Jeff Craven

About a quarter of patients with obstructive sleep apnea also had clinical depression and used antidepressants, recent research has shown.

Although patients in the study associated their sleep disorder with poorer quality of life as well as symptoms of anxiety and depression, it is unclear whether treating their obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) would alleviate these symptoms, said Melinda L. Jackson, PhD, from Monash University in Clayton, Victoria, Australia, and her colleagues.

“OSA is a modifiable factor that, if treated, may reduce the economic, health care, and personal burden of depression,” Dr. Jackson and her colleagues wrote in their study, recently published in the journal Sleep Medicine. “Findings from the treatment phase of this study will help us determine whether clinical depression is alleviated with CPAP use, taking into account antidepressant use; whether there are subgroups of patients who respond better to treatment; and what are the characteristics of patients who respond compared to those who remain depressed.”

The researchers used baseline data from 109 patients in the CPAP for OSA and Depression trial who were diagnosed with OSA. Participants (mean age, 52.6 years; 43.1% female) consecutively presented to a sleep laboratory where they answered interview questions to assess clinical depression and sleep habits. Data were collected using the structured clinical interview for depression (SCID-IV), Hospital Anxiety and Depression Scale, Pittsburgh Sleep Quality Index (PSQI), Functional Outcomes of Sleep Questionnaire (FOSQ), Epworth Sleepiness Scale, and Assessment of Quality of Life questionnaire. In addition, the researchers performed a meta-analysis of seven studies, including the current study, to determine the prevalence of clinical depression among patients with untreated OSA.

Overall, SCID-IV scores identified clinical depression in 25 participants (22.7%), and these participants said they had greater sleep disturbance and reported higher depressive, anxiety and stress as well as lower quality of life as a result of their clinical depression. Researchers found these participants also had significantly worse quality of sleep (P less than .05) and daytime dysfunction (P less than .05) as identified by PSQI scores, while FOSQ results showed participants with clinical depression had significantly lower activity levels, social outcomes, and general productivity, compared with patients without clinical depression (P less than .05). In a meta-analysis, Dr. Jackson and her colleagues found a pooled prevalence of 23% for clinical depression among participants with OSA.

Participants using antidepressants were examined separately from participants who had clinical depression. The researchers found 27 participants (24.8%) using antidepressants who also had reported higher symptoms of anxiety, depression and stress, lower quality of life, and poorer sleep outcomes. Participants using antidepressants also were more likely to have bipolar disorder or a condition such as hypertension, chronic obstructive pulmonary disease, high cholesterol, or type 2 diabetes, and 75% of these participants reported having some type of comorbid condition.

Dr. Jackson and her colleagues noted they were uncertain whether depression or OSA occurred first, or whether depression exacerbated symptoms of OSA through other factors such as weight gain, sleep disruption, inactivity, or alcohol use. Depression and OSA may also present independently of one another, they added.

“Development of scales to better capture information about when symptoms commenced and the length of time an individual has experienced OSA will provide a clearer understanding of the consequences of OSA on psychological and medical conditions,” the researchers said.

This study was funded by the Austin Medical Research Fund, and one authors reported support from an National Health and Medical Research Council Early Career Fellowship. The authors report no relevant conflicts of interest.

SOURCE: Jackson ML et al. Sleep Med. 2019 Mar 27. doi: 10.1016/j.sleep.2019.03.011.

About a quarter of patients with obstructive sleep apnea also had clinical depression and used antidepressants, recent research has shown.

Although patients in the study associated their sleep disorder with poorer quality of life as well as symptoms of anxiety and depression, it is unclear whether treating their obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) would alleviate these symptoms, said Melinda L. Jackson, PhD, from Monash University in Clayton, Victoria, Australia, and her colleagues.

“OSA is a modifiable factor that, if treated, may reduce the economic, health care, and personal burden of depression,” Dr. Jackson and her colleagues wrote in their study, recently published in the journal Sleep Medicine. “Findings from the treatment phase of this study will help us determine whether clinical depression is alleviated with CPAP use, taking into account antidepressant use; whether there are subgroups of patients who respond better to treatment; and what are the characteristics of patients who respond compared to those who remain depressed.”

The researchers used baseline data from 109 patients in the CPAP for OSA and Depression trial who were diagnosed with OSA. Participants (mean age, 52.6 years; 43.1% female) consecutively presented to a sleep laboratory where they answered interview questions to assess clinical depression and sleep habits. Data were collected using the structured clinical interview for depression (SCID-IV), Hospital Anxiety and Depression Scale, Pittsburgh Sleep Quality Index (PSQI), Functional Outcomes of Sleep Questionnaire (FOSQ), Epworth Sleepiness Scale, and Assessment of Quality of Life questionnaire. In addition, the researchers performed a meta-analysis of seven studies, including the current study, to determine the prevalence of clinical depression among patients with untreated OSA.

Overall, SCID-IV scores identified clinical depression in 25 participants (22.7%), and these participants said they had greater sleep disturbance and reported higher depressive, anxiety and stress as well as lower quality of life as a result of their clinical depression. Researchers found these participants also had significantly worse quality of sleep (P less than .05) and daytime dysfunction (P less than .05) as identified by PSQI scores, while FOSQ results showed participants with clinical depression had significantly lower activity levels, social outcomes, and general productivity, compared with patients without clinical depression (P less than .05). In a meta-analysis, Dr. Jackson and her colleagues found a pooled prevalence of 23% for clinical depression among participants with OSA.

Participants using antidepressants were examined separately from participants who had clinical depression. The researchers found 27 participants (24.8%) using antidepressants who also had reported higher symptoms of anxiety, depression and stress, lower quality of life, and poorer sleep outcomes. Participants using antidepressants also were more likely to have bipolar disorder or a condition such as hypertension, chronic obstructive pulmonary disease, high cholesterol, or type 2 diabetes, and 75% of these participants reported having some type of comorbid condition.

Dr. Jackson and her colleagues noted they were uncertain whether depression or OSA occurred first, or whether depression exacerbated symptoms of OSA through other factors such as weight gain, sleep disruption, inactivity, or alcohol use. Depression and OSA may also present independently of one another, they added.

“Development of scales to better capture information about when symptoms commenced and the length of time an individual has experienced OSA will provide a clearer understanding of the consequences of OSA on psychological and medical conditions,” the researchers said.

This study was funded by the Austin Medical Research Fund, and one authors reported support from an National Health and Medical Research Council Early Career Fellowship. The authors report no relevant conflicts of interest.

SOURCE: Jackson ML et al. Sleep Med. 2019 Mar 27. doi: 10.1016/j.sleep.2019.03.011.

About a quarter of patients with obstructive sleep apnea also had clinical depression and used antidepressants, recent research has shown.

Although patients in the study associated their sleep disorder with poorer quality of life as well as symptoms of anxiety and depression, it is unclear whether treating their obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) would alleviate these symptoms, said Melinda L. Jackson, PhD, from Monash University in Clayton, Victoria, Australia, and her colleagues.

“OSA is a modifiable factor that, if treated, may reduce the economic, health care, and personal burden of depression,” Dr. Jackson and her colleagues wrote in their study, recently published in the journal Sleep Medicine. “Findings from the treatment phase of this study will help us determine whether clinical depression is alleviated with CPAP use, taking into account antidepressant use; whether there are subgroups of patients who respond better to treatment; and what are the characteristics of patients who respond compared to those who remain depressed.”

The researchers used baseline data from 109 patients in the CPAP for OSA and Depression trial who were diagnosed with OSA. Participants (mean age, 52.6 years; 43.1% female) consecutively presented to a sleep laboratory where they answered interview questions to assess clinical depression and sleep habits. Data were collected using the structured clinical interview for depression (SCID-IV), Hospital Anxiety and Depression Scale, Pittsburgh Sleep Quality Index (PSQI), Functional Outcomes of Sleep Questionnaire (FOSQ), Epworth Sleepiness Scale, and Assessment of Quality of Life questionnaire. In addition, the researchers performed a meta-analysis of seven studies, including the current study, to determine the prevalence of clinical depression among patients with untreated OSA.

Overall, SCID-IV scores identified clinical depression in 25 participants (22.7%), and these participants said they had greater sleep disturbance and reported higher depressive, anxiety and stress as well as lower quality of life as a result of their clinical depression. Researchers found these participants also had significantly worse quality of sleep (P less than .05) and daytime dysfunction (P less than .05) as identified by PSQI scores, while FOSQ results showed participants with clinical depression had significantly lower activity levels, social outcomes, and general productivity, compared with patients without clinical depression (P less than .05). In a meta-analysis, Dr. Jackson and her colleagues found a pooled prevalence of 23% for clinical depression among participants with OSA.

Participants using antidepressants were examined separately from participants who had clinical depression. The researchers found 27 participants (24.8%) using antidepressants who also had reported higher symptoms of anxiety, depression and stress, lower quality of life, and poorer sleep outcomes. Participants using antidepressants also were more likely to have bipolar disorder or a condition such as hypertension, chronic obstructive pulmonary disease, high cholesterol, or type 2 diabetes, and 75% of these participants reported having some type of comorbid condition.

Dr. Jackson and her colleagues noted they were uncertain whether depression or OSA occurred first, or whether depression exacerbated symptoms of OSA through other factors such as weight gain, sleep disruption, inactivity, or alcohol use. Depression and OSA may also present independently of one another, they added.

“Development of scales to better capture information about when symptoms commenced and the length of time an individual has experienced OSA will provide a clearer understanding of the consequences of OSA on psychological and medical conditions,” the researchers said.

This study was funded by the Austin Medical Research Fund, and one authors reported support from an National Health and Medical Research Council Early Career Fellowship. The authors report no relevant conflicts of interest.

SOURCE: Jackson ML et al. Sleep Med. 2019 Mar 27. doi: 10.1016/j.sleep.2019.03.011.

Preterm infants with bronchopulmonary dysplasia (BPD) discharged with supplemental oxygen showed slightly better weight and significantly improved weight-for-length scores, but were more likely to use medical resources and had rates of neurodevelopmental impairment similar to those of infants not discharged with oxygen, according to research published in Pediatrics.

Herjua/Thinkstock

“With this study, we provide important and novel information that may aid the decision of whether to discharge an infant with supplemental oxygen, particularly for those infants who might be weaned off by some clinicians and not by others,” wrote Sara B. DeMauro, MD, MSCE, of University of Pennsylvania, Philadelphia, and Children’s Hospital of Philadelphia, and her colleagues. “This study helps to clarify, both for clinicians and parents, the potential benefits and harms that might be expected from home oxygen therapy among the subset of infants for whom the best course of action is unclear.”

Dr. DeMauro and her colleagues examined 1,039 preterm infants with BPD given supplemental oxygen by nasal cannula between January 2006 and December 2014, who were propensity matched to infants in a control group with a similar severity of BPD who were not discharged with oxygen. The infants were born at less than 27 weeks’ gestation and began receiving oxygen therapy or respiratory support at 36 weeks’ postmenstrual age. These infants were then measured for growth, neurodevelopment, and resource use from discharge to follow-up at 22-26 months corrected age.

At follow-up, infants discharged with oxygen showed marginal weight improvement scores (adjusted mean difference, 0.11) and significantly improved weight-for-length scores (adjusted mean difference, 0.13), but they had rates of neurodevelopmental impairment similar to those of infants with BPD discharged without supplemental oxygen. In addition, infants discharged with oxygen had a greater likelihood of rehospitalization due to respiratory illness (adjusted relative risk, 1.33), use of asthma or BPD medication (adjusted RR, 1.30), and use of medical equipment such as a pulse oximeter (adjusted RR, 2.94).

The researchers noted that their study’s design prevented them from examining all infants with BPD discharged with supplemental oxygen and what factors influenced discharge of infants with supplemental oxygen, as well as the effects of various durations of supplemental oxygen exposure.

“Definitive evaluation of the risk/benefit ratio of this therapy will require prospective controlled trials,” Dr. DeMauro and her colleagues wrote. “Such research will facilitate a more evidence-based approach to clinical decisions about postdischarge care of infants with BPD.”

This study received funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network and the National Institutes of Health. The authors reported no relevant financial disclosures.

SOURCE: DeMauro SB et al. Pediatrics. 2019 Apr 11. doi: 10.1542/peds.2018-2956.

Preterm infants with bronchopulmonary dysplasia (BPD) discharged with supplemental oxygen showed slightly better weight and significantly improved weight-for-length scores, but were more likely to use medical resources and had rates of neurodevelopmental impairment similar to those of infants not discharged with oxygen, according to research published in Pediatrics.

Herjua/Thinkstock

“With this study, we provide important and novel information that may aid the decision of whether to discharge an infant with supplemental oxygen, particularly for those infants who might be weaned off by some clinicians and not by others,” wrote Sara B. DeMauro, MD, MSCE, of University of Pennsylvania, Philadelphia, and Children’s Hospital of Philadelphia, and her colleagues. “This study helps to clarify, both for clinicians and parents, the potential benefits and harms that might be expected from home oxygen therapy among the subset of infants for whom the best course of action is unclear.”

Dr. DeMauro and her colleagues examined 1,039 preterm infants with BPD given supplemental oxygen by nasal cannula between January 2006 and December 2014, who were propensity matched to infants in a control group with a similar severity of BPD who were not discharged with oxygen. The infants were born at less than 27 weeks’ gestation and began receiving oxygen therapy or respiratory support at 36 weeks’ postmenstrual age. These infants were then measured for growth, neurodevelopment, and resource use from discharge to follow-up at 22-26 months corrected age.

At follow-up, infants discharged with oxygen showed marginal weight improvement scores (adjusted mean difference, 0.11) and significantly improved weight-for-length scores (adjusted mean difference, 0.13), but they had rates of neurodevelopmental impairment similar to those of infants with BPD discharged without supplemental oxygen. In addition, infants discharged with oxygen had a greater likelihood of rehospitalization due to respiratory illness (adjusted relative risk, 1.33), use of asthma or BPD medication (adjusted RR, 1.30), and use of medical equipment such as a pulse oximeter (adjusted RR, 2.94).

The researchers noted that their study’s design prevented them from examining all infants with BPD discharged with supplemental oxygen and what factors influenced discharge of infants with supplemental oxygen, as well as the effects of various durations of supplemental oxygen exposure.

“Definitive evaluation of the risk/benefit ratio of this therapy will require prospective controlled trials,” Dr. DeMauro and her colleagues wrote. “Such research will facilitate a more evidence-based approach to clinical decisions about postdischarge care of infants with BPD.”

This study received funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network and the National Institutes of Health. The authors reported no relevant financial disclosures.

SOURCE: DeMauro SB et al. Pediatrics. 2019 Apr 11. doi: 10.1542/peds.2018-2956.

Preterm infants with bronchopulmonary dysplasia (BPD) discharged with supplemental oxygen showed slightly better weight and significantly improved weight-for-length scores, but were more likely to use medical resources and had rates of neurodevelopmental impairment similar to those of infants not discharged with oxygen, according to research published in Pediatrics.

Herjua/Thinkstock

“With this study, we provide important and novel information that may aid the decision of whether to discharge an infant with supplemental oxygen, particularly for those infants who might be weaned off by some clinicians and not by others,” wrote Sara B. DeMauro, MD, MSCE, of University of Pennsylvania, Philadelphia, and Children’s Hospital of Philadelphia, and her colleagues. “This study helps to clarify, both for clinicians and parents, the potential benefits and harms that might be expected from home oxygen therapy among the subset of infants for whom the best course of action is unclear.”

Dr. DeMauro and her colleagues examined 1,039 preterm infants with BPD given supplemental oxygen by nasal cannula between January 2006 and December 2014, who were propensity matched to infants in a control group with a similar severity of BPD who were not discharged with oxygen. The infants were born at less than 27 weeks’ gestation and began receiving oxygen therapy or respiratory support at 36 weeks’ postmenstrual age. These infants were then measured for growth, neurodevelopment, and resource use from discharge to follow-up at 22-26 months corrected age.

At follow-up, infants discharged with oxygen showed marginal weight improvement scores (adjusted mean difference, 0.11) and significantly improved weight-for-length scores (adjusted mean difference, 0.13), but they had rates of neurodevelopmental impairment similar to those of infants with BPD discharged without supplemental oxygen. In addition, infants discharged with oxygen had a greater likelihood of rehospitalization due to respiratory illness (adjusted relative risk, 1.33), use of asthma or BPD medication (adjusted RR, 1.30), and use of medical equipment such as a pulse oximeter (adjusted RR, 2.94).

The researchers noted that their study’s design prevented them from examining all infants with BPD discharged with supplemental oxygen and what factors influenced discharge of infants with supplemental oxygen, as well as the effects of various durations of supplemental oxygen exposure.

“Definitive evaluation of the risk/benefit ratio of this therapy will require prospective controlled trials,” Dr. DeMauro and her colleagues wrote. “Such research will facilitate a more evidence-based approach to clinical decisions about postdischarge care of infants with BPD.”

This study received funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network and the National Institutes of Health. The authors reported no relevant financial disclosures.

SOURCE: DeMauro SB et al. Pediatrics. 2019 Apr 11. doi: 10.1542/peds.2018-2956.

WASHINGTON – Hidradenitis suppurativa (HS) management should be individualized in patients, with consideration of their comorbidities, and therapies should be layered and rotated to improve efficacy, Ginette Okoye, MD, said at the annual meeting of the American Academy of Dermatology.

Jeff Craven/MDedge News

Pregnant women with HS can benefit from treatment with metformin, but dermatologists should consult with the patient’s obstetrician-gynecologist as the medication is classified as pregnancy category B. In addition, metformin should not be given to patients with a glomerular filtration rate (GFR) less than 45 mL/min, and long-term use is associated with low vitamin B₁₂ levels, she said.

“I often layer this with the antibiotic therapy, so my patient may be on clindamycin, rifampin, and metformin,” said Dr. Okoye. “If they are, you can give them a much lower dose of metformin since rifampin increases the plasma concentration of metformin.”

Patients with HS may also respond well to finasteride at doses between 1 mg and 5 mg once daily, an off-label use for this medication. Finasteride, which targets type 2 5-alpha-reductase, reduces the levels of dihydrotestosterone within hair follicles, which can improve HS symptoms, she said. However, she discusses potential side effects of finasteride use with patients, which include reduced libido, abnormal ejaculation, breast tenderness, prostate cancer, and depression. She also referred to postmarketing data suggesting that finasteride can lead to post-finasteride syndrome, characterized by symptoms that include depression and anhedonia, even long after stopping treatment, she said.

“I still think that it’s worth a try,” Dr. Okoye commented. “Many of our HS patients already are dealing with depression because of their disease. ... In 3 months, we talk about their symptoms, [and] make sure that they’re feeling okay before continuing.”

While finasteride is not appropriate for women of childbearing potential (pregnancy category X), it can be an option for women with HS who are of childbearing age but are not at risk for becoming pregnant, Dr. Okoye added, which can be determined by discussing a patient’s family planning goals. For example, she said, “if you have a woman of childbearing age but she’s in a same-sex relationship and has no intention of having children, then maybe finasteride is an option for her.”

The mineralocorticoid- and aldosterone-receptor antagonist spironolactone, used off label for acne treatment, also has antiandrogenic properties and is an option for patients with HS “at the higher end of the dosing spectrum” with 100-200 mg daily. However, Dr. Okoye referred to a recently published single-center retrospective study that showed a low daily dose of 75 mg was effective for HS (J Am Acad Dermatol. 2019 Jan;80[1]:114-9).

While spironolactone increases the risk of hyperkalemia, in patients with no preexisting renal disease under 50 years of age, monitoring is not necessary because there is little to no risk of clinical hyperkalemia in these patients, she said. Combining spironolactone or finasteride with OCs may increase antiandrogenic activity, she noted.

The data on effectiveness of hormonal contraceptives are mixed with regard to treatment of HS, with some studies showing benefit or worsening of the disease with OC use. “I think one of the reasons the data is so ‘dirty’ is because OCs range widely in terms of their ingredients and in terms of how androgenic their progesterones are,” Dr. Okoye commented.

OCs increase the risk of venous thromboembolism (VTE), but Dr. Okoye noted the risk is less than a patient would experience during pregnancy. “When you talk to dermatologists, there are two camps: some dermatologists who are very comfortable prescribing OCs, and dermatologists who prefer not to, given the risk of VTEs,” she said. However, risk should also be applied to patient population and location, she noted.

“If you are in an area [where] you serve a patient population that has fewer options for access to care, and if you don’t prescribe the OCs, those patients have to wait several months before getting on therapy, said Dr. Okoye. “Maybe that’s a case where you might want to start the OC [with] one or two refills while they find an OB, but it’s really up to you and your risk aversion.”

Dietary factors may also contribute to HS, but more studies are needed to analyze how sugar and carbohydrates contribute to the condition. Instead of taking for granted that a patient will understand what reducing dietary carbohydrate and sugar intake means, Dr. Okoye said, “I like to get very specific; ask them what they’re drinking on a daily basis.”

With regard to weight loss, there is little to link significant weight loss and symptom improvement. However, weight loss could help with comorbid conditions in patients with HS, like metabolic syndrome, and subsequent skin reduction may reduce friction of intertriginous areas, she pointed out.

Dr. Okoye reports receiving grants and/or research funding from Eli Lilly.

WASHINGTON – Hidradenitis suppurativa (HS) management should be individualized in patients, with consideration of their comorbidities, and therapies should be layered and rotated to improve efficacy, Ginette Okoye, MD, said at the annual meeting of the American Academy of Dermatology.

Jeff Craven/MDedge News

Pregnant women with HS can benefit from treatment with metformin, but dermatologists should consult with the patient’s obstetrician-gynecologist as the medication is classified as pregnancy category B. In addition, metformin should not be given to patients with a glomerular filtration rate (GFR) less than 45 mL/min, and long-term use is associated with low vitamin B₁₂ levels, she said.

“I often layer this with the antibiotic therapy, so my patient may be on clindamycin, rifampin, and metformin,” said Dr. Okoye. “If they are, you can give them a much lower dose of metformin since rifampin increases the plasma concentration of metformin.”

Patients with HS may also respond well to finasteride at doses between 1 mg and 5 mg once daily, an off-label use for this medication. Finasteride, which targets type 2 5-alpha-reductase, reduces the levels of dihydrotestosterone within hair follicles, which can improve HS symptoms, she said. However, she discusses potential side effects of finasteride use with patients, which include reduced libido, abnormal ejaculation, breast tenderness, prostate cancer, and depression. She also referred to postmarketing data suggesting that finasteride can lead to post-finasteride syndrome, characterized by symptoms that include depression and anhedonia, even long after stopping treatment, she said.

“I still think that it’s worth a try,” Dr. Okoye commented. “Many of our HS patients already are dealing with depression because of their disease. ... In 3 months, we talk about their symptoms, [and] make sure that they’re feeling okay before continuing.”

While finasteride is not appropriate for women of childbearing potential (pregnancy category X), it can be an option for women with HS who are of childbearing age but are not at risk for becoming pregnant, Dr. Okoye added, which can be determined by discussing a patient’s family planning goals. For example, she said, “if you have a woman of childbearing age but she’s in a same-sex relationship and has no intention of having children, then maybe finasteride is an option for her.”

The mineralocorticoid- and aldosterone-receptor antagonist spironolactone, used off label for acne treatment, also has antiandrogenic properties and is an option for patients with HS “at the higher end of the dosing spectrum” with 100-200 mg daily. However, Dr. Okoye referred to a recently published single-center retrospective study that showed a low daily dose of 75 mg was effective for HS (J Am Acad Dermatol. 2019 Jan;80[1]:114-9).

While spironolactone increases the risk of hyperkalemia, in patients with no preexisting renal disease under 50 years of age, monitoring is not necessary because there is little to no risk of clinical hyperkalemia in these patients, she said. Combining spironolactone or finasteride with OCs may increase antiandrogenic activity, she noted.

The data on effectiveness of hormonal contraceptives are mixed with regard to treatment of HS, with some studies showing benefit or worsening of the disease with OC use. “I think one of the reasons the data is so ‘dirty’ is because OCs range widely in terms of their ingredients and in terms of how androgenic their progesterones are,” Dr. Okoye commented.

OCs increase the risk of venous thromboembolism (VTE), but Dr. Okoye noted the risk is less than a patient would experience during pregnancy. “When you talk to dermatologists, there are two camps: some dermatologists who are very comfortable prescribing OCs, and dermatologists who prefer not to, given the risk of VTEs,” she said. However, risk should also be applied to patient population and location, she noted.

“If you are in an area [where] you serve a patient population that has fewer options for access to care, and if you don’t prescribe the OCs, those patients have to wait several months before getting on therapy, said Dr. Okoye. “Maybe that’s a case where you might want to start the OC [with] one or two refills while they find an OB, but it’s really up to you and your risk aversion.”

Dietary factors may also contribute to HS, but more studies are needed to analyze how sugar and carbohydrates contribute to the condition. Instead of taking for granted that a patient will understand what reducing dietary carbohydrate and sugar intake means, Dr. Okoye said, “I like to get very specific; ask them what they’re drinking on a daily basis.”

With regard to weight loss, there is little to link significant weight loss and symptom improvement. However, weight loss could help with comorbid conditions in patients with HS, like metabolic syndrome, and subsequent skin reduction may reduce friction of intertriginous areas, she pointed out.

Dr. Okoye reports receiving grants and/or research funding from Eli Lilly.

WASHINGTON – Hidradenitis suppurativa (HS) management should be individualized in patients, with consideration of their comorbidities, and therapies should be layered and rotated to improve efficacy, Ginette Okoye, MD, said at the annual meeting of the American Academy of Dermatology.

Jeff Craven/MDedge News

Pregnant women with HS can benefit from treatment with metformin, but dermatologists should consult with the patient’s obstetrician-gynecologist as the medication is classified as pregnancy category B. In addition, metformin should not be given to patients with a glomerular filtration rate (GFR) less than 45 mL/min, and long-term use is associated with low vitamin B₁₂ levels, she said.

“I often layer this with the antibiotic therapy, so my patient may be on clindamycin, rifampin, and metformin,” said Dr. Okoye. “If they are, you can give them a much lower dose of metformin since rifampin increases the plasma concentration of metformin.”

Patients with HS may also respond well to finasteride at doses between 1 mg and 5 mg once daily, an off-label use for this medication. Finasteride, which targets type 2 5-alpha-reductase, reduces the levels of dihydrotestosterone within hair follicles, which can improve HS symptoms, she said. However, she discusses potential side effects of finasteride use with patients, which include reduced libido, abnormal ejaculation, breast tenderness, prostate cancer, and depression. She also referred to postmarketing data suggesting that finasteride can lead to post-finasteride syndrome, characterized by symptoms that include depression and anhedonia, even long after stopping treatment, she said.

“I still think that it’s worth a try,” Dr. Okoye commented. “Many of our HS patients already are dealing with depression because of their disease. ... In 3 months, we talk about their symptoms, [and] make sure that they’re feeling okay before continuing.”

While finasteride is not appropriate for women of childbearing potential (pregnancy category X), it can be an option for women with HS who are of childbearing age but are not at risk for becoming pregnant, Dr. Okoye added, which can be determined by discussing a patient’s family planning goals. For example, she said, “if you have a woman of childbearing age but she’s in a same-sex relationship and has no intention of having children, then maybe finasteride is an option for her.”

The mineralocorticoid- and aldosterone-receptor antagonist spironolactone, used off label for acne treatment, also has antiandrogenic properties and is an option for patients with HS “at the higher end of the dosing spectrum” with 100-200 mg daily. However, Dr. Okoye referred to a recently published single-center retrospective study that showed a low daily dose of 75 mg was effective for HS (J Am Acad Dermatol. 2019 Jan;80[1]:114-9).

While spironolactone increases the risk of hyperkalemia, in patients with no preexisting renal disease under 50 years of age, monitoring is not necessary because there is little to no risk of clinical hyperkalemia in these patients, she said. Combining spironolactone or finasteride with OCs may increase antiandrogenic activity, she noted.

The data on effectiveness of hormonal contraceptives are mixed with regard to treatment of HS, with some studies showing benefit or worsening of the disease with OC use. “I think one of the reasons the data is so ‘dirty’ is because OCs range widely in terms of their ingredients and in terms of how androgenic their progesterones are,” Dr. Okoye commented.

OCs increase the risk of venous thromboembolism (VTE), but Dr. Okoye noted the risk is less than a patient would experience during pregnancy. “When you talk to dermatologists, there are two camps: some dermatologists who are very comfortable prescribing OCs, and dermatologists who prefer not to, given the risk of VTEs,” she said. However, risk should also be applied to patient population and location, she noted.

“If you are in an area [where] you serve a patient population that has fewer options for access to care, and if you don’t prescribe the OCs, those patients have to wait several months before getting on therapy, said Dr. Okoye. “Maybe that’s a case where you might want to start the OC [with] one or two refills while they find an OB, but it’s really up to you and your risk aversion.”

Dietary factors may also contribute to HS, but more studies are needed to analyze how sugar and carbohydrates contribute to the condition. Instead of taking for granted that a patient will understand what reducing dietary carbohydrate and sugar intake means, Dr. Okoye said, “I like to get very specific; ask them what they’re drinking on a daily basis.”

With regard to weight loss, there is little to link significant weight loss and symptom improvement. However, weight loss could help with comorbid conditions in patients with HS, like metabolic syndrome, and subsequent skin reduction may reduce friction of intertriginous areas, she pointed out.

Dr. Okoye reports receiving grants and/or research funding from Eli Lilly.

On the big stage at HM19 in late March, Carrie Herzke, MD, FAAP, FACP, SFHM, and Christopher Moriates, MD, FACP, SFHM, undertook the daunting task of summarizing a year’s worth of research relevant to the practice of hospital medicine – all within the span of an hour.

As has been standard with the “Update in Hospital Medicine” session at previous SHM Annual Conferences, the presenters touched on lighter topics in the medical literature: a prospective cohort study that found drinking coffee was inversely associated with mortality, even for those who drink up to eight cups a day; a cross-sectional observational study in which patients noted that what a physician wears is an important consideration for them during care, with a white coat preferred over formal attire as the most highly rated preference in a clinical care setting; and a study from a pediatric journal in which researchers calculated the average transit time for a Lego figurine head ingested by an adult.

But Dr. Herzke and Dr. Moriates mainly covered more serious subjects. In an interview before the session, Dr. Herzke, associate vice chair for clinical affairs in the department of medicine at Johns Hopkins Medicine in Baltimore, said she and Dr. Moriates chose studies across the fields of infectious diseases, cardiology, and hematology that should make hospitalists question common practices and consider changing how they practice medicine at their home institution.

Dr. Moriates, assistant dean for health care value at the University of Texas at Austin, said in an interview that their topic choices reflected the breadth and diversity of patients taken care of by hospitalists.

For example, he noted during the HM19 session that results from several studies suggest hospitalists may soon choose oral antibiotics over IV antibiotics for care of certain patient populations: the recent POET trial suggests use of oral antibiotics for patients with left-sided infective endocarditis resulted in a lower length of stay in hospital (19 inpatient days) when compared with use of IV antibiotics (3 inpatient days and 17 additional treatment days post discharge), while the OVIVA trial found a lower but noninferior treatment failure rate among patients who received oral antibiotics for bone and joint infection, compared with IV antibiotics. Although these were both well-done studies, Dr. Moriates and Dr. Herzke emphasized that the results challenge widely accepted standards of care, and it may not yet be time for a paradigm shift.

Direct oral anticoagulants (DOACs) also are being studied in patients with end-stage renal disease (ESRD) and cancer, Dr. Herzke said, and apixaban (Eliquis) 5 mg appears to be the preferred dose for a lower risk of stroke and mortality in patients with ESRD and atrial fibrillation. The speakers said there are further studies being developed for management of AF in patients with heart failure and DOACs for patients with ESRD.

Another retrospective cohort study from research in the Massachusetts Public Health Dataset found that buprenorphine may have a number needed to treat of 50 for opioid use disorder, which Dr. Moriates said is close in proximity for the number needed to treat for aspirin. “It seems like it’s time for this to become standard of care,” he said.

The speakers also highlighted common practices hospitalists should stop performing based on the latest evidence.

In one example, they revealed that there is conflicting research on angiotensin-converting enzyme (ACE) inhibitors. One study found transient preoperative interruption of ACE inhibitors was associated with a reduction in intraoperative hypotension during a noncardiac, nonvascular surgery. A second study linked ACE inhibitor use with a reduction in all-cause mortality. However, long-term use of ACE inhibitors also appears to be associated with a 14% increase in lung cancers, with an increased incidence based on longer use duration.

Hospitalists should also be aware of recommendations from a study on oxygen therapy, Dr. Herzke noted, which found that extra oxygen therapy may harm patients with MI or stroke; as a result, hospitalists should “wean oxygen as tolerated” in these patients. In addition, hospitalists also may want to consider using oral vancomycin (Vancocin) or fidaxomicin (Dificid) for treatment of Clostridium difficile infections, based on new evidence that found there is a higher cure rate for those treatments, compared with metronidazole.

Dr. Moriates and Dr. Herzke had no relevant financial conflicts.

On the big stage at HM19 in late March, Carrie Herzke, MD, FAAP, FACP, SFHM, and Christopher Moriates, MD, FACP, SFHM, undertook the daunting task of summarizing a year’s worth of research relevant to the practice of hospital medicine – all within the span of an hour.

As has been standard with the “Update in Hospital Medicine” session at previous SHM Annual Conferences, the presenters touched on lighter topics in the medical literature: a prospective cohort study that found drinking coffee was inversely associated with mortality, even for those who drink up to eight cups a day; a cross-sectional observational study in which patients noted that what a physician wears is an important consideration for them during care, with a white coat preferred over formal attire as the most highly rated preference in a clinical care setting; and a study from a pediatric journal in which researchers calculated the average transit time for a Lego figurine head ingested by an adult.

But Dr. Herzke and Dr. Moriates mainly covered more serious subjects. In an interview before the session, Dr. Herzke, associate vice chair for clinical affairs in the department of medicine at Johns Hopkins Medicine in Baltimore, said she and Dr. Moriates chose studies across the fields of infectious diseases, cardiology, and hematology that should make hospitalists question common practices and consider changing how they practice medicine at their home institution.

Dr. Moriates, assistant dean for health care value at the University of Texas at Austin, said in an interview that their topic choices reflected the breadth and diversity of patients taken care of by hospitalists.

For example, he noted during the HM19 session that results from several studies suggest hospitalists may soon choose oral antibiotics over IV antibiotics for care of certain patient populations: the recent POET trial suggests use of oral antibiotics for patients with left-sided infective endocarditis resulted in a lower length of stay in hospital (19 inpatient days) when compared with use of IV antibiotics (3 inpatient days and 17 additional treatment days post discharge), while the OVIVA trial found a lower but noninferior treatment failure rate among patients who received oral antibiotics for bone and joint infection, compared with IV antibiotics. Although these were both well-done studies, Dr. Moriates and Dr. Herzke emphasized that the results challenge widely accepted standards of care, and it may not yet be time for a paradigm shift.

Direct oral anticoagulants (DOACs) also are being studied in patients with end-stage renal disease (ESRD) and cancer, Dr. Herzke said, and apixaban (Eliquis) 5 mg appears to be the preferred dose for a lower risk of stroke and mortality in patients with ESRD and atrial fibrillation. The speakers said there are further studies being developed for management of AF in patients with heart failure and DOACs for patients with ESRD.

Another retrospective cohort study from research in the Massachusetts Public Health Dataset found that buprenorphine may have a number needed to treat of 50 for opioid use disorder, which Dr. Moriates said is close in proximity for the number needed to treat for aspirin. “It seems like it’s time for this to become standard of care,” he said.

The speakers also highlighted common practices hospitalists should stop performing based on the latest evidence.

In one example, they revealed that there is conflicting research on angiotensin-converting enzyme (ACE) inhibitors. One study found transient preoperative interruption of ACE inhibitors was associated with a reduction in intraoperative hypotension during a noncardiac, nonvascular surgery. A second study linked ACE inhibitor use with a reduction in all-cause mortality. However, long-term use of ACE inhibitors also appears to be associated with a 14% increase in lung cancers, with an increased incidence based on longer use duration.

Hospitalists should also be aware of recommendations from a study on oxygen therapy, Dr. Herzke noted, which found that extra oxygen therapy may harm patients with MI or stroke; as a result, hospitalists should “wean oxygen as tolerated” in these patients. In addition, hospitalists also may want to consider using oral vancomycin (Vancocin) or fidaxomicin (Dificid) for treatment of Clostridium difficile infections, based on new evidence that found there is a higher cure rate for those treatments, compared with metronidazole.

Dr. Moriates and Dr. Herzke had no relevant financial conflicts.

On the big stage at HM19 in late March, Carrie Herzke, MD, FAAP, FACP, SFHM, and Christopher Moriates, MD, FACP, SFHM, undertook the daunting task of summarizing a year’s worth of research relevant to the practice of hospital medicine – all within the span of an hour.

As has been standard with the “Update in Hospital Medicine” session at previous SHM Annual Conferences, the presenters touched on lighter topics in the medical literature: a prospective cohort study that found drinking coffee was inversely associated with mortality, even for those who drink up to eight cups a day; a cross-sectional observational study in which patients noted that what a physician wears is an important consideration for them during care, with a white coat preferred over formal attire as the most highly rated preference in a clinical care setting; and a study from a pediatric journal in which researchers calculated the average transit time for a Lego figurine head ingested by an adult.

But Dr. Herzke and Dr. Moriates mainly covered more serious subjects. In an interview before the session, Dr. Herzke, associate vice chair for clinical affairs in the department of medicine at Johns Hopkins Medicine in Baltimore, said she and Dr. Moriates chose studies across the fields of infectious diseases, cardiology, and hematology that should make hospitalists question common practices and consider changing how they practice medicine at their home institution.

Dr. Moriates, assistant dean for health care value at the University of Texas at Austin, said in an interview that their topic choices reflected the breadth and diversity of patients taken care of by hospitalists.

For example, he noted during the HM19 session that results from several studies suggest hospitalists may soon choose oral antibiotics over IV antibiotics for care of certain patient populations: the recent POET trial suggests use of oral antibiotics for patients with left-sided infective endocarditis resulted in a lower length of stay in hospital (19 inpatient days) when compared with use of IV antibiotics (3 inpatient days and 17 additional treatment days post discharge), while the OVIVA trial found a lower but noninferior treatment failure rate among patients who received oral antibiotics for bone and joint infection, compared with IV antibiotics. Although these were both well-done studies, Dr. Moriates and Dr. Herzke emphasized that the results challenge widely accepted standards of care, and it may not yet be time for a paradigm shift.

Direct oral anticoagulants (DOACs) also are being studied in patients with end-stage renal disease (ESRD) and cancer, Dr. Herzke said, and apixaban (Eliquis) 5 mg appears to be the preferred dose for a lower risk of stroke and mortality in patients with ESRD and atrial fibrillation. The speakers said there are further studies being developed for management of AF in patients with heart failure and DOACs for patients with ESRD.

Another retrospective cohort study from research in the Massachusetts Public Health Dataset found that buprenorphine may have a number needed to treat of 50 for opioid use disorder, which Dr. Moriates said is close in proximity for the number needed to treat for aspirin. “It seems like it’s time for this to become standard of care,” he said.

The speakers also highlighted common practices hospitalists should stop performing based on the latest evidence.

In one example, they revealed that there is conflicting research on angiotensin-converting enzyme (ACE) inhibitors. One study found transient preoperative interruption of ACE inhibitors was associated with a reduction in intraoperative hypotension during a noncardiac, nonvascular surgery. A second study linked ACE inhibitor use with a reduction in all-cause mortality. However, long-term use of ACE inhibitors also appears to be associated with a 14% increase in lung cancers, with an increased incidence based on longer use duration.

Hospitalists should also be aware of recommendations from a study on oxygen therapy, Dr. Herzke noted, which found that extra oxygen therapy may harm patients with MI or stroke; as a result, hospitalists should “wean oxygen as tolerated” in these patients. In addition, hospitalists also may want to consider using oral vancomycin (Vancocin) or fidaxomicin (Dificid) for treatment of Clostridium difficile infections, based on new evidence that found there is a higher cure rate for those treatments, compared with metronidazole.

Dr. Moriates and Dr. Herzke had no relevant financial conflicts.

Use of rituximab for B-cell depletion was not associated with clinical improvement of fatigue scores for patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), according to results from the phase 3 RituxME trial.

Courtesy Kristin Risa

“The lack of clinical effect of B-cell depletion in this trial weakens the case for an important role of B lymphocytes in ME/CFS but does not exclude an immunologic basis,” Øystein Fluge, MD, PhD, of the department of oncology and medical physics at Haukeland University Hospital in Bergen, Norway, and his colleagues wrote April 1 in Annals of Internal Medicine.

The investigators noted that the basis for testing the effects of a B-cell–depleting intervention on clinical symptoms in patients with ME/CFS came from observations of its potential benefit in a subgroup of patients in previous studies. Dr. Fluge and his colleagues performed a three-patient case series in their own group that found benefit for patients who received rituximab for treatment of CFS (BMC Neurol. 2009 May 8;9:28. doi: 10.1186/1471-2377-9-28). A phase 2 trial of 30 patients with CFS also performed by his own group found improved fatigue scores in 66.7% of patients in the rituximab group, compared with placebo (PLOS One. 2011 Oct 19. doi: 10.1371/journal.pone.0026358).

In the double-blinded RituxME trial, 151 patients with ME/CFS from four university hospitals and one general hospital in Norway were recruited and randomized to receive infusions of rituximab (n = 77) or placebo (n = 74). The patients were aged 18-65 years old and had the disease ranging from 2 years to 15 years. Patients reported and rated their ME/CFS symptoms at baseline as well as completed forms for the SF-36, Hospital Anxiety and Depression Scale, Fatigue Severity Scale, and modified DePaul Symptom Questionnaire out to 24 months. The rituximab group received two infusions at 500 mg/m² across body surface area at 2 weeks apart. They then received 500-mg maintenance infusions at 3 months, 6 months, 9 months, and 12 months where they also self-reported changes in ME/CFS symptoms.

There were no significant differences between groups regarding fatigue score at any follow-up period, with an average between-group difference of 0.02 at 24 months (95% confidence interval, –0.27 to 0.31). The overall response rate was 26% with rituximab and 35% with placebo. Dr. Fluge and his colleagues also noted no significant differences regarding SF-36 scores, function level, and fatigue severity between groups.

Adverse event rates were higher in the rituximab group (63 patients; 82%) than in the placebo group (48 patients; 65%), and these were more often attributed to treatment for those taking rituximab (26 patients [34%]) than for placebo (12 patients [16%]). Adverse events requiring hospitalization also occurred more often among those taking rituximab (31 events in 20 patients [26%]) than for those who took placebo (16 events in 14 patients [19%]).

Some of the weaknesses of the trial included its use of self-referral and self-reported symptom scores, which might have been subject to recall bias. In commenting on the difference in outcome between the phase 3 trial and others, Dr. Fluge and his associates said the discrepancy could potentially be high expectations in the placebo group, unknown factors surrounding symptom variation in ME/CFS patients, and unknown patient selection effects.

“[T]he negative outcome of RituxME should spur research to assess patient subgroups and further elucidate disease mechanisms, of which recently disclosed impairment of energy metabolism may be important,” Dr. Fluge and his coauthors wrote.

The trial was funded by grants to the researchers from the Norwegian Research Council, the Norwegian Regional Health Trusts, the MEandYou Foundation, the Norwegian ME Association, and the legacy of Torstein Hereid.

SOURCE: Fluge Ø et al. Ann Intern Med. 2019 Apr 1. doi: 10.7326/M18-1451

Use of rituximab for B-cell depletion was not associated with clinical improvement of fatigue scores for patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), according to results from the phase 3 RituxME trial.

Courtesy Kristin Risa

“The lack of clinical effect of B-cell depletion in this trial weakens the case for an important role of B lymphocytes in ME/CFS but does not exclude an immunologic basis,” Øystein Fluge, MD, PhD, of the department of oncology and medical physics at Haukeland University Hospital in Bergen, Norway, and his colleagues wrote April 1 in Annals of Internal Medicine.

The investigators noted that the basis for testing the effects of a B-cell–depleting intervention on clinical symptoms in patients with ME/CFS came from observations of its potential benefit in a subgroup of patients in previous studies. Dr. Fluge and his colleagues performed a three-patient case series in their own group that found benefit for patients who received rituximab for treatment of CFS (BMC Neurol. 2009 May 8;9:28. doi: 10.1186/1471-2377-9-28). A phase 2 trial of 30 patients with CFS also performed by his own group found improved fatigue scores in 66.7% of patients in the rituximab group, compared with placebo (PLOS One. 2011 Oct 19. doi: 10.1371/journal.pone.0026358).

In the double-blinded RituxME trial, 151 patients with ME/CFS from four university hospitals and one general hospital in Norway were recruited and randomized to receive infusions of rituximab (n = 77) or placebo (n = 74). The patients were aged 18-65 years old and had the disease ranging from 2 years to 15 years. Patients reported and rated their ME/CFS symptoms at baseline as well as completed forms for the SF-36, Hospital Anxiety and Depression Scale, Fatigue Severity Scale, and modified DePaul Symptom Questionnaire out to 24 months. The rituximab group received two infusions at 500 mg/m² across body surface area at 2 weeks apart. They then received 500-mg maintenance infusions at 3 months, 6 months, 9 months, and 12 months where they also self-reported changes in ME/CFS symptoms.

There were no significant differences between groups regarding fatigue score at any follow-up period, with an average between-group difference of 0.02 at 24 months (95% confidence interval, –0.27 to 0.31). The overall response rate was 26% with rituximab and 35% with placebo. Dr. Fluge and his colleagues also noted no significant differences regarding SF-36 scores, function level, and fatigue severity between groups.

Adverse event rates were higher in the rituximab group (63 patients; 82%) than in the placebo group (48 patients; 65%), and these were more often attributed to treatment for those taking rituximab (26 patients [34%]) than for placebo (12 patients [16%]). Adverse events requiring hospitalization also occurred more often among those taking rituximab (31 events in 20 patients [26%]) than for those who took placebo (16 events in 14 patients [19%]).

Some of the weaknesses of the trial included its use of self-referral and self-reported symptom scores, which might have been subject to recall bias. In commenting on the difference in outcome between the phase 3 trial and others, Dr. Fluge and his associates said the discrepancy could potentially be high expectations in the placebo group, unknown factors surrounding symptom variation in ME/CFS patients, and unknown patient selection effects.

“[T]he negative outcome of RituxME should spur research to assess patient subgroups and further elucidate disease mechanisms, of which recently disclosed impairment of energy metabolism may be important,” Dr. Fluge and his coauthors wrote.

The trial was funded by grants to the researchers from the Norwegian Research Council, the Norwegian Regional Health Trusts, the MEandYou Foundation, the Norwegian ME Association, and the legacy of Torstein Hereid.

SOURCE: Fluge Ø et al. Ann Intern Med. 2019 Apr 1. doi: 10.7326/M18-1451

Use of rituximab for B-cell depletion was not associated with clinical improvement of fatigue scores for patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), according to results from the phase 3 RituxME trial.

Courtesy Kristin Risa

“The lack of clinical effect of B-cell depletion in this trial weakens the case for an important role of B lymphocytes in ME/CFS but does not exclude an immunologic basis,” Øystein Fluge, MD, PhD, of the department of oncology and medical physics at Haukeland University Hospital in Bergen, Norway, and his colleagues wrote April 1 in Annals of Internal Medicine.

The investigators noted that the basis for testing the effects of a B-cell–depleting intervention on clinical symptoms in patients with ME/CFS came from observations of its potential benefit in a subgroup of patients in previous studies. Dr. Fluge and his colleagues performed a three-patient case series in their own group that found benefit for patients who received rituximab for treatment of CFS (BMC Neurol. 2009 May 8;9:28. doi: 10.1186/1471-2377-9-28). A phase 2 trial of 30 patients with CFS also performed by his own group found improved fatigue scores in 66.7% of patients in the rituximab group, compared with placebo (PLOS One. 2011 Oct 19. doi: 10.1371/journal.pone.0026358).

In the double-blinded RituxME trial, 151 patients with ME/CFS from four university hospitals and one general hospital in Norway were recruited and randomized to receive infusions of rituximab (n = 77) or placebo (n = 74). The patients were aged 18-65 years old and had the disease ranging from 2 years to 15 years. Patients reported and rated their ME/CFS symptoms at baseline as well as completed forms for the SF-36, Hospital Anxiety and Depression Scale, Fatigue Severity Scale, and modified DePaul Symptom Questionnaire out to 24 months. The rituximab group received two infusions at 500 mg/m² across body surface area at 2 weeks apart. They then received 500-mg maintenance infusions at 3 months, 6 months, 9 months, and 12 months where they also self-reported changes in ME/CFS symptoms.

There were no significant differences between groups regarding fatigue score at any follow-up period, with an average between-group difference of 0.02 at 24 months (95% confidence interval, –0.27 to 0.31). The overall response rate was 26% with rituximab and 35% with placebo. Dr. Fluge and his colleagues also noted no significant differences regarding SF-36 scores, function level, and fatigue severity between groups.

Adverse event rates were higher in the rituximab group (63 patients; 82%) than in the placebo group (48 patients; 65%), and these were more often attributed to treatment for those taking rituximab (26 patients [34%]) than for placebo (12 patients [16%]). Adverse events requiring hospitalization also occurred more often among those taking rituximab (31 events in 20 patients [26%]) than for those who took placebo (16 events in 14 patients [19%]).

Some of the weaknesses of the trial included its use of self-referral and self-reported symptom scores, which might have been subject to recall bias. In commenting on the difference in outcome between the phase 3 trial and others, Dr. Fluge and his associates said the discrepancy could potentially be high expectations in the placebo group, unknown factors surrounding symptom variation in ME/CFS patients, and unknown patient selection effects.

“[T]he negative outcome of RituxME should spur research to assess patient subgroups and further elucidate disease mechanisms, of which recently disclosed impairment of energy metabolism may be important,” Dr. Fluge and his coauthors wrote.

The trial was funded by grants to the researchers from the Norwegian Research Council, the Norwegian Regional Health Trusts, the MEandYou Foundation, the Norwegian ME Association, and the legacy of Torstein Hereid.

SOURCE: Fluge Ø et al. Ann Intern Med. 2019 Apr 1. doi: 10.7326/M18-1451

Most people who could benefit from FDA-approved medications for opioid use disorder do not receive them, and access to those treatments is not equitable, according to a new consensus study report from the National Academies of Sciences, Engineering, and Medicine.

“Methadone, buprenorphine, and extended-release naltrexone are safe and highly effective medications that are already approved by the U.S. Food and Drug Administration to treat OUD,” the report said. “These medications save lives, but the majority of people with OUD in the United States receive no treatment at all.”

The report, called “Medications for Opioid Use Disorder Save Lives,” said a critical factor in addressing the crisis is “confronting the major barriers” to using those medications. It also said additional research will be needed to address opioid use disorder among subpopulations in the United States, such as adolescents, older adults, people with comorbidities, racial and ethnic groups, and people with low socioeconomic status. The National Academies’ report was sponsored by NIDA and SAMHSA.

A few weeks before the release of National Academies report, the National Academy of Medicine (NAM) held a webinar providing details on its Action Collaborative on Countering the U.S. Opioid Epidemic. The collaborative, a partnership of public and private stakeholders, aims to address the opioid crisis through a multidisciplinary, cross-sector effort.

The collaborative is represented by federal agencies, state and local governments, health care systems, provider groups, nonprofits, payers, industry, academia, patient organizations, and communities across about 55 organizations, according to Victor J. Dzau, MD, chair of the Action Collaborative and current NAM president. Over a 2-year period, the collaborative’s goal is to accelerate progress in overcoming the opioid crisis by recognizing the challenges, research gaps, and needs of organizations involved in the crisis and “elevate and accelerate evidence-based, multisectoral, and interprofessional solutions,” he said.

“This is not a problem that can be solved by a single sector. It is truly a whole of society problem,” said Adm. Brett P. Giroir, MD, assistant secretary for health at the U.S. Department of Health and Human Services, said during the webinar. “And the only way that we are going to be able to begin making inroads to reverse the trends of this crisis is if we work together.” Dr. Giroir also serves as cochair of the steering committee for the collaborative.

In its overview of the collaborative, the NAM outlined four working groups developed through a series of surveys and planning meetings that would identify the resources that currently exist to combat the opioid epidemic and determine which resources still need to be developed. In the Health Professional Education and Training Working Group, for example, the objective is to examine what is being taught to health professionals about acute and chronic pain management at an accreditation, certification, and regulatory level to develop educational tools based around knowledge gaps in those areas and analyze how the new resources are affecting health professions after they have been adopted, said Steve Singer, PhD, vice president of education and outreach at the Accreditation Council for Graduate Medical Education and colead of the working group.“Our goal is really to provide guidance and resources across the continuum of health professions and education with an interprofessional – and patient-informed view,” he said.

The Opioid Prescribing Guidelines and Evidence Standards Working Group plans to address the disparities in prescribing and tapering guidelines for acute and chronic pain as well as identify where pain management guidelines in different specialties “cannot be justified,” based on available evidence.

“Further, we think it’s really important to not just have guidelines that will sit on a shelf, but we also want to think about how we can support implementation of these guidelines into practice ... ” said Helen Burstin, MD, MPH, executive vice president and CEO for the Council of Medical Specialty Societies and colead of the working group.

Alonzo L. Plough, PhD, MPH, vice president of research-evaluation-learning at the Robert Wood Johnson Foundation and colead of the Prevention, Treatment, and Recovery Services Working Group, explained that the goal of his group is to identify the “essential elements and components” and best practices of prevention, treatment, and recovery for OUD. He noted that, although the working group will not be able to reach all patient populations affected by OUD, it has discussed targeting vulnerable high-risk populations, such as those involved in the criminal justice system, homeless veterans, mothers, and children.

“This is an ecosystem that requires great concentration and effort to make sure that there are integrated approaches throughout the continuum that work for patients and clients from different walks of life, and I think that our overall guidance is how we can recognize and use evidence to find those approaches and build on them for guidance,” he said.

The Research, Data, and Metrics Needs Working Group is tasked with collaborating with the other groups to obtain currently available information and identify what barriers exist to greater transparency, sharing and interoperability of data as well as what gaps in research currently exist that would further the collaborative’s mission, said Kelly J. Clark, MD, MBA, of the ASAM. “It is simply critical for us to utilize the data that’s out there, to pool it into more actionable information – and then to act on it,” Dr. Clark said.

The NAM is seeking new organizations interested in joining the collaborative as a network organization, which would receive updates and provide input on the collaborative but would not be a part of the working groups.

The first public meeting of the Action Collaborative on Countering the U.S. Opioid Epidemic will take place on April 30, 2019, in Washington.

Most people who could benefit from FDA-approved medications for opioid use disorder do not receive them, and access to those treatments is not equitable, according to a new consensus study report from the National Academies of Sciences, Engineering, and Medicine.

“Methadone, buprenorphine, and extended-release naltrexone are safe and highly effective medications that are already approved by the U.S. Food and Drug Administration to treat OUD,” the report said. “These medications save lives, but the majority of people with OUD in the United States receive no treatment at all.”

The report, called “Medications for Opioid Use Disorder Save Lives,” said a critical factor in addressing the crisis is “confronting the major barriers” to using those medications. It also said additional research will be needed to address opioid use disorder among subpopulations in the United States, such as adolescents, older adults, people with comorbidities, racial and ethnic groups, and people with low socioeconomic status. The National Academies’ report was sponsored by NIDA and SAMHSA.

A few weeks before the release of National Academies report, the National Academy of Medicine (NAM) held a webinar providing details on its Action Collaborative on Countering the U.S. Opioid Epidemic. The collaborative, a partnership of public and private stakeholders, aims to address the opioid crisis through a multidisciplinary, cross-sector effort.

The collaborative is represented by federal agencies, state and local governments, health care systems, provider groups, nonprofits, payers, industry, academia, patient organizations, and communities across about 55 organizations, according to Victor J. Dzau, MD, chair of the Action Collaborative and current NAM president. Over a 2-year period, the collaborative’s goal is to accelerate progress in overcoming the opioid crisis by recognizing the challenges, research gaps, and needs of organizations involved in the crisis and “elevate and accelerate evidence-based, multisectoral, and interprofessional solutions,” he said.

“This is not a problem that can be solved by a single sector. It is truly a whole of society problem,” said Adm. Brett P. Giroir, MD, assistant secretary for health at the U.S. Department of Health and Human Services, said during the webinar. “And the only way that we are going to be able to begin making inroads to reverse the trends of this crisis is if we work together.” Dr. Giroir also serves as cochair of the steering committee for the collaborative.

In its overview of the collaborative, the NAM outlined four working groups developed through a series of surveys and planning meetings that would identify the resources that currently exist to combat the opioid epidemic and determine which resources still need to be developed. In the Health Professional Education and Training Working Group, for example, the objective is to examine what is being taught to health professionals about acute and chronic pain management at an accreditation, certification, and regulatory level to develop educational tools based around knowledge gaps in those areas and analyze how the new resources are affecting health professions after they have been adopted, said Steve Singer, PhD, vice president of education and outreach at the Accreditation Council for Graduate Medical Education and colead of the working group.“Our goal is really to provide guidance and resources across the continuum of health professions and education with an interprofessional – and patient-informed view,” he said.

The Opioid Prescribing Guidelines and Evidence Standards Working Group plans to address the disparities in prescribing and tapering guidelines for acute and chronic pain as well as identify where pain management guidelines in different specialties “cannot be justified,” based on available evidence.

“Further, we think it’s really important to not just have guidelines that will sit on a shelf, but we also want to think about how we can support implementation of these guidelines into practice ... ” said Helen Burstin, MD, MPH, executive vice president and CEO for the Council of Medical Specialty Societies and colead of the working group.

Alonzo L. Plough, PhD, MPH, vice president of research-evaluation-learning at the Robert Wood Johnson Foundation and colead of the Prevention, Treatment, and Recovery Services Working Group, explained that the goal of his group is to identify the “essential elements and components” and best practices of prevention, treatment, and recovery for OUD. He noted that, although the working group will not be able to reach all patient populations affected by OUD, it has discussed targeting vulnerable high-risk populations, such as those involved in the criminal justice system, homeless veterans, mothers, and children.

“This is an ecosystem that requires great concentration and effort to make sure that there are integrated approaches throughout the continuum that work for patients and clients from different walks of life, and I think that our overall guidance is how we can recognize and use evidence to find those approaches and build on them for guidance,” he said.

The Research, Data, and Metrics Needs Working Group is tasked with collaborating with the other groups to obtain currently available information and identify what barriers exist to greater transparency, sharing and interoperability of data as well as what gaps in research currently exist that would further the collaborative’s mission, said Kelly J. Clark, MD, MBA, of the ASAM. “It is simply critical for us to utilize the data that’s out there, to pool it into more actionable information – and then to act on it,” Dr. Clark said.

The NAM is seeking new organizations interested in joining the collaborative as a network organization, which would receive updates and provide input on the collaborative but would not be a part of the working groups.

The first public meeting of the Action Collaborative on Countering the U.S. Opioid Epidemic will take place on April 30, 2019, in Washington.

Most people who could benefit from FDA-approved medications for opioid use disorder do not receive them, and access to those treatments is not equitable, according to a new consensus study report from the National Academies of Sciences, Engineering, and Medicine.

“Methadone, buprenorphine, and extended-release naltrexone are safe and highly effective medications that are already approved by the U.S. Food and Drug Administration to treat OUD,” the report said. “These medications save lives, but the majority of people with OUD in the United States receive no treatment at all.”

The report, called “Medications for Opioid Use Disorder Save Lives,” said a critical factor in addressing the crisis is “confronting the major barriers” to using those medications. It also said additional research will be needed to address opioid use disorder among subpopulations in the United States, such as adolescents, older adults, people with comorbidities, racial and ethnic groups, and people with low socioeconomic status. The National Academies’ report was sponsored by NIDA and SAMHSA.

A few weeks before the release of National Academies report, the National Academy of Medicine (NAM) held a webinar providing details on its Action Collaborative on Countering the U.S. Opioid Epidemic. The collaborative, a partnership of public and private stakeholders, aims to address the opioid crisis through a multidisciplinary, cross-sector effort.

The collaborative is represented by federal agencies, state and local governments, health care systems, provider groups, nonprofits, payers, industry, academia, patient organizations, and communities across about 55 organizations, according to Victor J. Dzau, MD, chair of the Action Collaborative and current NAM president. Over a 2-year period, the collaborative’s goal is to accelerate progress in overcoming the opioid crisis by recognizing the challenges, research gaps, and needs of organizations involved in the crisis and “elevate and accelerate evidence-based, multisectoral, and interprofessional solutions,” he said.

“This is not a problem that can be solved by a single sector. It is truly a whole of society problem,” said Adm. Brett P. Giroir, MD, assistant secretary for health at the U.S. Department of Health and Human Services, said during the webinar. “And the only way that we are going to be able to begin making inroads to reverse the trends of this crisis is if we work together.” Dr. Giroir also serves as cochair of the steering committee for the collaborative.

In its overview of the collaborative, the NAM outlined four working groups developed through a series of surveys and planning meetings that would identify the resources that currently exist to combat the opioid epidemic and determine which resources still need to be developed. In the Health Professional Education and Training Working Group, for example, the objective is to examine what is being taught to health professionals about acute and chronic pain management at an accreditation, certification, and regulatory level to develop educational tools based around knowledge gaps in those areas and analyze how the new resources are affecting health professions after they have been adopted, said Steve Singer, PhD, vice president of education and outreach at the Accreditation Council for Graduate Medical Education and colead of the working group.“Our goal is really to provide guidance and resources across the continuum of health professions and education with an interprofessional – and patient-informed view,” he said.

The Opioid Prescribing Guidelines and Evidence Standards Working Group plans to address the disparities in prescribing and tapering guidelines for acute and chronic pain as well as identify where pain management guidelines in different specialties “cannot be justified,” based on available evidence.

“Further, we think it’s really important to not just have guidelines that will sit on a shelf, but we also want to think about how we can support implementation of these guidelines into practice ... ” said Helen Burstin, MD, MPH, executive vice president and CEO for the Council of Medical Specialty Societies and colead of the working group.

Alonzo L. Plough, PhD, MPH, vice president of research-evaluation-learning at the Robert Wood Johnson Foundation and colead of the Prevention, Treatment, and Recovery Services Working Group, explained that the goal of his group is to identify the “essential elements and components” and best practices of prevention, treatment, and recovery for OUD. He noted that, although the working group will not be able to reach all patient populations affected by OUD, it has discussed targeting vulnerable high-risk populations, such as those involved in the criminal justice system, homeless veterans, mothers, and children.

“This is an ecosystem that requires great concentration and effort to make sure that there are integrated approaches throughout the continuum that work for patients and clients from different walks of life, and I think that our overall guidance is how we can recognize and use evidence to find those approaches and build on them for guidance,” he said.

The Research, Data, and Metrics Needs Working Group is tasked with collaborating with the other groups to obtain currently available information and identify what barriers exist to greater transparency, sharing and interoperability of data as well as what gaps in research currently exist that would further the collaborative’s mission, said Kelly J. Clark, MD, MBA, of the ASAM. “It is simply critical for us to utilize the data that’s out there, to pool it into more actionable information – and then to act on it,” Dr. Clark said.

The NAM is seeking new organizations interested in joining the collaborative as a network organization, which would receive updates and provide input on the collaborative but would not be a part of the working groups.

The first public meeting of the Action Collaborative on Countering the U.S. Opioid Epidemic will take place on April 30, 2019, in Washington.

Stress testing for patients with low-risk chest pain and use of venous thromboembolism chemoprophylaxis in low-risk patients are the latest practices to come under scrutiny and were discussed during a special session at HM19.

Anthony Breu, MD, a hospitalist and director of resident education in the Veterans Affairs Boston Healthcare System, presented “common practices that have low or no value.” He provided arguments against these practices based in both evidence and pathophysiology.

“Things We Do For No Reason: The 2019 Clinical Update for Hospitalists,” presented Tuesday morning, was the latest in a series of such sessions held during SHM’s Annual Conference. Leonard S. Feldman, MD, SFHM, from Johns Hopkins Medicine in Baltimore, presented the first “Things We Do For No Reason” session at the 2012 conference in San Diego, analyzing the 30% target hematocrit for cardiac patients, naso-gastric lavage in gastrointestinal bleeds, fractional excretion of sodium and urea in evaluating acute kidney injuries, and the use of daily chest x-rays in ICUs.

“For patients with low-risk chest pain, stress tests do not add value,” said Dr. Breu. There are a number of ways a hospitalist can determine whether a patient has low-risk chest pain, and the rates of acute MI and mortality at 30 days are “well below 1%” for these patients, he noted.

“Stress tests may lower this rate a bit, but they are unfortunately unable to identify all patients who will experience subsequent events,” he said. “Also, given that pretest probability of coronary artery disease is low in these patients, the false-positive rate approaches 50%.”

Dr. Breu attributed the continued use of stress tests in patients with low-risk chest pain to recent American College of Cardiology and American Heart Association statements on appropriate use of stress testing, which should occur during initial hospitalization or within 72 hours of discharge. In addition, many hospitalists believe a negative stress test result can help them rule out a diagnosis like coronary artery disease.

In a second example of suspect practices, the need for venous thromboembolism (VTE) chemoprophylaxis, such as with subcutaneous enoxaparin, in high-risk patients is based on evidence that shows a reduction in asymptomatic deep vein thrombosis (DVT). However, “the evidence is not as clear” on whether VTE chemoprophylaxis reduces symptomatic DVT or pulmonary embolism (PE), Dr. Breu said.

“When this is coupled with the fact that bleeding is increased with chemoprophylaxis, its use in low-risk patients should be avoided,” Dr. Breu said. “Unfortunately, there is evidence that many of us administer VTE prophylaxis to low-risk patients just as often as we do for high-risk patients.”

Dr. Breu said he suspects many providers “overestimate the benefits” of VTE chemoprophylaxis. “I suspect that if someone is on the fence about whether to administer VTE [chemoprophylaxis], many err on the side of administering, fearing that they will miss an opportunity to prevent a DVT or PE while not realizing the risk of bleeding is real.”

Dr. Breu presented evidence from the literature as support for his argument against the practice of ordering stress tests and administering VTE chemoprophylaxis in low-risk patients. The oldest study goes back to 1967, while the most recent study was published in February 2019, he said.

“My hope is that attendees will be less inclined to order stress tests in patients with low-risk chest pain,” Dr. Breu said in an interview. “I also hope that they will apply scoring systems to better identify patients who are at high risk for VTE and not administer chemoprophylaxis to all others.”

Dr. Breu reported having no relevant financial disclosures.

Stress testing for patients with low-risk chest pain and use of venous thromboembolism chemoprophylaxis in low-risk patients are the latest practices to come under scrutiny and were discussed during a special session at HM19.

Anthony Breu, MD, a hospitalist and director of resident education in the Veterans Affairs Boston Healthcare System, presented “common practices that have low or no value.” He provided arguments against these practices based in both evidence and pathophysiology.

“Things We Do For No Reason: The 2019 Clinical Update for Hospitalists,” presented Tuesday morning, was the latest in a series of such sessions held during SHM’s Annual Conference. Leonard S. Feldman, MD, SFHM, from Johns Hopkins Medicine in Baltimore, presented the first “Things We Do For No Reason” session at the 2012 conference in San Diego, analyzing the 30% target hematocrit for cardiac patients, naso-gastric lavage in gastrointestinal bleeds, fractional excretion of sodium and urea in evaluating acute kidney injuries, and the use of daily chest x-rays in ICUs.

“For patients with low-risk chest pain, stress tests do not add value,” said Dr. Breu. There are a number of ways a hospitalist can determine whether a patient has low-risk chest pain, and the rates of acute MI and mortality at 30 days are “well below 1%” for these patients, he noted.

“Stress tests may lower this rate a bit, but they are unfortunately unable to identify all patients who will experience subsequent events,” he said. “Also, given that pretest probability of coronary artery disease is low in these patients, the false-positive rate approaches 50%.”

Dr. Breu attributed the continued use of stress tests in patients with low-risk chest pain to recent American College of Cardiology and American Heart Association statements on appropriate use of stress testing, which should occur during initial hospitalization or within 72 hours of discharge. In addition, many hospitalists believe a negative stress test result can help them rule out a diagnosis like coronary artery disease.

In a second example of suspect practices, the need for venous thromboembolism (VTE) chemoprophylaxis, such as with subcutaneous enoxaparin, in high-risk patients is based on evidence that shows a reduction in asymptomatic deep vein thrombosis (DVT). However, “the evidence is not as clear” on whether VTE chemoprophylaxis reduces symptomatic DVT or pulmonary embolism (PE), Dr. Breu said.

“When this is coupled with the fact that bleeding is increased with chemoprophylaxis, its use in low-risk patients should be avoided,” Dr. Breu said. “Unfortunately, there is evidence that many of us administer VTE prophylaxis to low-risk patients just as often as we do for high-risk patients.”

Dr. Breu said he suspects many providers “overestimate the benefits” of VTE chemoprophylaxis. “I suspect that if someone is on the fence about whether to administer VTE [chemoprophylaxis], many err on the side of administering, fearing that they will miss an opportunity to prevent a DVT or PE while not realizing the risk of bleeding is real.”

Dr. Breu presented evidence from the literature as support for his argument against the practice of ordering stress tests and administering VTE chemoprophylaxis in low-risk patients. The oldest study goes back to 1967, while the most recent study was published in February 2019, he said.

“My hope is that attendees will be less inclined to order stress tests in patients with low-risk chest pain,” Dr. Breu said in an interview. “I also hope that they will apply scoring systems to better identify patients who are at high risk for VTE and not administer chemoprophylaxis to all others.”

Dr. Breu reported having no relevant financial disclosures.

Stress testing for patients with low-risk chest pain and use of venous thromboembolism chemoprophylaxis in low-risk patients are the latest practices to come under scrutiny and were discussed during a special session at HM19.

Anthony Breu, MD, a hospitalist and director of resident education in the Veterans Affairs Boston Healthcare System, presented “common practices that have low or no value.” He provided arguments against these practices based in both evidence and pathophysiology.

“Things We Do For No Reason: The 2019 Clinical Update for Hospitalists,” presented Tuesday morning, was the latest in a series of such sessions held during SHM’s Annual Conference. Leonard S. Feldman, MD, SFHM, from Johns Hopkins Medicine in Baltimore, presented the first “Things We Do For No Reason” session at the 2012 conference in San Diego, analyzing the 30% target hematocrit for cardiac patients, naso-gastric lavage in gastrointestinal bleeds, fractional excretion of sodium and urea in evaluating acute kidney injuries, and the use of daily chest x-rays in ICUs.

“For patients with low-risk chest pain, stress tests do not add value,” said Dr. Breu. There are a number of ways a hospitalist can determine whether a patient has low-risk chest pain, and the rates of acute MI and mortality at 30 days are “well below 1%” for these patients, he noted.

“Stress tests may lower this rate a bit, but they are unfortunately unable to identify all patients who will experience subsequent events,” he said. “Also, given that pretest probability of coronary artery disease is low in these patients, the false-positive rate approaches 50%.”

Dr. Breu attributed the continued use of stress tests in patients with low-risk chest pain to recent American College of Cardiology and American Heart Association statements on appropriate use of stress testing, which should occur during initial hospitalization or within 72 hours of discharge. In addition, many hospitalists believe a negative stress test result can help them rule out a diagnosis like coronary artery disease.

In a second example of suspect practices, the need for venous thromboembolism (VTE) chemoprophylaxis, such as with subcutaneous enoxaparin, in high-risk patients is based on evidence that shows a reduction in asymptomatic deep vein thrombosis (DVT). However, “the evidence is not as clear” on whether VTE chemoprophylaxis reduces symptomatic DVT or pulmonary embolism (PE), Dr. Breu said.

“When this is coupled with the fact that bleeding is increased with chemoprophylaxis, its use in low-risk patients should be avoided,” Dr. Breu said. “Unfortunately, there is evidence that many of us administer VTE prophylaxis to low-risk patients just as often as we do for high-risk patients.”

Dr. Breu said he suspects many providers “overestimate the benefits” of VTE chemoprophylaxis. “I suspect that if someone is on the fence about whether to administer VTE [chemoprophylaxis], many err on the side of administering, fearing that they will miss an opportunity to prevent a DVT or PE while not realizing the risk of bleeding is real.”

Dr. Breu presented evidence from the literature as support for his argument against the practice of ordering stress tests and administering VTE chemoprophylaxis in low-risk patients. The oldest study goes back to 1967, while the most recent study was published in February 2019, he said.

“My hope is that attendees will be less inclined to order stress tests in patients with low-risk chest pain,” Dr. Breu said in an interview. “I also hope that they will apply scoring systems to better identify patients who are at high risk for VTE and not administer chemoprophylaxis to all others.”

Dr. Breu reported having no relevant financial disclosures.

The word “hospitalist” is clear and concise. It declares that this type of physician is directly tied to hospitals, as much of a fixture as emergency departments, ICUs, and cafeterias. But what if a hospitalist appears on a screen instead of standing at bedside? Is that still hospital medicine?

Absolutely, according to hospitalists Ameet Doshi, MD, MBA, of HealthPartners in Bloomington, Minn.; and Ryan Brown, MD, FHM, and Brian Schroeder, MHA, FHM, FACHE, of Atrium Health in Charlotte, N.C. In an interview before the session, Dr. Doshi said telemedicine can help hospitalists and health care organizations address patient care challenges, ranging from staffing in rural hospitals to handling cross-cover surges, but telemedicine can help providers in any kind of care environment or location.

Currently, he said in the pre-session interview, “many groups are using real-time video capabilities to deliver hospitalist care where in-person providers are not available. This could be for nocturnist coverage at rural hospitals or even providing cross-cover services at larger hospitals where the in-person providers are at capacity.”

During the session, the presenters gave several use cases for telemedicine in rural health, critical care, and acute care environments. Dr. Doshi is a telehospitalist with HealthPartners, which provides inpatient telemedicine services to five hospitals across Minnesota and Wisconsin.

Dr. Brown, whose group provides telemedicine services at 12 facilities, said they allow hospitalists to interact virtually with patients, conduct physical exams, and perform many more duties.

As he explained, “we do nighttime cross-cover, perform admissions and consults, supervise NP/PAs in low-risk units, handle census surge situations, provide care in rural and critical-access hospitals that find recruiting difficult, use subspecialty support to keep patients at hospitals closer to their homes, triage transfers into our health care system, and see postdischarge patients for follow-ups in their homes from our transition clinic. Done correctly, telemedicine can be effectively used in many different care scenarios.”

Patients love telemedicine, he said. “The increased access to care where and when they want it is very attractive.” While objective data is not yet available, he noted in a survey of 124 patients in his institution, 37.1% of patients rated their overall care through telemedicine as a 10 out of 10, while 26.6% of patients and 20.2% of patients rated care at a 9 and an 8 out of 10, respectively.

During the HM19 session, Dr. Doshi and colleagues discussed several of the drivers behind the advent of telemedicine, including specific health care situations in which it can be applicable as well as the structural and financial requirements that will help an organization create a viable telemedicine service.

In the big picture, he said, “the biggest take-home we can give to our audience is the idea that telemedicine is not an esoteric, flight-of-fancy program that is only a niche issue. There are a plethora of situations where patient care can be optimally delivered with telemedicine, and we want to outline these situations as well as give the framework for how telemedicine can be organically grown within any organization.”


Randy Dotinga contributed to this report.

The word “hospitalist” is clear and concise. It declares that this type of physician is directly tied to hospitals, as much of a fixture as emergency departments, ICUs, and cafeterias. But what if a hospitalist appears on a screen instead of standing at bedside? Is that still hospital medicine?

Absolutely, according to hospitalists Ameet Doshi, MD, MBA, of HealthPartners in Bloomington, Minn.; and Ryan Brown, MD, FHM, and Brian Schroeder, MHA, FHM, FACHE, of Atrium Health in Charlotte, N.C. In an interview before the session, Dr. Doshi said telemedicine can help hospitalists and health care organizations address patient care challenges, ranging from staffing in rural hospitals to handling cross-cover surges, but telemedicine can help providers in any kind of care environment or location.

Currently, he said in the pre-session interview, “many groups are using real-time video capabilities to deliver hospitalist care where in-person providers are not available. This could be for nocturnist coverage at rural hospitals or even providing cross-cover services at larger hospitals where the in-person providers are at capacity.”

During the session, the presenters gave several use cases for telemedicine in rural health, critical care, and acute care environments. Dr. Doshi is a telehospitalist with HealthPartners, which provides inpatient telemedicine services to five hospitals across Minnesota and Wisconsin.

Dr. Brown, whose group provides telemedicine services at 12 facilities, said they allow hospitalists to interact virtually with patients, conduct physical exams, and perform many more duties.

As he explained, “we do nighttime cross-cover, perform admissions and consults, supervise NP/PAs in low-risk units, handle census surge situations, provide care in rural and critical-access hospitals that find recruiting difficult, use subspecialty support to keep patients at hospitals closer to their homes, triage transfers into our health care system, and see postdischarge patients for follow-ups in their homes from our transition clinic. Done correctly, telemedicine can be effectively used in many different care scenarios.”

Patients love telemedicine, he said. “The increased access to care where and when they want it is very attractive.” While objective data is not yet available, he noted in a survey of 124 patients in his institution, 37.1% of patients rated their overall care through telemedicine as a 10 out of 10, while 26.6% of patients and 20.2% of patients rated care at a 9 and an 8 out of 10, respectively.

During the HM19 session, Dr. Doshi and colleagues discussed several of the drivers behind the advent of telemedicine, including specific health care situations in which it can be applicable as well as the structural and financial requirements that will help an organization create a viable telemedicine service.

In the big picture, he said, “the biggest take-home we can give to our audience is the idea that telemedicine is not an esoteric, flight-of-fancy program that is only a niche issue. There are a plethora of situations where patient care can be optimally delivered with telemedicine, and we want to outline these situations as well as give the framework for how telemedicine can be organically grown within any organization.”


Randy Dotinga contributed to this report.

The word “hospitalist” is clear and concise. It declares that this type of physician is directly tied to hospitals, as much of a fixture as emergency departments, ICUs, and cafeterias. But what if a hospitalist appears on a screen instead of standing at bedside? Is that still hospital medicine?

Absolutely, according to hospitalists Ameet Doshi, MD, MBA, of HealthPartners in Bloomington, Minn.; and Ryan Brown, MD, FHM, and Brian Schroeder, MHA, FHM, FACHE, of Atrium Health in Charlotte, N.C. In an interview before the session, Dr. Doshi said telemedicine can help hospitalists and health care organizations address patient care challenges, ranging from staffing in rural hospitals to handling cross-cover surges, but telemedicine can help providers in any kind of care environment or location.

Currently, he said in the pre-session interview, “many groups are using real-time video capabilities to deliver hospitalist care where in-person providers are not available. This could be for nocturnist coverage at rural hospitals or even providing cross-cover services at larger hospitals where the in-person providers are at capacity.”

During the session, the presenters gave several use cases for telemedicine in rural health, critical care, and acute care environments. Dr. Doshi is a telehospitalist with HealthPartners, which provides inpatient telemedicine services to five hospitals across Minnesota and Wisconsin.

Dr. Brown, whose group provides telemedicine services at 12 facilities, said they allow hospitalists to interact virtually with patients, conduct physical exams, and perform many more duties.

As he explained, “we do nighttime cross-cover, perform admissions and consults, supervise NP/PAs in low-risk units, handle census surge situations, provide care in rural and critical-access hospitals that find recruiting difficult, use subspecialty support to keep patients at hospitals closer to their homes, triage transfers into our health care system, and see postdischarge patients for follow-ups in their homes from our transition clinic. Done correctly, telemedicine can be effectively used in many different care scenarios.”

Patients love telemedicine, he said. “The increased access to care where and when they want it is very attractive.” While objective data is not yet available, he noted in a survey of 124 patients in his institution, 37.1% of patients rated their overall care through telemedicine as a 10 out of 10, while 26.6% of patients and 20.2% of patients rated care at a 9 and an 8 out of 10, respectively.

During the HM19 session, Dr. Doshi and colleagues discussed several of the drivers behind the advent of telemedicine, including specific health care situations in which it can be applicable as well as the structural and financial requirements that will help an organization create a viable telemedicine service.

In the big picture, he said, “the biggest take-home we can give to our audience is the idea that telemedicine is not an esoteric, flight-of-fancy program that is only a niche issue. There are a plethora of situations where patient care can be optimally delivered with telemedicine, and we want to outline these situations as well as give the framework for how telemedicine can be organically grown within any organization.”


Randy Dotinga contributed to this report.

Social media can be more than a tool to connect with friends and family, said Vineet Chopra, MD, MBBS, FHM, Charlie Wray, DO, and Vineet Arora, MD, MAPP, MHM, at Monday’s “Tweet Your Way to the Top? Social Media as a Career Development Tool in Hospital Medicine” session.

Online outreach can play crucial roles in everything from continuing education and research to networking and career advancement, but most of the conversations in medicine are really focused in the Twittersphere, the three hospitalists said.

“Social media has allowed me to connect with leaders in hospital medicine and many other medical communities,” said Dr. Wray, an assistant professor of medicine at the University of California, San Francisco. “It has allowed me to share my work and success with the hospitalist community in addition to highlighting my trainees’ and colleagues’ successes. My engagement has created opportunities to get involved with projects that I could never have previously imagined. And it has extended my networking circle and made annual gatherings like the SHM Annual Conference even more beneficial and high yield for my career.”

For session copresenter Dr. Chopra, associate professor and chief of the division of hospital medicine at the University of Michigan, Ann Arbor, social media “helps develop your brand and your identity. It is a wonderful way for people to know what you do, who you are, what you stand for, and your views and opinions on various topics.”

On the career front, social media “can connect you to leaders in the community so that they know who you are and what you are accomplishing. So when time comes for you to move on, people within this community will know who you are and what you’re known for at a national level,” said Dr. Wray, who is also deputy digital media editor for the Journal of Hospital Medicine.

Sharing on social media – and Twitter in particular – for the medical profession is focused mainly on dissemination of information, engaging in communities, and networking beyond your institution. The three presenters shared tips of the trade during the session, such as how to boost exposure to a tweet by including hashtags, posting photos, and sharing links. To overcome time commitment barriers, tie your Twitter contributions to something you are doing already, said Dr. Arora, associate chief medical officer-clinical learning environment at the University of Chicago.

A presence on social media isn’t just a tool to boost your own profile, Dr. Wray said. It also helps you stay on top of medical news. “There is so much information and new data coming out nowadays, it can be hard to keep up,” he said. “A properly curated social media feed can help a busy clinician stay on top of what is really important. This is an invaluable skill for the modern hospitalist.”

But be careful how much you disclose on social media about yourself and, especially, other people. “A good rule of thumb is: Don’t put anything online that you wouldn’t want your mother to read,” Dr. Chopra said. “As well, sharing any personal or patient information without understanding your institution’s guidelines or obtaining explicit permission is a general no-no,” he said.

“Also, many employers look at social media profiles before they hire people. We certainly do so when we are looking at various individuals. We often call this a ‘Google biopsy.’ ”

Randy Dotinga contributed to this report.

Social media can be more than a tool to connect with friends and family, said Vineet Chopra, MD, MBBS, FHM, Charlie Wray, DO, and Vineet Arora, MD, MAPP, MHM, at Monday’s “Tweet Your Way to the Top? Social Media as a Career Development Tool in Hospital Medicine” session.

Online outreach can play crucial roles in everything from continuing education and research to networking and career advancement, but most of the conversations in medicine are really focused in the Twittersphere, the three hospitalists said.

“Social media has allowed me to connect with leaders in hospital medicine and many other medical communities,” said Dr. Wray, an assistant professor of medicine at the University of California, San Francisco. “It has allowed me to share my work and success with the hospitalist community in addition to highlighting my trainees’ and colleagues’ successes. My engagement has created opportunities to get involved with projects that I could never have previously imagined. And it has extended my networking circle and made annual gatherings like the SHM Annual Conference even more beneficial and high yield for my career.”

For session copresenter Dr. Chopra, associate professor and chief of the division of hospital medicine at the University of Michigan, Ann Arbor, social media “helps develop your brand and your identity. It is a wonderful way for people to know what you do, who you are, what you stand for, and your views and opinions on various topics.”

On the career front, social media “can connect you to leaders in the community so that they know who you are and what you are accomplishing. So when time comes for you to move on, people within this community will know who you are and what you’re known for at a national level,” said Dr. Wray, who is also deputy digital media editor for the Journal of Hospital Medicine.

Sharing on social media – and Twitter in particular – for the medical profession is focused mainly on dissemination of information, engaging in communities, and networking beyond your institution. The three presenters shared tips of the trade during the session, such as how to boost exposure to a tweet by including hashtags, posting photos, and sharing links. To overcome time commitment barriers, tie your Twitter contributions to something you are doing already, said Dr. Arora, associate chief medical officer-clinical learning environment at the University of Chicago.

A presence on social media isn’t just a tool to boost your own profile, Dr. Wray said. It also helps you stay on top of medical news. “There is so much information and new data coming out nowadays, it can be hard to keep up,” he said. “A properly curated social media feed can help a busy clinician stay on top of what is really important. This is an invaluable skill for the modern hospitalist.”

But be careful how much you disclose on social media about yourself and, especially, other people. “A good rule of thumb is: Don’t put anything online that you wouldn’t want your mother to read,” Dr. Chopra said. “As well, sharing any personal or patient information without understanding your institution’s guidelines or obtaining explicit permission is a general no-no,” he said.

“Also, many employers look at social media profiles before they hire people. We certainly do so when we are looking at various individuals. We often call this a ‘Google biopsy.’ ”

Randy Dotinga contributed to this report.

Social media can be more than a tool to connect with friends and family, said Vineet Chopra, MD, MBBS, FHM, Charlie Wray, DO, and Vineet Arora, MD, MAPP, MHM, at Monday’s “Tweet Your Way to the Top? Social Media as a Career Development Tool in Hospital Medicine” session.

Online outreach can play crucial roles in everything from continuing education and research to networking and career advancement, but most of the conversations in medicine are really focused in the Twittersphere, the three hospitalists said.

“Social media has allowed me to connect with leaders in hospital medicine and many other medical communities,” said Dr. Wray, an assistant professor of medicine at the University of California, San Francisco. “It has allowed me to share my work and success with the hospitalist community in addition to highlighting my trainees’ and colleagues’ successes. My engagement has created opportunities to get involved with projects that I could never have previously imagined. And it has extended my networking circle and made annual gatherings like the SHM Annual Conference even more beneficial and high yield for my career.”

For session copresenter Dr. Chopra, associate professor and chief of the division of hospital medicine at the University of Michigan, Ann Arbor, social media “helps develop your brand and your identity. It is a wonderful way for people to know what you do, who you are, what you stand for, and your views and opinions on various topics.”

On the career front, social media “can connect you to leaders in the community so that they know who you are and what you are accomplishing. So when time comes for you to move on, people within this community will know who you are and what you’re known for at a national level,” said Dr. Wray, who is also deputy digital media editor for the Journal of Hospital Medicine.

Sharing on social media – and Twitter in particular – for the medical profession is focused mainly on dissemination of information, engaging in communities, and networking beyond your institution. The three presenters shared tips of the trade during the session, such as how to boost exposure to a tweet by including hashtags, posting photos, and sharing links. To overcome time commitment barriers, tie your Twitter contributions to something you are doing already, said Dr. Arora, associate chief medical officer-clinical learning environment at the University of Chicago.

A presence on social media isn’t just a tool to boost your own profile, Dr. Wray said. It also helps you stay on top of medical news. “There is so much information and new data coming out nowadays, it can be hard to keep up,” he said. “A properly curated social media feed can help a busy clinician stay on top of what is really important. This is an invaluable skill for the modern hospitalist.”

But be careful how much you disclose on social media about yourself and, especially, other people. “A good rule of thumb is: Don’t put anything online that you wouldn’t want your mother to read,” Dr. Chopra said. “As well, sharing any personal or patient information without understanding your institution’s guidelines or obtaining explicit permission is a general no-no,” he said.

“Also, many employers look at social media profiles before they hire people. We certainly do so when we are looking at various individuals. We often call this a ‘Google biopsy.’ ”

Randy Dotinga contributed to this report.

WASHINGTON – Psoriasis induced by tumor necrosis factor (TNF) therapy is among the treatment-associated effects that involve the skin in patients with inflammatory bowel disease (IBD), Sophia Delano, MD, said during a session on the cutaneous effects of IBD at the annual meeting of the American Academy of Dermatology.

Jeff Craven/MDedge News

This is a paradoxical reaction, which can happen “weeks to years after starting a TNF blocker,” with about 70% of cases occurring during the first year of therapy, said Dr. Delano, an attending physician in the dermatology program at Boston Children’s Hospital.

Those receiving infliximab are more likely to develop TNF inhibitor–induced psoriasis, compared with those on adalimumab or etanercept. TNF inhibitor–induced psoriasis may not track with gastrointestinal activity, and some patients whose gastrointestinal disease is responding to treatment can begin to develop psoriasis, she noted.

The clinical presentation of TNF inhibitor–induced psoriasis can also vary. In one study of 216 cases, 26.9% of patients had a mixed morphology, with the most common presentations including plaque psoriasis (44.8%) and palmoplantar pustular psoriasis (36.3%). Other presentations were psoriasiform dermatitis (19.9%), scalp involvement with alopecia (7.5%), and generalized pustular psoriasis (10.9%). Locations affected were the soles of the feet (45.8%), extremities (45.4%), palms (44.9%), scalp (36.1%), and trunk (32.4%), Dr. Delano said.


TNF inhibitor–induced psoriasis is likely a class effect, she said, noting that, in the same review, symptoms resolved in 47.7% of patients who discontinued TNF inhibitors, in 36.7% of patients who switched to another TNF inhibitor, and in 32.9% of patients who continued their original therapy (J Am Acad Dermatol. 2017 Feb;76[2]:334-41). In the study, Crohn’s disease and RA were the most common diseases, in 40.7% and 37.0% of the patients, respectively.

There have been case reports of TNF antagonist–induced lupus-like syndrome (TAILS), which is more common in patients with RA and ulcerative colitis. TAILS occurs more often in women than in men; can present similarly to systemic lupus erythematosus, subacute cutaneous lupus erythematosus, and chronic cutaneous lupus; and resolves by stopping TNF inhibitor treatment, Dr. Delano said.

Skin cancer risk, infections, and injection site reactions

Both adult and pediatric patients treated with TNF inhibitors for IBD may be at increased risk for lymphoma, visceral tumors, melanoma, and nonmelanoma skin cancers. Dr. Delano referred to a study published in 2014, which identified 972 reports of melanoma in the Food and Drug Administration’s Adverse Event Reporting System database associated with TNF inhibitor use; of these, 69 cases involved patients using more than one TNF inhibitor. Infliximab, golimumab, etanercept, and adalimumab were associated with a safety signal for melanoma, but not certolizumab (Br J Dermatol. 2014 May;170[5]:1170-2).

Dr. Delano observed that thiopurines such as azathioprine are also associated with an increased cancer risk, as noted in one retrospective study that found that the risk of nonmelanoma skin cancer was 2.1 times higher in a mostly white male cohort with ulcerative colitis during treatment with thiopurines, compared with patients not treated with thiopurines (Am J Gastroenterol. 2014 Nov;109[11]:1781-93). A greater duration of treatment (more than 6 months) and higher doses were associated with higher risks.

Adalimumab, golimumab, and certolizumab can also cause injection site reactions, typically within 1- 2 days of injection, said Dr. Delano. In these cases, symptoms of erythema, warmth, burning, or pruritus are worse at the beginning of treatment and can be relieved by rotating the injection site as well as providing cool compresses, topical steroids, antihistamines, and supportive care.

“If you have a patient with a worsening reaction, consider it may represent the type 1 IgE-related hypersensitivity requiring desensitization to continue that systemic,” she noted.

Cutaneous bacterial, fungal, and viral infections such as molluscum contagiosum, verruca vulgaris, herpes simplex, and varicella zoster can occur as a result of TNF inhibition as well, and can be difficult to clear because of immunosuppression, she added.

Dr. Delano reported no relevant conflicts of interest.

WASHINGTON – Psoriasis induced by tumor necrosis factor (TNF) therapy is among the treatment-associated effects that involve the skin in patients with inflammatory bowel disease (IBD), Sophia Delano, MD, said during a session on the cutaneous effects of IBD at the annual meeting of the American Academy of Dermatology.

Jeff Craven/MDedge News

This is a paradoxical reaction, which can happen “weeks to years after starting a TNF blocker,” with about 70% of cases occurring during the first year of therapy, said Dr. Delano, an attending physician in the dermatology program at Boston Children’s Hospital.

Those receiving infliximab are more likely to develop TNF inhibitor–induced psoriasis, compared with those on adalimumab or etanercept. TNF inhibitor–induced psoriasis may not track with gastrointestinal activity, and some patients whose gastrointestinal disease is responding to treatment can begin to develop psoriasis, she noted.

The clinical presentation of TNF inhibitor–induced psoriasis can also vary. In one study of 216 cases, 26.9% of patients had a mixed morphology, with the most common presentations including plaque psoriasis (44.8%) and palmoplantar pustular psoriasis (36.3%). Other presentations were psoriasiform dermatitis (19.9%), scalp involvement with alopecia (7.5%), and generalized pustular psoriasis (10.9%). Locations affected were the soles of the feet (45.8%), extremities (45.4%), palms (44.9%), scalp (36.1%), and trunk (32.4%), Dr. Delano said.


TNF inhibitor–induced psoriasis is likely a class effect, she said, noting that, in the same review, symptoms resolved in 47.7% of patients who discontinued TNF inhibitors, in 36.7% of patients who switched to another TNF inhibitor, and in 32.9% of patients who continued their original therapy (J Am Acad Dermatol. 2017 Feb;76[2]:334-41). In the study, Crohn’s disease and RA were the most common diseases, in 40.7% and 37.0% of the patients, respectively.

There have been case reports of TNF antagonist–induced lupus-like syndrome (TAILS), which is more common in patients with RA and ulcerative colitis. TAILS occurs more often in women than in men; can present similarly to systemic lupus erythematosus, subacute cutaneous lupus erythematosus, and chronic cutaneous lupus; and resolves by stopping TNF inhibitor treatment, Dr. Delano said.

Skin cancer risk, infections, and injection site reactions

Both adult and pediatric patients treated with TNF inhibitors for IBD may be at increased risk for lymphoma, visceral tumors, melanoma, and nonmelanoma skin cancers. Dr. Delano referred to a study published in 2014, which identified 972 reports of melanoma in the Food and Drug Administration’s Adverse Event Reporting System database associated with TNF inhibitor use; of these, 69 cases involved patients using more than one TNF inhibitor. Infliximab, golimumab, etanercept, and adalimumab were associated with a safety signal for melanoma, but not certolizumab (Br J Dermatol. 2014 May;170[5]:1170-2).

Dr. Delano observed that thiopurines such as azathioprine are also associated with an increased cancer risk, as noted in one retrospective study that found that the risk of nonmelanoma skin cancer was 2.1 times higher in a mostly white male cohort with ulcerative colitis during treatment with thiopurines, compared with patients not treated with thiopurines (Am J Gastroenterol. 2014 Nov;109[11]:1781-93). A greater duration of treatment (more than 6 months) and higher doses were associated with higher risks.

Adalimumab, golimumab, and certolizumab can also cause injection site reactions, typically within 1- 2 days of injection, said Dr. Delano. In these cases, symptoms of erythema, warmth, burning, or pruritus are worse at the beginning of treatment and can be relieved by rotating the injection site as well as providing cool compresses, topical steroids, antihistamines, and supportive care.

“If you have a patient with a worsening reaction, consider it may represent the type 1 IgE-related hypersensitivity requiring desensitization to continue that systemic,” she noted.

Cutaneous bacterial, fungal, and viral infections such as molluscum contagiosum, verruca vulgaris, herpes simplex, and varicella zoster can occur as a result of TNF inhibition as well, and can be difficult to clear because of immunosuppression, she added.

Dr. Delano reported no relevant conflicts of interest.

WASHINGTON – Psoriasis induced by tumor necrosis factor (TNF) therapy is among the treatment-associated effects that involve the skin in patients with inflammatory bowel disease (IBD), Sophia Delano, MD, said during a session on the cutaneous effects of IBD at the annual meeting of the American Academy of Dermatology.

Jeff Craven/MDedge News

This is a paradoxical reaction, which can happen “weeks to years after starting a TNF blocker,” with about 70% of cases occurring during the first year of therapy, said Dr. Delano, an attending physician in the dermatology program at Boston Children’s Hospital.

Those receiving infliximab are more likely to develop TNF inhibitor–induced psoriasis, compared with those on adalimumab or etanercept. TNF inhibitor–induced psoriasis may not track with gastrointestinal activity, and some patients whose gastrointestinal disease is responding to treatment can begin to develop psoriasis, she noted.

The clinical presentation of TNF inhibitor–induced psoriasis can also vary. In one study of 216 cases, 26.9% of patients had a mixed morphology, with the most common presentations including plaque psoriasis (44.8%) and palmoplantar pustular psoriasis (36.3%). Other presentations were psoriasiform dermatitis (19.9%), scalp involvement with alopecia (7.5%), and generalized pustular psoriasis (10.9%). Locations affected were the soles of the feet (45.8%), extremities (45.4%), palms (44.9%), scalp (36.1%), and trunk (32.4%), Dr. Delano said.


TNF inhibitor–induced psoriasis is likely a class effect, she said, noting that, in the same review, symptoms resolved in 47.7% of patients who discontinued TNF inhibitors, in 36.7% of patients who switched to another TNF inhibitor, and in 32.9% of patients who continued their original therapy (J Am Acad Dermatol. 2017 Feb;76[2]:334-41). In the study, Crohn’s disease and RA were the most common diseases, in 40.7% and 37.0% of the patients, respectively.

There have been case reports of TNF antagonist–induced lupus-like syndrome (TAILS), which is more common in patients with RA and ulcerative colitis. TAILS occurs more often in women than in men; can present similarly to systemic lupus erythematosus, subacute cutaneous lupus erythematosus, and chronic cutaneous lupus; and resolves by stopping TNF inhibitor treatment, Dr. Delano said.

Skin cancer risk, infections, and injection site reactions

Both adult and pediatric patients treated with TNF inhibitors for IBD may be at increased risk for lymphoma, visceral tumors, melanoma, and nonmelanoma skin cancers. Dr. Delano referred to a study published in 2014, which identified 972 reports of melanoma in the Food and Drug Administration’s Adverse Event Reporting System database associated with TNF inhibitor use; of these, 69 cases involved patients using more than one TNF inhibitor. Infliximab, golimumab, etanercept, and adalimumab were associated with a safety signal for melanoma, but not certolizumab (Br J Dermatol. 2014 May;170[5]:1170-2).

Dr. Delano observed that thiopurines such as azathioprine are also associated with an increased cancer risk, as noted in one retrospective study that found that the risk of nonmelanoma skin cancer was 2.1 times higher in a mostly white male cohort with ulcerative colitis during treatment with thiopurines, compared with patients not treated with thiopurines (Am J Gastroenterol. 2014 Nov;109[11]:1781-93). A greater duration of treatment (more than 6 months) and higher doses were associated with higher risks.

Adalimumab, golimumab, and certolizumab can also cause injection site reactions, typically within 1- 2 days of injection, said Dr. Delano. In these cases, symptoms of erythema, warmth, burning, or pruritus are worse at the beginning of treatment and can be relieved by rotating the injection site as well as providing cool compresses, topical steroids, antihistamines, and supportive care.

“If you have a patient with a worsening reaction, consider it may represent the type 1 IgE-related hypersensitivity requiring desensitization to continue that systemic,” she noted.

Cutaneous bacterial, fungal, and viral infections such as molluscum contagiosum, verruca vulgaris, herpes simplex, and varicella zoster can occur as a result of TNF inhibition as well, and can be difficult to clear because of immunosuppression, she added.

Dr. Delano reported no relevant conflicts of interest.