niche populations for which the DOACs have not been studied,” one of the study authors, Ammie J. Patel, PharmD, said in an interview at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “This provides the opportunity for institutions and hospitals to study the use of these drugs in non-traditional ways.”

Dr. Patel, of Temple University, Philadelphia, said that postoperative atrial fibrillation occurs in about 30% of patients following CABG and that new-onset postoperative atrial fibrillation after CABG has been linked to a 21% increase in relative mortality.

Noting that patients with planned major surgery were excluded from RE-LY, ROCKET AF, ARISTOTLE, and other pivotal clinical trials of DOACs, she and her research mentor, Rachael Durie, PharmD, retrospectively evaluated the safety and efficacy of DOACs in 285 cases of new-onset postoperative atrial fibrillation following CABG performed at Jersey Shore University Medical Center, Neptune, N.J., between July 1, 2014, and June 30, 2016. They hypothesized that using DOACs in this patient population might offer advantages over warfarin, including rapid onset and earlier hospital discharge, fewer drug interactions, and no coagulation monitoring.

[email protected]

SOURCE: Patel AJ et al. THSNA 2018. Poster 64.

SAN DIEGO – The use of direct oral anticoagulants were not significantly different from warfarin for safety and efficacy in cases of postoperative atrial fibrillation following coronary artery bypass grafting, according to results from a single-center study.

In fact, patients who took rivaroxaban and apixaban had significantly shorter postoperative lengths of stay, which suggests a potential for reduced hospital stay-related costs. “There are several different niche populations for which the DOACs have not been studied,” one of the study authors, Ammie J. Patel, PharmD, said in an interview at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “This provides the opportunity for institutions and hospitals to study the use of these drugs in non-traditional ways.”

Dr. Patel, of Temple University, Philadelphia, said that postoperative atrial fibrillation occurs in about 30% of patients following CABG and that new-onset postoperative atrial fibrillation after CABG has been linked to a 21% increase in relative mortality.

Noting that patients with planned major surgery were excluded from RE-LY, ROCKET AF, ARISTOTLE, and other pivotal clinical trials of DOACs, she and her research mentor, Rachael Durie, PharmD, retrospectively evaluated the safety and efficacy of DOACs in 285 cases of new-onset postoperative atrial fibrillation following CABG performed at Jersey Shore University Medical Center, Neptune, N.J., between July 1, 2014, and June 30, 2016. They hypothesized that using DOACs in this patient population might offer advantages over warfarin, including rapid onset and earlier hospital discharge, fewer drug interactions, and no coagulation monitoring.

[email protected]

SOURCE: Patel AJ et al. THSNA 2018. Poster 64.

SAN DIEGO – Pediatric hematologists should consider testing for vitamin D deficiency to optimize bone health in children who will be receiving chronic anticoagulation. That’s a key message from a single-center retrospective review presented during a poster session at the biennial summit of the Thrombosis & Hemostasis Societies of North America.

“More research is needed to determine which children should be targeted for screening for low [bone mineral density], though our research suggests that children with prolonged treatment with steroids may be at the highest risk,” Kavita N. Patel, MD, one of the study’s authors, said in an interview.

The study population was a retrospective cohort of children aged 10-21 years who received anticoagulation for more than 1 year at Children’s Healthcare of Atlanta between Jan. 2, 2012, and Oct. 15, 2017. The researchers evaluated a number of factors, including demographic variables, anticoagulants used, vitamin D status, previously reported comorbid conditions and medications associated with changes in BMD. They defined vitamin D deficiency as less than 20 ng/mL and insufficiency as 20-29 ng/mL.

Dr. Patel reported results from 27 males and 23 females. Of these, 15 (30%) underwent bone density testing with dual-energy X-ray absorptiometry; 5 (10%) did not undergo dual-energy X-ray absorptiometry testing because there is no age-specific standardization below the age of 5 years. Nearly half of the patients (42%) were Caucasian, 34% were African American, 16% were Hispanic, and the rest were from other ethnicities. The top four common indications for extended anticoagulation were recurrent venous thromboembolism (26%), extended treatment for deep vein thrombosis (18%), antiphospholipid syndrome (14%), and thrombophilia plus a single venous thromboembolism (14%).

The anticoagulants most often utilized were enoxaparin (59%), warfarin (29%), and rivaroxaban (7%). The most frequent risk factor for low BMD was long-term use of steroids (16%; defined as greater than 6 months of continuous use in the year prior to BMD testing).

Vitamin D deficiency was identified in 52% of subjects who were tested, while another 24% had insufficient levels of vitamin D. Overall, the median lumbar spine z score was –1.4. Five (30%) subjects who completed BMD testing had low BMD, with median z score of –2.5. None met fracture criteria for pediatric osteoporosis. On linear regression, the only factor found to be significantly associated with a BMD lumbar spine z score in chronically anticoagulated children was the long-term use of steroids (P = .04).

Dr. Patel acknowledged certain limitations of the study, including its single-center design and the fact that not all of the children receiving chronic anticoagulation could be tested.

She reported having no financial disclosures.

[email protected]

SOURCE: Patel KN et al. THSNA 2018, Poster 65.

SAN DIEGO – Pediatric hematologists should consider testing for vitamin D deficiency to optimize bone health in children who will be receiving chronic anticoagulation. That’s a key message from a single-center retrospective review presented during a poster session at the biennial summit of the Thrombosis & Hemostasis Societies of North America.

“More research is needed to determine which children should be targeted for screening for low [bone mineral density], though our research suggests that children with prolonged treatment with steroids may be at the highest risk,” Kavita N. Patel, MD, one of the study’s authors, said in an interview.

The study population was a retrospective cohort of children aged 10-21 years who received anticoagulation for more than 1 year at Children’s Healthcare of Atlanta between Jan. 2, 2012, and Oct. 15, 2017. The researchers evaluated a number of factors, including demographic variables, anticoagulants used, vitamin D status, previously reported comorbid conditions and medications associated with changes in BMD. They defined vitamin D deficiency as less than 20 ng/mL and insufficiency as 20-29 ng/mL.

Dr. Patel reported results from 27 males and 23 females. Of these, 15 (30%) underwent bone density testing with dual-energy X-ray absorptiometry; 5 (10%) did not undergo dual-energy X-ray absorptiometry testing because there is no age-specific standardization below the age of 5 years. Nearly half of the patients (42%) were Caucasian, 34% were African American, 16% were Hispanic, and the rest were from other ethnicities. The top four common indications for extended anticoagulation were recurrent venous thromboembolism (26%), extended treatment for deep vein thrombosis (18%), antiphospholipid syndrome (14%), and thrombophilia plus a single venous thromboembolism (14%).

The anticoagulants most often utilized were enoxaparin (59%), warfarin (29%), and rivaroxaban (7%). The most frequent risk factor for low BMD was long-term use of steroids (16%; defined as greater than 6 months of continuous use in the year prior to BMD testing).

Vitamin D deficiency was identified in 52% of subjects who were tested, while another 24% had insufficient levels of vitamin D. Overall, the median lumbar spine z score was –1.4. Five (30%) subjects who completed BMD testing had low BMD, with median z score of –2.5. None met fracture criteria for pediatric osteoporosis. On linear regression, the only factor found to be significantly associated with a BMD lumbar spine z score in chronically anticoagulated children was the long-term use of steroids (P = .04).

Dr. Patel acknowledged certain limitations of the study, including its single-center design and the fact that not all of the children receiving chronic anticoagulation could be tested.

She reported having no financial disclosures.

[email protected]

SOURCE: Patel KN et al. THSNA 2018, Poster 65.

SAN DIEGO – Pediatric hematologists should consider testing for vitamin D deficiency to optimize bone health in children who will be receiving chronic anticoagulation. That’s a key message from a single-center retrospective review presented during a poster session at the biennial summit of the Thrombosis & Hemostasis Societies of North America.

“More research is needed to determine which children should be targeted for screening for low [bone mineral density], though our research suggests that children with prolonged treatment with steroids may be at the highest risk,” Kavita N. Patel, MD, one of the study’s authors, said in an interview.

The study population was a retrospective cohort of children aged 10-21 years who received anticoagulation for more than 1 year at Children’s Healthcare of Atlanta between Jan. 2, 2012, and Oct. 15, 2017. The researchers evaluated a number of factors, including demographic variables, anticoagulants used, vitamin D status, previously reported comorbid conditions and medications associated with changes in BMD. They defined vitamin D deficiency as less than 20 ng/mL and insufficiency as 20-29 ng/mL.

Dr. Patel reported results from 27 males and 23 females. Of these, 15 (30%) underwent bone density testing with dual-energy X-ray absorptiometry; 5 (10%) did not undergo dual-energy X-ray absorptiometry testing because there is no age-specific standardization below the age of 5 years. Nearly half of the patients (42%) were Caucasian, 34% were African American, 16% were Hispanic, and the rest were from other ethnicities. The top four common indications for extended anticoagulation were recurrent venous thromboembolism (26%), extended treatment for deep vein thrombosis (18%), antiphospholipid syndrome (14%), and thrombophilia plus a single venous thromboembolism (14%).

The anticoagulants most often utilized were enoxaparin (59%), warfarin (29%), and rivaroxaban (7%). The most frequent risk factor for low BMD was long-term use of steroids (16%; defined as greater than 6 months of continuous use in the year prior to BMD testing).

Vitamin D deficiency was identified in 52% of subjects who were tested, while another 24% had insufficient levels of vitamin D. Overall, the median lumbar spine z score was –1.4. Five (30%) subjects who completed BMD testing had low BMD, with median z score of –2.5. None met fracture criteria for pediatric osteoporosis. On linear regression, the only factor found to be significantly associated with a BMD lumbar spine z score in chronically anticoagulated children was the long-term use of steroids (P = .04).

Dr. Patel acknowledged certain limitations of the study, including its single-center design and the fact that not all of the children receiving chronic anticoagulation could be tested.

She reported having no financial disclosures.

[email protected]

SOURCE: Patel KN et al. THSNA 2018, Poster 65.

LAS VEGAS – Many potential but rare side effects, primarily arrhythmias, can occur from taking antipsychotics, according to Carrie L. Ernst, MD.

Risk factors for QT prolongation and torsades de pointes (TdP) include medications such as antiarrhythmics, many antibiotics such as macrolides and quinolones, antifungals, antiemetics, antimalarials, methadone, and antipsychotics and other psychotropics. Other risk factors include cardiac disease, electrolyte abnormalities, being female, age 65 and older, being on another medication that inhibits metabolism of the drug, genetic predisposition to prolonged QT, and impaired liver function.

Two drugs have the Food and Drug Administration boxed warning for prolonged QTc and TdP: thioridazine and mesoridazine. In addition, six medications carry a warning/precaution about prolonged QTc: ziprasidone, paliperidone, IV haloperidol, iloperidone, quetiapine, and asenapine. “Even though haloperidol is not approved for IV administration, FDA created a label warning for IV haloperidol knowing that many clinicians are using it,” she said. “The label advises clinicians to use particular caution in treating patients who have high risk for QTc prolongation and TdP.”

All antipsychotics prolong the QTc by some amount, but differences exist between agents. One prospective, randomized trial showed that ziprasidone and thioridazine prolonged the QTc more than four other antipsychotic drugs (J Clin Psychopharmacol. 2004;24:62-9). “I think the important point is that nobody had a QTc over 500 milliseconds and nobody had TdP,” Dr. Ernst said. “Some data estimate that even if the QTc is 600 milliseconds, the rate of a life-threatening event is probably no more than one in 4,000, so it’s very rare.”

In a more recent meta-analysis, researchers compared 15 antipsychotics among 43,049 adults participating in 212 clinical trials (Lancet. 2013;382:951-62). They found that the following drugs were not associated with QTc prolongation, compared with placebo: lurasidone, aripiprazole, paliperidone, and asenapine. A separate meta-analysis comparing numerous different antipsychotics in children found that ziprasidone was the only one to be associated with an increased risk of QTc prolongation (J Am Acad Child Adolesc Psychiatry. 2015:54:25-36).

There are also data to suggest an association between antipsychotic use and an increased risk of ventricular arrhythmia or sudden cardiac death. The relationship between prolonged QTc and sudden cardiac death is unclear. One large retrospective cohort study found that all antipsychotics carried a 2.5-fold increased risk of sudden cardiac death, compared with the general population not taking those agents (N Eng J Med. 2009;360[3]:225-35). “Risk seemed to be dose related,” Dr. Ernst said. All antipsychotics carry a boxed warning for increased mortality in elderly patients with dementia-related psychosis. Most of the deaths reported appear related to cardiovascular and infectious causes.

For patients with cardiac disease or some of the risk factors for prolonged QTc, Dr. Ernst recommends that psychiatrists order a baseline and steady state EKG, with intermittent QTc monitoring if warranted. “Closely weigh the risks and benefits and consider avoiding the antipsychotic if the baseline QTc is over 500 milliseconds,” she said. “Avoid low-potency typicals, IV haloperidol, and ziprasidone.”

For patients on IV haloperidol, she recommends obtaining a baseline and at least daily QTc, as well as electrolyte monitoring. Some guidelines suggest continuous EKG monitoring for those with baseline QTc of more than 500 milliseconds, risk factors, and/or high dose requirements. “If the QTc increases beyond 500 milliseconds, check and replete electrolytes, review the medication regimen for other agents that prolong the QTc, consider holding until the QTc is less than 500 milliseconds, consider alternative agents, and perform frequent EKG monitoring and a cardiology consult if you decide to continue,” she said.

In patients without any risk factors for prolonged QTc, there is no consensus on obtaining a baseline QTc or doing serial QTc monitoring. “Do a careful risk assessment, and if the QTc increases beyond 500 milliseconds or greater than 60 milliseconds from baseline during treatment, use the same approach as in high-risk patients,” Dr. Ernst said. “Maintain an updated medication list, and if QT prolonging medications are added or new pharmacokinetic interactions occur, approach them the same as you would a high-risk patient.”

She reported having no financial disclosures.

[email protected]

LAS VEGAS – Many potential but rare side effects, primarily arrhythmias, can occur from taking antipsychotics, according to Carrie L. Ernst, MD.

Risk factors for QT prolongation and torsades de pointes (TdP) include medications such as antiarrhythmics, many antibiotics such as macrolides and quinolones, antifungals, antiemetics, antimalarials, methadone, and antipsychotics and other psychotropics. Other risk factors include cardiac disease, electrolyte abnormalities, being female, age 65 and older, being on another medication that inhibits metabolism of the drug, genetic predisposition to prolonged QT, and impaired liver function.

Two drugs have the Food and Drug Administration boxed warning for prolonged QTc and TdP: thioridazine and mesoridazine. In addition, six medications carry a warning/precaution about prolonged QTc: ziprasidone, paliperidone, IV haloperidol, iloperidone, quetiapine, and asenapine. “Even though haloperidol is not approved for IV administration, FDA created a label warning for IV haloperidol knowing that many clinicians are using it,” she said. “The label advises clinicians to use particular caution in treating patients who have high risk for QTc prolongation and TdP.”

All antipsychotics prolong the QTc by some amount, but differences exist between agents. One prospective, randomized trial showed that ziprasidone and thioridazine prolonged the QTc more than four other antipsychotic drugs (J Clin Psychopharmacol. 2004;24:62-9). “I think the important point is that nobody had a QTc over 500 milliseconds and nobody had TdP,” Dr. Ernst said. “Some data estimate that even if the QTc is 600 milliseconds, the rate of a life-threatening event is probably no more than one in 4,000, so it’s very rare.”

In a more recent meta-analysis, researchers compared 15 antipsychotics among 43,049 adults participating in 212 clinical trials (Lancet. 2013;382:951-62). They found that the following drugs were not associated with QTc prolongation, compared with placebo: lurasidone, aripiprazole, paliperidone, and asenapine. A separate meta-analysis comparing numerous different antipsychotics in children found that ziprasidone was the only one to be associated with an increased risk of QTc prolongation (J Am Acad Child Adolesc Psychiatry. 2015:54:25-36).

There are also data to suggest an association between antipsychotic use and an increased risk of ventricular arrhythmia or sudden cardiac death. The relationship between prolonged QTc and sudden cardiac death is unclear. One large retrospective cohort study found that all antipsychotics carried a 2.5-fold increased risk of sudden cardiac death, compared with the general population not taking those agents (N Eng J Med. 2009;360[3]:225-35). “Risk seemed to be dose related,” Dr. Ernst said. All antipsychotics carry a boxed warning for increased mortality in elderly patients with dementia-related psychosis. Most of the deaths reported appear related to cardiovascular and infectious causes.

For patients with cardiac disease or some of the risk factors for prolonged QTc, Dr. Ernst recommends that psychiatrists order a baseline and steady state EKG, with intermittent QTc monitoring if warranted. “Closely weigh the risks and benefits and consider avoiding the antipsychotic if the baseline QTc is over 500 milliseconds,” she said. “Avoid low-potency typicals, IV haloperidol, and ziprasidone.”

For patients on IV haloperidol, she recommends obtaining a baseline and at least daily QTc, as well as electrolyte monitoring. Some guidelines suggest continuous EKG monitoring for those with baseline QTc of more than 500 milliseconds, risk factors, and/or high dose requirements. “If the QTc increases beyond 500 milliseconds, check and replete electrolytes, review the medication regimen for other agents that prolong the QTc, consider holding until the QTc is less than 500 milliseconds, consider alternative agents, and perform frequent EKG monitoring and a cardiology consult if you decide to continue,” she said.

In patients without any risk factors for prolonged QTc, there is no consensus on obtaining a baseline QTc or doing serial QTc monitoring. “Do a careful risk assessment, and if the QTc increases beyond 500 milliseconds or greater than 60 milliseconds from baseline during treatment, use the same approach as in high-risk patients,” Dr. Ernst said. “Maintain an updated medication list, and if QT prolonging medications are added or new pharmacokinetic interactions occur, approach them the same as you would a high-risk patient.”

She reported having no financial disclosures.

[email protected]

LAS VEGAS – Many potential but rare side effects, primarily arrhythmias, can occur from taking antipsychotics, according to Carrie L. Ernst, MD.

Risk factors for QT prolongation and torsades de pointes (TdP) include medications such as antiarrhythmics, many antibiotics such as macrolides and quinolones, antifungals, antiemetics, antimalarials, methadone, and antipsychotics and other psychotropics. Other risk factors include cardiac disease, electrolyte abnormalities, being female, age 65 and older, being on another medication that inhibits metabolism of the drug, genetic predisposition to prolonged QT, and impaired liver function.

Two drugs have the Food and Drug Administration boxed warning for prolonged QTc and TdP: thioridazine and mesoridazine. In addition, six medications carry a warning/precaution about prolonged QTc: ziprasidone, paliperidone, IV haloperidol, iloperidone, quetiapine, and asenapine. “Even though haloperidol is not approved for IV administration, FDA created a label warning for IV haloperidol knowing that many clinicians are using it,” she said. “The label advises clinicians to use particular caution in treating patients who have high risk for QTc prolongation and TdP.”

All antipsychotics prolong the QTc by some amount, but differences exist between agents. One prospective, randomized trial showed that ziprasidone and thioridazine prolonged the QTc more than four other antipsychotic drugs (J Clin Psychopharmacol. 2004;24:62-9). “I think the important point is that nobody had a QTc over 500 milliseconds and nobody had TdP,” Dr. Ernst said. “Some data estimate that even if the QTc is 600 milliseconds, the rate of a life-threatening event is probably no more than one in 4,000, so it’s very rare.”

In a more recent meta-analysis, researchers compared 15 antipsychotics among 43,049 adults participating in 212 clinical trials (Lancet. 2013;382:951-62). They found that the following drugs were not associated with QTc prolongation, compared with placebo: lurasidone, aripiprazole, paliperidone, and asenapine. A separate meta-analysis comparing numerous different antipsychotics in children found that ziprasidone was the only one to be associated with an increased risk of QTc prolongation (J Am Acad Child Adolesc Psychiatry. 2015:54:25-36).

There are also data to suggest an association between antipsychotic use and an increased risk of ventricular arrhythmia or sudden cardiac death. The relationship between prolonged QTc and sudden cardiac death is unclear. One large retrospective cohort study found that all antipsychotics carried a 2.5-fold increased risk of sudden cardiac death, compared with the general population not taking those agents (N Eng J Med. 2009;360[3]:225-35). “Risk seemed to be dose related,” Dr. Ernst said. All antipsychotics carry a boxed warning for increased mortality in elderly patients with dementia-related psychosis. Most of the deaths reported appear related to cardiovascular and infectious causes.

For patients with cardiac disease or some of the risk factors for prolonged QTc, Dr. Ernst recommends that psychiatrists order a baseline and steady state EKG, with intermittent QTc monitoring if warranted. “Closely weigh the risks and benefits and consider avoiding the antipsychotic if the baseline QTc is over 500 milliseconds,” she said. “Avoid low-potency typicals, IV haloperidol, and ziprasidone.”

For patients on IV haloperidol, she recommends obtaining a baseline and at least daily QTc, as well as electrolyte monitoring. Some guidelines suggest continuous EKG monitoring for those with baseline QTc of more than 500 milliseconds, risk factors, and/or high dose requirements. “If the QTc increases beyond 500 milliseconds, check and replete electrolytes, review the medication regimen for other agents that prolong the QTc, consider holding until the QTc is less than 500 milliseconds, consider alternative agents, and perform frequent EKG monitoring and a cardiology consult if you decide to continue,” she said.

In patients without any risk factors for prolonged QTc, there is no consensus on obtaining a baseline QTc or doing serial QTc monitoring. “Do a careful risk assessment, and if the QTc increases beyond 500 milliseconds or greater than 60 milliseconds from baseline during treatment, use the same approach as in high-risk patients,” Dr. Ernst said. “Maintain an updated medication list, and if QT prolonging medications are added or new pharmacokinetic interactions occur, approach them the same as you would a high-risk patient.”

She reported having no financial disclosures.

[email protected]

LAS VEGAS – Even if you do not believe in medical cannabis, be open to patients who ask you if it might benefit them, Kevin P. Hill, MD, advised.

“Being willing to talk to your patient about it is important,” said Dr. Hill, of the division of addiction psychiatry at Beth Israel Deaconess Medical Center, Boston, said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “Because what will happen is, they’ll say, ‘Look. I need medical marijuana to treat my anxiety.’ Then you can say, ‘Well, I have treatments that work for anxiety that we haven’t tried.’ Maybe you can get them into treatment because of that conversation.”

In his opinion, the appropriate candidate for medical cannabis is someone with a debilitating condition who has failed multiple first- and second-line treatments. “The policy of medical cannabis is ahead of the science,” he noted. “It’s not a good place to be, but now the question becomes: How do we give people what they want while addressing the risks? I think we need to do a better job of that. We can provide a service to patients and colleagues by being informed and thoughtful on the topic.”

Food and Drug Administration–approved cannabinoids to date are dronabinol (Marinol) and nabilone (Cesamet). These agents are approved for nausea and vomiting associated with chemotherapy and for appetite stimulation in wasting illnesses such as AIDS. “Your patients may come to you and say, ‘I think I need medical cannabis for condition X,’ ” said Dr. Hill, who authored the book “Marijuana: The Unbiased Truth About the World’s Most Popular Weed” (Center City, Minn.: Hazelden Publishing, 2015). “Maybe the cannabis plant can outperform the two approved agents that we have. I think we have to be open to that possibility. Maybe they offer some things that dronabinol and nabilone don’t.”

LAS VEGAS – Even if you do not believe in medical cannabis, be open to patients who ask you if it might benefit them, Kevin P. Hill, MD, advised.

“Being willing to talk to your patient about it is important,” said Dr. Hill, of the division of addiction psychiatry at Beth Israel Deaconess Medical Center, Boston, said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “Because what will happen is, they’ll say, ‘Look. I need medical marijuana to treat my anxiety.’ Then you can say, ‘Well, I have treatments that work for anxiety that we haven’t tried.’ Maybe you can get them into treatment because of that conversation.”

In his opinion, the appropriate candidate for medical cannabis is someone with a debilitating condition who has failed multiple first- and second-line treatments. “The policy of medical cannabis is ahead of the science,” he noted. “It’s not a good place to be, but now the question becomes: How do we give people what they want while addressing the risks? I think we need to do a better job of that. We can provide a service to patients and colleagues by being informed and thoughtful on the topic.”

Food and Drug Administration–approved cannabinoids to date are dronabinol (Marinol) and nabilone (Cesamet). These agents are approved for nausea and vomiting associated with chemotherapy and for appetite stimulation in wasting illnesses such as AIDS. “Your patients may come to you and say, ‘I think I need medical cannabis for condition X,’ ” said Dr. Hill, who authored the book “Marijuana: The Unbiased Truth About the World’s Most Popular Weed” (Center City, Minn.: Hazelden Publishing, 2015). “Maybe the cannabis plant can outperform the two approved agents that we have. I think we have to be open to that possibility. Maybe they offer some things that dronabinol and nabilone don’t.”

LAS VEGAS – Even if you do not believe in medical cannabis, be open to patients who ask you if it might benefit them, Kevin P. Hill, MD, advised.

“Being willing to talk to your patient about it is important,” said Dr. Hill, of the division of addiction psychiatry at Beth Israel Deaconess Medical Center, Boston, said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “Because what will happen is, they’ll say, ‘Look. I need medical marijuana to treat my anxiety.’ Then you can say, ‘Well, I have treatments that work for anxiety that we haven’t tried.’ Maybe you can get them into treatment because of that conversation.”

In his opinion, the appropriate candidate for medical cannabis is someone with a debilitating condition who has failed multiple first- and second-line treatments. “The policy of medical cannabis is ahead of the science,” he noted. “It’s not a good place to be, but now the question becomes: How do we give people what they want while addressing the risks? I think we need to do a better job of that. We can provide a service to patients and colleagues by being informed and thoughtful on the topic.”

Food and Drug Administration–approved cannabinoids to date are dronabinol (Marinol) and nabilone (Cesamet). These agents are approved for nausea and vomiting associated with chemotherapy and for appetite stimulation in wasting illnesses such as AIDS. “Your patients may come to you and say, ‘I think I need medical cannabis for condition X,’ ” said Dr. Hill, who authored the book “Marijuana: The Unbiased Truth About the World’s Most Popular Weed” (Center City, Minn.: Hazelden Publishing, 2015). “Maybe the cannabis plant can outperform the two approved agents that we have. I think we have to be open to that possibility. Maybe they offer some things that dronabinol and nabilone don’t.”

LAS VEGAS – Michael J. Gitlin, MD, was 6 months removed from his psychiatry residency in 1980 when, for the first time, a patient he cared for took his own life.

He was a chronically depressed young man receiving medication and psychotherapy, and had one prior suicide attempt, Dr. Gitlin, now professor of psychiatry and biobehavioral sciences at the University of California, Los Angeles, recalled at an annual psychopharmacology update held by the Nevada Psychiatric Association. “One day he came in and intimated that he was going to kill himself, but not in the near future so as to not upset his parents. I scheduled another visit with him in 2 days and told him, ‘If you’re really having trouble, I’ll put you in the hospital.’ ”

The man never showed for that planned visit. Dr. Gitlin telephoned acquaintances and eventually the police, and through the window of his apartment, they observed his dead body. “That was my first experience, where I began to think, ‘what does this do to us as psychiatrists, and how do we deal with it?’ ”

According to Dr. Gitlin, fewer than 25 papers in the medical literature address the topic of how to cope when a patient takes his or her own life. He considers it ironic, because about 42,000 people in the United States die from suicide each year. “Of that 42,000, a reasonable percentage have seen a health professional, and a little lower percentage a mental health professional, within a number of weeks before the suicide happened,” he said. “Probably 10,000 psychiatrists per year will have this experience.”

[email protected]

LAS VEGAS – Michael J. Gitlin, MD, was 6 months removed from his psychiatry residency in 1980 when, for the first time, a patient he cared for took his own life.

He was a chronically depressed young man receiving medication and psychotherapy, and had one prior suicide attempt, Dr. Gitlin, now professor of psychiatry and biobehavioral sciences at the University of California, Los Angeles, recalled at an annual psychopharmacology update held by the Nevada Psychiatric Association. “One day he came in and intimated that he was going to kill himself, but not in the near future so as to not upset his parents. I scheduled another visit with him in 2 days and told him, ‘If you’re really having trouble, I’ll put you in the hospital.’ ”

The man never showed for that planned visit. Dr. Gitlin telephoned acquaintances and eventually the police, and through the window of his apartment, they observed his dead body. “That was my first experience, where I began to think, ‘what does this do to us as psychiatrists, and how do we deal with it?’ ”

According to Dr. Gitlin, fewer than 25 papers in the medical literature address the topic of how to cope when a patient takes his or her own life. He considers it ironic, because about 42,000 people in the United States die from suicide each year. “Of that 42,000, a reasonable percentage have seen a health professional, and a little lower percentage a mental health professional, within a number of weeks before the suicide happened,” he said. “Probably 10,000 psychiatrists per year will have this experience.”

[email protected]

LAS VEGAS – Michael J. Gitlin, MD, was 6 months removed from his psychiatry residency in 1980 when, for the first time, a patient he cared for took his own life.

He was a chronically depressed young man receiving medication and psychotherapy, and had one prior suicide attempt, Dr. Gitlin, now professor of psychiatry and biobehavioral sciences at the University of California, Los Angeles, recalled at an annual psychopharmacology update held by the Nevada Psychiatric Association. “One day he came in and intimated that he was going to kill himself, but not in the near future so as to not upset his parents. I scheduled another visit with him in 2 days and told him, ‘If you’re really having trouble, I’ll put you in the hospital.’ ”

The man never showed for that planned visit. Dr. Gitlin telephoned acquaintances and eventually the police, and through the window of his apartment, they observed his dead body. “That was my first experience, where I began to think, ‘what does this do to us as psychiatrists, and how do we deal with it?’ ”

According to Dr. Gitlin, fewer than 25 papers in the medical literature address the topic of how to cope when a patient takes his or her own life. He considers it ironic, because about 42,000 people in the United States die from suicide each year. “Of that 42,000, a reasonable percentage have seen a health professional, and a little lower percentage a mental health professional, within a number of weeks before the suicide happened,” he said. “Probably 10,000 psychiatrists per year will have this experience.”

[email protected]

LAS VEGAS – The overlap of ADHD, conduct disorder, substance use disorder, and criminality likely reflect related underlying mechanisms, which may elucidate different developmental pathways of offending.

“Early interventions are key,” Praveen R. Kambam, MD, said at an annual psychopharmacology update held by the Nevada Psychiatric Association.

According to Dr. Kambam, a clinical and forensic psychiatrist at the University of California, Los Angeles, ADHD is overrepresented in correctional settings worldwide, especially the hyperactive-impulsive subtype. “In juvenile settings, ADHD rates are 3-4 times higher than rates in the general population,” he said. “If you combine juvenile and adult prison populations worldwide, the rates are about 2-5 times higher than the general population.”

The risks are increased for comorbid oppositional defiant disorder (ODD) and conduct disorder. In fact, ADHD and conduct disorder co-occur in about 50% of cases. In girls, the prevalence rate of conduct disorder is steady at 0.8% around age 5 years and increases to 2.8% around age 15 years, while in boys, conduct disorder is steady at 2.1% around age 5 years and rises to 5.5% at age 15 years.

According to a literature review of 18 prospective studies, 13 retrospective studies, and four reviews, individuals with ADHD plus or minus conduct disorder had an increased the risk of antisocial personality disorder, and those with ADHD plus conduct disorder had an increased risk of criminality (J Atten Disord. 2016;20[10]:815-24). “So it’s a subtle difference, where antisocial personality disorder and criminality are slightly different,” Dr. Kambam said. “It could be that the diagnostic criteria are catching the same thing. However, the added [conduct disorder] suggests that there may be subpopulations that are vulnerable.”

He went on to note that individuals with ADHD and delinquency tend to have more learning problems, poor academic achievement, peer relationship problems, and risk of social rejection, while individuals with oppositional defiant disorder and delinquency tend to have peer relationship problems, a negative parent-child relationship, and increased risk of developing conduct disorder.

ADHD is associated with alcohol and drug use in adulthood and nicotine use in adolescence. “Comorbidity between ADHD and ODD/[conduct disorder] is robustly related to substance outcomes,” Dr. Kambam said. “However, both initiation and continuation of substance use disorder are more likely when ADHD symptoms are present, even when controlling for ODD/[conduct disorder]. As for substance use disorder [SUD] and delinquency, the onset of delinquency is more likely in children with onset of SUD by age 11, and SUDs are closely linked with criminality in both juveniles and adults.”

Comorbidity of SUD with conduct disorder and ADHD likely reflects multifactorial mechanisms, he said, such as inherent novelty seeking or school failure leading to association with antisocial peers. Risk factors for chronic offending include early onset of criminal behaviors, ADHD plus conduct disorder, and ODD. ADHD has an independent yet weaker relationship with antisocial behaviors as well, while ADHD, conduct disorder, and SUD are independently associated with increased recidivism.

Environmental factors for chronic offending include the home environment, peer response, parenting skills, and in utero exposures and perinatal complications. “Whether ADHD develops into more severe conduct problems depends considerably on exposure to potentiating environmental factors,” Dr. Kambam said. “The converse is also true: Low-risk environments promote desistance from this pathway in impulsive boys.” He added that the chronic offenders/criminality pathway likely stems from underlying mechanisms, such as impulsivity, low self-control, and executive dysfunction.

If left untreated, ADHD is associated with poor academic and employment outcomes, SUDs, depression, bipolar disorder, suicide attempts, vehicular accidents, and use of mental health services. “The economic costs are estimated to be $42.5 billion annually, so it has a large impact,” he said.

Limited evidence exists to support pharmacological treatments for conduct disorder, although stimulants/alpha-agonists, antipsychotics, lithium, and mood stabilizers may offer some benefit for target symptoms. “Most of the treatment data center around multisystemic therapy, including behavioral modification/parent management training, and functional family training,” Dr. Kambam said. “Treating disruptive behavior disorders and SUDs are 

likely to reduce criminality and recidivism, particularly if started early. There are many beneficial economic impacts. Think about the cost of having youth detained in the criminal justice systems. In Los Angeles County, that cost is about $230,000 per year per kid. That money can probably be better spent somewhere else.”

Numerous studies show that the nonmedical use of stimulants ranges from 25%-40%. “They’re mostly used to enhance academic and/or work performance, but some are used for euphoric effect,” he said. “Individuals in college and just out of college seem to be at the highest risk. There is a strong relationship between [conduct disorder]/[antisocial personality disorder] or SUDs and nonmedical use.”

Treatment with stimulants in correctional settings is controversial. “Some say try after failure of nonstimulants, while others say never use them due to substance abuse, misuse, intimidation of patients to surrender medication, and security/costs,” Dr. Kambam said. “The protocol for ADHD treatment in Massachusetts prisons calls for use of nonstimulants first, followed by ‘crushable’ stimulants if indicated.” The methylphenidate patch and lisdexamfetamine also can be effective in the incarcerated population.

Dr. Kambam reported having no financial disclosures.

[email protected]

SOURCE: Kambam PR. NPA 2018.

LAS VEGAS – The overlap of ADHD, conduct disorder, substance use disorder, and criminality likely reflect related underlying mechanisms, which may elucidate different developmental pathways of offending.

“Early interventions are key,” Praveen R. Kambam, MD, said at an annual psychopharmacology update held by the Nevada Psychiatric Association.

According to Dr. Kambam, a clinical and forensic psychiatrist at the University of California, Los Angeles, ADHD is overrepresented in correctional settings worldwide, especially the hyperactive-impulsive subtype. “In juvenile settings, ADHD rates are 3-4 times higher than rates in the general population,” he said. “If you combine juvenile and adult prison populations worldwide, the rates are about 2-5 times higher than the general population.”

The risks are increased for comorbid oppositional defiant disorder (ODD) and conduct disorder. In fact, ADHD and conduct disorder co-occur in about 50% of cases. In girls, the prevalence rate of conduct disorder is steady at 0.8% around age 5 years and increases to 2.8% around age 15 years, while in boys, conduct disorder is steady at 2.1% around age 5 years and rises to 5.5% at age 15 years.

According to a literature review of 18 prospective studies, 13 retrospective studies, and four reviews, individuals with ADHD plus or minus conduct disorder had an increased the risk of antisocial personality disorder, and those with ADHD plus conduct disorder had an increased risk of criminality (J Atten Disord. 2016;20[10]:815-24). “So it’s a subtle difference, where antisocial personality disorder and criminality are slightly different,” Dr. Kambam said. “It could be that the diagnostic criteria are catching the same thing. However, the added [conduct disorder] suggests that there may be subpopulations that are vulnerable.”

He went on to note that individuals with ADHD and delinquency tend to have more learning problems, poor academic achievement, peer relationship problems, and risk of social rejection, while individuals with oppositional defiant disorder and delinquency tend to have peer relationship problems, a negative parent-child relationship, and increased risk of developing conduct disorder.

ADHD is associated with alcohol and drug use in adulthood and nicotine use in adolescence. “Comorbidity between ADHD and ODD/[conduct disorder] is robustly related to substance outcomes,” Dr. Kambam said. “However, both initiation and continuation of substance use disorder are more likely when ADHD symptoms are present, even when controlling for ODD/[conduct disorder]. As for substance use disorder [SUD] and delinquency, the onset of delinquency is more likely in children with onset of SUD by age 11, and SUDs are closely linked with criminality in both juveniles and adults.”

Comorbidity of SUD with conduct disorder and ADHD likely reflects multifactorial mechanisms, he said, such as inherent novelty seeking or school failure leading to association with antisocial peers. Risk factors for chronic offending include early onset of criminal behaviors, ADHD plus conduct disorder, and ODD. ADHD has an independent yet weaker relationship with antisocial behaviors as well, while ADHD, conduct disorder, and SUD are independently associated with increased recidivism.

Environmental factors for chronic offending include the home environment, peer response, parenting skills, and in utero exposures and perinatal complications. “Whether ADHD develops into more severe conduct problems depends considerably on exposure to potentiating environmental factors,” Dr. Kambam said. “The converse is also true: Low-risk environments promote desistance from this pathway in impulsive boys.” He added that the chronic offenders/criminality pathway likely stems from underlying mechanisms, such as impulsivity, low self-control, and executive dysfunction.

If left untreated, ADHD is associated with poor academic and employment outcomes, SUDs, depression, bipolar disorder, suicide attempts, vehicular accidents, and use of mental health services. “The economic costs are estimated to be $42.5 billion annually, so it has a large impact,” he said.

Limited evidence exists to support pharmacological treatments for conduct disorder, although stimulants/alpha-agonists, antipsychotics, lithium, and mood stabilizers may offer some benefit for target symptoms. “Most of the treatment data center around multisystemic therapy, including behavioral modification/parent management training, and functional family training,” Dr. Kambam said. “Treating disruptive behavior disorders and SUDs are 

likely to reduce criminality and recidivism, particularly if started early. There are many beneficial economic impacts. Think about the cost of having youth detained in the criminal justice systems. In Los Angeles County, that cost is about $230,000 per year per kid. That money can probably be better spent somewhere else.”

Numerous studies show that the nonmedical use of stimulants ranges from 25%-40%. “They’re mostly used to enhance academic and/or work performance, but some are used for euphoric effect,” he said. “Individuals in college and just out of college seem to be at the highest risk. There is a strong relationship between [conduct disorder]/[antisocial personality disorder] or SUDs and nonmedical use.”

Treatment with stimulants in correctional settings is controversial. “Some say try after failure of nonstimulants, while others say never use them due to substance abuse, misuse, intimidation of patients to surrender medication, and security/costs,” Dr. Kambam said. “The protocol for ADHD treatment in Massachusetts prisons calls for use of nonstimulants first, followed by ‘crushable’ stimulants if indicated.” The methylphenidate patch and lisdexamfetamine also can be effective in the incarcerated population.

Dr. Kambam reported having no financial disclosures.

[email protected]

SOURCE: Kambam PR. NPA 2018.

LAS VEGAS – The overlap of ADHD, conduct disorder, substance use disorder, and criminality likely reflect related underlying mechanisms, which may elucidate different developmental pathways of offending.

“Early interventions are key,” Praveen R. Kambam, MD, said at an annual psychopharmacology update held by the Nevada Psychiatric Association.

According to Dr. Kambam, a clinical and forensic psychiatrist at the University of California, Los Angeles, ADHD is overrepresented in correctional settings worldwide, especially the hyperactive-impulsive subtype. “In juvenile settings, ADHD rates are 3-4 times higher than rates in the general population,” he said. “If you combine juvenile and adult prison populations worldwide, the rates are about 2-5 times higher than the general population.”

The risks are increased for comorbid oppositional defiant disorder (ODD) and conduct disorder. In fact, ADHD and conduct disorder co-occur in about 50% of cases. In girls, the prevalence rate of conduct disorder is steady at 0.8% around age 5 years and increases to 2.8% around age 15 years, while in boys, conduct disorder is steady at 2.1% around age 5 years and rises to 5.5% at age 15 years.

According to a literature review of 18 prospective studies, 13 retrospective studies, and four reviews, individuals with ADHD plus or minus conduct disorder had an increased the risk of antisocial personality disorder, and those with ADHD plus conduct disorder had an increased risk of criminality (J Atten Disord. 2016;20[10]:815-24). “So it’s a subtle difference, where antisocial personality disorder and criminality are slightly different,” Dr. Kambam said. “It could be that the diagnostic criteria are catching the same thing. However, the added [conduct disorder] suggests that there may be subpopulations that are vulnerable.”

He went on to note that individuals with ADHD and delinquency tend to have more learning problems, poor academic achievement, peer relationship problems, and risk of social rejection, while individuals with oppositional defiant disorder and delinquency tend to have peer relationship problems, a negative parent-child relationship, and increased risk of developing conduct disorder.

ADHD is associated with alcohol and drug use in adulthood and nicotine use in adolescence. “Comorbidity between ADHD and ODD/[conduct disorder] is robustly related to substance outcomes,” Dr. Kambam said. “However, both initiation and continuation of substance use disorder are more likely when ADHD symptoms are present, even when controlling for ODD/[conduct disorder]. As for substance use disorder [SUD] and delinquency, the onset of delinquency is more likely in children with onset of SUD by age 11, and SUDs are closely linked with criminality in both juveniles and adults.”

Comorbidity of SUD with conduct disorder and ADHD likely reflects multifactorial mechanisms, he said, such as inherent novelty seeking or school failure leading to association with antisocial peers. Risk factors for chronic offending include early onset of criminal behaviors, ADHD plus conduct disorder, and ODD. ADHD has an independent yet weaker relationship with antisocial behaviors as well, while ADHD, conduct disorder, and SUD are independently associated with increased recidivism.

Environmental factors for chronic offending include the home environment, peer response, parenting skills, and in utero exposures and perinatal complications. “Whether ADHD develops into more severe conduct problems depends considerably on exposure to potentiating environmental factors,” Dr. Kambam said. “The converse is also true: Low-risk environments promote desistance from this pathway in impulsive boys.” He added that the chronic offenders/criminality pathway likely stems from underlying mechanisms, such as impulsivity, low self-control, and executive dysfunction.

If left untreated, ADHD is associated with poor academic and employment outcomes, SUDs, depression, bipolar disorder, suicide attempts, vehicular accidents, and use of mental health services. “The economic costs are estimated to be $42.5 billion annually, so it has a large impact,” he said.

Limited evidence exists to support pharmacological treatments for conduct disorder, although stimulants/alpha-agonists, antipsychotics, lithium, and mood stabilizers may offer some benefit for target symptoms. “Most of the treatment data center around multisystemic therapy, including behavioral modification/parent management training, and functional family training,” Dr. Kambam said. “Treating disruptive behavior disorders and SUDs are 

likely to reduce criminality and recidivism, particularly if started early. There are many beneficial economic impacts. Think about the cost of having youth detained in the criminal justice systems. In Los Angeles County, that cost is about $230,000 per year per kid. That money can probably be better spent somewhere else.”

Numerous studies show that the nonmedical use of stimulants ranges from 25%-40%. “They’re mostly used to enhance academic and/or work performance, but some are used for euphoric effect,” he said. “Individuals in college and just out of college seem to be at the highest risk. There is a strong relationship between [conduct disorder]/[antisocial personality disorder] or SUDs and nonmedical use.”

Treatment with stimulants in correctional settings is controversial. “Some say try after failure of nonstimulants, while others say never use them due to substance abuse, misuse, intimidation of patients to surrender medication, and security/costs,” Dr. Kambam said. “The protocol for ADHD treatment in Massachusetts prisons calls for use of nonstimulants first, followed by ‘crushable’ stimulants if indicated.” The methylphenidate patch and lisdexamfetamine also can be effective in the incarcerated population.

Dr. Kambam reported having no financial disclosures.

[email protected]

SOURCE: Kambam PR. NPA 2018.