Physicians with difficult patient scenarios regularly bring their questions to the AGA Community to seek advice from colleagues about therapy and disease management options, best practices, and diagnoses. In case you missed it, here are the most popular clinical discussions shared in the forum recently:

1. Combination therapy with Entyvio – The GI community shared their experiences with combination therapy of Entyvio and immunomodulators in patients with ulcerative colitis who have developed antibodies to anti-TNF therapy.

2. Small bowel ulcerations in anemic patient with rheumatoid arthritis – Read an update on this patient with rheumatoid arthritis who was experiencing recurrent abdominal pain associated with iron-deficiency anemia diagnosed with multiple small bowel ulcers.

3. When losing weight is too difficult – How do you approach NAFLD patients who have a difficult time committing to a weight-loss treatment plan?


Access these clinical cases and more discussions at https://community.gastro.org/discussions.

Physicians with difficult patient scenarios regularly bring their questions to the AGA Community to seek advice from colleagues about therapy and disease management options, best practices, and diagnoses. In case you missed it, here are the most popular clinical discussions shared in the forum recently:

1. Combination therapy with Entyvio – The GI community shared their experiences with combination therapy of Entyvio and immunomodulators in patients with ulcerative colitis who have developed antibodies to anti-TNF therapy.

2. Small bowel ulcerations in anemic patient with rheumatoid arthritis – Read an update on this patient with rheumatoid arthritis who was experiencing recurrent abdominal pain associated with iron-deficiency anemia diagnosed with multiple small bowel ulcers.

3. When losing weight is too difficult – How do you approach NAFLD patients who have a difficult time committing to a weight-loss treatment plan?


Access these clinical cases and more discussions at https://community.gastro.org/discussions.

Physicians with difficult patient scenarios regularly bring their questions to the AGA Community to seek advice from colleagues about therapy and disease management options, best practices, and diagnoses. In case you missed it, here are the most popular clinical discussions shared in the forum recently:

1. Combination therapy with Entyvio – The GI community shared their experiences with combination therapy of Entyvio and immunomodulators in patients with ulcerative colitis who have developed antibodies to anti-TNF therapy.

2. Small bowel ulcerations in anemic patient with rheumatoid arthritis – Read an update on this patient with rheumatoid arthritis who was experiencing recurrent abdominal pain associated with iron-deficiency anemia diagnosed with multiple small bowel ulcers.

3. When losing weight is too difficult – How do you approach NAFLD patients who have a difficult time committing to a weight-loss treatment plan?


Access these clinical cases and more discussions at https://community.gastro.org/discussions.

As an early-career gastroenterologist, I have become increasingly aware of the impact of advocacy in championing legislation important to our patients. Initially naive about health care advocacy, I owe much to AGA in preparing and arranging for opportunities to speak with elected officials and their staff on GI-related priorities and bills. As a member of the AGA Congressional Advocates Program, I received training and support in visiting Capitol Hill, discussing specific legislation and upcoming bills, writing op-eds, and hosting site visits.

Most recently, AGA sponsored my attendance at the Alliance of Specialty Medicine Annual Advocacy Fly In. With colleagues from around the country – in specialties ranging from ophthalmology to dermatology – we listened to invited congressional representatives and senators on important bills that can directly affect the care we provide to our patients. We had the opportunity to ask questions of these legislators, many of whom were fellow physicians, and gain advice on effective advocacy, as well as build camaraderie with our colleagues in other specialties who face similar issues.

With colleagues from Texas, and assisted by Kathleen Teixeira, AGA vice president, government affairs, we visited the offices of our congressional representatives and senators throughout the afternoon. During our meetings with congressional staff, we stressed the importance of making changes to current prior authorization and step-therapy approaches to make it easier for our patients to access the right treatments as soon as possible. We also discussed the importance of supporting graduate medical education to ensure we have a future cohort of gastroenterologists and other specialists to meet the rising demands of our population. We were well received, and the briefs prepared by the alliance and AGA, as well as tips on effectively communicating our positions, made the whole process seamless. Discussing our own personal experiences and sharing patient stories, we found our meetings to be productive and insightful.

Now, I hope to host my congresswoman, Rep. Lizzie Fletcher, D-Tex., for a site visit locally at Baylor, after a successful meeting with her aide on Capitol Hill.

None of this would have been possible without AGA’s support in arranging these presentations, meetings, and physically supporting us throughout the process. I encourage all of you to utilize AGA in advocating for our patients. It is fun, high impact, and incredibly insightful!
 

How to get involved in advocacy

Interested in advocacy but not sure how or whether you have time in your busy schedule? AGA has an array of options for how you can be active in advocacy. Some take as little as 5 minutes.

Letter writing. AGA uses GovPredict, an online advocacy platform that allows members to contact their member of Congress with just a few clicks. AGA develops messages on significant pieces of legislation, key efforts in Congress or on issues being advanced by federal agencies that have a great effect on gastroenterology. AGA’s ongoing letter writing campaigns can always be found on gastro.org, but be sure to keep an eye out for advocacy emails, AGA eDigest, and social media, so you do not miss your opportunity to take action on timely issues. AGA encourages its members to share letter writing campaigns with their colleagues, as well as posting them on social media.

Meetings with your member of Congress. In-person meetings are an excellent opportunity to share with your member of Congress, or their staff, how the issues that affect gastroenterology affect you, your patients, and your practice. AGA has a plethora of resources to help you set up a meeting with your member of Congress, including up-to-date issue briefs, tips and tricks for productive meetings, and webinars on how to host an on-site visit. AGA staff is always more than happy to help you arrange a meeting either in Washington, DC, or your home state. If you are interested in arranging a meeting with your member of Congress, please contact AGA Public Policy Coordinator, Jonathan Sollish, at [email protected] or 240-482-3228.

AGA PAC. AGA PAC is a voluntary, nonpartisan political organization affiliated with and supported by AGA. The only political action committee supported by a national gastroenterology society, its mission is to give gastroenterologists a greater presence on Capitol Hill and a more effective voice in policy discussions. AGA PAC supports candidates who support our policy priorities, such as fair reimbursement, cutting regulatory red tape, supporting patient protections and access to specialty care, and sustained federal funding of digestive disease research. If you are interested in learning more, contact AGA Government and Political Affairs Manager, Navneet Buttar, at [email protected] or 240-482-3221.

Congressional Advocates Program. This grassroots program is aimed at establishing a stronger foundation for our current and future advocacy initiatives by creating state teams to work on advocacy on the local, state, and national levels. Participation can include a wide variety of activities, ranging from creating educational posts on social media to meeting with members of Congress. Members of the Congressional Advocates Program are mentored and receive advocacy training by AGA leadership and staff. Participating members receive an AGA Congressional Advocate Program Certificate, a Digestive Disease Week^® (DDW) badge ribbon, policy badge on the AGA Community, and recognition on AGA’s website. Applications for the next cycle will be released in 2019.
 

[email protected]

As an early-career gastroenterologist, I have become increasingly aware of the impact of advocacy in championing legislation important to our patients. Initially naive about health care advocacy, I owe much to AGA in preparing and arranging for opportunities to speak with elected officials and their staff on GI-related priorities and bills. As a member of the AGA Congressional Advocates Program, I received training and support in visiting Capitol Hill, discussing specific legislation and upcoming bills, writing op-eds, and hosting site visits.

Most recently, AGA sponsored my attendance at the Alliance of Specialty Medicine Annual Advocacy Fly In. With colleagues from around the country – in specialties ranging from ophthalmology to dermatology – we listened to invited congressional representatives and senators on important bills that can directly affect the care we provide to our patients. We had the opportunity to ask questions of these legislators, many of whom were fellow physicians, and gain advice on effective advocacy, as well as build camaraderie with our colleagues in other specialties who face similar issues.

With colleagues from Texas, and assisted by Kathleen Teixeira, AGA vice president, government affairs, we visited the offices of our congressional representatives and senators throughout the afternoon. During our meetings with congressional staff, we stressed the importance of making changes to current prior authorization and step-therapy approaches to make it easier for our patients to access the right treatments as soon as possible. We also discussed the importance of supporting graduate medical education to ensure we have a future cohort of gastroenterologists and other specialists to meet the rising demands of our population. We were well received, and the briefs prepared by the alliance and AGA, as well as tips on effectively communicating our positions, made the whole process seamless. Discussing our own personal experiences and sharing patient stories, we found our meetings to be productive and insightful.

Now, I hope to host my congresswoman, Rep. Lizzie Fletcher, D-Tex., for a site visit locally at Baylor, after a successful meeting with her aide on Capitol Hill.

None of this would have been possible without AGA’s support in arranging these presentations, meetings, and physically supporting us throughout the process. I encourage all of you to utilize AGA in advocating for our patients. It is fun, high impact, and incredibly insightful!
 

How to get involved in advocacy

Interested in advocacy but not sure how or whether you have time in your busy schedule? AGA has an array of options for how you can be active in advocacy. Some take as little as 5 minutes.

Letter writing. AGA uses GovPredict, an online advocacy platform that allows members to contact their member of Congress with just a few clicks. AGA develops messages on significant pieces of legislation, key efforts in Congress or on issues being advanced by federal agencies that have a great effect on gastroenterology. AGA’s ongoing letter writing campaigns can always be found on gastro.org, but be sure to keep an eye out for advocacy emails, AGA eDigest, and social media, so you do not miss your opportunity to take action on timely issues. AGA encourages its members to share letter writing campaigns with their colleagues, as well as posting them on social media.

Meetings with your member of Congress. In-person meetings are an excellent opportunity to share with your member of Congress, or their staff, how the issues that affect gastroenterology affect you, your patients, and your practice. AGA has a plethora of resources to help you set up a meeting with your member of Congress, including up-to-date issue briefs, tips and tricks for productive meetings, and webinars on how to host an on-site visit. AGA staff is always more than happy to help you arrange a meeting either in Washington, DC, or your home state. If you are interested in arranging a meeting with your member of Congress, please contact AGA Public Policy Coordinator, Jonathan Sollish, at [email protected] or 240-482-3228.

AGA PAC. AGA PAC is a voluntary, nonpartisan political organization affiliated with and supported by AGA. The only political action committee supported by a national gastroenterology society, its mission is to give gastroenterologists a greater presence on Capitol Hill and a more effective voice in policy discussions. AGA PAC supports candidates who support our policy priorities, such as fair reimbursement, cutting regulatory red tape, supporting patient protections and access to specialty care, and sustained federal funding of digestive disease research. If you are interested in learning more, contact AGA Government and Political Affairs Manager, Navneet Buttar, at [email protected] or 240-482-3221.

Congressional Advocates Program. This grassroots program is aimed at establishing a stronger foundation for our current and future advocacy initiatives by creating state teams to work on advocacy on the local, state, and national levels. Participation can include a wide variety of activities, ranging from creating educational posts on social media to meeting with members of Congress. Members of the Congressional Advocates Program are mentored and receive advocacy training by AGA leadership and staff. Participating members receive an AGA Congressional Advocate Program Certificate, a Digestive Disease Week^® (DDW) badge ribbon, policy badge on the AGA Community, and recognition on AGA’s website. Applications for the next cycle will be released in 2019.
 

[email protected]

As an early-career gastroenterologist, I have become increasingly aware of the impact of advocacy in championing legislation important to our patients. Initially naive about health care advocacy, I owe much to AGA in preparing and arranging for opportunities to speak with elected officials and their staff on GI-related priorities and bills. As a member of the AGA Congressional Advocates Program, I received training and support in visiting Capitol Hill, discussing specific legislation and upcoming bills, writing op-eds, and hosting site visits.

Most recently, AGA sponsored my attendance at the Alliance of Specialty Medicine Annual Advocacy Fly In. With colleagues from around the country – in specialties ranging from ophthalmology to dermatology – we listened to invited congressional representatives and senators on important bills that can directly affect the care we provide to our patients. We had the opportunity to ask questions of these legislators, many of whom were fellow physicians, and gain advice on effective advocacy, as well as build camaraderie with our colleagues in other specialties who face similar issues.

With colleagues from Texas, and assisted by Kathleen Teixeira, AGA vice president, government affairs, we visited the offices of our congressional representatives and senators throughout the afternoon. During our meetings with congressional staff, we stressed the importance of making changes to current prior authorization and step-therapy approaches to make it easier for our patients to access the right treatments as soon as possible. We also discussed the importance of supporting graduate medical education to ensure we have a future cohort of gastroenterologists and other specialists to meet the rising demands of our population. We were well received, and the briefs prepared by the alliance and AGA, as well as tips on effectively communicating our positions, made the whole process seamless. Discussing our own personal experiences and sharing patient stories, we found our meetings to be productive and insightful.

Now, I hope to host my congresswoman, Rep. Lizzie Fletcher, D-Tex., for a site visit locally at Baylor, after a successful meeting with her aide on Capitol Hill.

None of this would have been possible without AGA’s support in arranging these presentations, meetings, and physically supporting us throughout the process. I encourage all of you to utilize AGA in advocating for our patients. It is fun, high impact, and incredibly insightful!
 

How to get involved in advocacy

Interested in advocacy but not sure how or whether you have time in your busy schedule? AGA has an array of options for how you can be active in advocacy. Some take as little as 5 minutes.

Letter writing. AGA uses GovPredict, an online advocacy platform that allows members to contact their member of Congress with just a few clicks. AGA develops messages on significant pieces of legislation, key efforts in Congress or on issues being advanced by federal agencies that have a great effect on gastroenterology. AGA’s ongoing letter writing campaigns can always be found on gastro.org, but be sure to keep an eye out for advocacy emails, AGA eDigest, and social media, so you do not miss your opportunity to take action on timely issues. AGA encourages its members to share letter writing campaigns with their colleagues, as well as posting them on social media.

Meetings with your member of Congress. In-person meetings are an excellent opportunity to share with your member of Congress, or their staff, how the issues that affect gastroenterology affect you, your patients, and your practice. AGA has a plethora of resources to help you set up a meeting with your member of Congress, including up-to-date issue briefs, tips and tricks for productive meetings, and webinars on how to host an on-site visit. AGA staff is always more than happy to help you arrange a meeting either in Washington, DC, or your home state. If you are interested in arranging a meeting with your member of Congress, please contact AGA Public Policy Coordinator, Jonathan Sollish, at [email protected] or 240-482-3228.

AGA PAC. AGA PAC is a voluntary, nonpartisan political organization affiliated with and supported by AGA. The only political action committee supported by a national gastroenterology society, its mission is to give gastroenterologists a greater presence on Capitol Hill and a more effective voice in policy discussions. AGA PAC supports candidates who support our policy priorities, such as fair reimbursement, cutting regulatory red tape, supporting patient protections and access to specialty care, and sustained federal funding of digestive disease research. If you are interested in learning more, contact AGA Government and Political Affairs Manager, Navneet Buttar, at [email protected] or 240-482-3221.

Congressional Advocates Program. This grassroots program is aimed at establishing a stronger foundation for our current and future advocacy initiatives by creating state teams to work on advocacy on the local, state, and national levels. Participation can include a wide variety of activities, ranging from creating educational posts on social media to meeting with members of Congress. Members of the Congressional Advocates Program are mentored and receive advocacy training by AGA leadership and staff. Participating members receive an AGA Congressional Advocate Program Certificate, a Digestive Disease Week^® (DDW) badge ribbon, policy badge on the AGA Community, and recognition on AGA’s website. Applications for the next cycle will be released in 2019.
 

[email protected]

Adolescent girls with heavy menstrual bleeding should be assessed for bleeding disorders, according to a Committee Opinion issued by the American College of Obstetricians and Gynecologists.

A bleeding disorder is secondary only to anovulation as a cause of heavy menstrual bleeding in adolescents.

Bleeding disorders affect 1%-2% of the general population, but are “found in approximately 20% of adolescent girls who present for evaluation of heavy menstrual bleeding and in 33% of adolescent girls hospitalized for heavy menstrual bleeding,” wrote Oluyemisi Adeyemi-Fowode, MD, and Judith Simms-Cendan, MD, and members of the ACOG Committee on Adolescent Health Care in the opinion, published in Obstetrics & Gynecology.

The committee advised that physical examination of teens with acute heavy menstrual bleeding should include assessment of hemodynamic stability with orthostatic blood pressure and pulse measurements. A speculum exam is not usually needed in teen girls with heavy menstrual bleeding. Evaluation should include screening for anemia attributable to blood loss with serum ferritin, endocrine disorders, and bleeding disorders. In suspected cases of bleeding disorders, laboratory evaluation and medical management should be done in consultation with a hematologist.

Those who are actively bleeding or hemodynamically unstable should be hospitalized for medical management, they said.

Ultrasonography is not necessary for an initial work-up of teens with heavy menstrual bleeding, but could be useful in patients who fail to respond to medical management.

Adolescent girls without contraindications to estrogen can be treated with hormone therapy in various forms including intravenous conjugated estrogen every 4-6 hours or oral 30-50 mg ethinyl estradiol every 6-8 hours until cessation of bleeding. Antifibrinolytics also can be used to stop bleeding.

Maintenance therapy after correction of acute heavy bleeding can include a combination of treatments such as hormonal contraceptives, oral and injectable progestins, and levonorgestrel-releasing intrauterine devices, the committee wrote. They also recommended oral iron replacement therapy for all women of reproductive age with anemia caused by menstrual bleeding.

If a patient fails to respond to medical therapy, nonmedical options or surgery may be considered, according to the committee. In addition, all teen girls with bleeding disorders should be advised about safe medication use, including the use of aspirin or NSAIDs only on the recommendation of a hematologist.

Patients and their families need education on menstrual issues including possible options for surgery in the future if heavy menstruation does not resolve. If a patient has a known bleeding disorder and is considering surgery, preoperative evaluation should include a consultation with a hematologist and an anesthesiologist, the committee noted.

Melissa Kottke, MD, MPH, said in an interview, “Every ob.gyn. will see a young patient with ‘heavy menstrual bleeding.’ And it becomes part of the art and challenge to work with the patient and family to collectively explore if this is, indeed, ‘heavy’ and of concern … or is it is a ‘normal’ menstrual period and simply reflects a newer life experience that would benefit from some education? And the stakes are high. Young people who have heavy menstrual cycles are much more likely to have an underlying bleeding disorder than the general population (20% vs. 1%-2%), and 75%-80% of adolescents with bleeding disorders report heavy menses as the most common clinical manifestation of their disorder. 

“Fortunately, Committee Opinion 785, ‘Screening and Management of Bleeding Disorders in Adolescents with Heavy Menstrual Bleeding’ from the ACOG Committee on Adolescent Health Care is detailed and pragmatic. It outlines how to translate everyday conversations with young people about their menses into a quantifiable estimate of bleeding, including a very teen-friendly Pictorial Blood Loss Assessment Chart. It also gives ob.gyns. ever-important guidance about what to do next for evaluation and diagnosis. This committee opinion nicely outlines how to help manage heavy bleeding in an adolescent with a detailed algorithm. And very importantly, it gives clear management guidance and encourages ob.gyns. to avoid frequently unnecessary (speculum exams and ultrasounds) and excessive (early transfusion or surgical interventions) approaches to management for the young patient. I think it will be a great resource for any provider who is taking care of heavy menstrual bleeding for a young person,” said Dr. Kottke, who is director of the Jane Fonda Center for Adolescent Reproductive Health and associate professor of gynecology and obstetrics, both at Emory University, Atlanta. Dr. Kottke is not a member of the ACOG Committee on Adolescent Health and was asked to comment on the opinion.* 


The complete opinion, ACOG Committee Opinion number 785, includes recommended laboratory tests, an eight-question screening tool, and a management algorithm.

The committee members had no financial conflicts to disclose. Dr. Kottke said she had no relevant financial disclosures.

SOURCE: Adeyemi-Fowode O and Simms-Cendan J. Obstet Gynecol. 2019 Sep. 134:e71-83.

*This article was updated on 9/9/2019.

Adolescent girls with heavy menstrual bleeding should be assessed for bleeding disorders, according to a Committee Opinion issued by the American College of Obstetricians and Gynecologists.

A bleeding disorder is secondary only to anovulation as a cause of heavy menstrual bleeding in adolescents.

Bleeding disorders affect 1%-2% of the general population, but are “found in approximately 20% of adolescent girls who present for evaluation of heavy menstrual bleeding and in 33% of adolescent girls hospitalized for heavy menstrual bleeding,” wrote Oluyemisi Adeyemi-Fowode, MD, and Judith Simms-Cendan, MD, and members of the ACOG Committee on Adolescent Health Care in the opinion, published in Obstetrics & Gynecology.

The committee advised that physical examination of teens with acute heavy menstrual bleeding should include assessment of hemodynamic stability with orthostatic blood pressure and pulse measurements. A speculum exam is not usually needed in teen girls with heavy menstrual bleeding. Evaluation should include screening for anemia attributable to blood loss with serum ferritin, endocrine disorders, and bleeding disorders. In suspected cases of bleeding disorders, laboratory evaluation and medical management should be done in consultation with a hematologist.

Those who are actively bleeding or hemodynamically unstable should be hospitalized for medical management, they said.

Ultrasonography is not necessary for an initial work-up of teens with heavy menstrual bleeding, but could be useful in patients who fail to respond to medical management.

Adolescent girls without contraindications to estrogen can be treated with hormone therapy in various forms including intravenous conjugated estrogen every 4-6 hours or oral 30-50 mg ethinyl estradiol every 6-8 hours until cessation of bleeding. Antifibrinolytics also can be used to stop bleeding.

Maintenance therapy after correction of acute heavy bleeding can include a combination of treatments such as hormonal contraceptives, oral and injectable progestins, and levonorgestrel-releasing intrauterine devices, the committee wrote. They also recommended oral iron replacement therapy for all women of reproductive age with anemia caused by menstrual bleeding.

If a patient fails to respond to medical therapy, nonmedical options or surgery may be considered, according to the committee. In addition, all teen girls with bleeding disorders should be advised about safe medication use, including the use of aspirin or NSAIDs only on the recommendation of a hematologist.

Patients and their families need education on menstrual issues including possible options for surgery in the future if heavy menstruation does not resolve. If a patient has a known bleeding disorder and is considering surgery, preoperative evaluation should include a consultation with a hematologist and an anesthesiologist, the committee noted.

Melissa Kottke, MD, MPH, said in an interview, “Every ob.gyn. will see a young patient with ‘heavy menstrual bleeding.’ And it becomes part of the art and challenge to work with the patient and family to collectively explore if this is, indeed, ‘heavy’ and of concern … or is it is a ‘normal’ menstrual period and simply reflects a newer life experience that would benefit from some education? And the stakes are high. Young people who have heavy menstrual cycles are much more likely to have an underlying bleeding disorder than the general population (20% vs. 1%-2%), and 75%-80% of adolescents with bleeding disorders report heavy menses as the most common clinical manifestation of their disorder. 

“Fortunately, Committee Opinion 785, ‘Screening and Management of Bleeding Disorders in Adolescents with Heavy Menstrual Bleeding’ from the ACOG Committee on Adolescent Health Care is detailed and pragmatic. It outlines how to translate everyday conversations with young people about their menses into a quantifiable estimate of bleeding, including a very teen-friendly Pictorial Blood Loss Assessment Chart. It also gives ob.gyns. ever-important guidance about what to do next for evaluation and diagnosis. This committee opinion nicely outlines how to help manage heavy bleeding in an adolescent with a detailed algorithm. And very importantly, it gives clear management guidance and encourages ob.gyns. to avoid frequently unnecessary (speculum exams and ultrasounds) and excessive (early transfusion or surgical interventions) approaches to management for the young patient. I think it will be a great resource for any provider who is taking care of heavy menstrual bleeding for a young person,” said Dr. Kottke, who is director of the Jane Fonda Center for Adolescent Reproductive Health and associate professor of gynecology and obstetrics, both at Emory University, Atlanta. Dr. Kottke is not a member of the ACOG Committee on Adolescent Health and was asked to comment on the opinion.* 


The complete opinion, ACOG Committee Opinion number 785, includes recommended laboratory tests, an eight-question screening tool, and a management algorithm.

The committee members had no financial conflicts to disclose. Dr. Kottke said she had no relevant financial disclosures.

SOURCE: Adeyemi-Fowode O and Simms-Cendan J. Obstet Gynecol. 2019 Sep. 134:e71-83.

*This article was updated on 9/9/2019.

Adolescent girls with heavy menstrual bleeding should be assessed for bleeding disorders, according to a Committee Opinion issued by the American College of Obstetricians and Gynecologists.

A bleeding disorder is secondary only to anovulation as a cause of heavy menstrual bleeding in adolescents.

Bleeding disorders affect 1%-2% of the general population, but are “found in approximately 20% of adolescent girls who present for evaluation of heavy menstrual bleeding and in 33% of adolescent girls hospitalized for heavy menstrual bleeding,” wrote Oluyemisi Adeyemi-Fowode, MD, and Judith Simms-Cendan, MD, and members of the ACOG Committee on Adolescent Health Care in the opinion, published in Obstetrics & Gynecology.

The committee advised that physical examination of teens with acute heavy menstrual bleeding should include assessment of hemodynamic stability with orthostatic blood pressure and pulse measurements. A speculum exam is not usually needed in teen girls with heavy menstrual bleeding. Evaluation should include screening for anemia attributable to blood loss with serum ferritin, endocrine disorders, and bleeding disorders. In suspected cases of bleeding disorders, laboratory evaluation and medical management should be done in consultation with a hematologist.

Those who are actively bleeding or hemodynamically unstable should be hospitalized for medical management, they said.

Ultrasonography is not necessary for an initial work-up of teens with heavy menstrual bleeding, but could be useful in patients who fail to respond to medical management.

Adolescent girls without contraindications to estrogen can be treated with hormone therapy in various forms including intravenous conjugated estrogen every 4-6 hours or oral 30-50 mg ethinyl estradiol every 6-8 hours until cessation of bleeding. Antifibrinolytics also can be used to stop bleeding.

Maintenance therapy after correction of acute heavy bleeding can include a combination of treatments such as hormonal contraceptives, oral and injectable progestins, and levonorgestrel-releasing intrauterine devices, the committee wrote. They also recommended oral iron replacement therapy for all women of reproductive age with anemia caused by menstrual bleeding.

If a patient fails to respond to medical therapy, nonmedical options or surgery may be considered, according to the committee. In addition, all teen girls with bleeding disorders should be advised about safe medication use, including the use of aspirin or NSAIDs only on the recommendation of a hematologist.

Patients and their families need education on menstrual issues including possible options for surgery in the future if heavy menstruation does not resolve. If a patient has a known bleeding disorder and is considering surgery, preoperative evaluation should include a consultation with a hematologist and an anesthesiologist, the committee noted.

Melissa Kottke, MD, MPH, said in an interview, “Every ob.gyn. will see a young patient with ‘heavy menstrual bleeding.’ And it becomes part of the art and challenge to work with the patient and family to collectively explore if this is, indeed, ‘heavy’ and of concern … or is it is a ‘normal’ menstrual period and simply reflects a newer life experience that would benefit from some education? And the stakes are high. Young people who have heavy menstrual cycles are much more likely to have an underlying bleeding disorder than the general population (20% vs. 1%-2%), and 75%-80% of adolescents with bleeding disorders report heavy menses as the most common clinical manifestation of their disorder. 

“Fortunately, Committee Opinion 785, ‘Screening and Management of Bleeding Disorders in Adolescents with Heavy Menstrual Bleeding’ from the ACOG Committee on Adolescent Health Care is detailed and pragmatic. It outlines how to translate everyday conversations with young people about their menses into a quantifiable estimate of bleeding, including a very teen-friendly Pictorial Blood Loss Assessment Chart. It also gives ob.gyns. ever-important guidance about what to do next for evaluation and diagnosis. This committee opinion nicely outlines how to help manage heavy bleeding in an adolescent with a detailed algorithm. And very importantly, it gives clear management guidance and encourages ob.gyns. to avoid frequently unnecessary (speculum exams and ultrasounds) and excessive (early transfusion or surgical interventions) approaches to management for the young patient. I think it will be a great resource for any provider who is taking care of heavy menstrual bleeding for a young person,” said Dr. Kottke, who is director of the Jane Fonda Center for Adolescent Reproductive Health and associate professor of gynecology and obstetrics, both at Emory University, Atlanta. Dr. Kottke is not a member of the ACOG Committee on Adolescent Health and was asked to comment on the opinion.* 


The complete opinion, ACOG Committee Opinion number 785, includes recommended laboratory tests, an eight-question screening tool, and a management algorithm.

The committee members had no financial conflicts to disclose. Dr. Kottke said she had no relevant financial disclosures.

SOURCE: Adeyemi-Fowode O and Simms-Cendan J. Obstet Gynecol. 2019 Sep. 134:e71-83.

*This article was updated on 9/9/2019.

All who attended the 2019 Vascular Annual Meeting can review sessions they attended, as well as “attend” those that they missed. Those who weren’t at VAM can now experience all they missed. Slides and audio presentations of nearly every session are included in VAM on Demand. The cost for one year of access is $199 for VAM attendees and $499 for non-attendees. Those who purchased VAM on Demand before the meeting ended can visit this site to gain access by logging in with their SVS credentials.

All who attended the 2019 Vascular Annual Meeting can review sessions they attended, as well as “attend” those that they missed. Those who weren’t at VAM can now experience all they missed. Slides and audio presentations of nearly every session are included in VAM on Demand. The cost for one year of access is $199 for VAM attendees and $499 for non-attendees. Those who purchased VAM on Demand before the meeting ended can visit this site to gain access by logging in with their SVS credentials.

All who attended the 2019 Vascular Annual Meeting can review sessions they attended, as well as “attend” those that they missed. Those who weren’t at VAM can now experience all they missed. Slides and audio presentations of nearly every session are included in VAM on Demand. The cost for one year of access is $199 for VAM attendees and $499 for non-attendees. Those who purchased VAM on Demand before the meeting ended can visit this site to gain access by logging in with their SVS credentials.

MILAN – Skin manifestations of the vasculitides can point the way to an accurate diagnosis and provide clues about disease severity, Robert Micheletti, MD, said at the World Congress of Dermatology.

In granulomatous vasculitis, histiocytes and giant cells can play a significant role, explained Dr. Micheletti, director of the cutaneous vasculitis clinic at the University of Pennsylvania, Philadelphia. The condition may be secondary to an autoimmune disease such as lupus erythematosus or RA; a granulomatous disease such as Crohn’s disease or sarcoidosis; infections such as tuberculosis, a fungal disease, or herpes or zoster viruses, or lymphoma, Dr. Micheletti said.

However, a primary systemic vasculitis such as granulomatosis with polyangiitis (GPA; formerly known as Wegener’s polyangiitis) or eosinophilic granulomatosis with polyangiitis (EGPA; also known as Churg-Strauss vasculitis), giant cell arteritis, or Takayasu arteritis may also be responsible, he said. Occasionally, the culprit can also be a drug-induced vasculitis.

The physical examination gives clues to the size of involved vessels, which in turn helps to classify the vasculitis, Dr. Micheletti said.

When vasculitis affects small vessels, the skin findings will be palpable purpura, urticarial papules, vesicles, and petechiae, he said, adding that “The small vessel involvement accounts for the small size of the lesions, and complement cascade and inflammation account for the palpability of the lesions and the symptomatology.” As red blood cells extravasate from the affected vessels, nonblanching purpura develop, and gravity’s effect on the deposition of immune complex material dictates how lesions are distributed.

“Manifestations more typical of medium vessel vasculitis include subcutaneous nodules, livedo reticularis, retiform purpura, larger hemorrhagic bullae, and more significant ulceration and necrosis,” he said. “If such lesions are seen, suspect medium-vessel vasculitis or vasculitis overlapping small and medium vessels.” Cutaneous or systemic polyarteritis nodosa, antineutrophilic cytoplasmic autoantibody (ANCA)–associated vasculitis, and cryoglobulinemic vasculitis are examples, he added.

The particularities of renal manifestations of vasculitis also offer clues to the vessels involved. When a vasculitis patient has glomerulonephritis, suspect small-vessel involvement, Dr. Micheletti said. However, vasculitis affecting medium-sized vessels will cause renovascular hypertension and, potentially renal arterial aneurysms.

Nerves are typically spared in small-vessel vasculitis, while wrist or foot drop can be seen in mononeuritis multiplex.

Recently, the Diagnostic and Classification Criteria in Vasculitis Study (DCVAS) looked at more than 6,800 patients at over 130 sites around the world, proposing new classification criteria for ANCA-associated vasculitis (AAV) and large-vessel vasculitis. The study found that skin findings are common in AAV, with 30%-50% of cases presenting initially with skin lesions. Petechiae and/or purpura are the most common of the skin manifestations, he said. By contrast, for EGPA, allergic and nonspecific findings were the most common findings.

Although skin biopsy can confirm the diagnosis in up to 94% of AAV cases, it’s underutilized and performed in less than half (24%-44%) of cases, Dr. Micheletti said. The study’s findings “demonstrate the importance of a good skin exam, as well as its utility for diagnosis” of vasculitis, he said.

An additional finding form the DCVAS study was that skin lesions can give clues to severity of vasculitis: “Among 1,184 patients with ANCA-associated vasculitis, those with cutaneous involvement were more likely to have systemic manifestations of disease, more likely to have such severe manifestations as glomerulonephritis, alveolar hemorrhage, and mononeuritis,” said Dr. Micheletti, with a hazard ratio of 2.0 among those individuals who had EGPA or GPA.

“Skin findings have diagnostic and, potentially, prognostic importance,” he said. “Use the physician exam and your clinical acumen to your advantage,” but always confirm vasculitis with a biopsy. “Clinicopathologic correlation is key.” A simple urinalysis will screen for renal involvement, and is of “paramount importance,” he added.

Dr. Micheletti reported that he had no relevant disclosures.

[email protected]

MILAN – Skin manifestations of the vasculitides can point the way to an accurate diagnosis and provide clues about disease severity, Robert Micheletti, MD, said at the World Congress of Dermatology.

In granulomatous vasculitis, histiocytes and giant cells can play a significant role, explained Dr. Micheletti, director of the cutaneous vasculitis clinic at the University of Pennsylvania, Philadelphia. The condition may be secondary to an autoimmune disease such as lupus erythematosus or RA; a granulomatous disease such as Crohn’s disease or sarcoidosis; infections such as tuberculosis, a fungal disease, or herpes or zoster viruses, or lymphoma, Dr. Micheletti said.

However, a primary systemic vasculitis such as granulomatosis with polyangiitis (GPA; formerly known as Wegener’s polyangiitis) or eosinophilic granulomatosis with polyangiitis (EGPA; also known as Churg-Strauss vasculitis), giant cell arteritis, or Takayasu arteritis may also be responsible, he said. Occasionally, the culprit can also be a drug-induced vasculitis.

The physical examination gives clues to the size of involved vessels, which in turn helps to classify the vasculitis, Dr. Micheletti said.

When vasculitis affects small vessels, the skin findings will be palpable purpura, urticarial papules, vesicles, and petechiae, he said, adding that “The small vessel involvement accounts for the small size of the lesions, and complement cascade and inflammation account for the palpability of the lesions and the symptomatology.” As red blood cells extravasate from the affected vessels, nonblanching purpura develop, and gravity’s effect on the deposition of immune complex material dictates how lesions are distributed.

“Manifestations more typical of medium vessel vasculitis include subcutaneous nodules, livedo reticularis, retiform purpura, larger hemorrhagic bullae, and more significant ulceration and necrosis,” he said. “If such lesions are seen, suspect medium-vessel vasculitis or vasculitis overlapping small and medium vessels.” Cutaneous or systemic polyarteritis nodosa, antineutrophilic cytoplasmic autoantibody (ANCA)–associated vasculitis, and cryoglobulinemic vasculitis are examples, he added.

The particularities of renal manifestations of vasculitis also offer clues to the vessels involved. When a vasculitis patient has glomerulonephritis, suspect small-vessel involvement, Dr. Micheletti said. However, vasculitis affecting medium-sized vessels will cause renovascular hypertension and, potentially renal arterial aneurysms.

Nerves are typically spared in small-vessel vasculitis, while wrist or foot drop can be seen in mononeuritis multiplex.

Recently, the Diagnostic and Classification Criteria in Vasculitis Study (DCVAS) looked at more than 6,800 patients at over 130 sites around the world, proposing new classification criteria for ANCA-associated vasculitis (AAV) and large-vessel vasculitis. The study found that skin findings are common in AAV, with 30%-50% of cases presenting initially with skin lesions. Petechiae and/or purpura are the most common of the skin manifestations, he said. By contrast, for EGPA, allergic and nonspecific findings were the most common findings.

Although skin biopsy can confirm the diagnosis in up to 94% of AAV cases, it’s underutilized and performed in less than half (24%-44%) of cases, Dr. Micheletti said. The study’s findings “demonstrate the importance of a good skin exam, as well as its utility for diagnosis” of vasculitis, he said.

An additional finding form the DCVAS study was that skin lesions can give clues to severity of vasculitis: “Among 1,184 patients with ANCA-associated vasculitis, those with cutaneous involvement were more likely to have systemic manifestations of disease, more likely to have such severe manifestations as glomerulonephritis, alveolar hemorrhage, and mononeuritis,” said Dr. Micheletti, with a hazard ratio of 2.0 among those individuals who had EGPA or GPA.

“Skin findings have diagnostic and, potentially, prognostic importance,” he said. “Use the physician exam and your clinical acumen to your advantage,” but always confirm vasculitis with a biopsy. “Clinicopathologic correlation is key.” A simple urinalysis will screen for renal involvement, and is of “paramount importance,” he added.

Dr. Micheletti reported that he had no relevant disclosures.

[email protected]

MILAN – Skin manifestations of the vasculitides can point the way to an accurate diagnosis and provide clues about disease severity, Robert Micheletti, MD, said at the World Congress of Dermatology.

In granulomatous vasculitis, histiocytes and giant cells can play a significant role, explained Dr. Micheletti, director of the cutaneous vasculitis clinic at the University of Pennsylvania, Philadelphia. The condition may be secondary to an autoimmune disease such as lupus erythematosus or RA; a granulomatous disease such as Crohn’s disease or sarcoidosis; infections such as tuberculosis, a fungal disease, or herpes or zoster viruses, or lymphoma, Dr. Micheletti said.

However, a primary systemic vasculitis such as granulomatosis with polyangiitis (GPA; formerly known as Wegener’s polyangiitis) or eosinophilic granulomatosis with polyangiitis (EGPA; also known as Churg-Strauss vasculitis), giant cell arteritis, or Takayasu arteritis may also be responsible, he said. Occasionally, the culprit can also be a drug-induced vasculitis.

The physical examination gives clues to the size of involved vessels, which in turn helps to classify the vasculitis, Dr. Micheletti said.

When vasculitis affects small vessels, the skin findings will be palpable purpura, urticarial papules, vesicles, and petechiae, he said, adding that “The small vessel involvement accounts for the small size of the lesions, and complement cascade and inflammation account for the palpability of the lesions and the symptomatology.” As red blood cells extravasate from the affected vessels, nonblanching purpura develop, and gravity’s effect on the deposition of immune complex material dictates how lesions are distributed.

“Manifestations more typical of medium vessel vasculitis include subcutaneous nodules, livedo reticularis, retiform purpura, larger hemorrhagic bullae, and more significant ulceration and necrosis,” he said. “If such lesions are seen, suspect medium-vessel vasculitis or vasculitis overlapping small and medium vessels.” Cutaneous or systemic polyarteritis nodosa, antineutrophilic cytoplasmic autoantibody (ANCA)–associated vasculitis, and cryoglobulinemic vasculitis are examples, he added.

The particularities of renal manifestations of vasculitis also offer clues to the vessels involved. When a vasculitis patient has glomerulonephritis, suspect small-vessel involvement, Dr. Micheletti said. However, vasculitis affecting medium-sized vessels will cause renovascular hypertension and, potentially renal arterial aneurysms.

Nerves are typically spared in small-vessel vasculitis, while wrist or foot drop can be seen in mononeuritis multiplex.

Recently, the Diagnostic and Classification Criteria in Vasculitis Study (DCVAS) looked at more than 6,800 patients at over 130 sites around the world, proposing new classification criteria for ANCA-associated vasculitis (AAV) and large-vessel vasculitis. The study found that skin findings are common in AAV, with 30%-50% of cases presenting initially with skin lesions. Petechiae and/or purpura are the most common of the skin manifestations, he said. By contrast, for EGPA, allergic and nonspecific findings were the most common findings.

Although skin biopsy can confirm the diagnosis in up to 94% of AAV cases, it’s underutilized and performed in less than half (24%-44%) of cases, Dr. Micheletti said. The study’s findings “demonstrate the importance of a good skin exam, as well as its utility for diagnosis” of vasculitis, he said.

An additional finding form the DCVAS study was that skin lesions can give clues to severity of vasculitis: “Among 1,184 patients with ANCA-associated vasculitis, those with cutaneous involvement were more likely to have systemic manifestations of disease, more likely to have such severe manifestations as glomerulonephritis, alveolar hemorrhage, and mononeuritis,” said Dr. Micheletti, with a hazard ratio of 2.0 among those individuals who had EGPA or GPA.

“Skin findings have diagnostic and, potentially, prognostic importance,” he said. “Use the physician exam and your clinical acumen to your advantage,” but always confirm vasculitis with a biopsy. “Clinicopathologic correlation is key.” A simple urinalysis will screen for renal involvement, and is of “paramount importance,” he added.

Dr. Micheletti reported that he had no relevant disclosures.

[email protected]

Attend the first ever International Symposium on Pediatric Renovascular Hypertension Nov. 11-12 at the University of Michigan in Ann Arbor. This conference will bring multi-disciplinary experts together to identify best practices in clinical management of unique pediatric patients. An array of distinguished physicians and researchers will highlight the best practices in patient care, recent discovery and ongoing research. Conference admission is free; breakfast, lunch and coffee breaks will be served. Register today.

Attend the first ever International Symposium on Pediatric Renovascular Hypertension Nov. 11-12 at the University of Michigan in Ann Arbor. This conference will bring multi-disciplinary experts together to identify best practices in clinical management of unique pediatric patients. An array of distinguished physicians and researchers will highlight the best practices in patient care, recent discovery and ongoing research. Conference admission is free; breakfast, lunch and coffee breaks will be served. Register today.

Attend the first ever International Symposium on Pediatric Renovascular Hypertension Nov. 11-12 at the University of Michigan in Ann Arbor. This conference will bring multi-disciplinary experts together to identify best practices in clinical management of unique pediatric patients. An array of distinguished physicians and researchers will highlight the best practices in patient care, recent discovery and ongoing research. Conference admission is free; breakfast, lunch and coffee breaks will be served. Register today.

September is PAD month. Did you know that the SVS Foundation offers free patient education fliers that you can easily customize with your own office name and contact information? We have one on PAD, one on Smoking and Vascular Disease, and seven others on various vascular-related topics. All are free and available for download in English and Spanish. Visit this page to view and celebrate PAD month with some patient education.

September is PAD month. Did you know that the SVS Foundation offers free patient education fliers that you can easily customize with your own office name and contact information? We have one on PAD, one on Smoking and Vascular Disease, and seven others on various vascular-related topics. All are free and available for download in English and Spanish. Visit this page to view and celebrate PAD month with some patient education.

September is PAD month. Did you know that the SVS Foundation offers free patient education fliers that you can easily customize with your own office name and contact information? We have one on PAD, one on Smoking and Vascular Disease, and seven others on various vascular-related topics. All are free and available for download in English and Spanish. Visit this page to view and celebrate PAD month with some patient education.

To the Editor:

A 75-year-old woman with a history of hypertension, gout, and adult-onset diabetes mellitus was started on dapagliflozin (5 mg) for glycemic control (hemoglobin A_1c, 7.9 [reference range, 4–7]). Within 1 week of starting the medication, she developed a fine papular eruption in a photodistributed area on the neck and chest with associated malaise. The rash progressed over the next 2 weeks, evolving into edematous papules and plaques, some with vesicles involving the neck, chest, postauricular areas, and nose. Approximately 3 weeks after starting dapagliflozin, the patient also developed bilateral painful, hemorrhagic, bullous plaques (10×3 cm overall) without satellite lesions on the dorsal aspects of the hands. The borders of the bullae had rapidly expanding geographic margins and were extremely painful. The patient’s primary care physician advised to discontinue dapagliflozin, as this medication was thought to be triggering the eruption. She was administered triamcinolone (40 mg intramuscularly) and advised to take ibuprofen as needed. She had malaise and reported that she felt hot but had no known fever. No laboratory tests were ordered. 

The lesions on the neck and chest began to fade within 1 week of stopping the medication and administering corticosteroids; however, the hand lesions continued to progress and began to involve the base of the digits (Figure 1). The patient was then seen by a dermatologist who biopsied the hand lesions. Histopathology was characteristic of Sweet syndrome, also known as acute febrile neutrophilic dermatosis and Gomm-Button disease. Notably, there was a dense nodular infiltrate of neutrophils, papillary dermal edema, and leukocytoclastic debris without leukocytoclastic vasculitis (Figure 2).

Because of the presence of lesions on the dorsal aspects of the hands in our patient, the differential diagnosis included the localized variant of Sweet syndrome known as neutrophilic dermatosis of the dorsal hands, but a diagnosis of classic Sweet syndrome was favored due to the lack of intense papillary dermal edema and vasculitis.^1,2 Although the hand lesions appeared after the neck and chest lesions, the temporal relationship of their appearance with medication usage and clearing once the medication was stopped favored these lesions as part of the same drug-induced response.

Dapagliflozin is a member of a new class of medications (gliflozins) used for the treatment of type 2 diabetes mellitus.^3,4 The medication lowers blood glucose by inhibiting the sodium-glucose cotransport protein 2, thus lowering the blood glucose levels by increasing urinary excretion of glucose. Because many patients with type 2 diabetes mellitus are overweight, these medications are poised to gain popularity for weight loss and decreased blood pressure side effects. Three other medications in this class also have been approved by US Food and Drug Administration: empagliflozin, canagliflozin, and ertugliflozin.

Sweet syndrome consists of 4 cardinal features that were first described in 1964: fever, leukocytosis, tender red plaques, and a dermal neutrophilic infiltrate.⁵ Since then, Su and Liu⁶ proposed guidelines consisting of major and minor criteria. In 1996, Walker and Cohen⁷ suggested a set of diagnostic criteria specifically for drug-induced Sweet syndrome, including painful erythematous plaques, histopathologic neutrophilic infiltrate, and fever. Additional criteria included a temporal relationship between drug ingestion and clinical presentation as well as resolution of lesions after drug withdrawal or treatment with systemic corticosteroids.⁷ The lesions of drug-induced Sweet syndrome often are described as painful red papules that can form plaques, may appear vesicular, and are more common in women. These lesions classically appear on the upper extremities, as well as the head, neck, trunk, and back.⁸ Clinically, symptoms most commonly include fever and musculoskeletal involvement, both of which were experienced by the patient who described herself as feeling feverish when the lesions first appeared and reported malaise. Our patient experienced all of these features, and although a fever was not measured in the acute stage of presentation, she reported feeling hot. Other symptoms that may occur include arthralgia, headache, and myalgia.⁹ Microscopically, there is a nodular infiltrate of neutrophils, papillary dermal edema, and leukocytoclastic debris. The pathogenesis of Sweet syndrome remains unclear but can be associated with malignancy, pregnancy, autoimmune disorders, and drug reactions.¹⁰ Many different classes of medications have been reported to cause drug-induced Sweet syndrome and are listed in the Table.^1,8,11 The recommended treatment of Sweet syndrome is systemic corticosteroids.¹²

To the Editor:

A 75-year-old woman with a history of hypertension, gout, and adult-onset diabetes mellitus was started on dapagliflozin (5 mg) for glycemic control (hemoglobin A_1c, 7.9 [reference range, 4–7]). Within 1 week of starting the medication, she developed a fine papular eruption in a photodistributed area on the neck and chest with associated malaise. The rash progressed over the next 2 weeks, evolving into edematous papules and plaques, some with vesicles involving the neck, chest, postauricular areas, and nose. Approximately 3 weeks after starting dapagliflozin, the patient also developed bilateral painful, hemorrhagic, bullous plaques (10×3 cm overall) without satellite lesions on the dorsal aspects of the hands. The borders of the bullae had rapidly expanding geographic margins and were extremely painful. The patient’s primary care physician advised to discontinue dapagliflozin, as this medication was thought to be triggering the eruption. She was administered triamcinolone (40 mg intramuscularly) and advised to take ibuprofen as needed. She had malaise and reported that she felt hot but had no known fever. No laboratory tests were ordered. 

The lesions on the neck and chest began to fade within 1 week of stopping the medication and administering corticosteroids; however, the hand lesions continued to progress and began to involve the base of the digits (Figure 1). The patient was then seen by a dermatologist who biopsied the hand lesions. Histopathology was characteristic of Sweet syndrome, also known as acute febrile neutrophilic dermatosis and Gomm-Button disease. Notably, there was a dense nodular infiltrate of neutrophils, papillary dermal edema, and leukocytoclastic debris without leukocytoclastic vasculitis (Figure 2).

Because of the presence of lesions on the dorsal aspects of the hands in our patient, the differential diagnosis included the localized variant of Sweet syndrome known as neutrophilic dermatosis of the dorsal hands, but a diagnosis of classic Sweet syndrome was favored due to the lack of intense papillary dermal edema and vasculitis.^1,2 Although the hand lesions appeared after the neck and chest lesions, the temporal relationship of their appearance with medication usage and clearing once the medication was stopped favored these lesions as part of the same drug-induced response.

Dapagliflozin is a member of a new class of medications (gliflozins) used for the treatment of type 2 diabetes mellitus.^3,4 The medication lowers blood glucose by inhibiting the sodium-glucose cotransport protein 2, thus lowering the blood glucose levels by increasing urinary excretion of glucose. Because many patients with type 2 diabetes mellitus are overweight, these medications are poised to gain popularity for weight loss and decreased blood pressure side effects. Three other medications in this class also have been approved by US Food and Drug Administration: empagliflozin, canagliflozin, and ertugliflozin.

Sweet syndrome consists of 4 cardinal features that were first described in 1964: fever, leukocytosis, tender red plaques, and a dermal neutrophilic infiltrate.⁵ Since then, Su and Liu⁶ proposed guidelines consisting of major and minor criteria. In 1996, Walker and Cohen⁷ suggested a set of diagnostic criteria specifically for drug-induced Sweet syndrome, including painful erythematous plaques, histopathologic neutrophilic infiltrate, and fever. Additional criteria included a temporal relationship between drug ingestion and clinical presentation as well as resolution of lesions after drug withdrawal or treatment with systemic corticosteroids.⁷ The lesions of drug-induced Sweet syndrome often are described as painful red papules that can form plaques, may appear vesicular, and are more common in women. These lesions classically appear on the upper extremities, as well as the head, neck, trunk, and back.⁸ Clinically, symptoms most commonly include fever and musculoskeletal involvement, both of which were experienced by the patient who described herself as feeling feverish when the lesions first appeared and reported malaise. Our patient experienced all of these features, and although a fever was not measured in the acute stage of presentation, she reported feeling hot. Other symptoms that may occur include arthralgia, headache, and myalgia.⁹ Microscopically, there is a nodular infiltrate of neutrophils, papillary dermal edema, and leukocytoclastic debris. The pathogenesis of Sweet syndrome remains unclear but can be associated with malignancy, pregnancy, autoimmune disorders, and drug reactions.¹⁰ Many different classes of medications have been reported to cause drug-induced Sweet syndrome and are listed in the Table.^1,8,11 The recommended treatment of Sweet syndrome is systemic corticosteroids.¹²

To the Editor:

A 75-year-old woman with a history of hypertension, gout, and adult-onset diabetes mellitus was started on dapagliflozin (5 mg) for glycemic control (hemoglobin A_1c, 7.9 [reference range, 4–7]). Within 1 week of starting the medication, she developed a fine papular eruption in a photodistributed area on the neck and chest with associated malaise. The rash progressed over the next 2 weeks, evolving into edematous papules and plaques, some with vesicles involving the neck, chest, postauricular areas, and nose. Approximately 3 weeks after starting dapagliflozin, the patient also developed bilateral painful, hemorrhagic, bullous plaques (10×3 cm overall) without satellite lesions on the dorsal aspects of the hands. The borders of the bullae had rapidly expanding geographic margins and were extremely painful. The patient’s primary care physician advised to discontinue dapagliflozin, as this medication was thought to be triggering the eruption. She was administered triamcinolone (40 mg intramuscularly) and advised to take ibuprofen as needed. She had malaise and reported that she felt hot but had no known fever. No laboratory tests were ordered. 

The lesions on the neck and chest began to fade within 1 week of stopping the medication and administering corticosteroids; however, the hand lesions continued to progress and began to involve the base of the digits (Figure 1). The patient was then seen by a dermatologist who biopsied the hand lesions. Histopathology was characteristic of Sweet syndrome, also known as acute febrile neutrophilic dermatosis and Gomm-Button disease. Notably, there was a dense nodular infiltrate of neutrophils, papillary dermal edema, and leukocytoclastic debris without leukocytoclastic vasculitis (Figure 2).

Because of the presence of lesions on the dorsal aspects of the hands in our patient, the differential diagnosis included the localized variant of Sweet syndrome known as neutrophilic dermatosis of the dorsal hands, but a diagnosis of classic Sweet syndrome was favored due to the lack of intense papillary dermal edema and vasculitis.^1,2 Although the hand lesions appeared after the neck and chest lesions, the temporal relationship of their appearance with medication usage and clearing once the medication was stopped favored these lesions as part of the same drug-induced response.

Dapagliflozin is a member of a new class of medications (gliflozins) used for the treatment of type 2 diabetes mellitus.^3,4 The medication lowers blood glucose by inhibiting the sodium-glucose cotransport protein 2, thus lowering the blood glucose levels by increasing urinary excretion of glucose. Because many patients with type 2 diabetes mellitus are overweight, these medications are poised to gain popularity for weight loss and decreased blood pressure side effects. Three other medications in this class also have been approved by US Food and Drug Administration: empagliflozin, canagliflozin, and ertugliflozin.

Sweet syndrome consists of 4 cardinal features that were first described in 1964: fever, leukocytosis, tender red plaques, and a dermal neutrophilic infiltrate.⁵ Since then, Su and Liu⁶ proposed guidelines consisting of major and minor criteria. In 1996, Walker and Cohen⁷ suggested a set of diagnostic criteria specifically for drug-induced Sweet syndrome, including painful erythematous plaques, histopathologic neutrophilic infiltrate, and fever. Additional criteria included a temporal relationship between drug ingestion and clinical presentation as well as resolution of lesions after drug withdrawal or treatment with systemic corticosteroids.⁷ The lesions of drug-induced Sweet syndrome often are described as painful red papules that can form plaques, may appear vesicular, and are more common in women. These lesions classically appear on the upper extremities, as well as the head, neck, trunk, and back.⁸ Clinically, symptoms most commonly include fever and musculoskeletal involvement, both of which were experienced by the patient who described herself as feeling feverish when the lesions first appeared and reported malaise. Our patient experienced all of these features, and although a fever was not measured in the acute stage of presentation, she reported feeling hot. Other symptoms that may occur include arthralgia, headache, and myalgia.⁹ Microscopically, there is a nodular infiltrate of neutrophils, papillary dermal edema, and leukocytoclastic debris. The pathogenesis of Sweet syndrome remains unclear but can be associated with malignancy, pregnancy, autoimmune disorders, and drug reactions.¹⁰ Many different classes of medications have been reported to cause drug-induced Sweet syndrome and are listed in the Table.^1,8,11 The recommended treatment of Sweet syndrome is systemic corticosteroids.¹²

The Food and Drug Administration has granted breakthrough therapy designation to acalabrutinib (Calquence) as a monotherapy for adults with chronic lymphocytic leukemia (CLL).

The Bruton tyrosine kinase inhibitor is already approved for the treatment of adults with mantle cell lymphoma who have received at least one prior therapy, and multiple trials are underway to evaluate the drug’s use in a variety of B-cell malignancies, according to the drug’s sponsor, AstraZeneca.

The current designation was based on preliminary results from two phase 3 trials – ELEVATE-TN and ASCEND. In the three-arm ELEVATE-TN trial, researchers evaluated acalabrutinib alone or in combination with obinutuzumab versus chlorambucil plus obinutuzumab in previously untreated patients with CLL. In the two-arm ASCEND trial, previously treated patients with CLL were randomized to receive acalabrutinib monotherapy or the physician’s choice of either rituximab plus idelalisib or rituximab plus bendamustine.

Interim analyses of the two trials showed that acalabrutinib alone, or in combination, significantly improved progression-free survival without raising safety concerns.

Breakthrough therapy designation allows for an expedited review by the FDA for treatments aimed at treating serious conditions where there is preliminary clinical evidence showing a substantial improvement over an available therapy or a clinically significant endpoint.

[email protected]

The Food and Drug Administration has granted breakthrough therapy designation to acalabrutinib (Calquence) as a monotherapy for adults with chronic lymphocytic leukemia (CLL).

The Bruton tyrosine kinase inhibitor is already approved for the treatment of adults with mantle cell lymphoma who have received at least one prior therapy, and multiple trials are underway to evaluate the drug’s use in a variety of B-cell malignancies, according to the drug’s sponsor, AstraZeneca.

The current designation was based on preliminary results from two phase 3 trials – ELEVATE-TN and ASCEND. In the three-arm ELEVATE-TN trial, researchers evaluated acalabrutinib alone or in combination with obinutuzumab versus chlorambucil plus obinutuzumab in previously untreated patients with CLL. In the two-arm ASCEND trial, previously treated patients with CLL were randomized to receive acalabrutinib monotherapy or the physician’s choice of either rituximab plus idelalisib or rituximab plus bendamustine.

Interim analyses of the two trials showed that acalabrutinib alone, or in combination, significantly improved progression-free survival without raising safety concerns.

Breakthrough therapy designation allows for an expedited review by the FDA for treatments aimed at treating serious conditions where there is preliminary clinical evidence showing a substantial improvement over an available therapy or a clinically significant endpoint.

[email protected]

The Food and Drug Administration has granted breakthrough therapy designation to acalabrutinib (Calquence) as a monotherapy for adults with chronic lymphocytic leukemia (CLL).

The Bruton tyrosine kinase inhibitor is already approved for the treatment of adults with mantle cell lymphoma who have received at least one prior therapy, and multiple trials are underway to evaluate the drug’s use in a variety of B-cell malignancies, according to the drug’s sponsor, AstraZeneca.

The current designation was based on preliminary results from two phase 3 trials – ELEVATE-TN and ASCEND. In the three-arm ELEVATE-TN trial, researchers evaluated acalabrutinib alone or in combination with obinutuzumab versus chlorambucil plus obinutuzumab in previously untreated patients with CLL. In the two-arm ASCEND trial, previously treated patients with CLL were randomized to receive acalabrutinib monotherapy or the physician’s choice of either rituximab plus idelalisib or rituximab plus bendamustine.

Interim analyses of the two trials showed that acalabrutinib alone, or in combination, significantly improved progression-free survival without raising safety concerns.

Breakthrough therapy designation allows for an expedited review by the FDA for treatments aimed at treating serious conditions where there is preliminary clinical evidence showing a substantial improvement over an available therapy or a clinically significant endpoint.

[email protected]

To the Editor:

Evidence-based recommendations for optimal medical management of patients with immunobullous diseases prior to elective surgery are sparse.^1,2 There is an uncertain balance between the use of immunomodulators and immunosuppressants, and implementation of these agents is heavily weighted against an increased infection risk from both active disease with denuded skin and suboptimal wound healing due to iatrogenic immunosuppression.^1-5 Historically, clinical management of epidermolysis bullosa acquisita (EBA) seldomly has resulted in substantial disease resolution.^1,3,4 Herein, we describe a case of recalcitrant EBA that was treated with a combination of intravenous immunoglobulin (IVIG) and dapsone, which resulted in a favorable clinical response and successful hip arthroplasty without cutaneous complications.

A 66-year-old man presented to an outside clinic with nonhealing ulcers on the oral mucosa, hands, groin, and feet. He was treated with systemic steroids after a histologic examination suggested bullous pemphigoid, but the lesions did not exhibit any appreciable improvement after several months of treatment. Despite the lack of improvement, the patient was continued on systemic steroids with a waxing and waning disease course.

Within a year, the patient presented to an orthopedist at our institution with severe left hip pain that had been limiting his mobility and had become unresponsive to conservative therapy. Radiologic investigations suggested advanced osteoarthritis and avascular necrosis of the left hip. Surgical intervention was delayed, as his orthopedist expressed concern that the extent of the body surface area affected by cutaneous denudation placed him at an unacceptable risk for infection. The orthopedic surgeon then referred the patient to our clinic for evaluation of the lesions. Physical examination revealed numerous crusted erosions in various stages of healing on the oral mucosa, palms, groin, and soles. Repeat biopsy of a denuded ulcer on the patient’s arm was obtained by our providers (nearly 1 year after the first biopsy by the outside physician). Histologic examination showed a pauci-immune subepidermal blister without acantholysis, which in combination with the clinical presentation of tense bullae on trauma-prone surfaces led to a favored diagnosis of EBA.

The patient began trials of several immunomodulatory and immunosuppressive agents, both in isolation and in combination, including systemic steroids, mycophenolate mofetil, four 1000-mg infusions of rituximab, and dapsone. Although results were suboptimal, dapsone 150 mg once daily for 3 months yielded the greatest clinical improvement with subsequent granulation and/or re-epithelialization of the chronic ulcers. After discussion during our department’s Grand Rounds, it was determined that the patient should undergo a trial of IVIG infusions, which were initiated with a loading dose of 2000 mg/kg over 5 consecutive days, followed by once-monthly maintenance infusion doses of 1200 mg/kg for 4 consecutive months. While receiving IVIG, he was maintained on a once-daily dose of dapsone 150 mg. This dual approach was designed to suppress both the humoral and cellular-mediated disease mechanisms so that his treatment would obviate the need for systemic corticosteroids.

Following this treatment regimen, he was noted to have marked improvement with only few scattered healing erosions. Upon completion of his last IVIG infusion, his cutaneous and mucosal manifestations of EBA were greatly minimized, demonstrating the best level of control that had been achieved during the disease course (Figure 1). This therapy completely cleared the cutaneous and mucosal ulcerations, thus permitting the patient to undergo a total left hip arthroplasty without complications (Figure 2).

Our report is novel in that it supports a combination of IVIG and dapsone as a viable presurgical therapy for patients with EBA, and this treatment also may be applicable for other primary immunobullous disorders.^2,5 Our case was particularly challenging in that the severity of the patient’s bullous disease precluded him from an elective orthopedic joint replacement due to the risk for wound dehiscence and surgical site infection.² We determined that IVIG and dapsone would be the most optimal combination therapy to facilitate superior disease control and concurrently allow for appropriate wound healing without impairing the host immune response. This report is unique from a clinical perspective in that a balance was successfully achieved between immune suppression, with avoidance of associated side effects, and disease activity.

To the Editor:

Evidence-based recommendations for optimal medical management of patients with immunobullous diseases prior to elective surgery are sparse.^1,2 There is an uncertain balance between the use of immunomodulators and immunosuppressants, and implementation of these agents is heavily weighted against an increased infection risk from both active disease with denuded skin and suboptimal wound healing due to iatrogenic immunosuppression.^1-5 Historically, clinical management of epidermolysis bullosa acquisita (EBA) seldomly has resulted in substantial disease resolution.^1,3,4 Herein, we describe a case of recalcitrant EBA that was treated with a combination of intravenous immunoglobulin (IVIG) and dapsone, which resulted in a favorable clinical response and successful hip arthroplasty without cutaneous complications.

A 66-year-old man presented to an outside clinic with nonhealing ulcers on the oral mucosa, hands, groin, and feet. He was treated with systemic steroids after a histologic examination suggested bullous pemphigoid, but the lesions did not exhibit any appreciable improvement after several months of treatment. Despite the lack of improvement, the patient was continued on systemic steroids with a waxing and waning disease course.

Within a year, the patient presented to an orthopedist at our institution with severe left hip pain that had been limiting his mobility and had become unresponsive to conservative therapy. Radiologic investigations suggested advanced osteoarthritis and avascular necrosis of the left hip. Surgical intervention was delayed, as his orthopedist expressed concern that the extent of the body surface area affected by cutaneous denudation placed him at an unacceptable risk for infection. The orthopedic surgeon then referred the patient to our clinic for evaluation of the lesions. Physical examination revealed numerous crusted erosions in various stages of healing on the oral mucosa, palms, groin, and soles. Repeat biopsy of a denuded ulcer on the patient’s arm was obtained by our providers (nearly 1 year after the first biopsy by the outside physician). Histologic examination showed a pauci-immune subepidermal blister without acantholysis, which in combination with the clinical presentation of tense bullae on trauma-prone surfaces led to a favored diagnosis of EBA.

The patient began trials of several immunomodulatory and immunosuppressive agents, both in isolation and in combination, including systemic steroids, mycophenolate mofetil, four 1000-mg infusions of rituximab, and dapsone. Although results were suboptimal, dapsone 150 mg once daily for 3 months yielded the greatest clinical improvement with subsequent granulation and/or re-epithelialization of the chronic ulcers. After discussion during our department’s Grand Rounds, it was determined that the patient should undergo a trial of IVIG infusions, which were initiated with a loading dose of 2000 mg/kg over 5 consecutive days, followed by once-monthly maintenance infusion doses of 1200 mg/kg for 4 consecutive months. While receiving IVIG, he was maintained on a once-daily dose of dapsone 150 mg. This dual approach was designed to suppress both the humoral and cellular-mediated disease mechanisms so that his treatment would obviate the need for systemic corticosteroids.

Following this treatment regimen, he was noted to have marked improvement with only few scattered healing erosions. Upon completion of his last IVIG infusion, his cutaneous and mucosal manifestations of EBA were greatly minimized, demonstrating the best level of control that had been achieved during the disease course (Figure 1). This therapy completely cleared the cutaneous and mucosal ulcerations, thus permitting the patient to undergo a total left hip arthroplasty without complications (Figure 2).

Our report is novel in that it supports a combination of IVIG and dapsone as a viable presurgical therapy for patients with EBA, and this treatment also may be applicable for other primary immunobullous disorders.^2,5 Our case was particularly challenging in that the severity of the patient’s bullous disease precluded him from an elective orthopedic joint replacement due to the risk for wound dehiscence and surgical site infection.² We determined that IVIG and dapsone would be the most optimal combination therapy to facilitate superior disease control and concurrently allow for appropriate wound healing without impairing the host immune response. This report is unique from a clinical perspective in that a balance was successfully achieved between immune suppression, with avoidance of associated side effects, and disease activity.

To the Editor:

Evidence-based recommendations for optimal medical management of patients with immunobullous diseases prior to elective surgery are sparse.^1,2 There is an uncertain balance between the use of immunomodulators and immunosuppressants, and implementation of these agents is heavily weighted against an increased infection risk from both active disease with denuded skin and suboptimal wound healing due to iatrogenic immunosuppression.^1-5 Historically, clinical management of epidermolysis bullosa acquisita (EBA) seldomly has resulted in substantial disease resolution.^1,3,4 Herein, we describe a case of recalcitrant EBA that was treated with a combination of intravenous immunoglobulin (IVIG) and dapsone, which resulted in a favorable clinical response and successful hip arthroplasty without cutaneous complications.

A 66-year-old man presented to an outside clinic with nonhealing ulcers on the oral mucosa, hands, groin, and feet. He was treated with systemic steroids after a histologic examination suggested bullous pemphigoid, but the lesions did not exhibit any appreciable improvement after several months of treatment. Despite the lack of improvement, the patient was continued on systemic steroids with a waxing and waning disease course.

Within a year, the patient presented to an orthopedist at our institution with severe left hip pain that had been limiting his mobility and had become unresponsive to conservative therapy. Radiologic investigations suggested advanced osteoarthritis and avascular necrosis of the left hip. Surgical intervention was delayed, as his orthopedist expressed concern that the extent of the body surface area affected by cutaneous denudation placed him at an unacceptable risk for infection. The orthopedic surgeon then referred the patient to our clinic for evaluation of the lesions. Physical examination revealed numerous crusted erosions in various stages of healing on the oral mucosa, palms, groin, and soles. Repeat biopsy of a denuded ulcer on the patient’s arm was obtained by our providers (nearly 1 year after the first biopsy by the outside physician). Histologic examination showed a pauci-immune subepidermal blister without acantholysis, which in combination with the clinical presentation of tense bullae on trauma-prone surfaces led to a favored diagnosis of EBA.

The patient began trials of several immunomodulatory and immunosuppressive agents, both in isolation and in combination, including systemic steroids, mycophenolate mofetil, four 1000-mg infusions of rituximab, and dapsone. Although results were suboptimal, dapsone 150 mg once daily for 3 months yielded the greatest clinical improvement with subsequent granulation and/or re-epithelialization of the chronic ulcers. After discussion during our department’s Grand Rounds, it was determined that the patient should undergo a trial of IVIG infusions, which were initiated with a loading dose of 2000 mg/kg over 5 consecutive days, followed by once-monthly maintenance infusion doses of 1200 mg/kg for 4 consecutive months. While receiving IVIG, he was maintained on a once-daily dose of dapsone 150 mg. This dual approach was designed to suppress both the humoral and cellular-mediated disease mechanisms so that his treatment would obviate the need for systemic corticosteroids.

Following this treatment regimen, he was noted to have marked improvement with only few scattered healing erosions. Upon completion of his last IVIG infusion, his cutaneous and mucosal manifestations of EBA were greatly minimized, demonstrating the best level of control that had been achieved during the disease course (Figure 1). This therapy completely cleared the cutaneous and mucosal ulcerations, thus permitting the patient to undergo a total left hip arthroplasty without complications (Figure 2).

Our report is novel in that it supports a combination of IVIG and dapsone as a viable presurgical therapy for patients with EBA, and this treatment also may be applicable for other primary immunobullous disorders.^2,5 Our case was particularly challenging in that the severity of the patient’s bullous disease precluded him from an elective orthopedic joint replacement due to the risk for wound dehiscence and surgical site infection.² We determined that IVIG and dapsone would be the most optimal combination therapy to facilitate superior disease control and concurrently allow for appropriate wound healing without impairing the host immune response. This report is unique from a clinical perspective in that a balance was successfully achieved between immune suppression, with avoidance of associated side effects, and disease activity.