New expert guidance to help clinicians manage the treatment of patients with epilepsy during pregnancy has been released.

Issued by the American Academy of Neurology, the American Epilepsy Society, and the Society for Maternal-Fetal Medicine, the new practice guideline covers the use of antiseizure medications (ASMs) and folic acid supplementation before conception and during pregnancy.

“Most children born to people with epilepsy are healthy, but there is a small risk of pregnancy-related problems, partly due to seizures and partly due to the effects of antiseizure medications,” the guidelines’ lead author Alison M. Pack, MD, MPH, professor of neurology and chief of the Epilepsy and Sleep Division, Columbia University, New York City, said in a news release.

“This guideline provides recommendations regarding the effects of antiseizure medications and folic acid supplementation on malformations at birth and the development of children during pregnancy, so that doctors and people with epilepsy can determine which treatments may be best for them,” she added. 

The guideline was published online in Neurology.
 

Why Now? 

The new guideline updates the 2009 guidance on epilepsy management during pregnancy. Since then, Dr. Pack told this news organization, there has been a wealth of new data on differential effects of different ASMs — notably, lamotrigine and levetiracetam — the most commonly prescribed medications in this population.

“In this guideline, we were able to assess differential effects of different ASMs on outcomes of interest, including major congenital malformations [MCMs], perinatal outcomes, and neurodevelopmental outcomes. In addition, we looked at the effect of folic acid supplementation on each of these outcomes,” she said.

The overarching goals of care for patients are to “optimize health outcomes both for individuals and their future offspring,” the authors wrote. Shared decision-making, they add, leads to better decision-making by providing a better understanding of the available treatment options and their potential risks, resulting in enhanced decision-making that aligns with personal values.

Clinicians should recommend ASMs that optimize seizure control and fetal outcomes, in the event of a pregnancy, at the earliest possible preconception time, the guideline authors note.

“Overall, treating clinicians need to balance treating the person with epilepsy to control convulsive seizures (generalized tonic-clonic seizures and focal-to-bilateral tonic-clonic seizures) to minimize potential risks to the birth parent and the possible risks of certain ASMs on the fetus if pregnancy occurs,” they wrote.

If a patient is already pregnant, the experts recommend that clinicians “exercise caution” in removing or replacing an ASM that controls convulsive seizures, even if it’s “not an optimal choice” for the fetus. 

In addition, they advise that ASM levels should be monitored throughout the pregnancy, guided by individual ASM pharmacokinetics and an individual patient’s clinical presentation. ASM dose, they note, should be adjusted during pregnancy in response to decreasing serum ASM levels or worsening seizure control.

The authors point out that there are limited data on “pregnancy-related outcomes with respect to acetazolamide, eslicarbazepine, ethosuximide, lacosamide, nitrazepam, perampanel, piracetam, pregabalin, rufinamide, stiripentol, tiagabine, and vigabatrin.”

Patients should be informed that the birth prevalence of any major congenital malformation in the general population ranges between 2.4% and 2.9%.
 

If Feasible, Avoid Valproic Acid 

“One of the most important take-home messages is that valproic acid has the highest unadjusted birth prevalence of all major congenital malformations — 9.7% — and the highest unadjusted birth prevalence of neural tube defects at 1.4%,” Dr. Pack said. As a result, the guideline authors advise against using valproic acid, if clinically feasible.

Valproic acid also has the highest prevalence of negative neurodevelopmental outcomes, including a reduction in global IQ and an increased prevalence of autism spectrum disorder (ASD). Patients should be counseled accordingly and advised of the increased risk for ASD and decreased IQ resulting from valproic acid.

Clinicians should consider using lamotrigine, levetiracetam, or oxcarbazepine when appropriate. Serum concentrations of most ASMs have a “defined therapeutic window” for effective seizure control and that concentration may decrease during pregnancy, particularly with lamotrigine and levetiracetam, the authors note.

Phenobarbital, topiramate, and valproic acid should because of the increased risk for cardiac malformations, oral clefts, and urogenital and renal malformations.

Fetal screening for major congenital malformations is recommended to enable early detection and timely intervention in patients treated with any ASM during pregnancy Patients receiving phenobarbital during pregnancy should also undergo fetal cardiac screenings.

Valproic acid and topiramate are also associated with children who are small for their gestational age. To enable early identification of fetal growth restriction, patients taking valproic acid or topiramate should be monitored. In addition, children exposed to these medications in utero should be monitored during childhood to ensure they are meeting age-appropriate developmental milestones. 

Folic acid taken during pregnancy can reduce the prevalence of negative neurodevelopment outcomes, but not major congenital malformations, Dr. Pack noted. 

“Due to limited available data, we were unable to define an optimal dose of folic acid supplementation beyond at least 0.4 mg/d,” Dr. Pack said. “Future studies, preferably randomized clinical trials, are needed to better define the optimal dose.”

She emphasized that epilepsy is one of the most common neurologic disorders, and 1 in 5 of those affected are people of childbearing potential. Understanding the effects of ASMs on pregnancy outcomes is critical for physicians who manage these patients.
 

Uncertainty Remains 

Commenting for this news organization, Kimford Meador, MD, a professor in the Department of Neurology and Neurological Sciences at Stanford University School of Medicine , Stanford Neuroscience Health Center, Palo Alto, California, noted that the new guidelines reflect the gains in knowledge since 2009 and that the recommendations are “reasonable, based on available data.”

However, “one very important point is how much remains unknown,” said Dr. Meador, who was not involved in writing the current guideline. “Many ASMs have no data, and several have estimates based on small samples or a single observational study.” Thus, “the risks for the majority of ASMs are uncertain.”

Given that randomized trials “are not possible in this population, and that all observational studies are subject to residual confounding, a reliable signal across multiple studies in humans is required to be certain of findings,” he stated.

This practice guideline was developed with financial support from the American Academy of Neurology. Dr. Pack serves on the editorial board for the journal Epilepsy Currents, receives royalties from UpToDate, receives funding from the National Institutes of Health for serving as coinvestigator and site principal investigator for the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study, and receives funding from Bayer for serving as a co-investigator on a study on women with epilepsy initiating a progestin intrauterine device. One of Dr. Pack’s immediate family members has received personal compensation for serving as an employee of REGENEXBIO. The other authors’ disclosures are listed on the original paper. Dr. Meador has received research support from the National Institutes of Health, Veterans Administration, Eisai, Inc, and Suno Medtronic Navigation, Inc, and the Epilepsy Study Consortium pays Dr. Meador’s university for his research on the Human Epilepsy Project and consultant time related to Eisai, UCB Pharma, and Xenon.

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

New expert guidance to help clinicians manage the treatment of patients with epilepsy during pregnancy has been released.

Issued by the American Academy of Neurology, the American Epilepsy Society, and the Society for Maternal-Fetal Medicine, the new practice guideline covers the use of antiseizure medications (ASMs) and folic acid supplementation before conception and during pregnancy.

“Most children born to people with epilepsy are healthy, but there is a small risk of pregnancy-related problems, partly due to seizures and partly due to the effects of antiseizure medications,” the guidelines’ lead author Alison M. Pack, MD, MPH, professor of neurology and chief of the Epilepsy and Sleep Division, Columbia University, New York City, said in a news release.

“This guideline provides recommendations regarding the effects of antiseizure medications and folic acid supplementation on malformations at birth and the development of children during pregnancy, so that doctors and people with epilepsy can determine which treatments may be best for them,” she added. 

The guideline was published online in Neurology.
 

Why Now? 

The new guideline updates the 2009 guidance on epilepsy management during pregnancy. Since then, Dr. Pack told this news organization, there has been a wealth of new data on differential effects of different ASMs — notably, lamotrigine and levetiracetam — the most commonly prescribed medications in this population.

“In this guideline, we were able to assess differential effects of different ASMs on outcomes of interest, including major congenital malformations [MCMs], perinatal outcomes, and neurodevelopmental outcomes. In addition, we looked at the effect of folic acid supplementation on each of these outcomes,” she said.

The overarching goals of care for patients are to “optimize health outcomes both for individuals and their future offspring,” the authors wrote. Shared decision-making, they add, leads to better decision-making by providing a better understanding of the available treatment options and their potential risks, resulting in enhanced decision-making that aligns with personal values.

Clinicians should recommend ASMs that optimize seizure control and fetal outcomes, in the event of a pregnancy, at the earliest possible preconception time, the guideline authors note.

“Overall, treating clinicians need to balance treating the person with epilepsy to control convulsive seizures (generalized tonic-clonic seizures and focal-to-bilateral tonic-clonic seizures) to minimize potential risks to the birth parent and the possible risks of certain ASMs on the fetus if pregnancy occurs,” they wrote.

If a patient is already pregnant, the experts recommend that clinicians “exercise caution” in removing or replacing an ASM that controls convulsive seizures, even if it’s “not an optimal choice” for the fetus. 

In addition, they advise that ASM levels should be monitored throughout the pregnancy, guided by individual ASM pharmacokinetics and an individual patient’s clinical presentation. ASM dose, they note, should be adjusted during pregnancy in response to decreasing serum ASM levels or worsening seizure control.

The authors point out that there are limited data on “pregnancy-related outcomes with respect to acetazolamide, eslicarbazepine, ethosuximide, lacosamide, nitrazepam, perampanel, piracetam, pregabalin, rufinamide, stiripentol, tiagabine, and vigabatrin.”

Patients should be informed that the birth prevalence of any major congenital malformation in the general population ranges between 2.4% and 2.9%.
 

If Feasible, Avoid Valproic Acid 

“One of the most important take-home messages is that valproic acid has the highest unadjusted birth prevalence of all major congenital malformations — 9.7% — and the highest unadjusted birth prevalence of neural tube defects at 1.4%,” Dr. Pack said. As a result, the guideline authors advise against using valproic acid, if clinically feasible.

Valproic acid also has the highest prevalence of negative neurodevelopmental outcomes, including a reduction in global IQ and an increased prevalence of autism spectrum disorder (ASD). Patients should be counseled accordingly and advised of the increased risk for ASD and decreased IQ resulting from valproic acid.

Clinicians should consider using lamotrigine, levetiracetam, or oxcarbazepine when appropriate. Serum concentrations of most ASMs have a “defined therapeutic window” for effective seizure control and that concentration may decrease during pregnancy, particularly with lamotrigine and levetiracetam, the authors note.

Phenobarbital, topiramate, and valproic acid should because of the increased risk for cardiac malformations, oral clefts, and urogenital and renal malformations.

Fetal screening for major congenital malformations is recommended to enable early detection and timely intervention in patients treated with any ASM during pregnancy Patients receiving phenobarbital during pregnancy should also undergo fetal cardiac screenings.

Valproic acid and topiramate are also associated with children who are small for their gestational age. To enable early identification of fetal growth restriction, patients taking valproic acid or topiramate should be monitored. In addition, children exposed to these medications in utero should be monitored during childhood to ensure they are meeting age-appropriate developmental milestones. 

Folic acid taken during pregnancy can reduce the prevalence of negative neurodevelopment outcomes, but not major congenital malformations, Dr. Pack noted. 

“Due to limited available data, we were unable to define an optimal dose of folic acid supplementation beyond at least 0.4 mg/d,” Dr. Pack said. “Future studies, preferably randomized clinical trials, are needed to better define the optimal dose.”

She emphasized that epilepsy is one of the most common neurologic disorders, and 1 in 5 of those affected are people of childbearing potential. Understanding the effects of ASMs on pregnancy outcomes is critical for physicians who manage these patients.
 

Uncertainty Remains 

Commenting for this news organization, Kimford Meador, MD, a professor in the Department of Neurology and Neurological Sciences at Stanford University School of Medicine , Stanford Neuroscience Health Center, Palo Alto, California, noted that the new guidelines reflect the gains in knowledge since 2009 and that the recommendations are “reasonable, based on available data.”

However, “one very important point is how much remains unknown,” said Dr. Meador, who was not involved in writing the current guideline. “Many ASMs have no data, and several have estimates based on small samples or a single observational study.” Thus, “the risks for the majority of ASMs are uncertain.”

Given that randomized trials “are not possible in this population, and that all observational studies are subject to residual confounding, a reliable signal across multiple studies in humans is required to be certain of findings,” he stated.

This practice guideline was developed with financial support from the American Academy of Neurology. Dr. Pack serves on the editorial board for the journal Epilepsy Currents, receives royalties from UpToDate, receives funding from the National Institutes of Health for serving as coinvestigator and site principal investigator for the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study, and receives funding from Bayer for serving as a co-investigator on a study on women with epilepsy initiating a progestin intrauterine device. One of Dr. Pack’s immediate family members has received personal compensation for serving as an employee of REGENEXBIO. The other authors’ disclosures are listed on the original paper. Dr. Meador has received research support from the National Institutes of Health, Veterans Administration, Eisai, Inc, and Suno Medtronic Navigation, Inc, and the Epilepsy Study Consortium pays Dr. Meador’s university for his research on the Human Epilepsy Project and consultant time related to Eisai, UCB Pharma, and Xenon.

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

New expert guidance to help clinicians manage the treatment of patients with epilepsy during pregnancy has been released.

Issued by the American Academy of Neurology, the American Epilepsy Society, and the Society for Maternal-Fetal Medicine, the new practice guideline covers the use of antiseizure medications (ASMs) and folic acid supplementation before conception and during pregnancy.

“Most children born to people with epilepsy are healthy, but there is a small risk of pregnancy-related problems, partly due to seizures and partly due to the effects of antiseizure medications,” the guidelines’ lead author Alison M. Pack, MD, MPH, professor of neurology and chief of the Epilepsy and Sleep Division, Columbia University, New York City, said in a news release.

“This guideline provides recommendations regarding the effects of antiseizure medications and folic acid supplementation on malformations at birth and the development of children during pregnancy, so that doctors and people with epilepsy can determine which treatments may be best for them,” she added. 

The guideline was published online in Neurology.
 

Why Now? 

The new guideline updates the 2009 guidance on epilepsy management during pregnancy. Since then, Dr. Pack told this news organization, there has been a wealth of new data on differential effects of different ASMs — notably, lamotrigine and levetiracetam — the most commonly prescribed medications in this population.

“In this guideline, we were able to assess differential effects of different ASMs on outcomes of interest, including major congenital malformations [MCMs], perinatal outcomes, and neurodevelopmental outcomes. In addition, we looked at the effect of folic acid supplementation on each of these outcomes,” she said.

The overarching goals of care for patients are to “optimize health outcomes both for individuals and their future offspring,” the authors wrote. Shared decision-making, they add, leads to better decision-making by providing a better understanding of the available treatment options and their potential risks, resulting in enhanced decision-making that aligns with personal values.

Clinicians should recommend ASMs that optimize seizure control and fetal outcomes, in the event of a pregnancy, at the earliest possible preconception time, the guideline authors note.

“Overall, treating clinicians need to balance treating the person with epilepsy to control convulsive seizures (generalized tonic-clonic seizures and focal-to-bilateral tonic-clonic seizures) to minimize potential risks to the birth parent and the possible risks of certain ASMs on the fetus if pregnancy occurs,” they wrote.

If a patient is already pregnant, the experts recommend that clinicians “exercise caution” in removing or replacing an ASM that controls convulsive seizures, even if it’s “not an optimal choice” for the fetus. 

In addition, they advise that ASM levels should be monitored throughout the pregnancy, guided by individual ASM pharmacokinetics and an individual patient’s clinical presentation. ASM dose, they note, should be adjusted during pregnancy in response to decreasing serum ASM levels or worsening seizure control.

The authors point out that there are limited data on “pregnancy-related outcomes with respect to acetazolamide, eslicarbazepine, ethosuximide, lacosamide, nitrazepam, perampanel, piracetam, pregabalin, rufinamide, stiripentol, tiagabine, and vigabatrin.”

Patients should be informed that the birth prevalence of any major congenital malformation in the general population ranges between 2.4% and 2.9%.
 

If Feasible, Avoid Valproic Acid 

“One of the most important take-home messages is that valproic acid has the highest unadjusted birth prevalence of all major congenital malformations — 9.7% — and the highest unadjusted birth prevalence of neural tube defects at 1.4%,” Dr. Pack said. As a result, the guideline authors advise against using valproic acid, if clinically feasible.

Valproic acid also has the highest prevalence of negative neurodevelopmental outcomes, including a reduction in global IQ and an increased prevalence of autism spectrum disorder (ASD). Patients should be counseled accordingly and advised of the increased risk for ASD and decreased IQ resulting from valproic acid.

Clinicians should consider using lamotrigine, levetiracetam, or oxcarbazepine when appropriate. Serum concentrations of most ASMs have a “defined therapeutic window” for effective seizure control and that concentration may decrease during pregnancy, particularly with lamotrigine and levetiracetam, the authors note.

Phenobarbital, topiramate, and valproic acid should because of the increased risk for cardiac malformations, oral clefts, and urogenital and renal malformations.

Fetal screening for major congenital malformations is recommended to enable early detection and timely intervention in patients treated with any ASM during pregnancy Patients receiving phenobarbital during pregnancy should also undergo fetal cardiac screenings.

Valproic acid and topiramate are also associated with children who are small for their gestational age. To enable early identification of fetal growth restriction, patients taking valproic acid or topiramate should be monitored. In addition, children exposed to these medications in utero should be monitored during childhood to ensure they are meeting age-appropriate developmental milestones. 

Folic acid taken during pregnancy can reduce the prevalence of negative neurodevelopment outcomes, but not major congenital malformations, Dr. Pack noted. 

“Due to limited available data, we were unable to define an optimal dose of folic acid supplementation beyond at least 0.4 mg/d,” Dr. Pack said. “Future studies, preferably randomized clinical trials, are needed to better define the optimal dose.”

She emphasized that epilepsy is one of the most common neurologic disorders, and 1 in 5 of those affected are people of childbearing potential. Understanding the effects of ASMs on pregnancy outcomes is critical for physicians who manage these patients.
 

Uncertainty Remains 

Commenting for this news organization, Kimford Meador, MD, a professor in the Department of Neurology and Neurological Sciences at Stanford University School of Medicine , Stanford Neuroscience Health Center, Palo Alto, California, noted that the new guidelines reflect the gains in knowledge since 2009 and that the recommendations are “reasonable, based on available data.”

However, “one very important point is how much remains unknown,” said Dr. Meador, who was not involved in writing the current guideline. “Many ASMs have no data, and several have estimates based on small samples or a single observational study.” Thus, “the risks for the majority of ASMs are uncertain.”

Given that randomized trials “are not possible in this population, and that all observational studies are subject to residual confounding, a reliable signal across multiple studies in humans is required to be certain of findings,” he stated.

This practice guideline was developed with financial support from the American Academy of Neurology. Dr. Pack serves on the editorial board for the journal Epilepsy Currents, receives royalties from UpToDate, receives funding from the National Institutes of Health for serving as coinvestigator and site principal investigator for the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study, and receives funding from Bayer for serving as a co-investigator on a study on women with epilepsy initiating a progestin intrauterine device. One of Dr. Pack’s immediate family members has received personal compensation for serving as an employee of REGENEXBIO. The other authors’ disclosures are listed on the original paper. Dr. Meador has received research support from the National Institutes of Health, Veterans Administration, Eisai, Inc, and Suno Medtronic Navigation, Inc, and the Epilepsy Study Consortium pays Dr. Meador’s university for his research on the Human Epilepsy Project and consultant time related to Eisai, UCB Pharma, and Xenon.

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

SAN FRANCISCO — Discussion of gestational weight gain occurred in only half of first-time obstetric visits, most often brought up by the provider, according to data presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

“Weight can be a challenging and sensitive topic at a healthcare visit,” Malini Harinath, an undergraduate research assistant at Magee-Women’s Research Institute at University of Pittsburgh Medical Center, told attendees. “Providers discussed weight gain recommendations in less than half of conversations.”

The researchers analyzed an existing dataset of audio-recorded first obstetric visits to find out how often gestational weight gain was brought up, who initiated the discussion, whether ACOG guidelines were discussed, and what the provider’s comments were.

Among 150 visits, half (50%) involved discussion of weight, with patients bringing it up 24% of the time and providers bringing it up 72% of the time. In the other 3% of visits, it was brought up by a third party, such as a partner or other family member with the patient.

Only two of those visits mentioned body mass index (BMI) specifically, and ACOG guidelines on gestational weight gain were brought up in only six visits (8% of the visits where weight was mentioned). However, mention of recommendations on gestational weight gain was more frequent, coming up in nearly half (46.7%) of the visits where weight was mentioned, though that was still just 23% of all visits.

Concern about weight was brought up in 25.3% of visits where weight was discussed, and the provider’s reassurance to the patient occurred in about a third (32%) of those visits. General comments about the patient’s body occurred in 16% of visits, such as a clinician saying, “Usually we start trying [to find the heartbeat] at about 15 weeks, but you are so skinny we might be able to find it now.”

Ms. Harinath intends to look in future research at whether patient race or BMI are associated with the frequency and content of gestational weight gain conversations and to explore how patients react to different ways that discussion of weight is brought up.

Katherine Kaak, MD, a second-year resident at the University of Tennessee Graduate School of Medicine in Knoxville, was surprised that weight was brought up in only half of the visits. “The clinical takeaway is just how important counseling in the prenatal time is and how a lot of this discussion is preventive medicine,” Dr. Kaak said. “Even though we think of those visits as being quick, it’s good to keep in mind that we need to really take our time and make sure we counsel the patient as best we can.”

There’s a fair amount of research suggesting that existing recommendations on gestational weight gain are not very good because they’re very generic, Jill Maples, PhD, associate professor of ob.gyn. research at the University of Tennessee Graduate School of Medicine, said in an interview. For example, the guidelines are generally the same for everyone with a BMI over 30, but a person with a BMI of 30 is very different from someone with a BMI of 50, she said.

“There’s not even a lot of clarity on what is appropriate weight gain for that group because some people have seen good outcomes on the lower end of gestational weight gain,” Dr. Maples said. She said it’s important that clinicians not forget about the importance of these discussions, however, because lifestyle habits and gestational weight gain are related to maternal and neonatal outcomes.

The authors, Dr. Kaak, and Dr. Maples had no disclosures. The research was funded by the National Institute on Drug Abuse.

SAN FRANCISCO — Discussion of gestational weight gain occurred in only half of first-time obstetric visits, most often brought up by the provider, according to data presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

“Weight can be a challenging and sensitive topic at a healthcare visit,” Malini Harinath, an undergraduate research assistant at Magee-Women’s Research Institute at University of Pittsburgh Medical Center, told attendees. “Providers discussed weight gain recommendations in less than half of conversations.”

The researchers analyzed an existing dataset of audio-recorded first obstetric visits to find out how often gestational weight gain was brought up, who initiated the discussion, whether ACOG guidelines were discussed, and what the provider’s comments were.

Among 150 visits, half (50%) involved discussion of weight, with patients bringing it up 24% of the time and providers bringing it up 72% of the time. In the other 3% of visits, it was brought up by a third party, such as a partner or other family member with the patient.

Only two of those visits mentioned body mass index (BMI) specifically, and ACOG guidelines on gestational weight gain were brought up in only six visits (8% of the visits where weight was mentioned). However, mention of recommendations on gestational weight gain was more frequent, coming up in nearly half (46.7%) of the visits where weight was mentioned, though that was still just 23% of all visits.

Concern about weight was brought up in 25.3% of visits where weight was discussed, and the provider’s reassurance to the patient occurred in about a third (32%) of those visits. General comments about the patient’s body occurred in 16% of visits, such as a clinician saying, “Usually we start trying [to find the heartbeat] at about 15 weeks, but you are so skinny we might be able to find it now.”

Ms. Harinath intends to look in future research at whether patient race or BMI are associated with the frequency and content of gestational weight gain conversations and to explore how patients react to different ways that discussion of weight is brought up.

Katherine Kaak, MD, a second-year resident at the University of Tennessee Graduate School of Medicine in Knoxville, was surprised that weight was brought up in only half of the visits. “The clinical takeaway is just how important counseling in the prenatal time is and how a lot of this discussion is preventive medicine,” Dr. Kaak said. “Even though we think of those visits as being quick, it’s good to keep in mind that we need to really take our time and make sure we counsel the patient as best we can.”

There’s a fair amount of research suggesting that existing recommendations on gestational weight gain are not very good because they’re very generic, Jill Maples, PhD, associate professor of ob.gyn. research at the University of Tennessee Graduate School of Medicine, said in an interview. For example, the guidelines are generally the same for everyone with a BMI over 30, but a person with a BMI of 30 is very different from someone with a BMI of 50, she said.

“There’s not even a lot of clarity on what is appropriate weight gain for that group because some people have seen good outcomes on the lower end of gestational weight gain,” Dr. Maples said. She said it’s important that clinicians not forget about the importance of these discussions, however, because lifestyle habits and gestational weight gain are related to maternal and neonatal outcomes.

The authors, Dr. Kaak, and Dr. Maples had no disclosures. The research was funded by the National Institute on Drug Abuse.

SAN FRANCISCO — Discussion of gestational weight gain occurred in only half of first-time obstetric visits, most often brought up by the provider, according to data presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

“Weight can be a challenging and sensitive topic at a healthcare visit,” Malini Harinath, an undergraduate research assistant at Magee-Women’s Research Institute at University of Pittsburgh Medical Center, told attendees. “Providers discussed weight gain recommendations in less than half of conversations.”

The researchers analyzed an existing dataset of audio-recorded first obstetric visits to find out how often gestational weight gain was brought up, who initiated the discussion, whether ACOG guidelines were discussed, and what the provider’s comments were.

Among 150 visits, half (50%) involved discussion of weight, with patients bringing it up 24% of the time and providers bringing it up 72% of the time. In the other 3% of visits, it was brought up by a third party, such as a partner or other family member with the patient.

Only two of those visits mentioned body mass index (BMI) specifically, and ACOG guidelines on gestational weight gain were brought up in only six visits (8% of the visits where weight was mentioned). However, mention of recommendations on gestational weight gain was more frequent, coming up in nearly half (46.7%) of the visits where weight was mentioned, though that was still just 23% of all visits.

Concern about weight was brought up in 25.3% of visits where weight was discussed, and the provider’s reassurance to the patient occurred in about a third (32%) of those visits. General comments about the patient’s body occurred in 16% of visits, such as a clinician saying, “Usually we start trying [to find the heartbeat] at about 15 weeks, but you are so skinny we might be able to find it now.”

Ms. Harinath intends to look in future research at whether patient race or BMI are associated with the frequency and content of gestational weight gain conversations and to explore how patients react to different ways that discussion of weight is brought up.

Katherine Kaak, MD, a second-year resident at the University of Tennessee Graduate School of Medicine in Knoxville, was surprised that weight was brought up in only half of the visits. “The clinical takeaway is just how important counseling in the prenatal time is and how a lot of this discussion is preventive medicine,” Dr. Kaak said. “Even though we think of those visits as being quick, it’s good to keep in mind that we need to really take our time and make sure we counsel the patient as best we can.”

There’s a fair amount of research suggesting that existing recommendations on gestational weight gain are not very good because they’re very generic, Jill Maples, PhD, associate professor of ob.gyn. research at the University of Tennessee Graduate School of Medicine, said in an interview. For example, the guidelines are generally the same for everyone with a BMI over 30, but a person with a BMI of 30 is very different from someone with a BMI of 50, she said.

“There’s not even a lot of clarity on what is appropriate weight gain for that group because some people have seen good outcomes on the lower end of gestational weight gain,” Dr. Maples said. She said it’s important that clinicians not forget about the importance of these discussions, however, because lifestyle habits and gestational weight gain are related to maternal and neonatal outcomes.

The authors, Dr. Kaak, and Dr. Maples had no disclosures. The research was funded by the National Institute on Drug Abuse.

SAN FRANCISCO — Women who used marijuana during pregnancy were significantly less likely to view it as risky even in a state where it was not legalized, according to prospectively collected data presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. But most of those women had not received any counseling about stopping its use, and more than half wanted more information about its effects on pregnancy complications.

“The biggest thing we recognized was that our counseling in prenatal visits was lower than what it really should have been,” Abigail M. Ramseyer, DO, of University of Michigan Health– Sparrow in Lansing, said in an interview. She said doctors really need to be asking their patients about marijuana use and having a conversation about the risks of its use during pregnancy.

An estimated 3%-30% of pregnant women use marijuana, depending on the population, but prevalence has been rising as more states legalize its use. Yet research has shown an association between marijuana use during pregnancy and multiple neonatal complications, including fetal growth restriction and low birth weight.

Pregnant women at a single center in Arkansas were invited during their prenatal visits to complete a 35-question, anonymous survey electronically or on paper. Of the 460 approached, 88.7% completed the survey and 11.8% of those women reported use of marijuana during pregnancy. Among those who used it while pregnant, 50% reported using it 2-3 times a week, 27% reported using it once weekly, and 18.8% reported using it daily.

The women who used it while pregnant were less likely to have a college degree and half (50%) were aged 18-24, with use declining with increasing age. A third of those who use it were White (33.3%), 52.1% were Black, and 6.3% were Hispanic.

More than half of the women (52.7%) who used marijuana during pregnancy reported that there had not been any discussion about substance use during pregnancy at the prenatal visit, and 82.4% said they had not received any counseling about stopping its use during pregnancy. Yet 54% of them wanted more information about pregnancy complications linked to cannabis use.

The other questions asked respondents on a 5-point Likert scale how much they agreed or disagreed with various statements related to perceptions of marijuana, its use during pregnancy, and its risks.

Most respondents strongly agreed that “marijuana isn’t as bad as other drugs like heroin, cocaine or meth,” but average agreement was higher among those who used marijuana (4.88) than who didn’t (4.02, P < .001).

Respondents largely neither agreed nor disagreed with its being okay to use marijuana during pregnancy with a prescription, but agreement was still higher among those who used it (3.68) than didn’t use it (2.82, P < .001). Those who used marijuana were more likely to agree that it’s “a natural substance and not a drug” (4.67 vs. 3.38, P < .001); to believe “marijuana has minimal health risks during and outside of pregnancy” (4.15 vs. 2.96, P < .001); and to believe “marijuana has less risk for treating symptoms in pregnancy than prescription medication from my provider” (4.19 vs. 3.01, P < .001).

It was not surprising that patients using marijuana would have more favorable opinions toward legalizing it, Dr. Ramseyer said, but it was interesting that the respondents’ attitude overall, regardless of use, was positive in a fairly conservative state where it was still illegal. She said her research group has data they are starting to analyze about the perceptions of patients’ partners and family members regarding marijuana use during pregnancy.

Animesh Upadhyay, MD, a resident at Yale–New Haven Medical Center in Connecticut, was also surprised by how positive the attitudes toward marijuana use and legalization were in a state where it’s illegal.

“The thing that disturbs me is that nobody has spoken about the risks of marijuana in pregnancy” to many of the respondents, said Dr. Upadhyay, who was not involved in the study. Based on the findings, Dr. Upadhyay said he would definitely begin asking patients more about their use of marijuana and their beliefs about it.

In a separate poster, Sarah Dzubay, BS, of Oregon Health & Science University, Portland, presented data examining potential associations between cannabis use and fertility. Previous research has suggested an association, but the cross-sectional analysis by Ms. Dzubay identified only a nonsignificant trend toward an association.

The researchers analyzed data from the 2013-2018 National Health and Nutrition Examination Study (NHANES) for woman aged 20-49 based on self-reported use of cannabis. Among 3166 women, 51% reported never using cannabis, 29% reported irregular use, and 20% reported regular use at least monthly.

“Women reporting regular use were younger, of lower income and educational attainment, and more likely to be single,” Ms. Dzubay reported. Those reporting irregular use, meanwhile, were more likely to be college graduates.

More of the women who used cannabis regularly (15.4%) reported an inability to conceive within one year than women who used cannabis irregularly (10.8%) or never (12.6%). The higher odds ratio of infertility among those using cannabis regularly (OR 1.47) compared to never using it was not statistically significant, however, nor was the reduced odds ratio among those using it irregularly (OR 0.83).

Because the results were not significant, the possibility of a link to infertility is “something to keep in mind,” Ms. Dzubay said, but “a lot more data has to be collected about this question before we can definitively say there’s a risk.”

The authors and Dr. Upadhyay had no disclosures. Neither study noted any external funding.

SAN FRANCISCO — Women who used marijuana during pregnancy were significantly less likely to view it as risky even in a state where it was not legalized, according to prospectively collected data presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. But most of those women had not received any counseling about stopping its use, and more than half wanted more information about its effects on pregnancy complications.

“The biggest thing we recognized was that our counseling in prenatal visits was lower than what it really should have been,” Abigail M. Ramseyer, DO, of University of Michigan Health– Sparrow in Lansing, said in an interview. She said doctors really need to be asking their patients about marijuana use and having a conversation about the risks of its use during pregnancy.

An estimated 3%-30% of pregnant women use marijuana, depending on the population, but prevalence has been rising as more states legalize its use. Yet research has shown an association between marijuana use during pregnancy and multiple neonatal complications, including fetal growth restriction and low birth weight.

Pregnant women at a single center in Arkansas were invited during their prenatal visits to complete a 35-question, anonymous survey electronically or on paper. Of the 460 approached, 88.7% completed the survey and 11.8% of those women reported use of marijuana during pregnancy. Among those who used it while pregnant, 50% reported using it 2-3 times a week, 27% reported using it once weekly, and 18.8% reported using it daily.

The women who used it while pregnant were less likely to have a college degree and half (50%) were aged 18-24, with use declining with increasing age. A third of those who use it were White (33.3%), 52.1% were Black, and 6.3% were Hispanic.

More than half of the women (52.7%) who used marijuana during pregnancy reported that there had not been any discussion about substance use during pregnancy at the prenatal visit, and 82.4% said they had not received any counseling about stopping its use during pregnancy. Yet 54% of them wanted more information about pregnancy complications linked to cannabis use.

The other questions asked respondents on a 5-point Likert scale how much they agreed or disagreed with various statements related to perceptions of marijuana, its use during pregnancy, and its risks.

Most respondents strongly agreed that “marijuana isn’t as bad as other drugs like heroin, cocaine or meth,” but average agreement was higher among those who used marijuana (4.88) than who didn’t (4.02, P < .001).

Respondents largely neither agreed nor disagreed with its being okay to use marijuana during pregnancy with a prescription, but agreement was still higher among those who used it (3.68) than didn’t use it (2.82, P < .001). Those who used marijuana were more likely to agree that it’s “a natural substance and not a drug” (4.67 vs. 3.38, P < .001); to believe “marijuana has minimal health risks during and outside of pregnancy” (4.15 vs. 2.96, P < .001); and to believe “marijuana has less risk for treating symptoms in pregnancy than prescription medication from my provider” (4.19 vs. 3.01, P < .001).

It was not surprising that patients using marijuana would have more favorable opinions toward legalizing it, Dr. Ramseyer said, but it was interesting that the respondents’ attitude overall, regardless of use, was positive in a fairly conservative state where it was still illegal. She said her research group has data they are starting to analyze about the perceptions of patients’ partners and family members regarding marijuana use during pregnancy.

Animesh Upadhyay, MD, a resident at Yale–New Haven Medical Center in Connecticut, was also surprised by how positive the attitudes toward marijuana use and legalization were in a state where it’s illegal.

“The thing that disturbs me is that nobody has spoken about the risks of marijuana in pregnancy” to many of the respondents, said Dr. Upadhyay, who was not involved in the study. Based on the findings, Dr. Upadhyay said he would definitely begin asking patients more about their use of marijuana and their beliefs about it.

In a separate poster, Sarah Dzubay, BS, of Oregon Health & Science University, Portland, presented data examining potential associations between cannabis use and fertility. Previous research has suggested an association, but the cross-sectional analysis by Ms. Dzubay identified only a nonsignificant trend toward an association.

The researchers analyzed data from the 2013-2018 National Health and Nutrition Examination Study (NHANES) for woman aged 20-49 based on self-reported use of cannabis. Among 3166 women, 51% reported never using cannabis, 29% reported irregular use, and 20% reported regular use at least monthly.

“Women reporting regular use were younger, of lower income and educational attainment, and more likely to be single,” Ms. Dzubay reported. Those reporting irregular use, meanwhile, were more likely to be college graduates.

More of the women who used cannabis regularly (15.4%) reported an inability to conceive within one year than women who used cannabis irregularly (10.8%) or never (12.6%). The higher odds ratio of infertility among those using cannabis regularly (OR 1.47) compared to never using it was not statistically significant, however, nor was the reduced odds ratio among those using it irregularly (OR 0.83).

Because the results were not significant, the possibility of a link to infertility is “something to keep in mind,” Ms. Dzubay said, but “a lot more data has to be collected about this question before we can definitively say there’s a risk.”

The authors and Dr. Upadhyay had no disclosures. Neither study noted any external funding.

SAN FRANCISCO — Women who used marijuana during pregnancy were significantly less likely to view it as risky even in a state where it was not legalized, according to prospectively collected data presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. But most of those women had not received any counseling about stopping its use, and more than half wanted more information about its effects on pregnancy complications.

“The biggest thing we recognized was that our counseling in prenatal visits was lower than what it really should have been,” Abigail M. Ramseyer, DO, of University of Michigan Health– Sparrow in Lansing, said in an interview. She said doctors really need to be asking their patients about marijuana use and having a conversation about the risks of its use during pregnancy.

An estimated 3%-30% of pregnant women use marijuana, depending on the population, but prevalence has been rising as more states legalize its use. Yet research has shown an association between marijuana use during pregnancy and multiple neonatal complications, including fetal growth restriction and low birth weight.

Pregnant women at a single center in Arkansas were invited during their prenatal visits to complete a 35-question, anonymous survey electronically or on paper. Of the 460 approached, 88.7% completed the survey and 11.8% of those women reported use of marijuana during pregnancy. Among those who used it while pregnant, 50% reported using it 2-3 times a week, 27% reported using it once weekly, and 18.8% reported using it daily.

The women who used it while pregnant were less likely to have a college degree and half (50%) were aged 18-24, with use declining with increasing age. A third of those who use it were White (33.3%), 52.1% were Black, and 6.3% were Hispanic.

More than half of the women (52.7%) who used marijuana during pregnancy reported that there had not been any discussion about substance use during pregnancy at the prenatal visit, and 82.4% said they had not received any counseling about stopping its use during pregnancy. Yet 54% of them wanted more information about pregnancy complications linked to cannabis use.

The other questions asked respondents on a 5-point Likert scale how much they agreed or disagreed with various statements related to perceptions of marijuana, its use during pregnancy, and its risks.

Most respondents strongly agreed that “marijuana isn’t as bad as other drugs like heroin, cocaine or meth,” but average agreement was higher among those who used marijuana (4.88) than who didn’t (4.02, P < .001).

Respondents largely neither agreed nor disagreed with its being okay to use marijuana during pregnancy with a prescription, but agreement was still higher among those who used it (3.68) than didn’t use it (2.82, P < .001). Those who used marijuana were more likely to agree that it’s “a natural substance and not a drug” (4.67 vs. 3.38, P < .001); to believe “marijuana has minimal health risks during and outside of pregnancy” (4.15 vs. 2.96, P < .001); and to believe “marijuana has less risk for treating symptoms in pregnancy than prescription medication from my provider” (4.19 vs. 3.01, P < .001).

It was not surprising that patients using marijuana would have more favorable opinions toward legalizing it, Dr. Ramseyer said, but it was interesting that the respondents’ attitude overall, regardless of use, was positive in a fairly conservative state where it was still illegal. She said her research group has data they are starting to analyze about the perceptions of patients’ partners and family members regarding marijuana use during pregnancy.

Animesh Upadhyay, MD, a resident at Yale–New Haven Medical Center in Connecticut, was also surprised by how positive the attitudes toward marijuana use and legalization were in a state where it’s illegal.

“The thing that disturbs me is that nobody has spoken about the risks of marijuana in pregnancy” to many of the respondents, said Dr. Upadhyay, who was not involved in the study. Based on the findings, Dr. Upadhyay said he would definitely begin asking patients more about their use of marijuana and their beliefs about it.

In a separate poster, Sarah Dzubay, BS, of Oregon Health & Science University, Portland, presented data examining potential associations between cannabis use and fertility. Previous research has suggested an association, but the cross-sectional analysis by Ms. Dzubay identified only a nonsignificant trend toward an association.

The researchers analyzed data from the 2013-2018 National Health and Nutrition Examination Study (NHANES) for woman aged 20-49 based on self-reported use of cannabis. Among 3166 women, 51% reported never using cannabis, 29% reported irregular use, and 20% reported regular use at least monthly.

“Women reporting regular use were younger, of lower income and educational attainment, and more likely to be single,” Ms. Dzubay reported. Those reporting irregular use, meanwhile, were more likely to be college graduates.

More of the women who used cannabis regularly (15.4%) reported an inability to conceive within one year than women who used cannabis irregularly (10.8%) or never (12.6%). The higher odds ratio of infertility among those using cannabis regularly (OR 1.47) compared to never using it was not statistically significant, however, nor was the reduced odds ratio among those using it irregularly (OR 0.83).

Because the results were not significant, the possibility of a link to infertility is “something to keep in mind,” Ms. Dzubay said, but “a lot more data has to be collected about this question before we can definitively say there’s a risk.”

The authors and Dr. Upadhyay had no disclosures. Neither study noted any external funding.

On February 11, 2024, the American Academy of Ophthalmology (AAO) issued new guidelines regarding dry eye syndrome or keratoconjunctivitis sicca. According to the National Eye Institute, dry eye affects approximately 16 million Americans. Dry eye is a multifactorial disease with causes including excessive screen time and refractive surgery. While it may seem that dry eye is a nuisance disease, it can actually damage the cornea if not treated appropriately.

The guidelines state that dry eye can affect the quality of life as well as the outcomes of ocular surgeries such as cataract surgery. It is imperative that we discuss this potential complication before our patients undergo these procedures. As primary care physicians, we have seen that patients may not be well educated on their health conditions by other doctors. We may not be the one performing the surgery but it is likely the patient will seek our advice if any complication arises.

The guidelines say that clinical examination is the gold standard for diagnosing this disease. We need to be proficient at doing eye exams and refer to a specialist when appropriate. The treatment can likely be undertaken in the primary care office unless there are other symptoms such as loss of visual acuity. The guidelines suggest several diagnostic tests, such as the Schirmer test and tear osmolarity test, which may be outside the scope of the primary care setting. Often, clinical history will guide the diagnosis.

Treatments include several Food and Drug Administration–approved eye drops. We need to know what they are and when to prescribe them. We know they will not cure the disease but can keep it under control and improve the patient’s quality of life.

Dry eye may seem a trivial complaint in the sea of diseases we treat on a daily basis. However, it is not trivial to the patient. It can affect their vision and make their life miserable. We need to pay attention when our patients bring this to our attention. We are not just making them comfortable but protecting their corneas. This can be done in conjunction with routine ophthalmologic visits.

According to the authors of these guidelines, approximately 10% of patients with significantly dry eyes and mouth will have Sjögren’s syndrome. Autoimmune testing should be undertaken in these patients.

These guidelines also suggest a classification for dry eye including mild, moderate, and severe. Since the treatment varies depending on classification, we need to learn this classification system. They also stress follow-up visits. It is not enough just to diagnose the disease and start treatment, we need to see the patients back for follow-up.

Currently, most people work and play on electronic devices. Dry eye syndrome can make this more difficult and vice versa. While it is typically not a vision-threatening disease, it can be a life-altering one. Ocular symptoms are something we see frequently in our practices, from allergic conjunctivitis to glaucoma. Often, the patient starts seeking help in our office.

Yes, our patients may have more life-threatening diseases. Our job is not just to save lives but to help our patients live healthy lives. If their lives are being affected by any disease, we must step in and do something. Dry eye is not just an inconvenience but something that causes great suffering. Eventually we may end up referring the patient to the ophthalmologist, but if we can do something to ease their discomfort while they are waiting, we would be changing their lives. We must educate ourselves on this disease and appropriate treatments to be prescribed depending on the classification of disease.

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, NJ. She has no conflicts of interest.

On February 11, 2024, the American Academy of Ophthalmology (AAO) issued new guidelines regarding dry eye syndrome or keratoconjunctivitis sicca. According to the National Eye Institute, dry eye affects approximately 16 million Americans. Dry eye is a multifactorial disease with causes including excessive screen time and refractive surgery. While it may seem that dry eye is a nuisance disease, it can actually damage the cornea if not treated appropriately.

The guidelines state that dry eye can affect the quality of life as well as the outcomes of ocular surgeries such as cataract surgery. It is imperative that we discuss this potential complication before our patients undergo these procedures. As primary care physicians, we have seen that patients may not be well educated on their health conditions by other doctors. We may not be the one performing the surgery but it is likely the patient will seek our advice if any complication arises.

The guidelines say that clinical examination is the gold standard for diagnosing this disease. We need to be proficient at doing eye exams and refer to a specialist when appropriate. The treatment can likely be undertaken in the primary care office unless there are other symptoms such as loss of visual acuity. The guidelines suggest several diagnostic tests, such as the Schirmer test and tear osmolarity test, which may be outside the scope of the primary care setting. Often, clinical history will guide the diagnosis.

Treatments include several Food and Drug Administration–approved eye drops. We need to know what they are and when to prescribe them. We know they will not cure the disease but can keep it under control and improve the patient’s quality of life.

Dry eye may seem a trivial complaint in the sea of diseases we treat on a daily basis. However, it is not trivial to the patient. It can affect their vision and make their life miserable. We need to pay attention when our patients bring this to our attention. We are not just making them comfortable but protecting their corneas. This can be done in conjunction with routine ophthalmologic visits.

According to the authors of these guidelines, approximately 10% of patients with significantly dry eyes and mouth will have Sjögren’s syndrome. Autoimmune testing should be undertaken in these patients.

These guidelines also suggest a classification for dry eye including mild, moderate, and severe. Since the treatment varies depending on classification, we need to learn this classification system. They also stress follow-up visits. It is not enough just to diagnose the disease and start treatment, we need to see the patients back for follow-up.

Currently, most people work and play on electronic devices. Dry eye syndrome can make this more difficult and vice versa. While it is typically not a vision-threatening disease, it can be a life-altering one. Ocular symptoms are something we see frequently in our practices, from allergic conjunctivitis to glaucoma. Often, the patient starts seeking help in our office.

Yes, our patients may have more life-threatening diseases. Our job is not just to save lives but to help our patients live healthy lives. If their lives are being affected by any disease, we must step in and do something. Dry eye is not just an inconvenience but something that causes great suffering. Eventually we may end up referring the patient to the ophthalmologist, but if we can do something to ease their discomfort while they are waiting, we would be changing their lives. We must educate ourselves on this disease and appropriate treatments to be prescribed depending on the classification of disease.

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, NJ. She has no conflicts of interest.

On February 11, 2024, the American Academy of Ophthalmology (AAO) issued new guidelines regarding dry eye syndrome or keratoconjunctivitis sicca. According to the National Eye Institute, dry eye affects approximately 16 million Americans. Dry eye is a multifactorial disease with causes including excessive screen time and refractive surgery. While it may seem that dry eye is a nuisance disease, it can actually damage the cornea if not treated appropriately.

The guidelines state that dry eye can affect the quality of life as well as the outcomes of ocular surgeries such as cataract surgery. It is imperative that we discuss this potential complication before our patients undergo these procedures. As primary care physicians, we have seen that patients may not be well educated on their health conditions by other doctors. We may not be the one performing the surgery but it is likely the patient will seek our advice if any complication arises.

The guidelines say that clinical examination is the gold standard for diagnosing this disease. We need to be proficient at doing eye exams and refer to a specialist when appropriate. The treatment can likely be undertaken in the primary care office unless there are other symptoms such as loss of visual acuity. The guidelines suggest several diagnostic tests, such as the Schirmer test and tear osmolarity test, which may be outside the scope of the primary care setting. Often, clinical history will guide the diagnosis.

Treatments include several Food and Drug Administration–approved eye drops. We need to know what they are and when to prescribe them. We know they will not cure the disease but can keep it under control and improve the patient’s quality of life.

Dry eye may seem a trivial complaint in the sea of diseases we treat on a daily basis. However, it is not trivial to the patient. It can affect their vision and make their life miserable. We need to pay attention when our patients bring this to our attention. We are not just making them comfortable but protecting their corneas. This can be done in conjunction with routine ophthalmologic visits.

According to the authors of these guidelines, approximately 10% of patients with significantly dry eyes and mouth will have Sjögren’s syndrome. Autoimmune testing should be undertaken in these patients.

These guidelines also suggest a classification for dry eye including mild, moderate, and severe. Since the treatment varies depending on classification, we need to learn this classification system. They also stress follow-up visits. It is not enough just to diagnose the disease and start treatment, we need to see the patients back for follow-up.

Currently, most people work and play on electronic devices. Dry eye syndrome can make this more difficult and vice versa. While it is typically not a vision-threatening disease, it can be a life-altering one. Ocular symptoms are something we see frequently in our practices, from allergic conjunctivitis to glaucoma. Often, the patient starts seeking help in our office.

Yes, our patients may have more life-threatening diseases. Our job is not just to save lives but to help our patients live healthy lives. If their lives are being affected by any disease, we must step in and do something. Dry eye is not just an inconvenience but something that causes great suffering. Eventually we may end up referring the patient to the ophthalmologist, but if we can do something to ease their discomfort while they are waiting, we would be changing their lives. We must educate ourselves on this disease and appropriate treatments to be prescribed depending on the classification of disease.

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, NJ. She has no conflicts of interest.

Macadamia (Macadamia tetraphylla) is endemic to Australia and is now commercially cultivated worldwide.¹ It is closely related genetically to the other macadamia plants, including the other main one, M. integrifolia, cultivated for macadamia nuts. Known in Brazil as sapucaia or castanha-de-sapucaia, Lecythis pisonis (also referred to as “cream nut” or “monkey pot”) is a large, deciduous tropical tree and member of the Brazil nut family, Lecythidaceae.² Various parts of both of these plants have been associated with medicinal properties, including the potential for dermatologic activity. Notably, the leaves of L. pisonis have been used in traditional medicine to treat pruritus.²This column focuses on the studies suggesting the possible benefits of macadamia and sapucaia components for skin care.

Macadamia

Extraction to Harness Antioxidant Activity

In 2015, Dailey and Vuong developed an aqueous extraction process to recover the phenolic content and antioxidant functionality from the skin waste of M. tetraphylla using response surface methodology. As an environmentally suitable solvent that is also cheap and safe, water was chosen to maximize the extraction scenario. They identified the proper conditions (90° C, a time of 20 min, and a sample-to-solvent ratio of 5 g/100 mL) to obtain sufficient phenolic compounds, proanthocyanidins, and flavonoids to render robust antioxidant function.¹

Baumann Cosmetic &amp; Research Institute

Early in 2023, Somwongin et al. investigated various green extraction methods for viability in harnessing the cosmetic/cosmeceutical ingredients of M. integrifolia pericarps. Extracts were assessed for total phenolic content as well as antioxidant and anti–skin aging functions. They found that among the green extraction methods (ultrasound, micellar, microwave, and pulsed electric field extraction with water used as a clean solvent), the ultrasound-assisted extraction method netted the greatest yield and total phenolic content. It was also associated with the most robust antioxidant and anti–skin aging activities. Indeed, the researchers reported that its antioxidant activities were comparable to ascorbic acid and Trolox and its anti–skin aging potency on a par with epigallocatechin-3-gallate and oleanolic acid. The ultrasound-assisted extract was also deemed safe as it did not provoke irritation. The authors concluded that this environmentally suitable extraction method for M. integrifolia is appropriate for obtaining effective macadamia extracts for use in cosmetics and cosmeceuticals.³

Anti-Aging Activity

In 2017, Addy et al. set out to characterize skin surface lipid composition and differences in an age- and sex-controlled population as a foundation for developing a botanically derived skin surface lipid mimetic agent. They noted that fatty acids, triglycerides, cholesterol, steryl esters, wax esters, and squalene are the main constituents of skin surface lipids. The investigators obtained skin surface lipid samples from the foreheads of 59 healthy 22-year-old women, analyzed them, and used the raw components of M. integrifolia, Simmondsia chinensis, and Olea europaea to engineer a mimetic product. They reported that the esterification reactions of jojoba, macadamia, and tall oils, combined with squalene derived from O. europaea, yielded an appropriate skin surface lipid mimetic, which, when applied to delipidized skin, assisted in recovering barrier function, enhancing skin hydration, and improving elasticity as well as firmness in aged skin. The researchers concluded that this skin surface lipid mimetic could serve as an effective supplement to human skin surface lipids in aged skin and for conditions in which the stratum corneum is impaired.⁴

Two years later, Hanum et al. compared the effects of macadamia nut oil nanocream and conventional cream for treating cutaneous aging over a 4-week period. The macadamia nut oil nanocream, which contained macadamia nut oil 10%, tween 80, propylene glycol, cetyl alcohol, methylparaben, propylparaben, and distilled water, was compared with the conventional cream based on effects on moisture, evenness, pore size, melanin, and wrinkling. The macadamia nut oil was found to yield superior anti-aging activity along each parameter as compared with the conventional cream. The researchers concluded that the macadamia nut oil in nanocream can be an effective formulation for providing benefits in addressing cutaneous aging.⁵

Matthieu Sontag/Wikimedia Commons/CC-BY-SA

Antifungal Activity

In 2015, Vieira et al. characterized 12 fractions enriched in peptides derived from L. pisonis seeds to determine inhibitory activity against Candida albicans. The fraction that exerted the strongest activity at 10 μg/mL, suppressing C. albicans growth by 38.5% and inducing a 69.3% loss of viability, was identified as similar to plant defensins and thus dubbed “L. pisonis defensin 1 (Lp-Def1).” The investigators concluded that Lp-Def1 acts on C. albicans by slightly elevating the induction of reactive oxygen species and causing a significant reduction in mitochondrial activity. They suggested that their findings support the use of plant defensins, particularly Lp-Def1, in the formulation of antifungal products, especially to address C. albicans.¹⁰

Pruritus

In 2012, Silva et al. studied the antipruritic impact of L. pisonis leaf extracts in mice and rats. Pretreatment with the various fractions of L. pisonis as well as constituent mixed triterpenes (ursolic and oleanolic acids) significantly blocked scratching behavior provoked by compound 48/80. The degranulation of rat peritoneal mast cells caused by compound 48/80 was also substantially decreased from pretreatment with the ethanol extract of L. pisonis, ether-L. pisonis fraction, and mixed triterpenes. The L. pisonis ether fraction suppressed edema induced by carrageenan administration and the ethanol extract displayed no toxicity up to an oral dose of 2g/kg. The investigators concluded that their results strongly support the antipruritic effects of L. pisonis leaves as well as the traditional use of the plant to treat pruritus.²

Stability for Cosmetic Creams

In 2020, Rampazzo et al. assessed the stability and cytotoxicity of a cosmetic cream containing sapucaia nut oil. All three tested concentrations (1%, 5%, and 10%) of the cream were found to be stable, with an effective preservative system, and deemed safe for use on human skin. To maintain a pH appropriate for a body cream, the formulation requires a stabilizing agent. The cream with 5% nut oil was identified as the most stable and satisfying for use on the skin.⁷

More recently, Hertel Pereira et al. investigated the benefits of using L. pisonis pericarp extract, known to exhibit abundant antioxidants, in an all-natural skin cream. They found that formulation instability increased proportionally with the concentration of the extract, but the use of the outer pericarp of L. pisonis was well suited for the cream formulation, with physical-chemical and organoleptic qualities unchanged after the stability test.¹¹

Conclusion

The available literature on the medical applications of macadamia and sapucaia plants is sparse. Some recent findings are promising regarding possible uses in skin health. However, much more research is necessary before considering macadamia and sapucaia as viable sources of botanical agents capable of delivering significant cutaneous benefits.

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur in Miami. She founded the division of cosmetic dermatology at the University of Miami in 1997. The third edition of her bestselling textbook, “Cosmetic Dermatology,” was published in 2022. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Johnson & Johnson, and Burt’s Bees. She is the CEO of Skin Type Solutions Inc., an SaaS company used to generate skin care routines in office and as an e-commerce solution. Write to her at [email protected].

References

1. Dailey A and Vuong QV. Antioxidants (Basel). 2015 Nov 12;4(4):699-718.

2. Silva LL et al. J Ethnopharmacol. 2012 Jan 6;139(1):90-97.

3. Somwongin S et al. Ultrason Sonochem. 2023 Jan;92:106266.

4. Addy J et al. J Cosmet Sci. 2017 Jan/Feb;68(1):59-67.

5. Hanum TI et al. Open Access Maced J Med Sci. 2019 Nov 14;7(22):3917-3920.

6. Akhtar N and Yazan Y. Pak J Pharm Sci. 2008 Jan;21(1):45-50.

7. Rampazzo APS et al. J Cosmet Sci. 2020 Sep/Oct;71(5):239-250.

8. Rosa TLM et al. Food Res Int. 2020 Nov;137:109383.

9. Demoliner F et al. Food Res Int. 2018 Oct;112:434-442.

10. Vieira ME et al. Acta Biochim Biophys Sin (Shanghai). 2015 Sep;47(9):716-729.

11. Hertel Pereira AC et al. J Cosmet Sci. 2021 Mar-Apr;72(2):155-162.

Macadamia (Macadamia tetraphylla) is endemic to Australia and is now commercially cultivated worldwide.¹ It is closely related genetically to the other macadamia plants, including the other main one, M. integrifolia, cultivated for macadamia nuts. Known in Brazil as sapucaia or castanha-de-sapucaia, Lecythis pisonis (also referred to as “cream nut” or “monkey pot”) is a large, deciduous tropical tree and member of the Brazil nut family, Lecythidaceae.² Various parts of both of these plants have been associated with medicinal properties, including the potential for dermatologic activity. Notably, the leaves of L. pisonis have been used in traditional medicine to treat pruritus.²This column focuses on the studies suggesting the possible benefits of macadamia and sapucaia components for skin care.

Macadamia

Extraction to Harness Antioxidant Activity

In 2015, Dailey and Vuong developed an aqueous extraction process to recover the phenolic content and antioxidant functionality from the skin waste of M. tetraphylla using response surface methodology. As an environmentally suitable solvent that is also cheap and safe, water was chosen to maximize the extraction scenario. They identified the proper conditions (90° C, a time of 20 min, and a sample-to-solvent ratio of 5 g/100 mL) to obtain sufficient phenolic compounds, proanthocyanidins, and flavonoids to render robust antioxidant function.¹

Baumann Cosmetic &amp; Research Institute

Early in 2023, Somwongin et al. investigated various green extraction methods for viability in harnessing the cosmetic/cosmeceutical ingredients of M. integrifolia pericarps. Extracts were assessed for total phenolic content as well as antioxidant and anti–skin aging functions. They found that among the green extraction methods (ultrasound, micellar, microwave, and pulsed electric field extraction with water used as a clean solvent), the ultrasound-assisted extraction method netted the greatest yield and total phenolic content. It was also associated with the most robust antioxidant and anti–skin aging activities. Indeed, the researchers reported that its antioxidant activities were comparable to ascorbic acid and Trolox and its anti–skin aging potency on a par with epigallocatechin-3-gallate and oleanolic acid. The ultrasound-assisted extract was also deemed safe as it did not provoke irritation. The authors concluded that this environmentally suitable extraction method for M. integrifolia is appropriate for obtaining effective macadamia extracts for use in cosmetics and cosmeceuticals.³

Anti-Aging Activity

In 2017, Addy et al. set out to characterize skin surface lipid composition and differences in an age- and sex-controlled population as a foundation for developing a botanically derived skin surface lipid mimetic agent. They noted that fatty acids, triglycerides, cholesterol, steryl esters, wax esters, and squalene are the main constituents of skin surface lipids. The investigators obtained skin surface lipid samples from the foreheads of 59 healthy 22-year-old women, analyzed them, and used the raw components of M. integrifolia, Simmondsia chinensis, and Olea europaea to engineer a mimetic product. They reported that the esterification reactions of jojoba, macadamia, and tall oils, combined with squalene derived from O. europaea, yielded an appropriate skin surface lipid mimetic, which, when applied to delipidized skin, assisted in recovering barrier function, enhancing skin hydration, and improving elasticity as well as firmness in aged skin. The researchers concluded that this skin surface lipid mimetic could serve as an effective supplement to human skin surface lipids in aged skin and for conditions in which the stratum corneum is impaired.⁴

Two years later, Hanum et al. compared the effects of macadamia nut oil nanocream and conventional cream for treating cutaneous aging over a 4-week period. The macadamia nut oil nanocream, which contained macadamia nut oil 10%, tween 80, propylene glycol, cetyl alcohol, methylparaben, propylparaben, and distilled water, was compared with the conventional cream based on effects on moisture, evenness, pore size, melanin, and wrinkling. The macadamia nut oil was found to yield superior anti-aging activity along each parameter as compared with the conventional cream. The researchers concluded that the macadamia nut oil in nanocream can be an effective formulation for providing benefits in addressing cutaneous aging.⁵

Matthieu Sontag/Wikimedia Commons/CC-BY-SA

Antifungal Activity

In 2015, Vieira et al. characterized 12 fractions enriched in peptides derived from L. pisonis seeds to determine inhibitory activity against Candida albicans. The fraction that exerted the strongest activity at 10 μg/mL, suppressing C. albicans growth by 38.5% and inducing a 69.3% loss of viability, was identified as similar to plant defensins and thus dubbed “L. pisonis defensin 1 (Lp-Def1).” The investigators concluded that Lp-Def1 acts on C. albicans by slightly elevating the induction of reactive oxygen species and causing a significant reduction in mitochondrial activity. They suggested that their findings support the use of plant defensins, particularly Lp-Def1, in the formulation of antifungal products, especially to address C. albicans.¹⁰

Pruritus

In 2012, Silva et al. studied the antipruritic impact of L. pisonis leaf extracts in mice and rats. Pretreatment with the various fractions of L. pisonis as well as constituent mixed triterpenes (ursolic and oleanolic acids) significantly blocked scratching behavior provoked by compound 48/80. The degranulation of rat peritoneal mast cells caused by compound 48/80 was also substantially decreased from pretreatment with the ethanol extract of L. pisonis, ether-L. pisonis fraction, and mixed triterpenes. The L. pisonis ether fraction suppressed edema induced by carrageenan administration and the ethanol extract displayed no toxicity up to an oral dose of 2g/kg. The investigators concluded that their results strongly support the antipruritic effects of L. pisonis leaves as well as the traditional use of the plant to treat pruritus.²

Stability for Cosmetic Creams

In 2020, Rampazzo et al. assessed the stability and cytotoxicity of a cosmetic cream containing sapucaia nut oil. All three tested concentrations (1%, 5%, and 10%) of the cream were found to be stable, with an effective preservative system, and deemed safe for use on human skin. To maintain a pH appropriate for a body cream, the formulation requires a stabilizing agent. The cream with 5% nut oil was identified as the most stable and satisfying for use on the skin.⁷

More recently, Hertel Pereira et al. investigated the benefits of using L. pisonis pericarp extract, known to exhibit abundant antioxidants, in an all-natural skin cream. They found that formulation instability increased proportionally with the concentration of the extract, but the use of the outer pericarp of L. pisonis was well suited for the cream formulation, with physical-chemical and organoleptic qualities unchanged after the stability test.¹¹

Conclusion

The available literature on the medical applications of macadamia and sapucaia plants is sparse. Some recent findings are promising regarding possible uses in skin health. However, much more research is necessary before considering macadamia and sapucaia as viable sources of botanical agents capable of delivering significant cutaneous benefits.

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur in Miami. She founded the division of cosmetic dermatology at the University of Miami in 1997. The third edition of her bestselling textbook, “Cosmetic Dermatology,” was published in 2022. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Johnson & Johnson, and Burt’s Bees. She is the CEO of Skin Type Solutions Inc., an SaaS company used to generate skin care routines in office and as an e-commerce solution. Write to her at [email protected].

References

1. Dailey A and Vuong QV. Antioxidants (Basel). 2015 Nov 12;4(4):699-718.

2. Silva LL et al. J Ethnopharmacol. 2012 Jan 6;139(1):90-97.

3. Somwongin S et al. Ultrason Sonochem. 2023 Jan;92:106266.

4. Addy J et al. J Cosmet Sci. 2017 Jan/Feb;68(1):59-67.

5. Hanum TI et al. Open Access Maced J Med Sci. 2019 Nov 14;7(22):3917-3920.

6. Akhtar N and Yazan Y. Pak J Pharm Sci. 2008 Jan;21(1):45-50.

7. Rampazzo APS et al. J Cosmet Sci. 2020 Sep/Oct;71(5):239-250.

8. Rosa TLM et al. Food Res Int. 2020 Nov;137:109383.

9. Demoliner F et al. Food Res Int. 2018 Oct;112:434-442.

10. Vieira ME et al. Acta Biochim Biophys Sin (Shanghai). 2015 Sep;47(9):716-729.

11. Hertel Pereira AC et al. J Cosmet Sci. 2021 Mar-Apr;72(2):155-162.

Macadamia (Macadamia tetraphylla) is endemic to Australia and is now commercially cultivated worldwide.¹ It is closely related genetically to the other macadamia plants, including the other main one, M. integrifolia, cultivated for macadamia nuts. Known in Brazil as sapucaia or castanha-de-sapucaia, Lecythis pisonis (also referred to as “cream nut” or “monkey pot”) is a large, deciduous tropical tree and member of the Brazil nut family, Lecythidaceae.² Various parts of both of these plants have been associated with medicinal properties, including the potential for dermatologic activity. Notably, the leaves of L. pisonis have been used in traditional medicine to treat pruritus.²This column focuses on the studies suggesting the possible benefits of macadamia and sapucaia components for skin care.

Macadamia

Extraction to Harness Antioxidant Activity

In 2015, Dailey and Vuong developed an aqueous extraction process to recover the phenolic content and antioxidant functionality from the skin waste of M. tetraphylla using response surface methodology. As an environmentally suitable solvent that is also cheap and safe, water was chosen to maximize the extraction scenario. They identified the proper conditions (90° C, a time of 20 min, and a sample-to-solvent ratio of 5 g/100 mL) to obtain sufficient phenolic compounds, proanthocyanidins, and flavonoids to render robust antioxidant function.¹

Baumann Cosmetic &amp; Research Institute

Early in 2023, Somwongin et al. investigated various green extraction methods for viability in harnessing the cosmetic/cosmeceutical ingredients of M. integrifolia pericarps. Extracts were assessed for total phenolic content as well as antioxidant and anti–skin aging functions. They found that among the green extraction methods (ultrasound, micellar, microwave, and pulsed electric field extraction with water used as a clean solvent), the ultrasound-assisted extraction method netted the greatest yield and total phenolic content. It was also associated with the most robust antioxidant and anti–skin aging activities. Indeed, the researchers reported that its antioxidant activities were comparable to ascorbic acid and Trolox and its anti–skin aging potency on a par with epigallocatechin-3-gallate and oleanolic acid. The ultrasound-assisted extract was also deemed safe as it did not provoke irritation. The authors concluded that this environmentally suitable extraction method for M. integrifolia is appropriate for obtaining effective macadamia extracts for use in cosmetics and cosmeceuticals.³

Anti-Aging Activity

In 2017, Addy et al. set out to characterize skin surface lipid composition and differences in an age- and sex-controlled population as a foundation for developing a botanically derived skin surface lipid mimetic agent. They noted that fatty acids, triglycerides, cholesterol, steryl esters, wax esters, and squalene are the main constituents of skin surface lipids. The investigators obtained skin surface lipid samples from the foreheads of 59 healthy 22-year-old women, analyzed them, and used the raw components of M. integrifolia, Simmondsia chinensis, and Olea europaea to engineer a mimetic product. They reported that the esterification reactions of jojoba, macadamia, and tall oils, combined with squalene derived from O. europaea, yielded an appropriate skin surface lipid mimetic, which, when applied to delipidized skin, assisted in recovering barrier function, enhancing skin hydration, and improving elasticity as well as firmness in aged skin. The researchers concluded that this skin surface lipid mimetic could serve as an effective supplement to human skin surface lipids in aged skin and for conditions in which the stratum corneum is impaired.⁴

Two years later, Hanum et al. compared the effects of macadamia nut oil nanocream and conventional cream for treating cutaneous aging over a 4-week period. The macadamia nut oil nanocream, which contained macadamia nut oil 10%, tween 80, propylene glycol, cetyl alcohol, methylparaben, propylparaben, and distilled water, was compared with the conventional cream based on effects on moisture, evenness, pore size, melanin, and wrinkling. The macadamia nut oil was found to yield superior anti-aging activity along each parameter as compared with the conventional cream. The researchers concluded that the macadamia nut oil in nanocream can be an effective formulation for providing benefits in addressing cutaneous aging.⁵

Matthieu Sontag/Wikimedia Commons/CC-BY-SA

Antifungal Activity

In 2015, Vieira et al. characterized 12 fractions enriched in peptides derived from L. pisonis seeds to determine inhibitory activity against Candida albicans. The fraction that exerted the strongest activity at 10 μg/mL, suppressing C. albicans growth by 38.5% and inducing a 69.3% loss of viability, was identified as similar to plant defensins and thus dubbed “L. pisonis defensin 1 (Lp-Def1).” The investigators concluded that Lp-Def1 acts on C. albicans by slightly elevating the induction of reactive oxygen species and causing a significant reduction in mitochondrial activity. They suggested that their findings support the use of plant defensins, particularly Lp-Def1, in the formulation of antifungal products, especially to address C. albicans.¹⁰

Pruritus

In 2012, Silva et al. studied the antipruritic impact of L. pisonis leaf extracts in mice and rats. Pretreatment with the various fractions of L. pisonis as well as constituent mixed triterpenes (ursolic and oleanolic acids) significantly blocked scratching behavior provoked by compound 48/80. The degranulation of rat peritoneal mast cells caused by compound 48/80 was also substantially decreased from pretreatment with the ethanol extract of L. pisonis, ether-L. pisonis fraction, and mixed triterpenes. The L. pisonis ether fraction suppressed edema induced by carrageenan administration and the ethanol extract displayed no toxicity up to an oral dose of 2g/kg. The investigators concluded that their results strongly support the antipruritic effects of L. pisonis leaves as well as the traditional use of the plant to treat pruritus.²

Stability for Cosmetic Creams

In 2020, Rampazzo et al. assessed the stability and cytotoxicity of a cosmetic cream containing sapucaia nut oil. All three tested concentrations (1%, 5%, and 10%) of the cream were found to be stable, with an effective preservative system, and deemed safe for use on human skin. To maintain a pH appropriate for a body cream, the formulation requires a stabilizing agent. The cream with 5% nut oil was identified as the most stable and satisfying for use on the skin.⁷

More recently, Hertel Pereira et al. investigated the benefits of using L. pisonis pericarp extract, known to exhibit abundant antioxidants, in an all-natural skin cream. They found that formulation instability increased proportionally with the concentration of the extract, but the use of the outer pericarp of L. pisonis was well suited for the cream formulation, with physical-chemical and organoleptic qualities unchanged after the stability test.¹¹

Conclusion

The available literature on the medical applications of macadamia and sapucaia plants is sparse. Some recent findings are promising regarding possible uses in skin health. However, much more research is necessary before considering macadamia and sapucaia as viable sources of botanical agents capable of delivering significant cutaneous benefits.

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur in Miami. She founded the division of cosmetic dermatology at the University of Miami in 1997. The third edition of her bestselling textbook, “Cosmetic Dermatology,” was published in 2022. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Johnson & Johnson, and Burt’s Bees. She is the CEO of Skin Type Solutions Inc., an SaaS company used to generate skin care routines in office and as an e-commerce solution. Write to her at [email protected].

References

1. Dailey A and Vuong QV. Antioxidants (Basel). 2015 Nov 12;4(4):699-718.

2. Silva LL et al. J Ethnopharmacol. 2012 Jan 6;139(1):90-97.

3. Somwongin S et al. Ultrason Sonochem. 2023 Jan;92:106266.

4. Addy J et al. J Cosmet Sci. 2017 Jan/Feb;68(1):59-67.

5. Hanum TI et al. Open Access Maced J Med Sci. 2019 Nov 14;7(22):3917-3920.

6. Akhtar N and Yazan Y. Pak J Pharm Sci. 2008 Jan;21(1):45-50.

7. Rampazzo APS et al. J Cosmet Sci. 2020 Sep/Oct;71(5):239-250.

8. Rosa TLM et al. Food Res Int. 2020 Nov;137:109383.

9. Demoliner F et al. Food Res Int. 2018 Oct;112:434-442.

10. Vieira ME et al. Acta Biochim Biophys Sin (Shanghai). 2015 Sep;47(9):716-729.

11. Hertel Pereira AC et al. J Cosmet Sci. 2021 Mar-Apr;72(2):155-162.

Key clinical point: The odds of treatment failure were not increased, and no extrapyramidal adverse events were reported in pediatric patients with migraine when diphenhydramine was coadministered with prochlorperazine in an emergency department (ED) setting.

Major finding: The administration of diphenhydramine plus prochlorperazine vs prochlorperazine alone was not associated with increased odds of additional migraine therapy (P = .347), hospitalization rates (P = .425), and 72-hour return visit rates (P = .271). None of the patients in the diphenhydramine plus prochlorperazine group experienced extrapyramidal adverse events, while 2.4% of patients in prochlorperazine group experienced extrapyramidal adverse events.

Study details: Findings are from a retrospective cohort study that included 1683 pediatric patients with migraine presenting to the ED who received diphenhydramine plus prochlorperazine (n = 1215) or prochlorperazine only (n = 468).

Disclosures: This study did not disclose any funding source. The authors declared no conflicts of interest.

Source: Naeem S, Lozano JM, Ruiz Castaneda AM, Lowe D. Diphenhydramine and migraine treatment failure in pediatric patients receiving prochlorperazine. Pediatr Emerg Care. 2024 (May 9). doi: 10.1097/PEC.0000000000003202 Source

Key clinical point: The odds of treatment failure were not increased, and no extrapyramidal adverse events were reported in pediatric patients with migraine when diphenhydramine was coadministered with prochlorperazine in an emergency department (ED) setting.

Major finding: The administration of diphenhydramine plus prochlorperazine vs prochlorperazine alone was not associated with increased odds of additional migraine therapy (P = .347), hospitalization rates (P = .425), and 72-hour return visit rates (P = .271). None of the patients in the diphenhydramine plus prochlorperazine group experienced extrapyramidal adverse events, while 2.4% of patients in prochlorperazine group experienced extrapyramidal adverse events.

Study details: Findings are from a retrospective cohort study that included 1683 pediatric patients with migraine presenting to the ED who received diphenhydramine plus prochlorperazine (n = 1215) or prochlorperazine only (n = 468).

Disclosures: This study did not disclose any funding source. The authors declared no conflicts of interest.

Source: Naeem S, Lozano JM, Ruiz Castaneda AM, Lowe D. Diphenhydramine and migraine treatment failure in pediatric patients receiving prochlorperazine. Pediatr Emerg Care. 2024 (May 9). doi: 10.1097/PEC.0000000000003202 Source

Key clinical point: The odds of treatment failure were not increased, and no extrapyramidal adverse events were reported in pediatric patients with migraine when diphenhydramine was coadministered with prochlorperazine in an emergency department (ED) setting.

Major finding: The administration of diphenhydramine plus prochlorperazine vs prochlorperazine alone was not associated with increased odds of additional migraine therapy (P = .347), hospitalization rates (P = .425), and 72-hour return visit rates (P = .271). None of the patients in the diphenhydramine plus prochlorperazine group experienced extrapyramidal adverse events, while 2.4% of patients in prochlorperazine group experienced extrapyramidal adverse events.

Study details: Findings are from a retrospective cohort study that included 1683 pediatric patients with migraine presenting to the ED who received diphenhydramine plus prochlorperazine (n = 1215) or prochlorperazine only (n = 468).

Disclosures: This study did not disclose any funding source. The authors declared no conflicts of interest.

Source: Naeem S, Lozano JM, Ruiz Castaneda AM, Lowe D. Diphenhydramine and migraine treatment failure in pediatric patients receiving prochlorperazine. Pediatr Emerg Care. 2024 (May 9). doi: 10.1097/PEC.0000000000003202 Source

Key clinical point: Both cinnarizine and amitriptyline effectively improved migraine symptoms in children and adolescents with migraine, but amitriptyline was a more preferable treatment option since it reduced headache frequency and duration more effectively than cinnarizine.

Major finding: Amitriptyline was more effective than cinnarizine in reducing headache frequency at 4 weeks (mean difference [MD] −8.81 attacks/months; P = .004) and headache duration at 4 (MD −123.0 minutes; P = .017), 8 (MD −110.3 minutes; P = .033), and 12 (MD −123.3 minutes; P = .018) weeks. However, there were no significant differences in headache severity and migraine-related disability between the groups at 4, 8, and 12 weeks (all P > .005).

Study details: Findings are from a randomized, double-blind controlled trial including 43 children with migraine (age 4-17 years) who were randomly assigned to receive cinnarizine (n = 22) and amitriptyline (n = 21).

Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.

Source: Olfat M, Hosseinpour S, Masoumi S, et al. A comparative study on prophylactic efficacy of cinnarizine and amitriptyline in childhood migraine: A randomized double-blind clinical trial. Cephalalgia. 2024 (Apr 20). doi: 10.1177/03331024241230963 Source

Key clinical point: Both cinnarizine and amitriptyline effectively improved migraine symptoms in children and adolescents with migraine, but amitriptyline was a more preferable treatment option since it reduced headache frequency and duration more effectively than cinnarizine.

Major finding: Amitriptyline was more effective than cinnarizine in reducing headache frequency at 4 weeks (mean difference [MD] −8.81 attacks/months; P = .004) and headache duration at 4 (MD −123.0 minutes; P = .017), 8 (MD −110.3 minutes; P = .033), and 12 (MD −123.3 minutes; P = .018) weeks. However, there were no significant differences in headache severity and migraine-related disability between the groups at 4, 8, and 12 weeks (all P > .005).

Study details: Findings are from a randomized, double-blind controlled trial including 43 children with migraine (age 4-17 years) who were randomly assigned to receive cinnarizine (n = 22) and amitriptyline (n = 21).

Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.

Source: Olfat M, Hosseinpour S, Masoumi S, et al. A comparative study on prophylactic efficacy of cinnarizine and amitriptyline in childhood migraine: A randomized double-blind clinical trial. Cephalalgia. 2024 (Apr 20). doi: 10.1177/03331024241230963 Source

Key clinical point: Both cinnarizine and amitriptyline effectively improved migraine symptoms in children and adolescents with migraine, but amitriptyline was a more preferable treatment option since it reduced headache frequency and duration more effectively than cinnarizine.

Major finding: Amitriptyline was more effective than cinnarizine in reducing headache frequency at 4 weeks (mean difference [MD] −8.81 attacks/months; P = .004) and headache duration at 4 (MD −123.0 minutes; P = .017), 8 (MD −110.3 minutes; P = .033), and 12 (MD −123.3 minutes; P = .018) weeks. However, there were no significant differences in headache severity and migraine-related disability between the groups at 4, 8, and 12 weeks (all P > .005).

Study details: Findings are from a randomized, double-blind controlled trial including 43 children with migraine (age 4-17 years) who were randomly assigned to receive cinnarizine (n = 22) and amitriptyline (n = 21).

Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.

Source: Olfat M, Hosseinpour S, Masoumi S, et al. A comparative study on prophylactic efficacy of cinnarizine and amitriptyline in childhood migraine: A randomized double-blind clinical trial. Cephalalgia. 2024 (Apr 20). doi: 10.1177/03331024241230963 Source

Key clinical point: This cross-sectional study demonstrated a significant association between severe headache or migraine and erectile dysfunction (ED) in adult men in the US; however, the results should be interpreted carefully as it did not investigate the effects of depression and anxiety on ED.

Major finding: Presence vs absence of severe headache or migraine was associated with 51% increased risk of ED (adjusted odd ratio 1.51; P = .0036). Age of 40-60 years (P = 0.0292), body mass index < 25 kg/m² (P = .0406) or ≥30 kg/m² (P = .0222), metabolic disorders, such as hypertension (P = .0029), diabetes mellitus (P < .001), and hyperlipidemia (P = .0281), were significant risk factors for ED in those with severe headache or migraine.

Study details: This cross-sectional study included 3117 adult men with (n = 582) and without (n = 2535) history of ED from the US National Health and Nutrition Examination Survey (2001-2 and 2003-4), of whom 16.85% had severe headache or migraine.

Disclosures: This study was funded by National Natural Science Foundation of China. The authors declared no competing interests.

Source: Wu X, Zhang Y, Liu G, et al. Association between severe headache or migraine and erectile dysfunction in American adults: A cross-sectional of data study from the NHANES. Int J Impot Res. 2024 (Apr 12). doi: 10.1038/s41443-024-00867-w Source

Key clinical point: This cross-sectional study demonstrated a significant association between severe headache or migraine and erectile dysfunction (ED) in adult men in the US; however, the results should be interpreted carefully as it did not investigate the effects of depression and anxiety on ED.

Major finding: Presence vs absence of severe headache or migraine was associated with 51% increased risk of ED (adjusted odd ratio 1.51; P = .0036). Age of 40-60 years (P = 0.0292), body mass index < 25 kg/m² (P = .0406) or ≥30 kg/m² (P = .0222), metabolic disorders, such as hypertension (P = .0029), diabetes mellitus (P < .001), and hyperlipidemia (P = .0281), were significant risk factors for ED in those with severe headache or migraine.

Study details: This cross-sectional study included 3117 adult men with (n = 582) and without (n = 2535) history of ED from the US National Health and Nutrition Examination Survey (2001-2 and 2003-4), of whom 16.85% had severe headache or migraine.

Disclosures: This study was funded by National Natural Science Foundation of China. The authors declared no competing interests.

Source: Wu X, Zhang Y, Liu G, et al. Association between severe headache or migraine and erectile dysfunction in American adults: A cross-sectional of data study from the NHANES. Int J Impot Res. 2024 (Apr 12). doi: 10.1038/s41443-024-00867-w Source

Key clinical point: This cross-sectional study demonstrated a significant association between severe headache or migraine and erectile dysfunction (ED) in adult men in the US; however, the results should be interpreted carefully as it did not investigate the effects of depression and anxiety on ED.

Major finding: Presence vs absence of severe headache or migraine was associated with 51% increased risk of ED (adjusted odd ratio 1.51; P = .0036). Age of 40-60 years (P = 0.0292), body mass index < 25 kg/m² (P = .0406) or ≥30 kg/m² (P = .0222), metabolic disorders, such as hypertension (P = .0029), diabetes mellitus (P < .001), and hyperlipidemia (P = .0281), were significant risk factors for ED in those with severe headache or migraine.

Study details: This cross-sectional study included 3117 adult men with (n = 582) and without (n = 2535) history of ED from the US National Health and Nutrition Examination Survey (2001-2 and 2003-4), of whom 16.85% had severe headache or migraine.

Disclosures: This study was funded by National Natural Science Foundation of China. The authors declared no competing interests.

Source: Wu X, Zhang Y, Liu G, et al. Association between severe headache or migraine and erectile dysfunction in American adults: A cross-sectional of data study from the NHANES. Int J Impot Res. 2024 (Apr 12). doi: 10.1038/s41443-024-00867-w Source

Key clinical point: Presence of migraine poses a strong risk for incident venous thromboembolism (VTE), whereas VTE is modest risk factor for the onset of migraine.

Major finding: The risk of developing VTE was significantly higher in patients with vs without migraine (odds ratio [OR] 96.155; P = .004). Conversely, the risk for migraine was modestly higher in patients with vs without VTE (OR 1.002; P = .016).

Study details: This two-sample bidirectional Mendelian randomization study evaluated the causal association between migraine and VTE using single-nucleotide polymorphisms as instrumental variables obtained from large-scale Genome-Wide Association Studies public databases (IEU Open GWAS project, FinnGen).

Disclosures: The study did not disclose any funding. The authors declared no conflicts of interest.

Source: Wang Y, Hu X, Wang X, et al. Exploring the two-way link between migraines and venous thromboembolism: A bidirectional two-sample Mendelian randomization study. Thromb Haemost. 2024 (Apr 24). doi: 10.1055/a-2313-0311 Source

Key clinical point: Presence of migraine poses a strong risk for incident venous thromboembolism (VTE), whereas VTE is modest risk factor for the onset of migraine.

Major finding: The risk of developing VTE was significantly higher in patients with vs without migraine (odds ratio [OR] 96.155; P = .004). Conversely, the risk for migraine was modestly higher in patients with vs without VTE (OR 1.002; P = .016).

Study details: This two-sample bidirectional Mendelian randomization study evaluated the causal association between migraine and VTE using single-nucleotide polymorphisms as instrumental variables obtained from large-scale Genome-Wide Association Studies public databases (IEU Open GWAS project, FinnGen).

Disclosures: The study did not disclose any funding. The authors declared no conflicts of interest.

Source: Wang Y, Hu X, Wang X, et al. Exploring the two-way link between migraines and venous thromboembolism: A bidirectional two-sample Mendelian randomization study. Thromb Haemost. 2024 (Apr 24). doi: 10.1055/a-2313-0311 Source

Key clinical point: Presence of migraine poses a strong risk for incident venous thromboembolism (VTE), whereas VTE is modest risk factor for the onset of migraine.

Major finding: The risk of developing VTE was significantly higher in patients with vs without migraine (odds ratio [OR] 96.155; P = .004). Conversely, the risk for migraine was modestly higher in patients with vs without VTE (OR 1.002; P = .016).

Study details: This two-sample bidirectional Mendelian randomization study evaluated the causal association between migraine and VTE using single-nucleotide polymorphisms as instrumental variables obtained from large-scale Genome-Wide Association Studies public databases (IEU Open GWAS project, FinnGen).

Disclosures: The study did not disclose any funding. The authors declared no conflicts of interest.

Source: Wang Y, Hu X, Wang X, et al. Exploring the two-way link between migraines and venous thromboembolism: A bidirectional two-sample Mendelian randomization study. Thromb Haemost. 2024 (Apr 24). doi: 10.1055/a-2313-0311 Source

Key clinical point: Very low-quality evidence showed that serum pituitary adenylates cyclase–activating polypeptide (PACAP) levels were lower in adults with a longer history of migraine.

Major finding: Serum levels of PACAP were inversely associated with history of migraine duration in adults with migraine (summary r −0.35; P < .01). It was also seen that serum PACAP levels were higher during the ictal vs interictal period in both adults and children with migraine (standardized mean difference 0.41; 95% CI 0.17-0.66).

Study details: Findings are from a meta-analysis of eight observational studies including 674 patients with migraine and 371 control individuals without migraine.

Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.

Source: Zhu G, Wang M, Kong F. Blood serum levels of PACAP and migraine onset: A systematic review and meta-analysis of observational studies. Headache. 2024 (Apr 24). doi: 10.1111/head.14711 Source

Key clinical point: Very low-quality evidence showed that serum pituitary adenylates cyclase–activating polypeptide (PACAP) levels were lower in adults with a longer history of migraine.

Major finding: Serum levels of PACAP were inversely associated with history of migraine duration in adults with migraine (summary r −0.35; P < .01). It was also seen that serum PACAP levels were higher during the ictal vs interictal period in both adults and children with migraine (standardized mean difference 0.41; 95% CI 0.17-0.66).

Study details: Findings are from a meta-analysis of eight observational studies including 674 patients with migraine and 371 control individuals without migraine.

Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.

Source: Zhu G, Wang M, Kong F. Blood serum levels of PACAP and migraine onset: A systematic review and meta-analysis of observational studies. Headache. 2024 (Apr 24). doi: 10.1111/head.14711 Source

Key clinical point: Very low-quality evidence showed that serum pituitary adenylates cyclase–activating polypeptide (PACAP) levels were lower in adults with a longer history of migraine.

Major finding: Serum levels of PACAP were inversely associated with history of migraine duration in adults with migraine (summary r −0.35; P < .01). It was also seen that serum PACAP levels were higher during the ictal vs interictal period in both adults and children with migraine (standardized mean difference 0.41; 95% CI 0.17-0.66).

Study details: Findings are from a meta-analysis of eight observational studies including 674 patients with migraine and 371 control individuals without migraine.

Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.

Source: Zhu G, Wang M, Kong F. Blood serum levels of PACAP and migraine onset: A systematic review and meta-analysis of observational studies. Headache. 2024 (Apr 24). doi: 10.1111/head.14711 Source