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AAP urges prioritization of sexuality education in well visits
Talk about sex with patients and their families, and have ongoing, age-appropriate discussions over the course of a patient’s development, urges an updated clinical report from the American Academy of Pediatrics.
Citing gaps in school-based sexuality education programs nationally, the report calls on you to do more to ensure patients have adequate information about preventing teen pregnancy, HIV, and other sexually transmitted diseases.
The report will be seen as good news by pediatricians and others, lead author and chairperson of the AAP Committee on Adolescence, Cora Collette Breuner, MD, said in an interview.
“Pediatricians, parents, and school administrators have been asking for this updated information,” Dr. Breuner said. “Pediatricians want more clarification, more resources, and more evidence for what they are already doing.”
The report, Sexuality Education for Children and Adolescents, is published online and is free to the general public. It is the AAP’s first update on sexuality education since 2001, and includes lists of resources specifically for clinicians, parents, and schools.
“We found that only one out of three adolescent patients receive any information on sexuality from their pediatrician, and if they did, the conversation lasted less than 40 seconds,” Dr. Breuner said, citing a review of health maintenance visits. Dr. Breuneris also a professor of adolescent medicine at the Seattle Children’s Hospital.
Even if less than a minute is all that you have to devote to discussing sexual health with a patient, Dr. Breuner said it’s well worth it, in part because it can help prevent teens from turning to often unreliable sources of information on the Internet, and because it can help fill the gap for teens whose families don’t want to address the topic, or whose schools do not offer programs to address it.
“The conversations should cover a range of aspects of sexual health, including healthy sexual development, interpersonal and consensual relationships, affection, intimacy, and body image,” Dr. Breuner said. “The research shows that just talking about abstinence is not enough.”
Such conversations also should address sexual anatomy and reproduction, sexually transmitted infections, sexual orientation, gender identity, abstinence, contraception, and reproductive rights and responsibilities, according to the report.
The report cites a meta-analysis finding that parents who were trained on how to effectively communicate about sex with their adolescents had better conversations on the subject than parents who were not. Such conversations correlated with a delay in teen sexual debut and an increased use of contraception and condoms.
Talking with young persons about their sexuality is also a way to help screen them for depression and suicidality, Dr. Breuner said. “These issues can often be uncovered when talking with kids about sexuality, particularly with those who are questioning their sexual identity.”
The report also suggests pediatricians discuss issues of physical, cognitive, and psychosexual development with parents of young children during well visits over time.
Earlier this year, in conjunction with the North American Society of Pediatric and Adolescent Gynecology, the AAP issued its first clinical guidance on addressing sexual health in adolescents with special needs (Pediatrics. 2006. doi: 10.1542/peds.2006-1115).
Neither Dr. Breuner nor the authors of the clinical report had any relevant financial disclosures.
On Twitter @whitneymcknight
Parents and their progeny often see their pediatric providers as coaches. The pediatrician, by design, likes to be in a dyad with the parent and patient, yet sexual education is a topic that we don’t cover in residency extensively so we are being asked to do this counseling with little support, and for some of us, talking about it with patients makes us uncomfortable.
 |
Dr. M. Susan Jay |
Everyone would like to believe that the schools are taking care of all kids need to know about their sexuality, and that abstinence training is sufficient. This report shows that this is not the case. There is tremendous variability in what the schools are doing, and that’s not even considering parochial or charter schools.
Some of us might ask, “How the heck are we supposed to do all this?” in a short visit. But, much as immunizations have become linked to pediatric well visits, this review gives suggestions for how to provide serial “social immunization” messages using the resources provided. You can use these links to do much of the “talking,” and other resources can be put in the patient’s after-visit summary.
If you only get those 40 seconds to talk about sexuality and reproductive health with your patient, be sure you take that time to actually look not at the computer screen, but at your patient, and listen. You don’t have to be Freud. You just need to be open to listening.
M. Susan Jay, MD, is the program director of adolescent health and medicine at the Children’s Hospital of Wisconsin in Madison. She said she had no relevant financial disclosures.
Parents and their progeny often see their pediatric providers as coaches. The pediatrician, by design, likes to be in a dyad with the parent and patient, yet sexual education is a topic that we don’t cover in residency extensively so we are being asked to do this counseling with little support, and for some of us, talking about it with patients makes us uncomfortable.
|
Dr. M. Susan Jay |
Everyone would like to believe that the schools are taking care of all kids need to know about their sexuality, and that abstinence training is sufficient. This report shows that this is not the case. There is tremendous variability in what the schools are doing, and that’s not even considering parochial or charter schools.
Some of us might ask, “How the heck are we supposed to do all this?” in a short visit. But, much as immunizations have become linked to pediatric well visits, this review gives suggestions for how to provide serial “social immunization” messages using the resources provided. You can use these links to do much of the “talking,” and other resources can be put in the patient’s after-visit summary.
If you only get those 40 seconds to talk about sexuality and reproductive health with your patient, be sure you take that time to actually look not at the computer screen, but at your patient, and listen. You don’t have to be Freud. You just need to be open to listening.
M. Susan Jay, MD, is the program director of adolescent health and medicine at the Children’s Hospital of Wisconsin in Madison. She said she had no relevant financial disclosures.
Parents and their progeny often see their pediatric providers as coaches. The pediatrician, by design, likes to be in a dyad with the parent and patient, yet sexual education is a topic that we don’t cover in residency extensively so we are being asked to do this counseling with little support, and for some of us, talking about it with patients makes us uncomfortable.
|
Dr. M. Susan Jay |
Everyone would like to believe that the schools are taking care of all kids need to know about their sexuality, and that abstinence training is sufficient. This report shows that this is not the case. There is tremendous variability in what the schools are doing, and that’s not even considering parochial or charter schools.
Some of us might ask, “How the heck are we supposed to do all this?” in a short visit. But, much as immunizations have become linked to pediatric well visits, this review gives suggestions for how to provide serial “social immunization” messages using the resources provided. You can use these links to do much of the “talking,” and other resources can be put in the patient’s after-visit summary.
If you only get those 40 seconds to talk about sexuality and reproductive health with your patient, be sure you take that time to actually look not at the computer screen, but at your patient, and listen. You don’t have to be Freud. You just need to be open to listening.
M. Susan Jay, MD, is the program director of adolescent health and medicine at the Children’s Hospital of Wisconsin in Madison. She said she had no relevant financial disclosures.
Talk about sex with patients and their families, and have ongoing, age-appropriate discussions over the course of a patient’s development, urges an updated clinical report from the American Academy of Pediatrics.
Citing gaps in school-based sexuality education programs nationally, the report calls on you to do more to ensure patients have adequate information about preventing teen pregnancy, HIV, and other sexually transmitted diseases.
The report will be seen as good news by pediatricians and others, lead author and chairperson of the AAP Committee on Adolescence, Cora Collette Breuner, MD, said in an interview.
“Pediatricians, parents, and school administrators have been asking for this updated information,” Dr. Breuner said. “Pediatricians want more clarification, more resources, and more evidence for what they are already doing.”
The report, Sexuality Education for Children and Adolescents, is published online and is free to the general public. It is the AAP’s first update on sexuality education since 2001, and includes lists of resources specifically for clinicians, parents, and schools.
“We found that only one out of three adolescent patients receive any information on sexuality from their pediatrician, and if they did, the conversation lasted less than 40 seconds,” Dr. Breuner said, citing a review of health maintenance visits. Dr. Breuneris also a professor of adolescent medicine at the Seattle Children’s Hospital.
Even if less than a minute is all that you have to devote to discussing sexual health with a patient, Dr. Breuner said it’s well worth it, in part because it can help prevent teens from turning to often unreliable sources of information on the Internet, and because it can help fill the gap for teens whose families don’t want to address the topic, or whose schools do not offer programs to address it.
“The conversations should cover a range of aspects of sexual health, including healthy sexual development, interpersonal and consensual relationships, affection, intimacy, and body image,” Dr. Breuner said. “The research shows that just talking about abstinence is not enough.”
Such conversations also should address sexual anatomy and reproduction, sexually transmitted infections, sexual orientation, gender identity, abstinence, contraception, and reproductive rights and responsibilities, according to the report.
The report cites a meta-analysis finding that parents who were trained on how to effectively communicate about sex with their adolescents had better conversations on the subject than parents who were not. Such conversations correlated with a delay in teen sexual debut and an increased use of contraception and condoms.
Talking with young persons about their sexuality is also a way to help screen them for depression and suicidality, Dr. Breuner said. “These issues can often be uncovered when talking with kids about sexuality, particularly with those who are questioning their sexual identity.”
The report also suggests pediatricians discuss issues of physical, cognitive, and psychosexual development with parents of young children during well visits over time.
Earlier this year, in conjunction with the North American Society of Pediatric and Adolescent Gynecology, the AAP issued its first clinical guidance on addressing sexual health in adolescents with special needs (Pediatrics. 2006. doi: 10.1542/peds.2006-1115).
Neither Dr. Breuner nor the authors of the clinical report had any relevant financial disclosures.
On Twitter @whitneymcknight
Talk about sex with patients and their families, and have ongoing, age-appropriate discussions over the course of a patient’s development, urges an updated clinical report from the American Academy of Pediatrics.
Citing gaps in school-based sexuality education programs nationally, the report calls on you to do more to ensure patients have adequate information about preventing teen pregnancy, HIV, and other sexually transmitted diseases.
The report will be seen as good news by pediatricians and others, lead author and chairperson of the AAP Committee on Adolescence, Cora Collette Breuner, MD, said in an interview.
“Pediatricians, parents, and school administrators have been asking for this updated information,” Dr. Breuner said. “Pediatricians want more clarification, more resources, and more evidence for what they are already doing.”
The report, Sexuality Education for Children and Adolescents, is published online and is free to the general public. It is the AAP’s first update on sexuality education since 2001, and includes lists of resources specifically for clinicians, parents, and schools.
“We found that only one out of three adolescent patients receive any information on sexuality from their pediatrician, and if they did, the conversation lasted less than 40 seconds,” Dr. Breuner said, citing a review of health maintenance visits. Dr. Breuneris also a professor of adolescent medicine at the Seattle Children’s Hospital.
Even if less than a minute is all that you have to devote to discussing sexual health with a patient, Dr. Breuner said it’s well worth it, in part because it can help prevent teens from turning to often unreliable sources of information on the Internet, and because it can help fill the gap for teens whose families don’t want to address the topic, or whose schools do not offer programs to address it.
“The conversations should cover a range of aspects of sexual health, including healthy sexual development, interpersonal and consensual relationships, affection, intimacy, and body image,” Dr. Breuner said. “The research shows that just talking about abstinence is not enough.”
Such conversations also should address sexual anatomy and reproduction, sexually transmitted infections, sexual orientation, gender identity, abstinence, contraception, and reproductive rights and responsibilities, according to the report.
The report cites a meta-analysis finding that parents who were trained on how to effectively communicate about sex with their adolescents had better conversations on the subject than parents who were not. Such conversations correlated with a delay in teen sexual debut and an increased use of contraception and condoms.
Talking with young persons about their sexuality is also a way to help screen them for depression and suicidality, Dr. Breuner said. “These issues can often be uncovered when talking with kids about sexuality, particularly with those who are questioning their sexual identity.”
The report also suggests pediatricians discuss issues of physical, cognitive, and psychosexual development with parents of young children during well visits over time.
Earlier this year, in conjunction with the North American Society of Pediatric and Adolescent Gynecology, the AAP issued its first clinical guidance on addressing sexual health in adolescents with special needs (Pediatrics. 2006. doi: 10.1542/peds.2006-1115).
Neither Dr. Breuner nor the authors of the clinical report had any relevant financial disclosures.
On Twitter @whitneymcknight
FROM PEDIATRICS
Use simple algorithms to manage dementia
WASHINGTON – Alzheimer’s disease symptoms can be managed with simple algorithms that include ruling out other physiologic concerns and making some lifestyle modifications, according to an expert.
“These approaches are neither hopelessly complicated nor random,” Richard J. Caselli, MD, said at Summit in Neurology & Psychiatry, held by Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.
Key to diagnosis and management is to understand the differences between Alzheimer’s, dementia, and nondisabling cognitive impairment. “Alzheimer’s disease is the most common cause of dementia, but it is not synonymous with dementia,” said Dr. Caselli, a neurologist at the Mayo Clinic in Scottsdale, Ariz. “Dementia is not memory loss alone but the disabling impairment of multiple cognitive functions.”
Mild cognitive impairment typically means that a patient is still able to conduct his or her activities of daily living despite having memory (or other cognitive) problems.
Although it is possible for a traumatic event such as a family upset, hip replacement surgery, or an infection, to provoke signs of cognitive impairment, it is not usually “down to one day where all hell broke loose and ever since then, [the patient] hasn’t been the same,” Dr. Caselli said. “There are a lot of different reasons why a person can have cognitive difficulty, although with degenerative causes of dementia, it is a gradual onset problem.”
Alzheimer’s disease has a lengthy preclinical phase and can take as long as 15 years (or more) to finally present with symptoms of memory loss after onset, he added.
Changes in behavior, sleep
Behavioral changes in the patient, such as increasing paranoia, delusional states, aggression, and agitation, are an especially problematic aspect of the disease, Dr. Caselli said. Medications such as atypical and typical antipsychotics are off label, but can be effective in helping to manage psychosis and agitation, he said. Antipsychotic medications carry black box warnings from the Food and Drug Administration for use in the elderly, highlighting an increased risk of sudden death, especially in patients with underlying cardiac problems. Dr. Caselli said that, anecdotally, he had not yet seen any such severe adverse events when using atypical antipsychotics in this population, but vigilance should nonetheless be maintained. He also mentioned that pimavanserin, a selective serotonin 5-HT2A inverse agonist, recently was approved for psychosis in Parkinson’s disease, but that he so far has not had any personal experience with it.
Changes in sleep patterns also can offer clues to the type of dementia the patient may have. Pay close attention to the presence of any dream enactment behavior that may be a clue for REM sleep behavior disorder, which as been associated with Parkinson’s disease and dementia with Lewy bodies, according to Dr. Caselli.
Addressing other medical concerns such as restless legs syndrome, hypersomnolence, or nocturia can help patients get better sleep, and in turn, improve their overall disposition.
Physiologic concerns
Comorbid medical conditions such as a urinary tract infection, cancer, or end organ failure, as well as postoperative states and polypharmacy, also should be considered as potentially contributing to altered cognition. Although the physical exam for a person with Alzheimer’s disease tends to be normal, there are some types of dementia that might present with visual loss, aphasia, Parkinsonism, or signs of motor neuron disease, Dr. Caselli said.
Particularly in late-stage dementia, if patients have experienced a fracture or recently have had surgery, an abrupt decline in status could indicate they are in severe pain. “They aren’t going to be able to tell you that, though, and you will just have to be sensitive and attuned to that [possibility],” Dr. Caselli said.
Neuropsychological, other tests
A variety of widely available formal and informal tests can help evaluate a person’s orientation, learning and memory, and constructional and spatial abilities, such as accurately drawing the face of a clock. Language skills testing is important, particularly comprehension, which can be more subtle to detect but can prove key to the differential diagnosis and management.
Neuropsychological testing can reveal different patterns of cognitive impairment. For example, tests sensitive to mental or physical speed can help indicate whether a person has vascular dementia or Parkinson’s disease, two forms of impairment that involve slower cognition. Contrast this with people in the beginning stages of Alzheimer’s, who tend to be much less affected on such tests, Dr. Caselli said.
The conventional wisdom is that brain imaging often yields little diagnostic information in Alzheimer’s, but Dr. Caselli showed examples of tumors, strokes, focal atrophy, and amyloid angiopathy, as imaged abnormalities interfering with cognition. “Imaging in dementia is an important thing to do.”
Meanwhile, don’t ignore the basic lab tests such as blood counts, blood sugar, metabolic panels, and so forth. “Most of the time you don’t find these things, but sometimes you do,” Dr. Caselli said, noting that other clinical tests such as those used for a variety of encephalopathies or fungal infections also can be useful. “I am looking for something I can fix, not just reinforce that the 82-year-old man in front of me with a 2-year history of progressive memory loss has Alzheimer’s.”
There is a wide range of other differential diagnoses to consider testing for in the appropriate setting related to vascular, inflammatory, infectious, nutritional, neoplastic, metabolic, and other pathophysiologic processes. Just remember, it isn’t always Alzheimer’s, and because we can’t ‘fix’ Alzheimer’s, it’s important to make sure we have ruled out all other reasonable possibilities,” Dr. Caselli said. Keep in mind there is a lot of mixed pathology in dementia, he added.
Genetic testing can be important in patients with early-onset Alzheimer’s and a family history because there are several known disease-causing autosomal dominant mutations that, if identified in the patient, may have implications for first-degree relatives, including children. Young adult children have important life decisions to make that could be influenced by their own genetic status. Genetic testing is less likely to be helpful in patients with late-onset dementia with or without a family history, because the results will not alter management. Biomarkers can indicate the actual presence of pathology, but at this point, do not offer a reliable time frame for the evolution of symptoms, he said.
Dr. Caselli receives research funding from Merck as well as the National Institute on Aging.
On Twitter @whitneymcknight
WASHINGTON – Alzheimer’s disease symptoms can be managed with simple algorithms that include ruling out other physiologic concerns and making some lifestyle modifications, according to an expert.
“These approaches are neither hopelessly complicated nor random,” Richard J. Caselli, MD, said at Summit in Neurology & Psychiatry, held by Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.
Key to diagnosis and management is to understand the differences between Alzheimer’s, dementia, and nondisabling cognitive impairment. “Alzheimer’s disease is the most common cause of dementia, but it is not synonymous with dementia,” said Dr. Caselli, a neurologist at the Mayo Clinic in Scottsdale, Ariz. “Dementia is not memory loss alone but the disabling impairment of multiple cognitive functions.”
Mild cognitive impairment typically means that a patient is still able to conduct his or her activities of daily living despite having memory (or other cognitive) problems.
Although it is possible for a traumatic event such as a family upset, hip replacement surgery, or an infection, to provoke signs of cognitive impairment, it is not usually “down to one day where all hell broke loose and ever since then, [the patient] hasn’t been the same,” Dr. Caselli said. “There are a lot of different reasons why a person can have cognitive difficulty, although with degenerative causes of dementia, it is a gradual onset problem.”
Alzheimer’s disease has a lengthy preclinical phase and can take as long as 15 years (or more) to finally present with symptoms of memory loss after onset, he added.
Changes in behavior, sleep
Behavioral changes in the patient, such as increasing paranoia, delusional states, aggression, and agitation, are an especially problematic aspect of the disease, Dr. Caselli said. Medications such as atypical and typical antipsychotics are off label, but can be effective in helping to manage psychosis and agitation, he said. Antipsychotic medications carry black box warnings from the Food and Drug Administration for use in the elderly, highlighting an increased risk of sudden death, especially in patients with underlying cardiac problems. Dr. Caselli said that, anecdotally, he had not yet seen any such severe adverse events when using atypical antipsychotics in this population, but vigilance should nonetheless be maintained. He also mentioned that pimavanserin, a selective serotonin 5-HT2A inverse agonist, recently was approved for psychosis in Parkinson’s disease, but that he so far has not had any personal experience with it.
Changes in sleep patterns also can offer clues to the type of dementia the patient may have. Pay close attention to the presence of any dream enactment behavior that may be a clue for REM sleep behavior disorder, which as been associated with Parkinson’s disease and dementia with Lewy bodies, according to Dr. Caselli.
Addressing other medical concerns such as restless legs syndrome, hypersomnolence, or nocturia can help patients get better sleep, and in turn, improve their overall disposition.
Physiologic concerns
Comorbid medical conditions such as a urinary tract infection, cancer, or end organ failure, as well as postoperative states and polypharmacy, also should be considered as potentially contributing to altered cognition. Although the physical exam for a person with Alzheimer’s disease tends to be normal, there are some types of dementia that might present with visual loss, aphasia, Parkinsonism, or signs of motor neuron disease, Dr. Caselli said.
Particularly in late-stage dementia, if patients have experienced a fracture or recently have had surgery, an abrupt decline in status could indicate they are in severe pain. “They aren’t going to be able to tell you that, though, and you will just have to be sensitive and attuned to that [possibility],” Dr. Caselli said.
Neuropsychological, other tests
A variety of widely available formal and informal tests can help evaluate a person’s orientation, learning and memory, and constructional and spatial abilities, such as accurately drawing the face of a clock. Language skills testing is important, particularly comprehension, which can be more subtle to detect but can prove key to the differential diagnosis and management.
Neuropsychological testing can reveal different patterns of cognitive impairment. For example, tests sensitive to mental or physical speed can help indicate whether a person has vascular dementia or Parkinson’s disease, two forms of impairment that involve slower cognition. Contrast this with people in the beginning stages of Alzheimer’s, who tend to be much less affected on such tests, Dr. Caselli said.
The conventional wisdom is that brain imaging often yields little diagnostic information in Alzheimer’s, but Dr. Caselli showed examples of tumors, strokes, focal atrophy, and amyloid angiopathy, as imaged abnormalities interfering with cognition. “Imaging in dementia is an important thing to do.”
Meanwhile, don’t ignore the basic lab tests such as blood counts, blood sugar, metabolic panels, and so forth. “Most of the time you don’t find these things, but sometimes you do,” Dr. Caselli said, noting that other clinical tests such as those used for a variety of encephalopathies or fungal infections also can be useful. “I am looking for something I can fix, not just reinforce that the 82-year-old man in front of me with a 2-year history of progressive memory loss has Alzheimer’s.”
There is a wide range of other differential diagnoses to consider testing for in the appropriate setting related to vascular, inflammatory, infectious, nutritional, neoplastic, metabolic, and other pathophysiologic processes. Just remember, it isn’t always Alzheimer’s, and because we can’t ‘fix’ Alzheimer’s, it’s important to make sure we have ruled out all other reasonable possibilities,” Dr. Caselli said. Keep in mind there is a lot of mixed pathology in dementia, he added.
Genetic testing can be important in patients with early-onset Alzheimer’s and a family history because there are several known disease-causing autosomal dominant mutations that, if identified in the patient, may have implications for first-degree relatives, including children. Young adult children have important life decisions to make that could be influenced by their own genetic status. Genetic testing is less likely to be helpful in patients with late-onset dementia with or without a family history, because the results will not alter management. Biomarkers can indicate the actual presence of pathology, but at this point, do not offer a reliable time frame for the evolution of symptoms, he said.
Dr. Caselli receives research funding from Merck as well as the National Institute on Aging.
On Twitter @whitneymcknight
WASHINGTON – Alzheimer’s disease symptoms can be managed with simple algorithms that include ruling out other physiologic concerns and making some lifestyle modifications, according to an expert.
“These approaches are neither hopelessly complicated nor random,” Richard J. Caselli, MD, said at Summit in Neurology & Psychiatry, held by Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.
Key to diagnosis and management is to understand the differences between Alzheimer’s, dementia, and nondisabling cognitive impairment. “Alzheimer’s disease is the most common cause of dementia, but it is not synonymous with dementia,” said Dr. Caselli, a neurologist at the Mayo Clinic in Scottsdale, Ariz. “Dementia is not memory loss alone but the disabling impairment of multiple cognitive functions.”
Mild cognitive impairment typically means that a patient is still able to conduct his or her activities of daily living despite having memory (or other cognitive) problems.
Although it is possible for a traumatic event such as a family upset, hip replacement surgery, or an infection, to provoke signs of cognitive impairment, it is not usually “down to one day where all hell broke loose and ever since then, [the patient] hasn’t been the same,” Dr. Caselli said. “There are a lot of different reasons why a person can have cognitive difficulty, although with degenerative causes of dementia, it is a gradual onset problem.”
Alzheimer’s disease has a lengthy preclinical phase and can take as long as 15 years (or more) to finally present with symptoms of memory loss after onset, he added.
Changes in behavior, sleep
Behavioral changes in the patient, such as increasing paranoia, delusional states, aggression, and agitation, are an especially problematic aspect of the disease, Dr. Caselli said. Medications such as atypical and typical antipsychotics are off label, but can be effective in helping to manage psychosis and agitation, he said. Antipsychotic medications carry black box warnings from the Food and Drug Administration for use in the elderly, highlighting an increased risk of sudden death, especially in patients with underlying cardiac problems. Dr. Caselli said that, anecdotally, he had not yet seen any such severe adverse events when using atypical antipsychotics in this population, but vigilance should nonetheless be maintained. He also mentioned that pimavanserin, a selective serotonin 5-HT2A inverse agonist, recently was approved for psychosis in Parkinson’s disease, but that he so far has not had any personal experience with it.
Changes in sleep patterns also can offer clues to the type of dementia the patient may have. Pay close attention to the presence of any dream enactment behavior that may be a clue for REM sleep behavior disorder, which as been associated with Parkinson’s disease and dementia with Lewy bodies, according to Dr. Caselli.
Addressing other medical concerns such as restless legs syndrome, hypersomnolence, or nocturia can help patients get better sleep, and in turn, improve their overall disposition.
Physiologic concerns
Comorbid medical conditions such as a urinary tract infection, cancer, or end organ failure, as well as postoperative states and polypharmacy, also should be considered as potentially contributing to altered cognition. Although the physical exam for a person with Alzheimer’s disease tends to be normal, there are some types of dementia that might present with visual loss, aphasia, Parkinsonism, or signs of motor neuron disease, Dr. Caselli said.
Particularly in late-stage dementia, if patients have experienced a fracture or recently have had surgery, an abrupt decline in status could indicate they are in severe pain. “They aren’t going to be able to tell you that, though, and you will just have to be sensitive and attuned to that [possibility],” Dr. Caselli said.
Neuropsychological, other tests
A variety of widely available formal and informal tests can help evaluate a person’s orientation, learning and memory, and constructional and spatial abilities, such as accurately drawing the face of a clock. Language skills testing is important, particularly comprehension, which can be more subtle to detect but can prove key to the differential diagnosis and management.
Neuropsychological testing can reveal different patterns of cognitive impairment. For example, tests sensitive to mental or physical speed can help indicate whether a person has vascular dementia or Parkinson’s disease, two forms of impairment that involve slower cognition. Contrast this with people in the beginning stages of Alzheimer’s, who tend to be much less affected on such tests, Dr. Caselli said.
The conventional wisdom is that brain imaging often yields little diagnostic information in Alzheimer’s, but Dr. Caselli showed examples of tumors, strokes, focal atrophy, and amyloid angiopathy, as imaged abnormalities interfering with cognition. “Imaging in dementia is an important thing to do.”
Meanwhile, don’t ignore the basic lab tests such as blood counts, blood sugar, metabolic panels, and so forth. “Most of the time you don’t find these things, but sometimes you do,” Dr. Caselli said, noting that other clinical tests such as those used for a variety of encephalopathies or fungal infections also can be useful. “I am looking for something I can fix, not just reinforce that the 82-year-old man in front of me with a 2-year history of progressive memory loss has Alzheimer’s.”
There is a wide range of other differential diagnoses to consider testing for in the appropriate setting related to vascular, inflammatory, infectious, nutritional, neoplastic, metabolic, and other pathophysiologic processes. Just remember, it isn’t always Alzheimer’s, and because we can’t ‘fix’ Alzheimer’s, it’s important to make sure we have ruled out all other reasonable possibilities,” Dr. Caselli said. Keep in mind there is a lot of mixed pathology in dementia, he added.
Genetic testing can be important in patients with early-onset Alzheimer’s and a family history because there are several known disease-causing autosomal dominant mutations that, if identified in the patient, may have implications for first-degree relatives, including children. Young adult children have important life decisions to make that could be influenced by their own genetic status. Genetic testing is less likely to be helpful in patients with late-onset dementia with or without a family history, because the results will not alter management. Biomarkers can indicate the actual presence of pathology, but at this point, do not offer a reliable time frame for the evolution of symptoms, he said.
Dr. Caselli receives research funding from Merck as well as the National Institute on Aging.
On Twitter @whitneymcknight
EXPERT ANALYSIS AT SUMMIT IN NEUROLOGY & PSYCHIATRY
Case Study: Managing Opioid Addiction After a Back Injury
Has your patient’s opioid use escalated to opioid addiction? How can you tell, and what interventions can you take to help this patient in the context of a 15-minute appointment?
In this edition of Mental Health Consult, our panel discusses their recommendations for workup and next steps for managing a 45-year-old man who has no history of psychiatric disorders and appears to now be dependent on the opioid painkillers that he initially received after a back injury.
Join our panel of experts from George Washington University, Washington, including Daniel Lieberman, MD, professor of psychiatry and behavioral sciences clinical director; April Barbour, MD, MPH, director of the division of general internal medicine; and Lorenzo Norris, MD, medical director of psychiatric and behavioral services, as they discuss how to treat pain medication–related addiction, including when to refer to pain specialists and how various practice models drive treatment decisions and reimbursement.
Click here for a PDF of the case study.
Has your patient’s opioid use escalated to opioid addiction? How can you tell, and what interventions can you take to help this patient in the context of a 15-minute appointment?
In this edition of Mental Health Consult, our panel discusses their recommendations for workup and next steps for managing a 45-year-old man who has no history of psychiatric disorders and appears to now be dependent on the opioid painkillers that he initially received after a back injury.
Join our panel of experts from George Washington University, Washington, including Daniel Lieberman, MD, professor of psychiatry and behavioral sciences clinical director; April Barbour, MD, MPH, director of the division of general internal medicine; and Lorenzo Norris, MD, medical director of psychiatric and behavioral services, as they discuss how to treat pain medication–related addiction, including when to refer to pain specialists and how various practice models drive treatment decisions and reimbursement.
Click here for a PDF of the case study.
Has your patient’s opioid use escalated to opioid addiction? How can you tell, and what interventions can you take to help this patient in the context of a 15-minute appointment?
In this edition of Mental Health Consult, our panel discusses their recommendations for workup and next steps for managing a 45-year-old man who has no history of psychiatric disorders and appears to now be dependent on the opioid painkillers that he initially received after a back injury.
Join our panel of experts from George Washington University, Washington, including Daniel Lieberman, MD, professor of psychiatry and behavioral sciences clinical director; April Barbour, MD, MPH, director of the division of general internal medicine; and Lorenzo Norris, MD, medical director of psychiatric and behavioral services, as they discuss how to treat pain medication–related addiction, including when to refer to pain specialists and how various practice models drive treatment decisions and reimbursement.
Click here for a PDF of the case study.
VIDEO: A case study in managing opioid addiction after a back injury
Has your patient’s opioid use escalated to opioid addiction? How can you tell, and what interventions can you take to help this patient in the context of a 15-minute appointment?
In this edition of Mental Health Consult, our panel discusses their recommendations for workup and next steps for managing a 45-year-old man who has no history of psychiatric disorders and appears to now be dependent on the opioid painkillers that he initially received after a back injury.
Join our panel of experts from George Washington University, Washington, including Daniel Lieberman, MD, professor of psychiatry and behavioral sciences clinical director; April Barbour, MD, MPH, director of the division of general internal medicine; and Lorenzo Norris, MD, medical director of psychiatric and behavioral services, as they discuss how to treat pain medication–related addiction, including when to refer to pain specialists and how various practice models drive treatment decisions and reimbursement.
On Twitter @whitneymcknight
Has your patient’s opioid use escalated to opioid addiction? How can you tell, and what interventions can you take to help this patient in the context of a 15-minute appointment?
In this edition of Mental Health Consult, our panel discusses their recommendations for workup and next steps for managing a 45-year-old man who has no history of psychiatric disorders and appears to now be dependent on the opioid painkillers that he initially received after a back injury.
Join our panel of experts from George Washington University, Washington, including Daniel Lieberman, MD, professor of psychiatry and behavioral sciences clinical director; April Barbour, MD, MPH, director of the division of general internal medicine; and Lorenzo Norris, MD, medical director of psychiatric and behavioral services, as they discuss how to treat pain medication–related addiction, including when to refer to pain specialists and how various practice models drive treatment decisions and reimbursement.
On Twitter @whitneymcknight
Has your patient’s opioid use escalated to opioid addiction? How can you tell, and what interventions can you take to help this patient in the context of a 15-minute appointment?
In this edition of Mental Health Consult, our panel discusses their recommendations for workup and next steps for managing a 45-year-old man who has no history of psychiatric disorders and appears to now be dependent on the opioid painkillers that he initially received after a back injury.
Join our panel of experts from George Washington University, Washington, including Daniel Lieberman, MD, professor of psychiatry and behavioral sciences clinical director; April Barbour, MD, MPH, director of the division of general internal medicine; and Lorenzo Norris, MD, medical director of psychiatric and behavioral services, as they discuss how to treat pain medication–related addiction, including when to refer to pain specialists and how various practice models drive treatment decisions and reimbursement.
On Twitter @whitneymcknight
Maximize depression treatment efforts with measurement-based care
WASHINGTON – Challenging patients with depression to stay engaged in their recovery while rigorously monitoring and measuring their treatment response can mean the difference between remission or resistance, according to an expert.
“We all wish for better treatments, but we really don’t have any coming available to us in the near future, so our task is to do as well as we can with what we have,” Michael E. Thase, MD, professor of psychiatry at the University of Pennsylvania, Philadelphia, said at Summit in Neurology & Psychiatry.
“We know far too well that there is a large gap between what we might be able to accomplish and what actually happens in clinical practice,” Dr. Thase said.
To close that gap, start with evaluating what can be done to combat patient nonadherence. A 2007 study indicated that just under 20% of patients adhere to antidepressant medication guidelines (Prim Care Companion J Clin Psychiatry. 2007;9[2]:91-9.), and according to Dr. Thase, less than 10% of patients being seen for depression in primary care actually fill their prescriptions.
“Don’t delude yourself that these patients drop out of treatment because they no longer need it. They drop out mostly because they have gotten disgusted, disappointed, or discouraged,” said Dr. Thase, attributing the high rate of nonadherence to the nature of depression itself.
“Depression is a state of pessimism, low confidence, and of not really feeling capable.”
Helping patients overcome their reluctance to follow treatment guidelines begins with accurately assessing their symptom severity. Patients who rate 4 or less on the Patient Health Questionnaire–9 (PHQ-9), which is based on the DSM-IV, are considered in remission or not to have severe depression. Similarly, patients who score 5 or less on the Quick Inventory of Depressive Symptomatology (QIDS) are not considered in the danger zone.
The severity ratings included in the DSM-5 can help clinicians pinpoint the level of depression a patient is experiencing, as can a therapeutic relationship with the patient and the family, Dr. Thase said at the summit, held by Global Academy for Medical Education.
He urged clinicians to monitor adherence routinely by asking patients whether or not they have filled or refilled their prescriptions. It is helpful to ask patients about missing doses and whether they are feeling any improvement, he said.
“It’s a very simple process: You keep track of the patients. Chase after them if they don’t follow through. If you’re not keeping track, the patients think [what they do] doesn’t matter,” Dr. Thase said.
A 2010 study of chronic depression treatment in primary care practices showed that compared with regular care, aggressive monitoring of patient adherence and outcomes in 728 adults with depression resulted in better remission rates across 18 months of treatment. At 6 months 43.4% of patients who had been contacted regularly by nursing and social worker staff were in remission, compared with 33.3% of the 78 who had received regular care (P = .11). At 12 months, the results were 52% vs. 33.9% (P = .012), and at 18 months remission was reported in 49.2% vs. 27.3% (P = .004) (Ann Fam Med. 2010 Sep;8[5]:387-96).
By being alert to side effects, using a rating scale to measure symptom reduction, and not staying “locked” into the idea that all treatments require 6-8 weeks before patients see any improvement, clinicians can boost chances for adherence – and thus for remission – since patients who don’t improve in the first 2 weeks have just a 15% chance for improvement, Dr. Thase said. “You need 6-8 weeks to get to the maximum titration. That old 8-week rule applies mostly to patients who are showing improvement by week 2.”
If by week 2, the patient is not tolerating the medication’s side effects and has no symptom reduction, then move on to the next medication, Dr. Thase said, emphasizing the importance of seeing patients at least twice monthly. “If we’re only seeing a patient once a month, we’ve already fallen behind in the up-titration part, and we’ve missed the opportunity for early intervention if the patient is having side effects.”
Algorithms for choosing depression treatments should be a “fact of life,” he said. Start with the safest, easiest to tolerate, and least expensive of the available antidepressants, such as escitalopram and fluoxetine before working through the second- and third-line therapies and adjunctive therapies, all of which have greater risk profiles as you move through them. This algorithmic approach has been shown to result in patients scoring at least 10 points higher on a depression rating scale (JAMA Psychiatry. 2004;61:[7]669-80), which Dr. Thase said is equivalent to about a 30% higher chance of remission. “Don’t go over and over with the simple treatments that aren’t [evoking] a response. Move briskly on to the more complex treatments until patients respond.”
Treatment algorithms can include psychotherapies, either in combination with pharmacotherapy or as monotherapy. He encouraged clinicians to refer to the American Psychiatric Association (APA) practice guideline for depression for more details. The absence of depressive symptoms alone is not indicative of remission, according to the guideline, which Dr. Thase coauthored. The presence of positive emotions and resilience, along with a sense of control over emotions and hope for the future, indicates remission.
If after applying those methods a patient remains depressed and has been negatively screened for bipolar disorder, the use of tricyclics or monoamine oxidase inhibitors (MAOIs) may be appropriate. “MAOIs account for less than 1 in every 1,000 prescriptions for antidepressants, yet for people who don’t respond to modern antidepressants, they still can carry a 30%-40% response rate. So, if you don’t prescribe them yourself, please get access to someone who does,” Dr. Thase said.
The tenets of measurement-based care are essentially the lessons learned from the landmark Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial, which sought to address how pharmacologic care for depression could be delivered based on adequate dosing, attenuation of symptoms, fewer side effects, and other factors (Am J Psychiatry. 2006;163:1905-17).
Now,10 years later, measurement-based treatment is still finding its way into practice, Dr. Thase said in an interview. “But, there’s no reason to be unduly pessimistic. Ten years ago, depression screening was in the same position, and now it is both considered to be the standard of care and is widely done.”
Dr. Thase reported having extensive industry relationships, noting that he has been involved in the development of nearly every drug for the treatment of mood disorders. Global Academy and this news organization are owned by the same company.
On Twitter @whitneymcknight
Ten years ago, the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study highlighted the importance of close monitoring of patients with depression. This is best done with a team-based approach; it’s best suited to handle issues of compliance, side effects, efficacy, and close follow-up. The team may consist of a psychotherapist, nurse, and, possibly, a pharmacist – in addition to the internist, Nitin S. Damle, MD, said in an interview.
 |
| Courtesy American College of Physicians Dr. Nitin S. Damle |
Integrating behavioral health into primary care practices involves structure, which includes office visits – even every 2 weeks until stable – follow-up phone calls by the nurse to assess adherence and problems with medication, and a pharmacist to track refill rates and side effects, and to recommend changes to medication due to lack of efficacy or side effects, he said.
Treatment algorithms are an effective means to find the most effective and safest medication, and screening with PHQ-9 and even QIDS has become more common in the primary care office. Still, the adaption of measurement-based care has been slow, partly because of the absence of adequate funding for an integrated primary care team-based approach to mental illness. Now there is no mechanism to cover the costs of personnel and infrastructure to provide for the level of monitoring and treatment that measurement-based care requires, according to Dr. Damle.
Health plans need to review the evidence, such as that from the STAR*D and other studies, and create funding mechanisms so that their members stay healthy and avoid complications of mental illness.
Dr. Damle is president of the American College of Physicians and clinical associate professor of medicine at Brown University, Providence, R.I. He has no relevant disclosures.
Ten years ago, the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study highlighted the importance of close monitoring of patients with depression. This is best done with a team-based approach; it’s best suited to handle issues of compliance, side effects, efficacy, and close follow-up. The team may consist of a psychotherapist, nurse, and, possibly, a pharmacist – in addition to the internist, Nitin S. Damle, MD, said in an interview.
|
| Courtesy American College of Physicians Dr. Nitin S. Damle |
Integrating behavioral health into primary care practices involves structure, which includes office visits – even every 2 weeks until stable – follow-up phone calls by the nurse to assess adherence and problems with medication, and a pharmacist to track refill rates and side effects, and to recommend changes to medication due to lack of efficacy or side effects, he said.
Treatment algorithms are an effective means to find the most effective and safest medication, and screening with PHQ-9 and even QIDS has become more common in the primary care office. Still, the adaption of measurement-based care has been slow, partly because of the absence of adequate funding for an integrated primary care team-based approach to mental illness. Now there is no mechanism to cover the costs of personnel and infrastructure to provide for the level of monitoring and treatment that measurement-based care requires, according to Dr. Damle.
Health plans need to review the evidence, such as that from the STAR*D and other studies, and create funding mechanisms so that their members stay healthy and avoid complications of mental illness.
Dr. Damle is president of the American College of Physicians and clinical associate professor of medicine at Brown University, Providence, R.I. He has no relevant disclosures.
Ten years ago, the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study highlighted the importance of close monitoring of patients with depression. This is best done with a team-based approach; it’s best suited to handle issues of compliance, side effects, efficacy, and close follow-up. The team may consist of a psychotherapist, nurse, and, possibly, a pharmacist – in addition to the internist, Nitin S. Damle, MD, said in an interview.
|
| Courtesy American College of Physicians Dr. Nitin S. Damle |
Integrating behavioral health into primary care practices involves structure, which includes office visits – even every 2 weeks until stable – follow-up phone calls by the nurse to assess adherence and problems with medication, and a pharmacist to track refill rates and side effects, and to recommend changes to medication due to lack of efficacy or side effects, he said.
Treatment algorithms are an effective means to find the most effective and safest medication, and screening with PHQ-9 and even QIDS has become more common in the primary care office. Still, the adaption of measurement-based care has been slow, partly because of the absence of adequate funding for an integrated primary care team-based approach to mental illness. Now there is no mechanism to cover the costs of personnel and infrastructure to provide for the level of monitoring and treatment that measurement-based care requires, according to Dr. Damle.
Health plans need to review the evidence, such as that from the STAR*D and other studies, and create funding mechanisms so that their members stay healthy and avoid complications of mental illness.
Dr. Damle is president of the American College of Physicians and clinical associate professor of medicine at Brown University, Providence, R.I. He has no relevant disclosures.
WASHINGTON – Challenging patients with depression to stay engaged in their recovery while rigorously monitoring and measuring their treatment response can mean the difference between remission or resistance, according to an expert.
“We all wish for better treatments, but we really don’t have any coming available to us in the near future, so our task is to do as well as we can with what we have,” Michael E. Thase, MD, professor of psychiatry at the University of Pennsylvania, Philadelphia, said at Summit in Neurology & Psychiatry.
“We know far too well that there is a large gap between what we might be able to accomplish and what actually happens in clinical practice,” Dr. Thase said.
To close that gap, start with evaluating what can be done to combat patient nonadherence. A 2007 study indicated that just under 20% of patients adhere to antidepressant medication guidelines (Prim Care Companion J Clin Psychiatry. 2007;9[2]:91-9.), and according to Dr. Thase, less than 10% of patients being seen for depression in primary care actually fill their prescriptions.
“Don’t delude yourself that these patients drop out of treatment because they no longer need it. They drop out mostly because they have gotten disgusted, disappointed, or discouraged,” said Dr. Thase, attributing the high rate of nonadherence to the nature of depression itself.
“Depression is a state of pessimism, low confidence, and of not really feeling capable.”
Helping patients overcome their reluctance to follow treatment guidelines begins with accurately assessing their symptom severity. Patients who rate 4 or less on the Patient Health Questionnaire–9 (PHQ-9), which is based on the DSM-IV, are considered in remission or not to have severe depression. Similarly, patients who score 5 or less on the Quick Inventory of Depressive Symptomatology (QIDS) are not considered in the danger zone.
The severity ratings included in the DSM-5 can help clinicians pinpoint the level of depression a patient is experiencing, as can a therapeutic relationship with the patient and the family, Dr. Thase said at the summit, held by Global Academy for Medical Education.
He urged clinicians to monitor adherence routinely by asking patients whether or not they have filled or refilled their prescriptions. It is helpful to ask patients about missing doses and whether they are feeling any improvement, he said.
“It’s a very simple process: You keep track of the patients. Chase after them if they don’t follow through. If you’re not keeping track, the patients think [what they do] doesn’t matter,” Dr. Thase said.
A 2010 study of chronic depression treatment in primary care practices showed that compared with regular care, aggressive monitoring of patient adherence and outcomes in 728 adults with depression resulted in better remission rates across 18 months of treatment. At 6 months 43.4% of patients who had been contacted regularly by nursing and social worker staff were in remission, compared with 33.3% of the 78 who had received regular care (P = .11). At 12 months, the results were 52% vs. 33.9% (P = .012), and at 18 months remission was reported in 49.2% vs. 27.3% (P = .004) (Ann Fam Med. 2010 Sep;8[5]:387-96).
By being alert to side effects, using a rating scale to measure symptom reduction, and not staying “locked” into the idea that all treatments require 6-8 weeks before patients see any improvement, clinicians can boost chances for adherence – and thus for remission – since patients who don’t improve in the first 2 weeks have just a 15% chance for improvement, Dr. Thase said. “You need 6-8 weeks to get to the maximum titration. That old 8-week rule applies mostly to patients who are showing improvement by week 2.”
If by week 2, the patient is not tolerating the medication’s side effects and has no symptom reduction, then move on to the next medication, Dr. Thase said, emphasizing the importance of seeing patients at least twice monthly. “If we’re only seeing a patient once a month, we’ve already fallen behind in the up-titration part, and we’ve missed the opportunity for early intervention if the patient is having side effects.”
Algorithms for choosing depression treatments should be a “fact of life,” he said. Start with the safest, easiest to tolerate, and least expensive of the available antidepressants, such as escitalopram and fluoxetine before working through the second- and third-line therapies and adjunctive therapies, all of which have greater risk profiles as you move through them. This algorithmic approach has been shown to result in patients scoring at least 10 points higher on a depression rating scale (JAMA Psychiatry. 2004;61:[7]669-80), which Dr. Thase said is equivalent to about a 30% higher chance of remission. “Don’t go over and over with the simple treatments that aren’t [evoking] a response. Move briskly on to the more complex treatments until patients respond.”
Treatment algorithms can include psychotherapies, either in combination with pharmacotherapy or as monotherapy. He encouraged clinicians to refer to the American Psychiatric Association (APA) practice guideline for depression for more details. The absence of depressive symptoms alone is not indicative of remission, according to the guideline, which Dr. Thase coauthored. The presence of positive emotions and resilience, along with a sense of control over emotions and hope for the future, indicates remission.
If after applying those methods a patient remains depressed and has been negatively screened for bipolar disorder, the use of tricyclics or monoamine oxidase inhibitors (MAOIs) may be appropriate. “MAOIs account for less than 1 in every 1,000 prescriptions for antidepressants, yet for people who don’t respond to modern antidepressants, they still can carry a 30%-40% response rate. So, if you don’t prescribe them yourself, please get access to someone who does,” Dr. Thase said.
The tenets of measurement-based care are essentially the lessons learned from the landmark Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial, which sought to address how pharmacologic care for depression could be delivered based on adequate dosing, attenuation of symptoms, fewer side effects, and other factors (Am J Psychiatry. 2006;163:1905-17).
Now,10 years later, measurement-based treatment is still finding its way into practice, Dr. Thase said in an interview. “But, there’s no reason to be unduly pessimistic. Ten years ago, depression screening was in the same position, and now it is both considered to be the standard of care and is widely done.”
Dr. Thase reported having extensive industry relationships, noting that he has been involved in the development of nearly every drug for the treatment of mood disorders. Global Academy and this news organization are owned by the same company.
On Twitter @whitneymcknight
WASHINGTON – Challenging patients with depression to stay engaged in their recovery while rigorously monitoring and measuring their treatment response can mean the difference between remission or resistance, according to an expert.
“We all wish for better treatments, but we really don’t have any coming available to us in the near future, so our task is to do as well as we can with what we have,” Michael E. Thase, MD, professor of psychiatry at the University of Pennsylvania, Philadelphia, said at Summit in Neurology & Psychiatry.
“We know far too well that there is a large gap between what we might be able to accomplish and what actually happens in clinical practice,” Dr. Thase said.
To close that gap, start with evaluating what can be done to combat patient nonadherence. A 2007 study indicated that just under 20% of patients adhere to antidepressant medication guidelines (Prim Care Companion J Clin Psychiatry. 2007;9[2]:91-9.), and according to Dr. Thase, less than 10% of patients being seen for depression in primary care actually fill their prescriptions.
“Don’t delude yourself that these patients drop out of treatment because they no longer need it. They drop out mostly because they have gotten disgusted, disappointed, or discouraged,” said Dr. Thase, attributing the high rate of nonadherence to the nature of depression itself.
“Depression is a state of pessimism, low confidence, and of not really feeling capable.”
Helping patients overcome their reluctance to follow treatment guidelines begins with accurately assessing their symptom severity. Patients who rate 4 or less on the Patient Health Questionnaire–9 (PHQ-9), which is based on the DSM-IV, are considered in remission or not to have severe depression. Similarly, patients who score 5 or less on the Quick Inventory of Depressive Symptomatology (QIDS) are not considered in the danger zone.
The severity ratings included in the DSM-5 can help clinicians pinpoint the level of depression a patient is experiencing, as can a therapeutic relationship with the patient and the family, Dr. Thase said at the summit, held by Global Academy for Medical Education.
He urged clinicians to monitor adherence routinely by asking patients whether or not they have filled or refilled their prescriptions. It is helpful to ask patients about missing doses and whether they are feeling any improvement, he said.
“It’s a very simple process: You keep track of the patients. Chase after them if they don’t follow through. If you’re not keeping track, the patients think [what they do] doesn’t matter,” Dr. Thase said.
A 2010 study of chronic depression treatment in primary care practices showed that compared with regular care, aggressive monitoring of patient adherence and outcomes in 728 adults with depression resulted in better remission rates across 18 months of treatment. At 6 months 43.4% of patients who had been contacted regularly by nursing and social worker staff were in remission, compared with 33.3% of the 78 who had received regular care (P = .11). At 12 months, the results were 52% vs. 33.9% (P = .012), and at 18 months remission was reported in 49.2% vs. 27.3% (P = .004) (Ann Fam Med. 2010 Sep;8[5]:387-96).
By being alert to side effects, using a rating scale to measure symptom reduction, and not staying “locked” into the idea that all treatments require 6-8 weeks before patients see any improvement, clinicians can boost chances for adherence – and thus for remission – since patients who don’t improve in the first 2 weeks have just a 15% chance for improvement, Dr. Thase said. “You need 6-8 weeks to get to the maximum titration. That old 8-week rule applies mostly to patients who are showing improvement by week 2.”
If by week 2, the patient is not tolerating the medication’s side effects and has no symptom reduction, then move on to the next medication, Dr. Thase said, emphasizing the importance of seeing patients at least twice monthly. “If we’re only seeing a patient once a month, we’ve already fallen behind in the up-titration part, and we’ve missed the opportunity for early intervention if the patient is having side effects.”
Algorithms for choosing depression treatments should be a “fact of life,” he said. Start with the safest, easiest to tolerate, and least expensive of the available antidepressants, such as escitalopram and fluoxetine before working through the second- and third-line therapies and adjunctive therapies, all of which have greater risk profiles as you move through them. This algorithmic approach has been shown to result in patients scoring at least 10 points higher on a depression rating scale (JAMA Psychiatry. 2004;61:[7]669-80), which Dr. Thase said is equivalent to about a 30% higher chance of remission. “Don’t go over and over with the simple treatments that aren’t [evoking] a response. Move briskly on to the more complex treatments until patients respond.”
Treatment algorithms can include psychotherapies, either in combination with pharmacotherapy or as monotherapy. He encouraged clinicians to refer to the American Psychiatric Association (APA) practice guideline for depression for more details. The absence of depressive symptoms alone is not indicative of remission, according to the guideline, which Dr. Thase coauthored. The presence of positive emotions and resilience, along with a sense of control over emotions and hope for the future, indicates remission.
If after applying those methods a patient remains depressed and has been negatively screened for bipolar disorder, the use of tricyclics or monoamine oxidase inhibitors (MAOIs) may be appropriate. “MAOIs account for less than 1 in every 1,000 prescriptions for antidepressants, yet for people who don’t respond to modern antidepressants, they still can carry a 30%-40% response rate. So, if you don’t prescribe them yourself, please get access to someone who does,” Dr. Thase said.
The tenets of measurement-based care are essentially the lessons learned from the landmark Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial, which sought to address how pharmacologic care for depression could be delivered based on adequate dosing, attenuation of symptoms, fewer side effects, and other factors (Am J Psychiatry. 2006;163:1905-17).
Now,10 years later, measurement-based treatment is still finding its way into practice, Dr. Thase said in an interview. “But, there’s no reason to be unduly pessimistic. Ten years ago, depression screening was in the same position, and now it is both considered to be the standard of care and is widely done.”
Dr. Thase reported having extensive industry relationships, noting that he has been involved in the development of nearly every drug for the treatment of mood disorders. Global Academy and this news organization are owned by the same company.
On Twitter @whitneymcknight
EXPERT ANALYSIS FROM SUMMIT OF NEUROLOGY & PSYCHIATRY
AUDIO: New bipolar disorder algorithm changes ranking of first-line therapies
WASHINGTON – In 2015, the Florida Agency for Health Care Administration published clinical guidelines for numerous psychiatric conditions, including bipolar disorder, demoting several first-line therapies, and promoting others.
Because the authors of the Florida Best Practice Psychotherapeutic Medication Guidelines for Adults agreed that inflammation is a mechanism of action in bipolar disorder, they adopted an approach to care that seeks to avoid inflammation at all costs.
“Some medications create metabolic disturbances, which can be disruptive to the inflammatory milieu,” said Roger McIntyre, MD, a professor of psychiatry and pharmacology at the University of Toronto, and head of the Mood Disorders Psychopharmacology Unit at the University Health Network, Toronto. Dr. McIntyre, one of the coauthors of the guidelines, discussed why the combination of olanzapine and fluoxetine has been deferred in the algorithm, why other medications have moved further up, why antidepressants also are lower in the order of priority, and why psychoeducation, social rhythm therapy, and lifestyle changes have been emphasized more than ever before.
“There is no way our bipolar patients are going to achieve their goals with medication alone,” Dr. McIntyre said at the meeting, held by the Global Academy for Medical Education. In addition, Dr. McIntyre outlined why adding bipolar screening in the primary care setting is critical in 2016, and called the new recommendations “the most up-to-date guidelines for treating bipolar disorder, and the new nosology of major depression disorder with mixed features.”
To access the Florida Best Practice Psychotherapeutic Medication Guidelines for Adults online, visit the Florida Medicaid Drug Therapy Management Program for Behavioral Health website.
Dr. McIntyre has numerous industry relationships, including research funding from Eli Lilly, Janssen-Ortho, Astra-Zeneca; Pfizer, and Lundbeck. Global Academy and this news organization are owned by the same company.
On Twitter @whitneymcknight
WASHINGTON – In 2015, the Florida Agency for Health Care Administration published clinical guidelines for numerous psychiatric conditions, including bipolar disorder, demoting several first-line therapies, and promoting others.
Because the authors of the Florida Best Practice Psychotherapeutic Medication Guidelines for Adults agreed that inflammation is a mechanism of action in bipolar disorder, they adopted an approach to care that seeks to avoid inflammation at all costs.
“Some medications create metabolic disturbances, which can be disruptive to the inflammatory milieu,” said Roger McIntyre, MD, a professor of psychiatry and pharmacology at the University of Toronto, and head of the Mood Disorders Psychopharmacology Unit at the University Health Network, Toronto. Dr. McIntyre, one of the coauthors of the guidelines, discussed why the combination of olanzapine and fluoxetine has been deferred in the algorithm, why other medications have moved further up, why antidepressants also are lower in the order of priority, and why psychoeducation, social rhythm therapy, and lifestyle changes have been emphasized more than ever before.
“There is no way our bipolar patients are going to achieve their goals with medication alone,” Dr. McIntyre said at the meeting, held by the Global Academy for Medical Education. In addition, Dr. McIntyre outlined why adding bipolar screening in the primary care setting is critical in 2016, and called the new recommendations “the most up-to-date guidelines for treating bipolar disorder, and the new nosology of major depression disorder with mixed features.”
To access the Florida Best Practice Psychotherapeutic Medication Guidelines for Adults online, visit the Florida Medicaid Drug Therapy Management Program for Behavioral Health website.
Dr. McIntyre has numerous industry relationships, including research funding from Eli Lilly, Janssen-Ortho, Astra-Zeneca; Pfizer, and Lundbeck. Global Academy and this news organization are owned by the same company.
On Twitter @whitneymcknight
WASHINGTON – In 2015, the Florida Agency for Health Care Administration published clinical guidelines for numerous psychiatric conditions, including bipolar disorder, demoting several first-line therapies, and promoting others.
Because the authors of the Florida Best Practice Psychotherapeutic Medication Guidelines for Adults agreed that inflammation is a mechanism of action in bipolar disorder, they adopted an approach to care that seeks to avoid inflammation at all costs.
“Some medications create metabolic disturbances, which can be disruptive to the inflammatory milieu,” said Roger McIntyre, MD, a professor of psychiatry and pharmacology at the University of Toronto, and head of the Mood Disorders Psychopharmacology Unit at the University Health Network, Toronto. Dr. McIntyre, one of the coauthors of the guidelines, discussed why the combination of olanzapine and fluoxetine has been deferred in the algorithm, why other medications have moved further up, why antidepressants also are lower in the order of priority, and why psychoeducation, social rhythm therapy, and lifestyle changes have been emphasized more than ever before.
“There is no way our bipolar patients are going to achieve their goals with medication alone,” Dr. McIntyre said at the meeting, held by the Global Academy for Medical Education. In addition, Dr. McIntyre outlined why adding bipolar screening in the primary care setting is critical in 2016, and called the new recommendations “the most up-to-date guidelines for treating bipolar disorder, and the new nosology of major depression disorder with mixed features.”
To access the Florida Best Practice Psychotherapeutic Medication Guidelines for Adults online, visit the Florida Medicaid Drug Therapy Management Program for Behavioral Health website.
Dr. McIntyre has numerous industry relationships, including research funding from Eli Lilly, Janssen-Ortho, Astra-Zeneca; Pfizer, and Lundbeck. Global Academy and this news organization are owned by the same company.
On Twitter @whitneymcknight
AT SUMMIT IN NEUROLOGY & PSYCHIATRY
July 2016: Click for Credit
Here are 4 articles in the July issue of Clinician Reviews (individual articles are valid for one year from date of publication—expiration dates below):
1. Pregnancy Alters Pharmacodynamics of Anti-TNF Agents in Women With IBD
To take the posttest, go to: http://bit.ly/1VQFIHf
Expires May 24, 2017
VITALS
Key clinical point: Blood levels of infliximab rose during pregnancy, while adalimumab levels remained stable, even after researchers accounted for changes in albumin, body mass index, and C-reactive protein levels.
Major finding: Median infliximab concentrations rose from 8.5 mcg/mL in the first trimester to a peak of 21 mcg/mL during the middle of the third trimester (P = .04). Median adalimumab levels ranged between 8.6 and 12.2 mcg/mL during pregnancy.
Data source: A prospective study of 25 pregnant women with ulcerative colitis or Crohn's disease.
Disclosures: Dr. Seow disclosed ties with Janssen, AbbVie, Takeda, Shire, and Actavis.
2. Vascular Disease Linked to Sight Loss in Giant Cell Arteritis
To take the posttest, go to: http://bit.ly/1UqLuu5
Expires May 10, 2017
VITALS
Key clinical point: Patients with vascular disease who develop giant cell arteritis may require careful monitoring for sight loss.
Major finding: Overall, 42.9% of patients had some visual disturbance at first clinic review; 7.9% were blind at 6 months.
Data source: Analysis of 433 patients newly diagnosed with GCA participating in the Diagnostic and Classification Criteria in Vasculitis Study (DCVAS).
Disclosures: The DCVAS study is supported by the American College of Rheumatology and is funded by the European League Against Rheumatism and the Vasculitis Foundation. Dr. Yates reported that he had no relevant disclosures.
3. Pediatric and Adolescent Mental Health
Part 1: Diagnoses, drug prescribing vary widely
To take the posttest, go to: http://bit.ly/24FHTxY
Expires April 1, 2017
VITALS
Key clinical point: A lack of psychiatrists only partially accounted for substantial variations in rates of mental illness diagnosis and prescriptions for psychotropic medications given in practices nationwide, a study has shown.
Major finding: Nationwide, 15% of pediatric patients received a mental health diagnosis, and 14% were prescribed psychotropic medications in primary care, regardless of colocated mental health services.
Data source: A retrospective study of electronic health records for 294,748 patients aged 4-18 years.
Disclosures: Dr. Alexander G. Fiks is an investigator for Pfizer; the other researchers said they had no relevant financial disclosures. This study was funded by the National Institutes of Health and the National Institute of Child Health and Human Development under the Best Pharmaceuticals for Children Act.
Part 2: Disorders prevalent in young transgender women
To take the posttest, go to: http://bit.ly/24FCDdq
Expires March 21, 2017
VITALS
Key clinical point: Young transgender women have a high prevalence of psychiatric disorders that is two to four times higher than that in the general population.
Major finding: 41.5% of the study participants had at least one psychiatric disorder, such as major depressive disorder, suicidality, generalized anxiety, PTSD, and alcohol or substance dependence.
Data source: An observational cohort study involving 298 transgender women aged 16-29 years residing in Chicago and Boston.
Disclosures: This study was supported by the National Institute of Mental Health. Dr. Reisner and his associates reported having no relevant financial disclosures.
Here are 4 articles in the July issue of Clinician Reviews (individual articles are valid for one year from date of publication—expiration dates below):
1. Pregnancy Alters Pharmacodynamics of Anti-TNF Agents in Women With IBD
To take the posttest, go to: http://bit.ly/1VQFIHf
Expires May 24, 2017
VITALS
Key clinical point: Blood levels of infliximab rose during pregnancy, while adalimumab levels remained stable, even after researchers accounted for changes in albumin, body mass index, and C-reactive protein levels.
Major finding: Median infliximab concentrations rose from 8.5 mcg/mL in the first trimester to a peak of 21 mcg/mL during the middle of the third trimester (P = .04). Median adalimumab levels ranged between 8.6 and 12.2 mcg/mL during pregnancy.
Data source: A prospective study of 25 pregnant women with ulcerative colitis or Crohn's disease.
Disclosures: Dr. Seow disclosed ties with Janssen, AbbVie, Takeda, Shire, and Actavis.
2. Vascular Disease Linked to Sight Loss in Giant Cell Arteritis
To take the posttest, go to: http://bit.ly/1UqLuu5
Expires May 10, 2017
VITALS
Key clinical point: Patients with vascular disease who develop giant cell arteritis may require careful monitoring for sight loss.
Major finding: Overall, 42.9% of patients had some visual disturbance at first clinic review; 7.9% were blind at 6 months.
Data source: Analysis of 433 patients newly diagnosed with GCA participating in the Diagnostic and Classification Criteria in Vasculitis Study (DCVAS).
Disclosures: The DCVAS study is supported by the American College of Rheumatology and is funded by the European League Against Rheumatism and the Vasculitis Foundation. Dr. Yates reported that he had no relevant disclosures.
3. Pediatric and Adolescent Mental Health
Part 1: Diagnoses, drug prescribing vary widely
To take the posttest, go to: http://bit.ly/24FHTxY
Expires April 1, 2017
VITALS
Key clinical point: A lack of psychiatrists only partially accounted for substantial variations in rates of mental illness diagnosis and prescriptions for psychotropic medications given in practices nationwide, a study has shown.
Major finding: Nationwide, 15% of pediatric patients received a mental health diagnosis, and 14% were prescribed psychotropic medications in primary care, regardless of colocated mental health services.
Data source: A retrospective study of electronic health records for 294,748 patients aged 4-18 years.
Disclosures: Dr. Alexander G. Fiks is an investigator for Pfizer; the other researchers said they had no relevant financial disclosures. This study was funded by the National Institutes of Health and the National Institute of Child Health and Human Development under the Best Pharmaceuticals for Children Act.
Part 2: Disorders prevalent in young transgender women
To take the posttest, go to: http://bit.ly/24FCDdq
Expires March 21, 2017
VITALS
Key clinical point: Young transgender women have a high prevalence of psychiatric disorders that is two to four times higher than that in the general population.
Major finding: 41.5% of the study participants had at least one psychiatric disorder, such as major depressive disorder, suicidality, generalized anxiety, PTSD, and alcohol or substance dependence.
Data source: An observational cohort study involving 298 transgender women aged 16-29 years residing in Chicago and Boston.
Disclosures: This study was supported by the National Institute of Mental Health. Dr. Reisner and his associates reported having no relevant financial disclosures.
Here are 4 articles in the July issue of Clinician Reviews (individual articles are valid for one year from date of publication—expiration dates below):
1. Pregnancy Alters Pharmacodynamics of Anti-TNF Agents in Women With IBD
To take the posttest, go to: http://bit.ly/1VQFIHf
Expires May 24, 2017
VITALS
Key clinical point: Blood levels of infliximab rose during pregnancy, while adalimumab levels remained stable, even after researchers accounted for changes in albumin, body mass index, and C-reactive protein levels.
Major finding: Median infliximab concentrations rose from 8.5 mcg/mL in the first trimester to a peak of 21 mcg/mL during the middle of the third trimester (P = .04). Median adalimumab levels ranged between 8.6 and 12.2 mcg/mL during pregnancy.
Data source: A prospective study of 25 pregnant women with ulcerative colitis or Crohn's disease.
Disclosures: Dr. Seow disclosed ties with Janssen, AbbVie, Takeda, Shire, and Actavis.
2. Vascular Disease Linked to Sight Loss in Giant Cell Arteritis
To take the posttest, go to: http://bit.ly/1UqLuu5
Expires May 10, 2017
VITALS
Key clinical point: Patients with vascular disease who develop giant cell arteritis may require careful monitoring for sight loss.
Major finding: Overall, 42.9% of patients had some visual disturbance at first clinic review; 7.9% were blind at 6 months.
Data source: Analysis of 433 patients newly diagnosed with GCA participating in the Diagnostic and Classification Criteria in Vasculitis Study (DCVAS).
Disclosures: The DCVAS study is supported by the American College of Rheumatology and is funded by the European League Against Rheumatism and the Vasculitis Foundation. Dr. Yates reported that he had no relevant disclosures.
3. Pediatric and Adolescent Mental Health
Part 1: Diagnoses, drug prescribing vary widely
To take the posttest, go to: http://bit.ly/24FHTxY
Expires April 1, 2017
VITALS
Key clinical point: A lack of psychiatrists only partially accounted for substantial variations in rates of mental illness diagnosis and prescriptions for psychotropic medications given in practices nationwide, a study has shown.
Major finding: Nationwide, 15% of pediatric patients received a mental health diagnosis, and 14% were prescribed psychotropic medications in primary care, regardless of colocated mental health services.
Data source: A retrospective study of electronic health records for 294,748 patients aged 4-18 years.
Disclosures: Dr. Alexander G. Fiks is an investigator for Pfizer; the other researchers said they had no relevant financial disclosures. This study was funded by the National Institutes of Health and the National Institute of Child Health and Human Development under the Best Pharmaceuticals for Children Act.
Part 2: Disorders prevalent in young transgender women
To take the posttest, go to: http://bit.ly/24FCDdq
Expires March 21, 2017
VITALS
Key clinical point: Young transgender women have a high prevalence of psychiatric disorders that is two to four times higher than that in the general population.
Major finding: 41.5% of the study participants had at least one psychiatric disorder, such as major depressive disorder, suicidality, generalized anxiety, PTSD, and alcohol or substance dependence.
Data source: An observational cohort study involving 298 transgender women aged 16-29 years residing in Chicago and Boston.
Disclosures: This study was supported by the National Institute of Mental Health. Dr. Reisner and his associates reported having no relevant financial disclosures.
ACIP hints at move from three-dose to two-dose HPV vaccination schedule for youth
A work group for the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices is leaning toward recommending a change from three to two doses of the human papillomavirus (HPV) vaccine in boys and girls aged 11-12 years.
Members of the ACIP Human Papillomavirus Work Group told the entire committee at ACIP’s June meeting that a review of all available data showed that, regardless of whether the HPV vaccine were bivalent, quadrivalent, or nine-valent, two doses were found to be noninferior, compared with three doses. A two-dose schedule, therefore, could possibly be recommended at the next ACIP meeting later this year.
The work group said it also could recommend that HPV vaccine–naive women up to age 26 years and HPV vaccine-naive men up to age 21 years also receive the vaccine. For persons who initiated but did not complete vaccination before age 15 years, or for persons who initiate the schedule after their 15th birthday – the same schedule as is currently recommended for 11- and 12-year-olds – a similar schedule is likely to be recommended again.
The recommendation for immunocompromised persons of any age would be to receive the three-dose schedule.
If these recommendations are put forth officially, the question of whether families also should be given a three-dose option will need to be decided, work group members said.
Although studies are ongoing to determine antibody persistence and long-term effectiveness after two doses, existing data indicate that waning antibody responses to HPV18 in persons vaccinated with three doses of quadrivalent HPV were not associated with loss of protection. This could mean that protective levels are actually lower than the minimum levels detected by assays, or that antibodies against other epitopes also are protective.
Predictive modeling showed that, if a two-dose schedule can provide more than 20 years of protection, over $118,000 per quality adjusted life year could be realized without sacrificing population health benefits.
The current CDC vaccination schedule for HPV in adolescents is for a three-dose series of the vaccine on a schedule of 0, 1-2, and 6 months. The same vaccination schedule is recommended for “catch-up” of previously unvaccinated adolescents aged 13-18 years.
On Twitter @whitneymcknight
A work group for the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices is leaning toward recommending a change from three to two doses of the human papillomavirus (HPV) vaccine in boys and girls aged 11-12 years.
Members of the ACIP Human Papillomavirus Work Group told the entire committee at ACIP’s June meeting that a review of all available data showed that, regardless of whether the HPV vaccine were bivalent, quadrivalent, or nine-valent, two doses were found to be noninferior, compared with three doses. A two-dose schedule, therefore, could possibly be recommended at the next ACIP meeting later this year.
The work group said it also could recommend that HPV vaccine–naive women up to age 26 years and HPV vaccine-naive men up to age 21 years also receive the vaccine. For persons who initiated but did not complete vaccination before age 15 years, or for persons who initiate the schedule after their 15th birthday – the same schedule as is currently recommended for 11- and 12-year-olds – a similar schedule is likely to be recommended again.
The recommendation for immunocompromised persons of any age would be to receive the three-dose schedule.
If these recommendations are put forth officially, the question of whether families also should be given a three-dose option will need to be decided, work group members said.
Although studies are ongoing to determine antibody persistence and long-term effectiveness after two doses, existing data indicate that waning antibody responses to HPV18 in persons vaccinated with three doses of quadrivalent HPV were not associated with loss of protection. This could mean that protective levels are actually lower than the minimum levels detected by assays, or that antibodies against other epitopes also are protective.
Predictive modeling showed that, if a two-dose schedule can provide more than 20 years of protection, over $118,000 per quality adjusted life year could be realized without sacrificing population health benefits.
The current CDC vaccination schedule for HPV in adolescents is for a three-dose series of the vaccine on a schedule of 0, 1-2, and 6 months. The same vaccination schedule is recommended for “catch-up” of previously unvaccinated adolescents aged 13-18 years.
On Twitter @whitneymcknight
A work group for the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices is leaning toward recommending a change from three to two doses of the human papillomavirus (HPV) vaccine in boys and girls aged 11-12 years.
Members of the ACIP Human Papillomavirus Work Group told the entire committee at ACIP’s June meeting that a review of all available data showed that, regardless of whether the HPV vaccine were bivalent, quadrivalent, or nine-valent, two doses were found to be noninferior, compared with three doses. A two-dose schedule, therefore, could possibly be recommended at the next ACIP meeting later this year.
The work group said it also could recommend that HPV vaccine–naive women up to age 26 years and HPV vaccine-naive men up to age 21 years also receive the vaccine. For persons who initiated but did not complete vaccination before age 15 years, or for persons who initiate the schedule after their 15th birthday – the same schedule as is currently recommended for 11- and 12-year-olds – a similar schedule is likely to be recommended again.
The recommendation for immunocompromised persons of any age would be to receive the three-dose schedule.
If these recommendations are put forth officially, the question of whether families also should be given a three-dose option will need to be decided, work group members said.
Although studies are ongoing to determine antibody persistence and long-term effectiveness after two doses, existing data indicate that waning antibody responses to HPV18 in persons vaccinated with three doses of quadrivalent HPV were not associated with loss of protection. This could mean that protective levels are actually lower than the minimum levels detected by assays, or that antibodies against other epitopes also are protective.
Predictive modeling showed that, if a two-dose schedule can provide more than 20 years of protection, over $118,000 per quality adjusted life year could be realized without sacrificing population health benefits.
The current CDC vaccination schedule for HPV in adolescents is for a three-dose series of the vaccine on a schedule of 0, 1-2, and 6 months. The same vaccination schedule is recommended for “catch-up” of previously unvaccinated adolescents aged 13-18 years.
On Twitter @whitneymcknight
FROM AN ACIP MEETING
ACIP votes to scrap LAIV vaccine for 2016-2017 influenza season
The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices has voted to scrap the use of the live attenuated influenza vaccine for the 2016-2017 flu season.
ACIP’s interim recommendation guidance to the CDC is that “no live attenuated influenza vaccines (LAIV) should be used in any setting,” after reviewing data showing that for three consecutive influenza seasons, LAIV’s vaccine effectiveness (VE) against any flu virus was 3% (95% confidence interval, -49%-37%) in children aged 2-17 years. Meanwhile, injectable inactivated influenza vaccine (IIV) had a VE estimate of 63% (95% CI, 52%-72%) against any flu virus in that age group. Findings were similar across age groups.
CDC epidemiologist Brendan Flannery, Ph.D., painted a damning picture of the intranasal LAIV, presenting preliminary data from the U.S. Flu Vaccine Effectiveness Network for 2015-2016 that showed quadrivalent LAIV offered children “no significant protection against influenza A(H1N1)pdm09.” He also presented 2015-2016 national cohort data from Finland showing that unadjusted vaccine effectiveness (VE) against the H1N1 strain for LAIV in 2-year-olds was 47%, compared with 78% for IIV. Dr. Flannery also cited a series of other U.S. and international studies that did not support the use of LAIV, including unpublished Department of Defense 2015-2016 influenza season data for military families indicating that VE for LAIV against the strain last season was “insignificant” in children aged 2-17 years.
Data from an industry study of the quadrivalent LAIV FluMist (MedImmune) also indicated that in this cohort, for the 2015-2016 influenza season, LAIV underperformed compared with IIV, 46% vs. 65%.
Still more bad news for LAIV came from an English study published online just as the ACIP meeting was getting underway. Those data showed that from October 2015 through May 2016, LAIV in children aged 2-17 years had a VE of 57.6% against influenza A and B.
Debate over whether to pull support for LAIV entirely or to allow the use of it in certain circumstances – such as when a person declined a flu shot – hinged on the projected upheaval pulling LAIV is likely to cause.
Concerns were raised around what would happen in the case of LAIV vaccine orders already placed, over whether pulling LAIV would mean a shortage of other vaccine alternatives, and how communicating contingencies might only confuse the public, but several committee members spoke forcefully in favor of what they said the data compelled them to do.
“The science simply shows that LAIV has not worked for the past 3 years, whereas IIV has,” American Academy of Pediatrics Infectious Disease Committee’s Red Book editor, and AAP liaison to ACIP, Dr. David Kimberlin said before the vote.
Restricting but not prohibiting LAIV also would have allowed for an easier transition back to LAIV if the vaccine were successfully reformulated, ACIP Influenza Work Group Chair Dr. Ruth Karron said while presenting potential policy recommendations.
During the debate over whether to pull or limit support for the inhaled vaccine, Dr. Karron reminded the committee that at the time the Food and Drug Administration approved LAIV, serum antibody responses to both the tri- and quadrivalent vaccine were modest, prompting the FDA to call for effectiveness studies. “So, my question to the FDA now is, ‘What are their plans?’ ”
“We’ve seen the studies, but we’ve not really reviewed all the data,” Dr. Wellington Sun, the FDA’s ACIP liaison responded. “I think we have to acknowledge that LAIV has offered advantages over IIV in the past. At this point, we’re not ready to undertake a program for changing the prescriber’s information. We want to continue to work with MedImmune to find out the root cause of this phenomenon.”
“We’ve increased our research into understanding the biology of the H1N1pdm09 LAIV strains so we can improve their effectiveness in future seasons,” Dr. Chris Ambrose, vice president of U.S. medical affairs for infectious disease at MedImmune’s parent company AstraZeneca, told the committee.
“I think this is a very sad day for the influenza vaccination program,” ACIP chair Dr. Nancy Bennett said before adjourning the meeting. “We all had great hopes. It’s not over. If you’ve seen 1 influenza year, you’ve seen 1 influenza year. We may be back here next year having a very different discussion.”
The CDC is not obligated to adopt ACIP recommendations, but typically does. The committee also accepted a resolution to update the Vaccines for Children program in accordance with the recommendation to deny support for LAIV this flu season.
Thirteen members of the committee voted in favor of the recommendation. Dr. Edward Belongia abstained citing a conflict of interest, and Ms. Cynthia Pelligrini voted no, citing “insufficient time to consider this information.” The ICICLE trial NCT01997450, was sponsored by MedImmune, a subsidiary of AstraZeneca where Dr. Ambrose is vice president of U.S. medical affairs for infectious disease.
On Twitter @whitneymcknight
The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices has voted to scrap the use of the live attenuated influenza vaccine for the 2016-2017 flu season.
ACIP’s interim recommendation guidance to the CDC is that “no live attenuated influenza vaccines (LAIV) should be used in any setting,” after reviewing data showing that for three consecutive influenza seasons, LAIV’s vaccine effectiveness (VE) against any flu virus was 3% (95% confidence interval, -49%-37%) in children aged 2-17 years. Meanwhile, injectable inactivated influenza vaccine (IIV) had a VE estimate of 63% (95% CI, 52%-72%) against any flu virus in that age group. Findings were similar across age groups.
CDC epidemiologist Brendan Flannery, Ph.D., painted a damning picture of the intranasal LAIV, presenting preliminary data from the U.S. Flu Vaccine Effectiveness Network for 2015-2016 that showed quadrivalent LAIV offered children “no significant protection against influenza A(H1N1)pdm09.” He also presented 2015-2016 national cohort data from Finland showing that unadjusted vaccine effectiveness (VE) against the H1N1 strain for LAIV in 2-year-olds was 47%, compared with 78% for IIV. Dr. Flannery also cited a series of other U.S. and international studies that did not support the use of LAIV, including unpublished Department of Defense 2015-2016 influenza season data for military families indicating that VE for LAIV against the strain last season was “insignificant” in children aged 2-17 years.
Data from an industry study of the quadrivalent LAIV FluMist (MedImmune) also indicated that in this cohort, for the 2015-2016 influenza season, LAIV underperformed compared with IIV, 46% vs. 65%.
Still more bad news for LAIV came from an English study published online just as the ACIP meeting was getting underway. Those data showed that from October 2015 through May 2016, LAIV in children aged 2-17 years had a VE of 57.6% against influenza A and B.
Debate over whether to pull support for LAIV entirely or to allow the use of it in certain circumstances – such as when a person declined a flu shot – hinged on the projected upheaval pulling LAIV is likely to cause.
Concerns were raised around what would happen in the case of LAIV vaccine orders already placed, over whether pulling LAIV would mean a shortage of other vaccine alternatives, and how communicating contingencies might only confuse the public, but several committee members spoke forcefully in favor of what they said the data compelled them to do.
“The science simply shows that LAIV has not worked for the past 3 years, whereas IIV has,” American Academy of Pediatrics Infectious Disease Committee’s Red Book editor, and AAP liaison to ACIP, Dr. David Kimberlin said before the vote.
Restricting but not prohibiting LAIV also would have allowed for an easier transition back to LAIV if the vaccine were successfully reformulated, ACIP Influenza Work Group Chair Dr. Ruth Karron said while presenting potential policy recommendations.
During the debate over whether to pull or limit support for the inhaled vaccine, Dr. Karron reminded the committee that at the time the Food and Drug Administration approved LAIV, serum antibody responses to both the tri- and quadrivalent vaccine were modest, prompting the FDA to call for effectiveness studies. “So, my question to the FDA now is, ‘What are their plans?’ ”
“We’ve seen the studies, but we’ve not really reviewed all the data,” Dr. Wellington Sun, the FDA’s ACIP liaison responded. “I think we have to acknowledge that LAIV has offered advantages over IIV in the past. At this point, we’re not ready to undertake a program for changing the prescriber’s information. We want to continue to work with MedImmune to find out the root cause of this phenomenon.”
“We’ve increased our research into understanding the biology of the H1N1pdm09 LAIV strains so we can improve their effectiveness in future seasons,” Dr. Chris Ambrose, vice president of U.S. medical affairs for infectious disease at MedImmune’s parent company AstraZeneca, told the committee.
“I think this is a very sad day for the influenza vaccination program,” ACIP chair Dr. Nancy Bennett said before adjourning the meeting. “We all had great hopes. It’s not over. If you’ve seen 1 influenza year, you’ve seen 1 influenza year. We may be back here next year having a very different discussion.”
The CDC is not obligated to adopt ACIP recommendations, but typically does. The committee also accepted a resolution to update the Vaccines for Children program in accordance with the recommendation to deny support for LAIV this flu season.
Thirteen members of the committee voted in favor of the recommendation. Dr. Edward Belongia abstained citing a conflict of interest, and Ms. Cynthia Pelligrini voted no, citing “insufficient time to consider this information.” The ICICLE trial NCT01997450, was sponsored by MedImmune, a subsidiary of AstraZeneca where Dr. Ambrose is vice president of U.S. medical affairs for infectious disease.
On Twitter @whitneymcknight
The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices has voted to scrap the use of the live attenuated influenza vaccine for the 2016-2017 flu season.
ACIP’s interim recommendation guidance to the CDC is that “no live attenuated influenza vaccines (LAIV) should be used in any setting,” after reviewing data showing that for three consecutive influenza seasons, LAIV’s vaccine effectiveness (VE) against any flu virus was 3% (95% confidence interval, -49%-37%) in children aged 2-17 years. Meanwhile, injectable inactivated influenza vaccine (IIV) had a VE estimate of 63% (95% CI, 52%-72%) against any flu virus in that age group. Findings were similar across age groups.
CDC epidemiologist Brendan Flannery, Ph.D., painted a damning picture of the intranasal LAIV, presenting preliminary data from the U.S. Flu Vaccine Effectiveness Network for 2015-2016 that showed quadrivalent LAIV offered children “no significant protection against influenza A(H1N1)pdm09.” He also presented 2015-2016 national cohort data from Finland showing that unadjusted vaccine effectiveness (VE) against the H1N1 strain for LAIV in 2-year-olds was 47%, compared with 78% for IIV. Dr. Flannery also cited a series of other U.S. and international studies that did not support the use of LAIV, including unpublished Department of Defense 2015-2016 influenza season data for military families indicating that VE for LAIV against the strain last season was “insignificant” in children aged 2-17 years.
Data from an industry study of the quadrivalent LAIV FluMist (MedImmune) also indicated that in this cohort, for the 2015-2016 influenza season, LAIV underperformed compared with IIV, 46% vs. 65%.
Still more bad news for LAIV came from an English study published online just as the ACIP meeting was getting underway. Those data showed that from October 2015 through May 2016, LAIV in children aged 2-17 years had a VE of 57.6% against influenza A and B.
Debate over whether to pull support for LAIV entirely or to allow the use of it in certain circumstances – such as when a person declined a flu shot – hinged on the projected upheaval pulling LAIV is likely to cause.
Concerns were raised around what would happen in the case of LAIV vaccine orders already placed, over whether pulling LAIV would mean a shortage of other vaccine alternatives, and how communicating contingencies might only confuse the public, but several committee members spoke forcefully in favor of what they said the data compelled them to do.
“The science simply shows that LAIV has not worked for the past 3 years, whereas IIV has,” American Academy of Pediatrics Infectious Disease Committee’s Red Book editor, and AAP liaison to ACIP, Dr. David Kimberlin said before the vote.
Restricting but not prohibiting LAIV also would have allowed for an easier transition back to LAIV if the vaccine were successfully reformulated, ACIP Influenza Work Group Chair Dr. Ruth Karron said while presenting potential policy recommendations.
During the debate over whether to pull or limit support for the inhaled vaccine, Dr. Karron reminded the committee that at the time the Food and Drug Administration approved LAIV, serum antibody responses to both the tri- and quadrivalent vaccine were modest, prompting the FDA to call for effectiveness studies. “So, my question to the FDA now is, ‘What are their plans?’ ”
“We’ve seen the studies, but we’ve not really reviewed all the data,” Dr. Wellington Sun, the FDA’s ACIP liaison responded. “I think we have to acknowledge that LAIV has offered advantages over IIV in the past. At this point, we’re not ready to undertake a program for changing the prescriber’s information. We want to continue to work with MedImmune to find out the root cause of this phenomenon.”
“We’ve increased our research into understanding the biology of the H1N1pdm09 LAIV strains so we can improve their effectiveness in future seasons,” Dr. Chris Ambrose, vice president of U.S. medical affairs for infectious disease at MedImmune’s parent company AstraZeneca, told the committee.
“I think this is a very sad day for the influenza vaccination program,” ACIP chair Dr. Nancy Bennett said before adjourning the meeting. “We all had great hopes. It’s not over. If you’ve seen 1 influenza year, you’ve seen 1 influenza year. We may be back here next year having a very different discussion.”
The CDC is not obligated to adopt ACIP recommendations, but typically does. The committee also accepted a resolution to update the Vaccines for Children program in accordance with the recommendation to deny support for LAIV this flu season.
Thirteen members of the committee voted in favor of the recommendation. Dr. Edward Belongia abstained citing a conflict of interest, and Ms. Cynthia Pelligrini voted no, citing “insufficient time to consider this information.” The ICICLE trial NCT01997450, was sponsored by MedImmune, a subsidiary of AstraZeneca where Dr. Ambrose is vice president of U.S. medical affairs for infectious disease.
On Twitter @whitneymcknight
FROM AN ACIP MEETING
ACIP recommends MenACWY vaccine for HIV-infected persons 2 months and older
The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices unanimously voted to recommend that all HIV-infected persons aged 2 months and older receive the meningococcal ACWY (MenACWY) vaccine.
Guidance for this recommendation states that persons 2 months and older with HIV who have not been vaccinated previously should receive a two-dose, primary series of MenACWY; and that HIV-infected persons who have been vaccinated previously with one dose of MenACWY should receive a second dose at the earliest opportunity, with an 8-week minimum interval between doses. After that, boosters are to be given at the appropriate intervals.
Committee members voted in favor of immunizing earlier rather than waiting until 11 years of age or older, in part because human complement (hSBA) antibody titers following up to two doses of MenACWY vaccine in HIV-infected children ages 2-10 years is higher than in those ages 11-24 years. Also, the agreed upon recommended policy for earlier immunization is in step with current ACIP recommendations for use of the vaccine in persons with functional/anatomic asplenia or complement component deficiencies.
Despite an overall decline in the risk of meningococcal disease in the United States, there was a 13-fold increased risk in HIV-infected persons aged 25-64 years between 2000 and 2008, according to surveillance data presented to ACIP by Ms. Jessica MacNeil, MPH, an epidemiologist at the National Center for Immunization and Respiratory Diseases at the CDC in Atlanta. A ten-fold increase in risk was recorded in New York City alone in this population between 2000 and 2011.
Although fatality data are mixed, the infections were due primarily to serogroups C, W, and Y, for which the immune response wanes rapidly, according to Ms. MacNeil.
There are no safety or immunogenicity data currently available for the use of serogroup B meningococcal vaccines in HIV-infected persons, she said.
ACIP members also unanimously recommended this vaccine be covered under the Vaccines for Children program.
No information about disclosures was available at press time.
On Twitter @whitneymcknight
The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices unanimously voted to recommend that all HIV-infected persons aged 2 months and older receive the meningococcal ACWY (MenACWY) vaccine.
Guidance for this recommendation states that persons 2 months and older with HIV who have not been vaccinated previously should receive a two-dose, primary series of MenACWY; and that HIV-infected persons who have been vaccinated previously with one dose of MenACWY should receive a second dose at the earliest opportunity, with an 8-week minimum interval between doses. After that, boosters are to be given at the appropriate intervals.
Committee members voted in favor of immunizing earlier rather than waiting until 11 years of age or older, in part because human complement (hSBA) antibody titers following up to two doses of MenACWY vaccine in HIV-infected children ages 2-10 years is higher than in those ages 11-24 years. Also, the agreed upon recommended policy for earlier immunization is in step with current ACIP recommendations for use of the vaccine in persons with functional/anatomic asplenia or complement component deficiencies.
Despite an overall decline in the risk of meningococcal disease in the United States, there was a 13-fold increased risk in HIV-infected persons aged 25-64 years between 2000 and 2008, according to surveillance data presented to ACIP by Ms. Jessica MacNeil, MPH, an epidemiologist at the National Center for Immunization and Respiratory Diseases at the CDC in Atlanta. A ten-fold increase in risk was recorded in New York City alone in this population between 2000 and 2011.
Although fatality data are mixed, the infections were due primarily to serogroups C, W, and Y, for which the immune response wanes rapidly, according to Ms. MacNeil.
There are no safety or immunogenicity data currently available for the use of serogroup B meningococcal vaccines in HIV-infected persons, she said.
ACIP members also unanimously recommended this vaccine be covered under the Vaccines for Children program.
No information about disclosures was available at press time.
On Twitter @whitneymcknight
The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices unanimously voted to recommend that all HIV-infected persons aged 2 months and older receive the meningococcal ACWY (MenACWY) vaccine.
Guidance for this recommendation states that persons 2 months and older with HIV who have not been vaccinated previously should receive a two-dose, primary series of MenACWY; and that HIV-infected persons who have been vaccinated previously with one dose of MenACWY should receive a second dose at the earliest opportunity, with an 8-week minimum interval between doses. After that, boosters are to be given at the appropriate intervals.
Committee members voted in favor of immunizing earlier rather than waiting until 11 years of age or older, in part because human complement (hSBA) antibody titers following up to two doses of MenACWY vaccine in HIV-infected children ages 2-10 years is higher than in those ages 11-24 years. Also, the agreed upon recommended policy for earlier immunization is in step with current ACIP recommendations for use of the vaccine in persons with functional/anatomic asplenia or complement component deficiencies.
Despite an overall decline in the risk of meningococcal disease in the United States, there was a 13-fold increased risk in HIV-infected persons aged 25-64 years between 2000 and 2008, according to surveillance data presented to ACIP by Ms. Jessica MacNeil, MPH, an epidemiologist at the National Center for Immunization and Respiratory Diseases at the CDC in Atlanta. A ten-fold increase in risk was recorded in New York City alone in this population between 2000 and 2011.
Although fatality data are mixed, the infections were due primarily to serogroups C, W, and Y, for which the immune response wanes rapidly, according to Ms. MacNeil.
There are no safety or immunogenicity data currently available for the use of serogroup B meningococcal vaccines in HIV-infected persons, she said.
ACIP members also unanimously recommended this vaccine be covered under the Vaccines for Children program.
No information about disclosures was available at press time.
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FROM AN ACIP MEETING
