TOPLINE:

The disease-modifying treatment (DMT) delays conversion to clinical multiple sclerosis (MS) for patients with radiologically isolated syndrome (RIS) and has a reassuring long-term safety profile, new research shows.

METHODOLOGY:

Early use of DMTs is typically recommended for patients with established MS, but mounting evidence, including the ARISE trial, which assessed Tecfidera, suggests these agents benefit patients with RIS, the earliest detectable preclinical MS stage.

The new study, known as Teriflunomide in Radiologically Isolated Syndrome (TERIS), included 89 adult patients with RIS (mean age, 37.8 years) from centers in France, Switzerland, and Turkey. Participants were randomly assigned to receive placebo or teriflunomide 14 mg daily. Teriflunomide is an oral immunomodulator approved for treating relapsing remitting MS.

Investigators performed MRI at baseline and at weeks 48, 96, and 144 and at any time during the study if warranted.

Researchers adjusted for potential confounders, including sex, age at RIS diagnosis, MS family history, brain T2-weighted hyperintense lesion volume, and presence of Gd+/− lesions.

The primary outcome was time to a first acute or progressive neurologic event resulting from central nervous system demyelination, expressed as a rate of conversion to clinical MS.
 

TAKEAWAY:

Eighteen participants – nine in each group – discontinued the study, resulting in a dropout rate of 20%.

The risk of a first clinical event was significantly reduced in the teriflunomide arm (mean time to event, 128.2 weeks) with 8 clinical events (6 acute, 2 progressive) in comparison with the placebo arm (mean time to event, 109.6 weeks) with 20 clinical events (18 acute, 2 progressive) and an adjusted hazard ratio of 0.28 (95% CI, 0.11-0.71; P = .007).

All secondary MRI measures, including the cumulative number of new and/or newly enlarging T2 lesions and the cumulative number of Gd+ lesions, did not reach statistical significance, although these were numerically lower in the teriflunomide arm, possibly because participants with early events switched to the treatment arm.

The most common adverse events that occurred more often in patients treated with teriflunomide were gastrointestinal disorders (11.4%), dysmenorrhea (9.1%), benign respiratory infections (6.8%), general disorders/conditions (6.8%), and transient increase of transaminases (4.5%).
 

IN PRACTICE:

“These results suggest that for the first time, we may have an opportunity to better identify those at risk for a primary progressive clinical course at this preclinical stage and prevent or delay clinical progression from the onset, which is a clear unmet need in MS clinical practice,” wrote the authors.

SOURCE:

The study was carried out by Christine Lebrun-Frénay MD, PhD, head of the inflammatory neurological disorders clinical research unit and MS center at the University of Nice (France). It was published online in JAMA Neurology.

LIMITATIONS:

The investigators could not stratify at-risk subgroups according to risk factors for developing MS, mainly because of power issues. The study was prematurely discontinued by its financial sponsor (Sanofi), owing primarily to slow enrollment that resulted from national regulations on activating recruitment sites and the impact of the COVID-19 pandemic. Another challenge for the study was that some individuals with RIS had already been exposed to a DMT or hesitated to participate in a clinical trial. The financial sponsor, which provided the study drug and placebo tablets, terminated their availability, given the anticipated release of generic teriflunomide.

DISCLOSURES:

The study was supported by Sanofi, the University Hospital of Nice, University Cote d’Azur, and the Radiologically Isolated Syndrome Consortium. Lebrun-Frénay has no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

TOPLINE:

The disease-modifying treatment (DMT) delays conversion to clinical multiple sclerosis (MS) for patients with radiologically isolated syndrome (RIS) and has a reassuring long-term safety profile, new research shows.

METHODOLOGY:

Early use of DMTs is typically recommended for patients with established MS, but mounting evidence, including the ARISE trial, which assessed Tecfidera, suggests these agents benefit patients with RIS, the earliest detectable preclinical MS stage.

The new study, known as Teriflunomide in Radiologically Isolated Syndrome (TERIS), included 89 adult patients with RIS (mean age, 37.8 years) from centers in France, Switzerland, and Turkey. Participants were randomly assigned to receive placebo or teriflunomide 14 mg daily. Teriflunomide is an oral immunomodulator approved for treating relapsing remitting MS.

Investigators performed MRI at baseline and at weeks 48, 96, and 144 and at any time during the study if warranted.

Researchers adjusted for potential confounders, including sex, age at RIS diagnosis, MS family history, brain T2-weighted hyperintense lesion volume, and presence of Gd+/− lesions.

The primary outcome was time to a first acute or progressive neurologic event resulting from central nervous system demyelination, expressed as a rate of conversion to clinical MS.
 

TAKEAWAY:

Eighteen participants – nine in each group – discontinued the study, resulting in a dropout rate of 20%.

The risk of a first clinical event was significantly reduced in the teriflunomide arm (mean time to event, 128.2 weeks) with 8 clinical events (6 acute, 2 progressive) in comparison with the placebo arm (mean time to event, 109.6 weeks) with 20 clinical events (18 acute, 2 progressive) and an adjusted hazard ratio of 0.28 (95% CI, 0.11-0.71; P = .007).

All secondary MRI measures, including the cumulative number of new and/or newly enlarging T2 lesions and the cumulative number of Gd+ lesions, did not reach statistical significance, although these were numerically lower in the teriflunomide arm, possibly because participants with early events switched to the treatment arm.

The most common adverse events that occurred more often in patients treated with teriflunomide were gastrointestinal disorders (11.4%), dysmenorrhea (9.1%), benign respiratory infections (6.8%), general disorders/conditions (6.8%), and transient increase of transaminases (4.5%).
 

IN PRACTICE:

“These results suggest that for the first time, we may have an opportunity to better identify those at risk for a primary progressive clinical course at this preclinical stage and prevent or delay clinical progression from the onset, which is a clear unmet need in MS clinical practice,” wrote the authors.

SOURCE:

The study was carried out by Christine Lebrun-Frénay MD, PhD, head of the inflammatory neurological disorders clinical research unit and MS center at the University of Nice (France). It was published online in JAMA Neurology.

LIMITATIONS:

The investigators could not stratify at-risk subgroups according to risk factors for developing MS, mainly because of power issues. The study was prematurely discontinued by its financial sponsor (Sanofi), owing primarily to slow enrollment that resulted from national regulations on activating recruitment sites and the impact of the COVID-19 pandemic. Another challenge for the study was that some individuals with RIS had already been exposed to a DMT or hesitated to participate in a clinical trial. The financial sponsor, which provided the study drug and placebo tablets, terminated their availability, given the anticipated release of generic teriflunomide.

DISCLOSURES:

The study was supported by Sanofi, the University Hospital of Nice, University Cote d’Azur, and the Radiologically Isolated Syndrome Consortium. Lebrun-Frénay has no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

TOPLINE:

The disease-modifying treatment (DMT) delays conversion to clinical multiple sclerosis (MS) for patients with radiologically isolated syndrome (RIS) and has a reassuring long-term safety profile, new research shows.

METHODOLOGY:

Early use of DMTs is typically recommended for patients with established MS, but mounting evidence, including the ARISE trial, which assessed Tecfidera, suggests these agents benefit patients with RIS, the earliest detectable preclinical MS stage.

The new study, known as Teriflunomide in Radiologically Isolated Syndrome (TERIS), included 89 adult patients with RIS (mean age, 37.8 years) from centers in France, Switzerland, and Turkey. Participants were randomly assigned to receive placebo or teriflunomide 14 mg daily. Teriflunomide is an oral immunomodulator approved for treating relapsing remitting MS.

Investigators performed MRI at baseline and at weeks 48, 96, and 144 and at any time during the study if warranted.

Researchers adjusted for potential confounders, including sex, age at RIS diagnosis, MS family history, brain T2-weighted hyperintense lesion volume, and presence of Gd+/− lesions.

The primary outcome was time to a first acute or progressive neurologic event resulting from central nervous system demyelination, expressed as a rate of conversion to clinical MS.
 

TAKEAWAY:

Eighteen participants – nine in each group – discontinued the study, resulting in a dropout rate of 20%.

The risk of a first clinical event was significantly reduced in the teriflunomide arm (mean time to event, 128.2 weeks) with 8 clinical events (6 acute, 2 progressive) in comparison with the placebo arm (mean time to event, 109.6 weeks) with 20 clinical events (18 acute, 2 progressive) and an adjusted hazard ratio of 0.28 (95% CI, 0.11-0.71; P = .007).

All secondary MRI measures, including the cumulative number of new and/or newly enlarging T2 lesions and the cumulative number of Gd+ lesions, did not reach statistical significance, although these were numerically lower in the teriflunomide arm, possibly because participants with early events switched to the treatment arm.

The most common adverse events that occurred more often in patients treated with teriflunomide were gastrointestinal disorders (11.4%), dysmenorrhea (9.1%), benign respiratory infections (6.8%), general disorders/conditions (6.8%), and transient increase of transaminases (4.5%).
 

IN PRACTICE:

“These results suggest that for the first time, we may have an opportunity to better identify those at risk for a primary progressive clinical course at this preclinical stage and prevent or delay clinical progression from the onset, which is a clear unmet need in MS clinical practice,” wrote the authors.

SOURCE:

The study was carried out by Christine Lebrun-Frénay MD, PhD, head of the inflammatory neurological disorders clinical research unit and MS center at the University of Nice (France). It was published online in JAMA Neurology.

LIMITATIONS:

The investigators could not stratify at-risk subgroups according to risk factors for developing MS, mainly because of power issues. The study was prematurely discontinued by its financial sponsor (Sanofi), owing primarily to slow enrollment that resulted from national regulations on activating recruitment sites and the impact of the COVID-19 pandemic. Another challenge for the study was that some individuals with RIS had already been exposed to a DMT or hesitated to participate in a clinical trial. The financial sponsor, which provided the study drug and placebo tablets, terminated their availability, given the anticipated release of generic teriflunomide.

DISCLOSURES:

The study was supported by Sanofi, the University Hospital of Nice, University Cote d’Azur, and the Radiologically Isolated Syndrome Consortium. Lebrun-Frénay has no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

TOPLINE:

A decision-support model for managing patients with heartburn in whom proton pump inhibitor (PPI) therapy fails suggests that endoscopy with ambulatory reflux monitoring is the optimal cost-effective approach, matching therapy to phenotype.

METHODOLOGY:

• Researchers compared the cost-effectiveness over 1 year of four strategies for managing patients in whom empirical PPI treatment failed.
• Strategies were PPI optimization without diagnostic testing; endoscopy with PPI optimization to identify erosive reflux disease; endoscopy with PPI discontinuation when no erosive reflux disease was found; and combined endoscopy/ambulatory reflux monitoring and PPI discontinuation as appropriate for the phenotype (i.e., erosive disease, nonerosive disease, or functional heartburn).
• All index testing was assumed to be done while patients were off PPI treatment.

TAKEAWAY:

• PPI optimization without testing cost insurers $3,784 a year and patients $3,128 a year owing to health care expenses and lower work productivity associated with suboptimal symptom relief, resulting in a loss of 40 healthy days over the course of the year.
• Endoscopy with PPI optimization lowered insurer costs by $1,020 a year and patient costs by $1,621 a year, compared with optimization without testing, and added 11 healthy days a year by identifying erosive reflux disease.
• Endoscopy with PPI discontinuation added 11 healthy days a year by identifying patients without erosive reflux disease who did not need PPI therapy.
• Endoscopy with ambulatory reflux monitoring and a trial of PPI discontinuation was the most effective strategy, optimizing phenotype-guided treatment, saving insurers $2,183 and patients $2,396 a year, and adding 22 healthy days a year.
• The findings support recent clinical practice guidelines from the American Gastroenterological Association and the 

IN PRACTICE:

“[A]n algorithmic approach to comprehensively stratify erosive and non-erosive reflux disease from functional heartburn combined with a trial of PPI discontinuation for patients without erosive findings provides value to patients and insurers,” the authors wrote.

SOURCE:

Eric D. Shah, MD, MBA, division of gastroenterology and hepatology, Michigan Medicine, Ann Arbor, led the study, which was published online in Clinical Gastroenterology and Hepatology.

LIMITATIONS:

Centers may have limited capacity for routine ambulatory reflux monitoring or may not perform it at all. Single-center and older studies were used for model inputs when no other data were available.

DISCLOSURES:

The study had no specific funding. Dr. Shah is supported by a National Institutes of Health grant and disclosed that he has consulted for Salix, Mahana, Neuraxis, Phathom, Takeda, Ardelyx, Sanofi, and GI Supply. Other coauthors have consulted for pharmaceutical and/or biotech companies.
 

A version of this article appeared on Medscape.com.

TOPLINE:

A decision-support model for managing patients with heartburn in whom proton pump inhibitor (PPI) therapy fails suggests that endoscopy with ambulatory reflux monitoring is the optimal cost-effective approach, matching therapy to phenotype.

METHODOLOGY:

• Researchers compared the cost-effectiveness over 1 year of four strategies for managing patients in whom empirical PPI treatment failed.
• Strategies were PPI optimization without diagnostic testing; endoscopy with PPI optimization to identify erosive reflux disease; endoscopy with PPI discontinuation when no erosive reflux disease was found; and combined endoscopy/ambulatory reflux monitoring and PPI discontinuation as appropriate for the phenotype (i.e., erosive disease, nonerosive disease, or functional heartburn).
• All index testing was assumed to be done while patients were off PPI treatment.

TAKEAWAY:

• PPI optimization without testing cost insurers $3,784 a year and patients $3,128 a year owing to health care expenses and lower work productivity associated with suboptimal symptom relief, resulting in a loss of 40 healthy days over the course of the year.
• Endoscopy with PPI optimization lowered insurer costs by $1,020 a year and patient costs by $1,621 a year, compared with optimization without testing, and added 11 healthy days a year by identifying erosive reflux disease.
• Endoscopy with PPI discontinuation added 11 healthy days a year by identifying patients without erosive reflux disease who did not need PPI therapy.
• Endoscopy with ambulatory reflux monitoring and a trial of PPI discontinuation was the most effective strategy, optimizing phenotype-guided treatment, saving insurers $2,183 and patients $2,396 a year, and adding 22 healthy days a year.
• The findings support recent clinical practice guidelines from the American Gastroenterological Association and the 

IN PRACTICE:

“[A]n algorithmic approach to comprehensively stratify erosive and non-erosive reflux disease from functional heartburn combined with a trial of PPI discontinuation for patients without erosive findings provides value to patients and insurers,” the authors wrote.

SOURCE:

Eric D. Shah, MD, MBA, division of gastroenterology and hepatology, Michigan Medicine, Ann Arbor, led the study, which was published online in Clinical Gastroenterology and Hepatology.

LIMITATIONS:

Centers may have limited capacity for routine ambulatory reflux monitoring or may not perform it at all. Single-center and older studies were used for model inputs when no other data were available.

DISCLOSURES:

The study had no specific funding. Dr. Shah is supported by a National Institutes of Health grant and disclosed that he has consulted for Salix, Mahana, Neuraxis, Phathom, Takeda, Ardelyx, Sanofi, and GI Supply. Other coauthors have consulted for pharmaceutical and/or biotech companies.
 

A version of this article appeared on Medscape.com.

TOPLINE:

A decision-support model for managing patients with heartburn in whom proton pump inhibitor (PPI) therapy fails suggests that endoscopy with ambulatory reflux monitoring is the optimal cost-effective approach, matching therapy to phenotype.

METHODOLOGY:

• Researchers compared the cost-effectiveness over 1 year of four strategies for managing patients in whom empirical PPI treatment failed.
• Strategies were PPI optimization without diagnostic testing; endoscopy with PPI optimization to identify erosive reflux disease; endoscopy with PPI discontinuation when no erosive reflux disease was found; and combined endoscopy/ambulatory reflux monitoring and PPI discontinuation as appropriate for the phenotype (i.e., erosive disease, nonerosive disease, or functional heartburn).
• All index testing was assumed to be done while patients were off PPI treatment.

TAKEAWAY:

• PPI optimization without testing cost insurers $3,784 a year and patients $3,128 a year owing to health care expenses and lower work productivity associated with suboptimal symptom relief, resulting in a loss of 40 healthy days over the course of the year.
• Endoscopy with PPI optimization lowered insurer costs by $1,020 a year and patient costs by $1,621 a year, compared with optimization without testing, and added 11 healthy days a year by identifying erosive reflux disease.
• Endoscopy with PPI discontinuation added 11 healthy days a year by identifying patients without erosive reflux disease who did not need PPI therapy.
• Endoscopy with ambulatory reflux monitoring and a trial of PPI discontinuation was the most effective strategy, optimizing phenotype-guided treatment, saving insurers $2,183 and patients $2,396 a year, and adding 22 healthy days a year.
• The findings support recent clinical practice guidelines from the American Gastroenterological Association and the 

IN PRACTICE:

“[A]n algorithmic approach to comprehensively stratify erosive and non-erosive reflux disease from functional heartburn combined with a trial of PPI discontinuation for patients without erosive findings provides value to patients and insurers,” the authors wrote.

SOURCE:

Eric D. Shah, MD, MBA, division of gastroenterology and hepatology, Michigan Medicine, Ann Arbor, led the study, which was published online in Clinical Gastroenterology and Hepatology.

LIMITATIONS:

Centers may have limited capacity for routine ambulatory reflux monitoring or may not perform it at all. Single-center and older studies were used for model inputs when no other data were available.

DISCLOSURES:

The study had no specific funding. Dr. Shah is supported by a National Institutes of Health grant and disclosed that he has consulted for Salix, Mahana, Neuraxis, Phathom, Takeda, Ardelyx, Sanofi, and GI Supply. Other coauthors have consulted for pharmaceutical and/or biotech companies.
 

A version of this article appeared on Medscape.com.

Hospitalizations for COVID-19 in the United States have increased for 8 weeks in a row.

Data from Florida and Georgia signal that respiratory syncytial virus (RSV) season has begun.

As for flu shots, experts say patients with long COVID should get them in 2023, although federal health agencies have not addressed that specific question.

Paul G. Auwaerter, MD, MBA, an infectious disease consultant, said many patients in his primary care practice worry about “the big three” – COVID, influenza, and RSV.

This news organization spoke with Dr. Auwaerter, as well as family physician Santina J. G. Wheat, MD, MPH, and clinical pharmacist Spencer H. Durham, PharmD, about their approach to 2023’s respiratory virus season.

They discussed how to handle COVID boosters, the use of Paxlovid, vaccine hesitancy, and the correct order of operations for patients getting vaccinated against all three diseases.
 

Paul G. Auwaerter, MD, MBA, clinical director of the division of infectious diseases and the Sherrilyn and Ken Fisher Professor of Medicine at Johns Hopkins University, BaltimoreQuestion: How should primary care physicians be preparing to handle what everyone is predicting will be a major surge in cases of respiratory infections?

Auwaerter: Although I’m an infectious disease consultant, I still have a small primary care practice. So, I field questions for my patients all the time, and many patients, especially those with health problems, are worried about the big three: RSV, COVID, and influenza – at least, my more motivated patients are.

People frequently ask if they need the COVID booster. I think that’s been something many people think maybe they can avoid. The good news is that the early in vitro data suggest that the XBB1.5x-based vaccine seems to offer sufficient neutralizing activity against the circulating newer variants since the vaccine was approved earlier this year. I am suggesting that everyone get a booster, especially those at high risk, because we know that the risk for hospitalization decreases based on earlier studies for 4-6 months after a COVID booster. We can simultaneously administer the revised COVID booster vaccine and the annual influenza vaccine. The timing is good, as influenza immunization should be accomplished by October or early November at the latest. Like many parts of the country, we in Maryland are in the middle of a COVID boomlet. I have issued more Paxlovid prescriptions since mid-August than I did all spring and early summer.

Q: Are you seeing a lot of rebound COVID in your patients taking Paxlovid [nirmatrelvir/ritonavir]?

Dr. Auwaerter: I think the frequency is probably around 10%. It has been quoted much higher – at 20% – but careful studies have put it down at just single digits. I think it just depends on symptomatology and how you ask the question. But I think it’s important that I try to persuade people to take a direct-acting antiviral if they’re in a high-risk category rather than tough it out. Increasing data suggest taking an antiviral also reduces the risk for long COVID. Also, we know that rebound symptoms are not always infectious virus. Sometimes, they’re just inflammatory. Unless a person is immune suppressed, they rarely have a culturable virus 7-8 days after onset of symptoms. So, for most people, I don’t administer second courses of Paxlovid, although I know some physicians do. One has to realize the risk for hospitalization from a rebound is tiny, and many people don’t even have infectious virus when they take the second course of a drug such as Paxlovid.

Q: You mentioned motivated patients, which seems to be an important factor to consider, particularly for new vaccines.

Dr. Auwaerter: There are always early adopters who are less afraid. And then some people say: This is a brand-new vaccine; I’m going to wait for a year to let this shake out, and make sure it seems safe. People more engaged in their health have asked me about the RSV vaccine. For anyone who has cardiopulmonary problems and other major health problems, I’ve advised it. But if someone’s in good health and 65 or 70, the RSV illness is probably pretty mild if they get it. For them, I would say the vaccine is optional.

For people over 75, I have been advising the RSV vaccine because that is a group we tend to see hospitalized with RSV; they’re the highest-risk group, similar to COVID. The older you are, the more likely this infection will land you in the hospital. You can acquire RSV even if you don’t have young grandchildren around.

Q: You have called respiratory virus seasons unstable? What does it mean, and what is the significance for clinicians?

Dr. Auwaerter: It’s less predictable than in the past. If you had a cough and fever, you could think it was influenza if you knew you had influenza circulating in your community. Maybe you thought about RSV for your immunocompromised or older patients, but we didn’t have any therapy for it anyway. I sometimes refer to the respiratory virus season as a cage match between the major infections. Last year, RSV came out first, and we got some influenza and COVID. What does the situation look like this year? I don’t know at this point, but we are seeing more COVID earlier. What’s different is we continue to have the emergence of viral variants of SARS-CoV-2. Also, with both influenza and COVID, it’s harder to make a clinical judgment about what people have.

I think we have to rely more on tests to treat these patients. Options include having point of care testing in the office for rapid results (molecular assays preferred) for both influenza and SARS-CoV-2 or home antigen testing. There are home kits that do test for both if influenza is known to be circulating significantly in the community. But there are still barriers. For one, COVID and COVID/influenza antigen kits are no longer free, although some health insurance companies do provide COVID kits free of charge. In offices, you don’t want to have ill people with respiratory infections in your waiting room unless you can isolate or have negative pressure rooms. Do you ask for masking in your offices? Telemedicine has been a big help since the pandemic in managing nonsevere respiratory infections at home; however, you must be licensed in the state to practice, which limits helping your out-of-state patients.

Q: How has the advent of in-home antigen tests changed practice?

Dr. Auwaerter: Home antigen tests have been groundbreaking in facilitating care. When I see patients via telemedicine, I don’t want to prescribe medications for influenza and COVID to people simultaneously. I want to pick one or the other – and now I’m able to ask for a COVID test or a COVID/influenza test if the patient or family is able to get a kit. Some offices do have real-time molecular testing, which is the ideal and the CDC-recommended approach, but they’re expensive, and not everyone has access to them.

Q: People talk about the “tripledemic,” but does doing so ignore the fourth horseman of the respiratory apocalypse: pneumococcal pneumonia?

Dr. Auwaerter: Pneumonia remains a leading cause of hospitalization, except we’ve seen much more viral than bacterial pneumonia in recent years of the pandemic. We’ve lost sight, and pneumococcal pneumonia is important, especially in older patients. What we have seen pretty clearly is a rise in group A streptococcal infections. This is another consequence of the pandemic, where people did not socialize for a year or 2. There was much less group A strep infection in younger children, and even in adults, the amount of invasive group A streptococcal infections has clearly taken a jump, according to the NHS in Great Britain. Our pediatric practices here at Johns Hopkins are seeing far more cases of acute rheumatic fever than they’ve seen in decades. And I think, again, this is a consequence of the frequency of group A strep infections definitely taking an uptick. And that was no doubt probably from social mitigation measures and just an interruption in normal circumstances that bacterial and respiratory pathogens tend to circulate and colonize.

Q: Do you have any concerns about immunogenicity or side effects associated with receiving several vaccines at once?

Dr. Auwaerter: I think three injections at once is only for the heroic, and there is actually no guidance for getting all three at the moment. COVID, RSV, and influenza are not live vaccines. I’ve been recommending the new COVID booster and flu together, and then wait 2 weeks and then get RSV or vice-versa. A part of the reason is RSV is new. People have gotten COVID and flu vaccines before; they’re no different than in the past in terms of anticipating adverse effects. But RSV is new, so I’ve usually been recommending that as a standalone to gauge if there are issues as an RSV booster may be recommended at some point down the road.

Q: Unfortunately, some people are going to see or hear misinformation that the COVID boosters have not been properly tested or proven safe. What’s your response to the patient who says something to that effect?

Dr. Auwaerter: My response is, the basic components of the vaccine are the same, right? If you have the mRNA vaccine, you’re getting the vaccine components, the lipids, and the mRNA coding for spike proteins, which has just been modified slightly to adjust to the Omicron subvariant composition. We do the same thing with the influenza vaccine every year, and we don’t see much change in the side effect profile. I think it’s important for my staff in the office and myself to be very comfortable to field questions such as these.

We try to inform all of our staff about a vaccine, especially a new one like RSV, just so they have some comfort level with it, whether they’re getting it or not. Vaccine-hesitant patients need very little to dissuade and to take a pass – to the probable detriment of their health and their family’s health. We know the influenza vaccine helps reduce absenteeism and transmission in addition to reducing serious illness in high-risk patients. Even COVID vaccine efficacy is not as robust as initially reported, falling from 95% to under 70% depending on the study – you are provided with protection against serious illness and hospitalization. The same goes for influenza, and that’s how we try to pitch it to people. Are they going to get the flu? Maybe, but you didn’t land in the hospital. That’s why it’s these vaccines are so important.
 

Spencer H. Durham, PharmD, associate clinical professor in the department of pharmacy practice at Auburn (Ala.) University, and clinical pharmacist, Internal Medicine & Infectious Diseases, at the UAB Heersink School of Medicine in Huntsville.Q: What is known, if anything, about the risks/desirability of giving three vaccinations at once to patients (particularly older patients) – flu, COVID-19 and RSV? Any potential vaccine interactions physicians should know about?

Dr. Durham: There are currently no data about giving all three of these vaccines together at the same time. However, there is both data and practical experience of giving both the flu and COVID vaccines at the same time. The best approach right now for these three vaccines would be to get the flu and COVID vaccines at the same time, then give the RSV vaccine at a different date. In general, they should be separated by about 2 weeks, although it does not matter in what order they are given (that is, patients could get RSV first, then flu/COVID, or they could get flu/COVID first, followed by RSV).

Having said this, there is no theoretical reason why patients couldn’t get all three at once, so if there is only one opportunity to vaccinate a patient, then it would be okay to give all three. But, if the patient can come for two separate visits, the recommendation would currently be to separate these. In the future, there likely will be data on giving all three vaccines at once, so it may not be an issue to administer all three at the same time.

Lastly, I would point out that the RSV vaccine is not necessarily recommended for everyone age 60 and above. The Advisory Committee on Immunization Practices recommends using shared clinical decision-making to determine if that vaccine is right for the patient. In general, the flu and COVID vaccines are recommended for everyone, although the specific COVID recommendations for fall 2023 have not yet been released. There are no particular vaccine interactions that are concerning with these vaccines.

Q: What if any special considerations are there regarding the storage, handling, and ordering of these vaccines? Should primary care practices take any special steps they might not already be taking?

Dr. Durham: I don’t think there are any special considerations that providers might not already be doing. All of the vaccines do require refrigeration, but each individual product may vary some on beyond-use dates or how long they are good after being reconstituted. All providers administering these vaccines should carefully examine the labeling of each individual product to ensure correct storage and handling. In addition, the Centers for Disease Control and Prevention has an online toolkit for vaccine storage and handling and can be found at https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/index.html.

Santina J. G. Wheat, MD, MPH, vice chair of diversity, equity, and inclusion, department of family and community medicine, and associate professor of family and community medicine, Northwestern University, ChicagoQ: What can primary care doctors/family physicians and their staff do to increase patient access to the vaccines? Any lessons learned from the earlier phases of the pandemic that might pertain not only to COVID-19 but also to RSV and/or influenza?

Dr. Wheat: I think the most important thing family physicians can do is speak with their patients about the importance of vaccines and specific recommendations they have for the situations of individuals and families. When vaccines started becoming available, I had many patients who wanted to hear from me – as their primary physician – what I truly thought and what I was planning to do for my own family.

I also think if our teams can know where vaccines are easily accessible, that makes it much easier for our patients. I have heard great stories and seen my own clinical support staff look at websites with patients to help them find the best location to get vaccines. In particular, about the RSV vaccine, I have had a handful of patients already come to ask me about my recommendations. When vaccines are available at my location, I find it much easier for my patients to be willing to get vaccinated. Similarly, if I am sending patients to pick up a prescription and they can get it at the same time, I have found success in them being willing to be vaccinated while picking up their prescription. In both instances, they do not need to make an additional stop; they are just able to be vaccinated while already at the clinic or pharmacy.

Q: Do you see any extra difficulties involved in trying to get groups of patients – in this case, older people – to be receptive to three vaccines, especially in this climate where it appears a growing number of people are hostile to immunization?

Dr. Wheat: Recently, I have found myself negotiating vaccines with patients not just with these, but as recommendations have changed for vaccines such as the pneumococcal vaccines and the hepatitis B vaccines. I think primary care providers can recommend all of them, but still help patients prioritize what is most important for that patient and family. For example, if welcoming a new baby soon, they might prioritize the vaccines for pertussis or influenza over the hepatitis vaccine with a plan to revisit the conversations later.

I have had some patients tell me they have gotten enough vaccines – and we know that even before the pandemic there was resistance to the influenza vaccine for some. I think we need to be prepared to address the concerns and, at times, the apathy. We also need to ask every time, because we never know which visit will be the one when a patient agrees.

Dr. Auwaerter reported financial relationships with Pfizer, Shionogi, Gilead, and Wellstat. Dr. Durham and Dr. Wheat disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

Hospitalizations for COVID-19 in the United States have increased for 8 weeks in a row.

Data from Florida and Georgia signal that respiratory syncytial virus (RSV) season has begun.

As for flu shots, experts say patients with long COVID should get them in 2023, although federal health agencies have not addressed that specific question.

Paul G. Auwaerter, MD, MBA, an infectious disease consultant, said many patients in his primary care practice worry about “the big three” – COVID, influenza, and RSV.

This news organization spoke with Dr. Auwaerter, as well as family physician Santina J. G. Wheat, MD, MPH, and clinical pharmacist Spencer H. Durham, PharmD, about their approach to 2023’s respiratory virus season.

They discussed how to handle COVID boosters, the use of Paxlovid, vaccine hesitancy, and the correct order of operations for patients getting vaccinated against all three diseases.
 

Paul G. Auwaerter, MD, MBA, clinical director of the division of infectious diseases and the Sherrilyn and Ken Fisher Professor of Medicine at Johns Hopkins University, BaltimoreQuestion: How should primary care physicians be preparing to handle what everyone is predicting will be a major surge in cases of respiratory infections?

Auwaerter: Although I’m an infectious disease consultant, I still have a small primary care practice. So, I field questions for my patients all the time, and many patients, especially those with health problems, are worried about the big three: RSV, COVID, and influenza – at least, my more motivated patients are.

People frequently ask if they need the COVID booster. I think that’s been something many people think maybe they can avoid. The good news is that the early in vitro data suggest that the XBB1.5x-based vaccine seems to offer sufficient neutralizing activity against the circulating newer variants since the vaccine was approved earlier this year. I am suggesting that everyone get a booster, especially those at high risk, because we know that the risk for hospitalization decreases based on earlier studies for 4-6 months after a COVID booster. We can simultaneously administer the revised COVID booster vaccine and the annual influenza vaccine. The timing is good, as influenza immunization should be accomplished by October or early November at the latest. Like many parts of the country, we in Maryland are in the middle of a COVID boomlet. I have issued more Paxlovid prescriptions since mid-August than I did all spring and early summer.

Q: Are you seeing a lot of rebound COVID in your patients taking Paxlovid [nirmatrelvir/ritonavir]?

Dr. Auwaerter: I think the frequency is probably around 10%. It has been quoted much higher – at 20% – but careful studies have put it down at just single digits. I think it just depends on symptomatology and how you ask the question. But I think it’s important that I try to persuade people to take a direct-acting antiviral if they’re in a high-risk category rather than tough it out. Increasing data suggest taking an antiviral also reduces the risk for long COVID. Also, we know that rebound symptoms are not always infectious virus. Sometimes, they’re just inflammatory. Unless a person is immune suppressed, they rarely have a culturable virus 7-8 days after onset of symptoms. So, for most people, I don’t administer second courses of Paxlovid, although I know some physicians do. One has to realize the risk for hospitalization from a rebound is tiny, and many people don’t even have infectious virus when they take the second course of a drug such as Paxlovid.

Q: You mentioned motivated patients, which seems to be an important factor to consider, particularly for new vaccines.

Dr. Auwaerter: There are always early adopters who are less afraid. And then some people say: This is a brand-new vaccine; I’m going to wait for a year to let this shake out, and make sure it seems safe. People more engaged in their health have asked me about the RSV vaccine. For anyone who has cardiopulmonary problems and other major health problems, I’ve advised it. But if someone’s in good health and 65 or 70, the RSV illness is probably pretty mild if they get it. For them, I would say the vaccine is optional.

For people over 75, I have been advising the RSV vaccine because that is a group we tend to see hospitalized with RSV; they’re the highest-risk group, similar to COVID. The older you are, the more likely this infection will land you in the hospital. You can acquire RSV even if you don’t have young grandchildren around.

Q: You have called respiratory virus seasons unstable? What does it mean, and what is the significance for clinicians?

Dr. Auwaerter: It’s less predictable than in the past. If you had a cough and fever, you could think it was influenza if you knew you had influenza circulating in your community. Maybe you thought about RSV for your immunocompromised or older patients, but we didn’t have any therapy for it anyway. I sometimes refer to the respiratory virus season as a cage match between the major infections. Last year, RSV came out first, and we got some influenza and COVID. What does the situation look like this year? I don’t know at this point, but we are seeing more COVID earlier. What’s different is we continue to have the emergence of viral variants of SARS-CoV-2. Also, with both influenza and COVID, it’s harder to make a clinical judgment about what people have.

I think we have to rely more on tests to treat these patients. Options include having point of care testing in the office for rapid results (molecular assays preferred) for both influenza and SARS-CoV-2 or home antigen testing. There are home kits that do test for both if influenza is known to be circulating significantly in the community. But there are still barriers. For one, COVID and COVID/influenza antigen kits are no longer free, although some health insurance companies do provide COVID kits free of charge. In offices, you don’t want to have ill people with respiratory infections in your waiting room unless you can isolate or have negative pressure rooms. Do you ask for masking in your offices? Telemedicine has been a big help since the pandemic in managing nonsevere respiratory infections at home; however, you must be licensed in the state to practice, which limits helping your out-of-state patients.

Q: How has the advent of in-home antigen tests changed practice?

Dr. Auwaerter: Home antigen tests have been groundbreaking in facilitating care. When I see patients via telemedicine, I don’t want to prescribe medications for influenza and COVID to people simultaneously. I want to pick one or the other – and now I’m able to ask for a COVID test or a COVID/influenza test if the patient or family is able to get a kit. Some offices do have real-time molecular testing, which is the ideal and the CDC-recommended approach, but they’re expensive, and not everyone has access to them.

Q: People talk about the “tripledemic,” but does doing so ignore the fourth horseman of the respiratory apocalypse: pneumococcal pneumonia?

Dr. Auwaerter: Pneumonia remains a leading cause of hospitalization, except we’ve seen much more viral than bacterial pneumonia in recent years of the pandemic. We’ve lost sight, and pneumococcal pneumonia is important, especially in older patients. What we have seen pretty clearly is a rise in group A streptococcal infections. This is another consequence of the pandemic, where people did not socialize for a year or 2. There was much less group A strep infection in younger children, and even in adults, the amount of invasive group A streptococcal infections has clearly taken a jump, according to the NHS in Great Britain. Our pediatric practices here at Johns Hopkins are seeing far more cases of acute rheumatic fever than they’ve seen in decades. And I think, again, this is a consequence of the frequency of group A strep infections definitely taking an uptick. And that was no doubt probably from social mitigation measures and just an interruption in normal circumstances that bacterial and respiratory pathogens tend to circulate and colonize.

Q: Do you have any concerns about immunogenicity or side effects associated with receiving several vaccines at once?

Dr. Auwaerter: I think three injections at once is only for the heroic, and there is actually no guidance for getting all three at the moment. COVID, RSV, and influenza are not live vaccines. I’ve been recommending the new COVID booster and flu together, and then wait 2 weeks and then get RSV or vice-versa. A part of the reason is RSV is new. People have gotten COVID and flu vaccines before; they’re no different than in the past in terms of anticipating adverse effects. But RSV is new, so I’ve usually been recommending that as a standalone to gauge if there are issues as an RSV booster may be recommended at some point down the road.

Q: Unfortunately, some people are going to see or hear misinformation that the COVID boosters have not been properly tested or proven safe. What’s your response to the patient who says something to that effect?

Dr. Auwaerter: My response is, the basic components of the vaccine are the same, right? If you have the mRNA vaccine, you’re getting the vaccine components, the lipids, and the mRNA coding for spike proteins, which has just been modified slightly to adjust to the Omicron subvariant composition. We do the same thing with the influenza vaccine every year, and we don’t see much change in the side effect profile. I think it’s important for my staff in the office and myself to be very comfortable to field questions such as these.

We try to inform all of our staff about a vaccine, especially a new one like RSV, just so they have some comfort level with it, whether they’re getting it or not. Vaccine-hesitant patients need very little to dissuade and to take a pass – to the probable detriment of their health and their family’s health. We know the influenza vaccine helps reduce absenteeism and transmission in addition to reducing serious illness in high-risk patients. Even COVID vaccine efficacy is not as robust as initially reported, falling from 95% to under 70% depending on the study – you are provided with protection against serious illness and hospitalization. The same goes for influenza, and that’s how we try to pitch it to people. Are they going to get the flu? Maybe, but you didn’t land in the hospital. That’s why it’s these vaccines are so important.
 

Spencer H. Durham, PharmD, associate clinical professor in the department of pharmacy practice at Auburn (Ala.) University, and clinical pharmacist, Internal Medicine & Infectious Diseases, at the UAB Heersink School of Medicine in Huntsville.Q: What is known, if anything, about the risks/desirability of giving three vaccinations at once to patients (particularly older patients) – flu, COVID-19 and RSV? Any potential vaccine interactions physicians should know about?

Dr. Durham: There are currently no data about giving all three of these vaccines together at the same time. However, there is both data and practical experience of giving both the flu and COVID vaccines at the same time. The best approach right now for these three vaccines would be to get the flu and COVID vaccines at the same time, then give the RSV vaccine at a different date. In general, they should be separated by about 2 weeks, although it does not matter in what order they are given (that is, patients could get RSV first, then flu/COVID, or they could get flu/COVID first, followed by RSV).

Having said this, there is no theoretical reason why patients couldn’t get all three at once, so if there is only one opportunity to vaccinate a patient, then it would be okay to give all three. But, if the patient can come for two separate visits, the recommendation would currently be to separate these. In the future, there likely will be data on giving all three vaccines at once, so it may not be an issue to administer all three at the same time.

Lastly, I would point out that the RSV vaccine is not necessarily recommended for everyone age 60 and above. The Advisory Committee on Immunization Practices recommends using shared clinical decision-making to determine if that vaccine is right for the patient. In general, the flu and COVID vaccines are recommended for everyone, although the specific COVID recommendations for fall 2023 have not yet been released. There are no particular vaccine interactions that are concerning with these vaccines.

Q: What if any special considerations are there regarding the storage, handling, and ordering of these vaccines? Should primary care practices take any special steps they might not already be taking?

Dr. Durham: I don’t think there are any special considerations that providers might not already be doing. All of the vaccines do require refrigeration, but each individual product may vary some on beyond-use dates or how long they are good after being reconstituted. All providers administering these vaccines should carefully examine the labeling of each individual product to ensure correct storage and handling. In addition, the Centers for Disease Control and Prevention has an online toolkit for vaccine storage and handling and can be found at https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/index.html.

Santina J. G. Wheat, MD, MPH, vice chair of diversity, equity, and inclusion, department of family and community medicine, and associate professor of family and community medicine, Northwestern University, ChicagoQ: What can primary care doctors/family physicians and their staff do to increase patient access to the vaccines? Any lessons learned from the earlier phases of the pandemic that might pertain not only to COVID-19 but also to RSV and/or influenza?

Dr. Wheat: I think the most important thing family physicians can do is speak with their patients about the importance of vaccines and specific recommendations they have for the situations of individuals and families. When vaccines started becoming available, I had many patients who wanted to hear from me – as their primary physician – what I truly thought and what I was planning to do for my own family.

I also think if our teams can know where vaccines are easily accessible, that makes it much easier for our patients. I have heard great stories and seen my own clinical support staff look at websites with patients to help them find the best location to get vaccines. In particular, about the RSV vaccine, I have had a handful of patients already come to ask me about my recommendations. When vaccines are available at my location, I find it much easier for my patients to be willing to get vaccinated. Similarly, if I am sending patients to pick up a prescription and they can get it at the same time, I have found success in them being willing to be vaccinated while picking up their prescription. In both instances, they do not need to make an additional stop; they are just able to be vaccinated while already at the clinic or pharmacy.

Q: Do you see any extra difficulties involved in trying to get groups of patients – in this case, older people – to be receptive to three vaccines, especially in this climate where it appears a growing number of people are hostile to immunization?

Dr. Wheat: Recently, I have found myself negotiating vaccines with patients not just with these, but as recommendations have changed for vaccines such as the pneumococcal vaccines and the hepatitis B vaccines. I think primary care providers can recommend all of them, but still help patients prioritize what is most important for that patient and family. For example, if welcoming a new baby soon, they might prioritize the vaccines for pertussis or influenza over the hepatitis vaccine with a plan to revisit the conversations later.

I have had some patients tell me they have gotten enough vaccines – and we know that even before the pandemic there was resistance to the influenza vaccine for some. I think we need to be prepared to address the concerns and, at times, the apathy. We also need to ask every time, because we never know which visit will be the one when a patient agrees.

Dr. Auwaerter reported financial relationships with Pfizer, Shionogi, Gilead, and Wellstat. Dr. Durham and Dr. Wheat disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

Hospitalizations for COVID-19 in the United States have increased for 8 weeks in a row.

Data from Florida and Georgia signal that respiratory syncytial virus (RSV) season has begun.

As for flu shots, experts say patients with long COVID should get them in 2023, although federal health agencies have not addressed that specific question.

Paul G. Auwaerter, MD, MBA, an infectious disease consultant, said many patients in his primary care practice worry about “the big three” – COVID, influenza, and RSV.

This news organization spoke with Dr. Auwaerter, as well as family physician Santina J. G. Wheat, MD, MPH, and clinical pharmacist Spencer H. Durham, PharmD, about their approach to 2023’s respiratory virus season.

They discussed how to handle COVID boosters, the use of Paxlovid, vaccine hesitancy, and the correct order of operations for patients getting vaccinated against all three diseases.
 

Paul G. Auwaerter, MD, MBA, clinical director of the division of infectious diseases and the Sherrilyn and Ken Fisher Professor of Medicine at Johns Hopkins University, BaltimoreQuestion: How should primary care physicians be preparing to handle what everyone is predicting will be a major surge in cases of respiratory infections?

Auwaerter: Although I’m an infectious disease consultant, I still have a small primary care practice. So, I field questions for my patients all the time, and many patients, especially those with health problems, are worried about the big three: RSV, COVID, and influenza – at least, my more motivated patients are.

People frequently ask if they need the COVID booster. I think that’s been something many people think maybe they can avoid. The good news is that the early in vitro data suggest that the XBB1.5x-based vaccine seems to offer sufficient neutralizing activity against the circulating newer variants since the vaccine was approved earlier this year. I am suggesting that everyone get a booster, especially those at high risk, because we know that the risk for hospitalization decreases based on earlier studies for 4-6 months after a COVID booster. We can simultaneously administer the revised COVID booster vaccine and the annual influenza vaccine. The timing is good, as influenza immunization should be accomplished by October or early November at the latest. Like many parts of the country, we in Maryland are in the middle of a COVID boomlet. I have issued more Paxlovid prescriptions since mid-August than I did all spring and early summer.

Q: Are you seeing a lot of rebound COVID in your patients taking Paxlovid [nirmatrelvir/ritonavir]?

Dr. Auwaerter: I think the frequency is probably around 10%. It has been quoted much higher – at 20% – but careful studies have put it down at just single digits. I think it just depends on symptomatology and how you ask the question. But I think it’s important that I try to persuade people to take a direct-acting antiviral if they’re in a high-risk category rather than tough it out. Increasing data suggest taking an antiviral also reduces the risk for long COVID. Also, we know that rebound symptoms are not always infectious virus. Sometimes, they’re just inflammatory. Unless a person is immune suppressed, they rarely have a culturable virus 7-8 days after onset of symptoms. So, for most people, I don’t administer second courses of Paxlovid, although I know some physicians do. One has to realize the risk for hospitalization from a rebound is tiny, and many people don’t even have infectious virus when they take the second course of a drug such as Paxlovid.

Q: You mentioned motivated patients, which seems to be an important factor to consider, particularly for new vaccines.

Dr. Auwaerter: There are always early adopters who are less afraid. And then some people say: This is a brand-new vaccine; I’m going to wait for a year to let this shake out, and make sure it seems safe. People more engaged in their health have asked me about the RSV vaccine. For anyone who has cardiopulmonary problems and other major health problems, I’ve advised it. But if someone’s in good health and 65 or 70, the RSV illness is probably pretty mild if they get it. For them, I would say the vaccine is optional.

For people over 75, I have been advising the RSV vaccine because that is a group we tend to see hospitalized with RSV; they’re the highest-risk group, similar to COVID. The older you are, the more likely this infection will land you in the hospital. You can acquire RSV even if you don’t have young grandchildren around.

Q: You have called respiratory virus seasons unstable? What does it mean, and what is the significance for clinicians?

Dr. Auwaerter: It’s less predictable than in the past. If you had a cough and fever, you could think it was influenza if you knew you had influenza circulating in your community. Maybe you thought about RSV for your immunocompromised or older patients, but we didn’t have any therapy for it anyway. I sometimes refer to the respiratory virus season as a cage match between the major infections. Last year, RSV came out first, and we got some influenza and COVID. What does the situation look like this year? I don’t know at this point, but we are seeing more COVID earlier. What’s different is we continue to have the emergence of viral variants of SARS-CoV-2. Also, with both influenza and COVID, it’s harder to make a clinical judgment about what people have.

I think we have to rely more on tests to treat these patients. Options include having point of care testing in the office for rapid results (molecular assays preferred) for both influenza and SARS-CoV-2 or home antigen testing. There are home kits that do test for both if influenza is known to be circulating significantly in the community. But there are still barriers. For one, COVID and COVID/influenza antigen kits are no longer free, although some health insurance companies do provide COVID kits free of charge. In offices, you don’t want to have ill people with respiratory infections in your waiting room unless you can isolate or have negative pressure rooms. Do you ask for masking in your offices? Telemedicine has been a big help since the pandemic in managing nonsevere respiratory infections at home; however, you must be licensed in the state to practice, which limits helping your out-of-state patients.

Q: How has the advent of in-home antigen tests changed practice?

Dr. Auwaerter: Home antigen tests have been groundbreaking in facilitating care. When I see patients via telemedicine, I don’t want to prescribe medications for influenza and COVID to people simultaneously. I want to pick one or the other – and now I’m able to ask for a COVID test or a COVID/influenza test if the patient or family is able to get a kit. Some offices do have real-time molecular testing, which is the ideal and the CDC-recommended approach, but they’re expensive, and not everyone has access to them.

Q: People talk about the “tripledemic,” but does doing so ignore the fourth horseman of the respiratory apocalypse: pneumococcal pneumonia?

Dr. Auwaerter: Pneumonia remains a leading cause of hospitalization, except we’ve seen much more viral than bacterial pneumonia in recent years of the pandemic. We’ve lost sight, and pneumococcal pneumonia is important, especially in older patients. What we have seen pretty clearly is a rise in group A streptococcal infections. This is another consequence of the pandemic, where people did not socialize for a year or 2. There was much less group A strep infection in younger children, and even in adults, the amount of invasive group A streptococcal infections has clearly taken a jump, according to the NHS in Great Britain. Our pediatric practices here at Johns Hopkins are seeing far more cases of acute rheumatic fever than they’ve seen in decades. And I think, again, this is a consequence of the frequency of group A strep infections definitely taking an uptick. And that was no doubt probably from social mitigation measures and just an interruption in normal circumstances that bacterial and respiratory pathogens tend to circulate and colonize.

Q: Do you have any concerns about immunogenicity or side effects associated with receiving several vaccines at once?

Dr. Auwaerter: I think three injections at once is only for the heroic, and there is actually no guidance for getting all three at the moment. COVID, RSV, and influenza are not live vaccines. I’ve been recommending the new COVID booster and flu together, and then wait 2 weeks and then get RSV or vice-versa. A part of the reason is RSV is new. People have gotten COVID and flu vaccines before; they’re no different than in the past in terms of anticipating adverse effects. But RSV is new, so I’ve usually been recommending that as a standalone to gauge if there are issues as an RSV booster may be recommended at some point down the road.

Q: Unfortunately, some people are going to see or hear misinformation that the COVID boosters have not been properly tested or proven safe. What’s your response to the patient who says something to that effect?

Dr. Auwaerter: My response is, the basic components of the vaccine are the same, right? If you have the mRNA vaccine, you’re getting the vaccine components, the lipids, and the mRNA coding for spike proteins, which has just been modified slightly to adjust to the Omicron subvariant composition. We do the same thing with the influenza vaccine every year, and we don’t see much change in the side effect profile. I think it’s important for my staff in the office and myself to be very comfortable to field questions such as these.

We try to inform all of our staff about a vaccine, especially a new one like RSV, just so they have some comfort level with it, whether they’re getting it or not. Vaccine-hesitant patients need very little to dissuade and to take a pass – to the probable detriment of their health and their family’s health. We know the influenza vaccine helps reduce absenteeism and transmission in addition to reducing serious illness in high-risk patients. Even COVID vaccine efficacy is not as robust as initially reported, falling from 95% to under 70% depending on the study – you are provided with protection against serious illness and hospitalization. The same goes for influenza, and that’s how we try to pitch it to people. Are they going to get the flu? Maybe, but you didn’t land in the hospital. That’s why it’s these vaccines are so important.
 

Spencer H. Durham, PharmD, associate clinical professor in the department of pharmacy practice at Auburn (Ala.) University, and clinical pharmacist, Internal Medicine & Infectious Diseases, at the UAB Heersink School of Medicine in Huntsville.Q: What is known, if anything, about the risks/desirability of giving three vaccinations at once to patients (particularly older patients) – flu, COVID-19 and RSV? Any potential vaccine interactions physicians should know about?

Dr. Durham: There are currently no data about giving all three of these vaccines together at the same time. However, there is both data and practical experience of giving both the flu and COVID vaccines at the same time. The best approach right now for these three vaccines would be to get the flu and COVID vaccines at the same time, then give the RSV vaccine at a different date. In general, they should be separated by about 2 weeks, although it does not matter in what order they are given (that is, patients could get RSV first, then flu/COVID, or they could get flu/COVID first, followed by RSV).

Having said this, there is no theoretical reason why patients couldn’t get all three at once, so if there is only one opportunity to vaccinate a patient, then it would be okay to give all three. But, if the patient can come for two separate visits, the recommendation would currently be to separate these. In the future, there likely will be data on giving all three vaccines at once, so it may not be an issue to administer all three at the same time.

Lastly, I would point out that the RSV vaccine is not necessarily recommended for everyone age 60 and above. The Advisory Committee on Immunization Practices recommends using shared clinical decision-making to determine if that vaccine is right for the patient. In general, the flu and COVID vaccines are recommended for everyone, although the specific COVID recommendations for fall 2023 have not yet been released. There are no particular vaccine interactions that are concerning with these vaccines.

Q: What if any special considerations are there regarding the storage, handling, and ordering of these vaccines? Should primary care practices take any special steps they might not already be taking?

Dr. Durham: I don’t think there are any special considerations that providers might not already be doing. All of the vaccines do require refrigeration, but each individual product may vary some on beyond-use dates or how long they are good after being reconstituted. All providers administering these vaccines should carefully examine the labeling of each individual product to ensure correct storage and handling. In addition, the Centers for Disease Control and Prevention has an online toolkit for vaccine storage and handling and can be found at https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/index.html.

Santina J. G. Wheat, MD, MPH, vice chair of diversity, equity, and inclusion, department of family and community medicine, and associate professor of family and community medicine, Northwestern University, ChicagoQ: What can primary care doctors/family physicians and their staff do to increase patient access to the vaccines? Any lessons learned from the earlier phases of the pandemic that might pertain not only to COVID-19 but also to RSV and/or influenza?

Dr. Wheat: I think the most important thing family physicians can do is speak with their patients about the importance of vaccines and specific recommendations they have for the situations of individuals and families. When vaccines started becoming available, I had many patients who wanted to hear from me – as their primary physician – what I truly thought and what I was planning to do for my own family.

I also think if our teams can know where vaccines are easily accessible, that makes it much easier for our patients. I have heard great stories and seen my own clinical support staff look at websites with patients to help them find the best location to get vaccines. In particular, about the RSV vaccine, I have had a handful of patients already come to ask me about my recommendations. When vaccines are available at my location, I find it much easier for my patients to be willing to get vaccinated. Similarly, if I am sending patients to pick up a prescription and they can get it at the same time, I have found success in them being willing to be vaccinated while picking up their prescription. In both instances, they do not need to make an additional stop; they are just able to be vaccinated while already at the clinic or pharmacy.

Q: Do you see any extra difficulties involved in trying to get groups of patients – in this case, older people – to be receptive to three vaccines, especially in this climate where it appears a growing number of people are hostile to immunization?

Dr. Wheat: Recently, I have found myself negotiating vaccines with patients not just with these, but as recommendations have changed for vaccines such as the pneumococcal vaccines and the hepatitis B vaccines. I think primary care providers can recommend all of them, but still help patients prioritize what is most important for that patient and family. For example, if welcoming a new baby soon, they might prioritize the vaccines for pertussis or influenza over the hepatitis vaccine with a plan to revisit the conversations later.

I have had some patients tell me they have gotten enough vaccines – and we know that even before the pandemic there was resistance to the influenza vaccine for some. I think we need to be prepared to address the concerns and, at times, the apathy. We also need to ask every time, because we never know which visit will be the one when a patient agrees.

Dr. Auwaerter reported financial relationships with Pfizer, Shionogi, Gilead, and Wellstat. Dr. Durham and Dr. Wheat disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

Key clinical point: Upadacitinib was safe and effective in patients with atopic dermatitis (AD) who recently discontinued dupilumab therapy due to lack of desired efficacy or an adverse event (AE).

Major finding: By week 16, a ≥75% improvement in the Eczema Area and Severity Index score or an Investigator’s Global Assessment score of 0 or 1 was achieved by 75% and 81.8% of patients receiving 15 mg and 30 mg upadacitinib, respectively. The treatment-related AE rate was 30.7%, and none of the patients discontinued treatment during the 16-week treatment period.

Study details: Findings are from a real-world multicenter retrospective study that included 39 adult patients with AD who were treated with upadacitinib after discontinuing treatment with dupilumab due to inefficacy or an AE.

Disclosures: This study did not receive any funding. Two authors declared serving as advisors, consultants, speakers, or investigators for various organizations. The other authors declared no conflicts of interest.

Source: Georgakopoulos JR et al. Real-world effectiveness and safety of upadacitinib for the treatment of atopic dermatitis in adult patients switched from dupilumab: A multicenter retrospective study. J Am Acad Dermatol. 2023 (Aug 28). doi: 10.1016/j.jaad.2023.08.059

Key clinical point: Upadacitinib was safe and effective in patients with atopic dermatitis (AD) who recently discontinued dupilumab therapy due to lack of desired efficacy or an adverse event (AE).

Major finding: By week 16, a ≥75% improvement in the Eczema Area and Severity Index score or an Investigator’s Global Assessment score of 0 or 1 was achieved by 75% and 81.8% of patients receiving 15 mg and 30 mg upadacitinib, respectively. The treatment-related AE rate was 30.7%, and none of the patients discontinued treatment during the 16-week treatment period.

Study details: Findings are from a real-world multicenter retrospective study that included 39 adult patients with AD who were treated with upadacitinib after discontinuing treatment with dupilumab due to inefficacy or an AE.

Disclosures: This study did not receive any funding. Two authors declared serving as advisors, consultants, speakers, or investigators for various organizations. The other authors declared no conflicts of interest.

Source: Georgakopoulos JR et al. Real-world effectiveness and safety of upadacitinib for the treatment of atopic dermatitis in adult patients switched from dupilumab: A multicenter retrospective study. J Am Acad Dermatol. 2023 (Aug 28). doi: 10.1016/j.jaad.2023.08.059

Key clinical point: Upadacitinib was safe and effective in patients with atopic dermatitis (AD) who recently discontinued dupilumab therapy due to lack of desired efficacy or an adverse event (AE).

Major finding: By week 16, a ≥75% improvement in the Eczema Area and Severity Index score or an Investigator’s Global Assessment score of 0 or 1 was achieved by 75% and 81.8% of patients receiving 15 mg and 30 mg upadacitinib, respectively. The treatment-related AE rate was 30.7%, and none of the patients discontinued treatment during the 16-week treatment period.

Study details: Findings are from a real-world multicenter retrospective study that included 39 adult patients with AD who were treated with upadacitinib after discontinuing treatment with dupilumab due to inefficacy or an AE.

Disclosures: This study did not receive any funding. Two authors declared serving as advisors, consultants, speakers, or investigators for various organizations. The other authors declared no conflicts of interest.

Source: Georgakopoulos JR et al. Real-world effectiveness and safety of upadacitinib for the treatment of atopic dermatitis in adult patients switched from dupilumab: A multicenter retrospective study. J Am Acad Dermatol. 2023 (Aug 28). doi: 10.1016/j.jaad.2023.08.059

Key clinical point: Treatment with dupilumab vs cyclosporine or mycophenolate is not associated with an increased risk for arthralgia in patients with atopic dermatitis (AD).

Major finding: The pooled 180-day incidence rate of arthralgia for dupilumab vs cyclosporine or mycophenolate was 100.7 vs 65.4/1000 person-years (adjusted hazard ratio 1.27; 95% CI 0.93-1.72).

Study details: Findings are from a cohort study that included patients age < 50 years with AD who initiated treatment with either dupilumab (n = 4011) or cyclosporine/mycophenolate (n = 2220).

Disclosures: This study was supported by a grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, USA. Some authors declared serving as consultants or investigators for or receiving research grants from various sources.

Source: Schneeweiss MC et al. Joint pain in patients with atopic dermatitis receiving treatment with dupilumab: A US nation-wide cohort study. J Am Acad Dermatol. 2023 (Aug 18). doi: 10.1016/j.jaad.2023.08.025

Key clinical point: Treatment with dupilumab vs cyclosporine or mycophenolate is not associated with an increased risk for arthralgia in patients with atopic dermatitis (AD).

Major finding: The pooled 180-day incidence rate of arthralgia for dupilumab vs cyclosporine or mycophenolate was 100.7 vs 65.4/1000 person-years (adjusted hazard ratio 1.27; 95% CI 0.93-1.72).

Study details: Findings are from a cohort study that included patients age < 50 years with AD who initiated treatment with either dupilumab (n = 4011) or cyclosporine/mycophenolate (n = 2220).

Disclosures: This study was supported by a grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, USA. Some authors declared serving as consultants or investigators for or receiving research grants from various sources.

Source: Schneeweiss MC et al. Joint pain in patients with atopic dermatitis receiving treatment with dupilumab: A US nation-wide cohort study. J Am Acad Dermatol. 2023 (Aug 18). doi: 10.1016/j.jaad.2023.08.025

Key clinical point: Treatment with dupilumab vs cyclosporine or mycophenolate is not associated with an increased risk for arthralgia in patients with atopic dermatitis (AD).

Major finding: The pooled 180-day incidence rate of arthralgia for dupilumab vs cyclosporine or mycophenolate was 100.7 vs 65.4/1000 person-years (adjusted hazard ratio 1.27; 95% CI 0.93-1.72).

Study details: Findings are from a cohort study that included patients age < 50 years with AD who initiated treatment with either dupilumab (n = 4011) or cyclosporine/mycophenolate (n = 2220).

Disclosures: This study was supported by a grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, USA. Some authors declared serving as consultants or investigators for or receiving research grants from various sources.

Source: Schneeweiss MC et al. Joint pain in patients with atopic dermatitis receiving treatment with dupilumab: A US nation-wide cohort study. J Am Acad Dermatol. 2023 (Aug 18). doi: 10.1016/j.jaad.2023.08.025

Key clinical point: Patients with non-alcoholic fatty liver disease (NAFLD), especially younger patients, have a significantly decreased risk of developing atopic dermatitis (AD).

Major finding: The risk for AD was significantly lower among patients with NAFLD (adjusted hazard ratio [aHR] 0.93; P = .024), particularly those age ≤ 40 years (aHR 0.80; P < .001), compared with control individuals without NAFLD.

Study details: This retrospective cohort study included 307,743 patients with NAFLD and 1,230,972 matched control individuals without NAFLD.

Disclosures: This study was funded by the Chung Shan Medical University Hospital and China Medical University, Taiwan. The authors declared no conflicts of interest.

Source: Gau SY et al. The association between non-alcoholic fatty liver disease and atopic dermatitis: A population-based cohort study. Front Immunol. 2023;14:1171804 (Aug 18). doi: 10.3389/fimmu.2023.1171804

Key clinical point: Patients with non-alcoholic fatty liver disease (NAFLD), especially younger patients, have a significantly decreased risk of developing atopic dermatitis (AD).

Major finding: The risk for AD was significantly lower among patients with NAFLD (adjusted hazard ratio [aHR] 0.93; P = .024), particularly those age ≤ 40 years (aHR 0.80; P < .001), compared with control individuals without NAFLD.

Study details: This retrospective cohort study included 307,743 patients with NAFLD and 1,230,972 matched control individuals without NAFLD.

Disclosures: This study was funded by the Chung Shan Medical University Hospital and China Medical University, Taiwan. The authors declared no conflicts of interest.

Source: Gau SY et al. The association between non-alcoholic fatty liver disease and atopic dermatitis: A population-based cohort study. Front Immunol. 2023;14:1171804 (Aug 18). doi: 10.3389/fimmu.2023.1171804

Key clinical point: Patients with non-alcoholic fatty liver disease (NAFLD), especially younger patients, have a significantly decreased risk of developing atopic dermatitis (AD).

Major finding: The risk for AD was significantly lower among patients with NAFLD (adjusted hazard ratio [aHR] 0.93; P = .024), particularly those age ≤ 40 years (aHR 0.80; P < .001), compared with control individuals without NAFLD.

Study details: This retrospective cohort study included 307,743 patients with NAFLD and 1,230,972 matched control individuals without NAFLD.

Disclosures: This study was funded by the Chung Shan Medical University Hospital and China Medical University, Taiwan. The authors declared no conflicts of interest.

Source: Gau SY et al. The association between non-alcoholic fatty liver disease and atopic dermatitis: A population-based cohort study. Front Immunol. 2023;14:1171804 (Aug 18). doi: 10.3389/fimmu.2023.1171804

Key clinical point: Among patients with atopic dermatitis (AD), those with vs without a history of Staphylococcus aureus skin infections have significantly higher odds of having a history of eczema herpeticum (EH).

Major finding: Patients with AD and with vs without a history of S aureus skin infections had a 6.60-fold increased risk of having a history of EH (adjusted odds ratio 6.60; P = .002).

Study details: This multicenter, clinical registry study included 112 patients with AD and with (n = 56) or without (n = 56) a history of EH, matched by age and AD severity.

Disclosures: This study was supported partly by a National Eczema Association Engagement Research Grant. Several authors declared serving as consultants or investigator for or receiving grants, personal fees, or clinical trial support from various organizations.

Source: Moran MC et al. History of S. aureus skin infection significantly associates with history of eczema herpeticum in patients with atopic dermatitis. Dermatol Ther (Heidelb). 2023 (Aug 24). doi: 10.1007/s13555-023-00996-y

Key clinical point: Among patients with atopic dermatitis (AD), those with vs without a history of Staphylococcus aureus skin infections have significantly higher odds of having a history of eczema herpeticum (EH).

Major finding: Patients with AD and with vs without a history of S aureus skin infections had a 6.60-fold increased risk of having a history of EH (adjusted odds ratio 6.60; P = .002).

Study details: This multicenter, clinical registry study included 112 patients with AD and with (n = 56) or without (n = 56) a history of EH, matched by age and AD severity.

Disclosures: This study was supported partly by a National Eczema Association Engagement Research Grant. Several authors declared serving as consultants or investigator for or receiving grants, personal fees, or clinical trial support from various organizations.

Source: Moran MC et al. History of S. aureus skin infection significantly associates with history of eczema herpeticum in patients with atopic dermatitis. Dermatol Ther (Heidelb). 2023 (Aug 24). doi: 10.1007/s13555-023-00996-y

Key clinical point: Among patients with atopic dermatitis (AD), those with vs without a history of Staphylococcus aureus skin infections have significantly higher odds of having a history of eczema herpeticum (EH).

Major finding: Patients with AD and with vs without a history of S aureus skin infections had a 6.60-fold increased risk of having a history of EH (adjusted odds ratio 6.60; P = .002).

Study details: This multicenter, clinical registry study included 112 patients with AD and with (n = 56) or without (n = 56) a history of EH, matched by age and AD severity.

Disclosures: This study was supported partly by a National Eczema Association Engagement Research Grant. Several authors declared serving as consultants or investigator for or receiving grants, personal fees, or clinical trial support from various organizations.

Source: Moran MC et al. History of S. aureus skin infection significantly associates with history of eczema herpeticum in patients with atopic dermatitis. Dermatol Ther (Heidelb). 2023 (Aug 24). doi: 10.1007/s13555-023-00996-y

Key clinical point: Dupilumab rapidly improves the severity of atopic dermatitis (AD) symptoms and shows a favorable safety profile in children with moderate-to-severe AD.

Major finding: Dupilumab significantly reduced the mean Eczema Area and Severity Index (EASI) score at weeks 16, 24, and 52 (all P < .0001) and from weeks 16 to 24 (P < .01) and weeks 16 to 52 (P < .001). By week 52, 86.8% of patients had achieved a ≥ 75% improvement in the EASI score. No serious adverse events were observed, and none of the children discontinued treatment.

Study details: Findings are from a retrospective, observational, real-life study including 96 children (age 6-11 years) with moderate-to-severe AD inadequately controlled with conventional topical therapies who received dupilumab (300 mg on days 1 and 15 and 300 mg every 4 weeks).

Disclosures: This study did not receive any funding. Several authors reported receiving honoraria, travel support, or personal fees from or serving as consultants, investigators, speakers, or advisory board members for or having other ties with various sources.

Source: Patruno C et al. A 52-week multicenter retrospective real-world study on effectiveness and safety of dupilumab in children with atopic dermatitis aged from 6 to 11 years. J Dermatolog Treat. 2023;34:2246602 (Aug 14). doi: 10.1080/09546634.2023.2246602

Key clinical point: Dupilumab rapidly improves the severity of atopic dermatitis (AD) symptoms and shows a favorable safety profile in children with moderate-to-severe AD.

Major finding: Dupilumab significantly reduced the mean Eczema Area and Severity Index (EASI) score at weeks 16, 24, and 52 (all P < .0001) and from weeks 16 to 24 (P < .01) and weeks 16 to 52 (P < .001). By week 52, 86.8% of patients had achieved a ≥ 75% improvement in the EASI score. No serious adverse events were observed, and none of the children discontinued treatment.

Study details: Findings are from a retrospective, observational, real-life study including 96 children (age 6-11 years) with moderate-to-severe AD inadequately controlled with conventional topical therapies who received dupilumab (300 mg on days 1 and 15 and 300 mg every 4 weeks).

Disclosures: This study did not receive any funding. Several authors reported receiving honoraria, travel support, or personal fees from or serving as consultants, investigators, speakers, or advisory board members for or having other ties with various sources.

Source: Patruno C et al. A 52-week multicenter retrospective real-world study on effectiveness and safety of dupilumab in children with atopic dermatitis aged from 6 to 11 years. J Dermatolog Treat. 2023;34:2246602 (Aug 14). doi: 10.1080/09546634.2023.2246602

Key clinical point: Dupilumab rapidly improves the severity of atopic dermatitis (AD) symptoms and shows a favorable safety profile in children with moderate-to-severe AD.

Major finding: Dupilumab significantly reduced the mean Eczema Area and Severity Index (EASI) score at weeks 16, 24, and 52 (all P < .0001) and from weeks 16 to 24 (P < .01) and weeks 16 to 52 (P < .001). By week 52, 86.8% of patients had achieved a ≥ 75% improvement in the EASI score. No serious adverse events were observed, and none of the children discontinued treatment.

Study details: Findings are from a retrospective, observational, real-life study including 96 children (age 6-11 years) with moderate-to-severe AD inadequately controlled with conventional topical therapies who received dupilumab (300 mg on days 1 and 15 and 300 mg every 4 weeks).

Disclosures: This study did not receive any funding. Several authors reported receiving honoraria, travel support, or personal fees from or serving as consultants, investigators, speakers, or advisory board members for or having other ties with various sources.

Source: Patruno C et al. A 52-week multicenter retrospective real-world study on effectiveness and safety of dupilumab in children with atopic dermatitis aged from 6 to 11 years. J Dermatolog Treat. 2023;34:2246602 (Aug 14). doi: 10.1080/09546634.2023.2246602

Key clinical point: Severe atopic dermatitis (AD) is associated with higher risks for venous thromboembolism and cardiovascular diseases in both children and adults.

Major finding: Children with severe AD vs those without AD had a significantly increased risk (adjusted hazard ratio; 95% CI) for cerebrovascular accidents (2.43; 1.13-5.22), diabetes (1.46; 1.06-2.01), and deep vein thrombosis (DVT; 2.13; 1.17-3.87). Among adults, the severe AD vs non-AD group had a significantly higher risk for cerebrovascular accidents (1.21; 1.13-1.30), diabetes (1.15; 1.09-1.22), dyslipidemia (1.11; 1.06-1.17), myocardial infarction (1.27; 1.15-1.39), DVT (1.64; 1.49-1.82), and pulmonary embolism (1.39; 1.21-1.60).

Study details: This population-based cohort study included 409,431 children (age < 18 years) and 625,083 adults with AD who were matched with 1,809,029 children and 2,678,888 adults without AD, respectively.

Disclosures: This study was supported by a contract from Pfizer, Inc. Some authors declared serving as consultants for or receiving research grants, honoraria, or consulting fees from various sources, including Pfizer. AR Lemeshow declared being an employee of Pfizer, Inc.

Source: Wan J, Chiesa Fuxench  ZC, et al. Incidence of cardiovascular disease and venous thromboembolism in patients with atopic dermatitis. J Allergy Clin Immunol Pract. 2023 (Aug 10). doi: 10.1016/j.jaip.2023.08.007

Key clinical point: Severe atopic dermatitis (AD) is associated with higher risks for venous thromboembolism and cardiovascular diseases in both children and adults.

Major finding: Children with severe AD vs those without AD had a significantly increased risk (adjusted hazard ratio; 95% CI) for cerebrovascular accidents (2.43; 1.13-5.22), diabetes (1.46; 1.06-2.01), and deep vein thrombosis (DVT; 2.13; 1.17-3.87). Among adults, the severe AD vs non-AD group had a significantly higher risk for cerebrovascular accidents (1.21; 1.13-1.30), diabetes (1.15; 1.09-1.22), dyslipidemia (1.11; 1.06-1.17), myocardial infarction (1.27; 1.15-1.39), DVT (1.64; 1.49-1.82), and pulmonary embolism (1.39; 1.21-1.60).

Study details: This population-based cohort study included 409,431 children (age < 18 years) and 625,083 adults with AD who were matched with 1,809,029 children and 2,678,888 adults without AD, respectively.

Disclosures: This study was supported by a contract from Pfizer, Inc. Some authors declared serving as consultants for or receiving research grants, honoraria, or consulting fees from various sources, including Pfizer. AR Lemeshow declared being an employee of Pfizer, Inc.

Source: Wan J, Chiesa Fuxench  ZC, et al. Incidence of cardiovascular disease and venous thromboembolism in patients with atopic dermatitis. J Allergy Clin Immunol Pract. 2023 (Aug 10). doi: 10.1016/j.jaip.2023.08.007

Key clinical point: Severe atopic dermatitis (AD) is associated with higher risks for venous thromboembolism and cardiovascular diseases in both children and adults.

Major finding: Children with severe AD vs those without AD had a significantly increased risk (adjusted hazard ratio; 95% CI) for cerebrovascular accidents (2.43; 1.13-5.22), diabetes (1.46; 1.06-2.01), and deep vein thrombosis (DVT; 2.13; 1.17-3.87). Among adults, the severe AD vs non-AD group had a significantly higher risk for cerebrovascular accidents (1.21; 1.13-1.30), diabetes (1.15; 1.09-1.22), dyslipidemia (1.11; 1.06-1.17), myocardial infarction (1.27; 1.15-1.39), DVT (1.64; 1.49-1.82), and pulmonary embolism (1.39; 1.21-1.60).

Study details: This population-based cohort study included 409,431 children (age < 18 years) and 625,083 adults with AD who were matched with 1,809,029 children and 2,678,888 adults without AD, respectively.

Disclosures: This study was supported by a contract from Pfizer, Inc. Some authors declared serving as consultants for or receiving research grants, honoraria, or consulting fees from various sources, including Pfizer. AR Lemeshow declared being an employee of Pfizer, Inc.

Source: Wan J, Chiesa Fuxench  ZC, et al. Incidence of cardiovascular disease and venous thromboembolism in patients with atopic dermatitis. J Allergy Clin Immunol Pract. 2023 (Aug 10). doi: 10.1016/j.jaip.2023.08.007

Key clinical point: Adults with newly diagnosed atopic dermatitis (AD) have a 44% increased risk of subsequently developing type 2 diabetes (T2D).

Major finding: The risk for new-onset T2D was significantly higher in adults with newly diagnosed AD vs control individuals without AD (adjusted hazard ratio 1.44; P < .001), with the risk being significantly greater in both men and women with AD (both P < .001).

Study details: Findings are from a retrospective cohort study including 36,692 adult patients with AD and 36,692 matched control individuals who had never been diagnosed with AD.

Disclosures: This study was supported by the National Research Foundation of Korea funded by the Ministry of Education, Science, and Technology and others. The authors declared no conflicts of interest.

Source: Won Lee S et al. Risk of type 2 diabetes mellitus in adult patients with atopic dermatitis. Diabetes Res Clin Pract. 2023;110883 (Aug 16). doi: 10.1016/j.diabres.2023.110883

Key clinical point: Adults with newly diagnosed atopic dermatitis (AD) have a 44% increased risk of subsequently developing type 2 diabetes (T2D).

Major finding: The risk for new-onset T2D was significantly higher in adults with newly diagnosed AD vs control individuals without AD (adjusted hazard ratio 1.44; P < .001), with the risk being significantly greater in both men and women with AD (both P < .001).

Study details: Findings are from a retrospective cohort study including 36,692 adult patients with AD and 36,692 matched control individuals who had never been diagnosed with AD.

Disclosures: This study was supported by the National Research Foundation of Korea funded by the Ministry of Education, Science, and Technology and others. The authors declared no conflicts of interest.

Source: Won Lee S et al. Risk of type 2 diabetes mellitus in adult patients with atopic dermatitis. Diabetes Res Clin Pract. 2023;110883 (Aug 16). doi: 10.1016/j.diabres.2023.110883

Key clinical point: Adults with newly diagnosed atopic dermatitis (AD) have a 44% increased risk of subsequently developing type 2 diabetes (T2D).

Major finding: The risk for new-onset T2D was significantly higher in adults with newly diagnosed AD vs control individuals without AD (adjusted hazard ratio 1.44; P < .001), with the risk being significantly greater in both men and women with AD (both P < .001).

Study details: Findings are from a retrospective cohort study including 36,692 adult patients with AD and 36,692 matched control individuals who had never been diagnosed with AD.

Disclosures: This study was supported by the National Research Foundation of Korea funded by the Ministry of Education, Science, and Technology and others. The authors declared no conflicts of interest.

Source: Won Lee S et al. Risk of type 2 diabetes mellitus in adult patients with atopic dermatitis. Diabetes Res Clin Pract. 2023;110883 (Aug 16). doi: 10.1016/j.diabres.2023.110883