Lee M. Chambliss, MD, MSPH

Evidence summary

Warfarin, at both low and conventional doses, has been shown to be effective in preventing recurrence of DVT. A large, 4-year placebo-controlled randomized controlled trial showed that long-term low-dose warfarin (international normalized ratio [INR], 1.5-1.9) was more effective than placebo for prevention of DVT (hazard ratio=0.36; 95% confidence interval [CI], 0.19-0.67).¹

A double-blind randomized controlled trial of 738 patients demonstrated that conventional-intensity warfarin therapy (INR=2.0-3.0) was more effective than low-intensity therapy (INR=1.5-1.9) in prevention of recurrent DVT. There were 1.9 vs 0.7 DVTs per 100 person-years in the low-intensity vs conventional-intensity therapy groups (hazard ratio=2.8; 95% CI, 1.1-7.0; number needed to treat [NNT]=37). No significant difference was seen in the frequency of bleeding complications between the groups.² This and other studies suggest that low-intensity warfarin therapy reduces the relative risk of thrombosis by about 75%, and conventional-intensity therapy reduces this risk by over 90%.²

Several studies have examined the duration of warfarin therapy. A meta-analysis found treatment with warfarin for 12 to 24 weeks decreased DVT recurrence compared with 2- to 6-week regimens (relative risk [RR]=0.60; 95% CI, 0.45-0.79; NNT=21).³ A multicenter randomized controlled trial found extending warfarin treatment for 12 months vs 3 months resulted in a 95% relative risk reduction (RRR) in risk of DVT recurrence (95% CI, 63-99; NNT=5).⁴ A multicenter randomized trial showed similar results, but risk for recurrence was the same after treatment was stopped, regardless of the length of treatment.⁵

In patients with cancer, warfarin was shown to be more effective than placebo in prevention of DVT. In a trial of 311 breast cancer patients receiving chemotherapy, treatment with very-low-dose warfarin (INR=1.3-1.9) decreased thrombotic events compared with placebo, with no increase in bleeding complications (RRR=85%; P=.031; NNT=27).⁶ A later cost analysis showed that very-low-dose warfarin can be used in prevention of DVT in breast cancer patients on chemotherapy without an increase in health care costs.⁷

Although immobilized patients are at high risk for DVT, no randomized controlled trials exist for the use of warfarin in these patients. A few small studies suggest that warfarin reduces DVT rates in spinal-cord-injured patients.⁸ A small trial randomized stroke patients undergoing rehabilitation to placebo or fixed 1- or 2-mg doses of warfarin. This underpowered study showed a nonsignificant decrease in the risk of development of DVT (RR=0.39; 95% CI, 0.13-1.37).⁸

Recommendations from others

The 6th American College of Chest Physicians Consensus Conference on Antithrombotic Therapy makes these recommendations:⁹

Prior DVT: Oral anticoagulation therapy (INR=2.0-3.0) is indicated for at least 3 months for patients with proximal DVT or for at least 6 months in those with idiopathic proximal vein thrombosis or recurrent venous thrombosis. Indefinite anticoagulation is indicated for patients with more than 1 episode of idiopathic proximal vein thrombosis or pulmonary embolus.

Malignancy: Indefinite anticoagulation (INR= 2.0-3.0) is indicated for patients with thrombosis complicating malignancy. Prophylaxis with low-intensity warfarin in ambulatory patients with cancer to prevent initial DVT warrants further study.

Acute spinal cord injuries: Low-molecular-weight heparin or switch to full-dose oral anti-coagulation (INR=2.0-3.0) for the duration of the rehabilitation phase.

Evidence summary

Warfarin, at both low and conventional doses, has been shown to be effective in preventing recurrence of DVT. A large, 4-year placebo-controlled randomized controlled trial showed that long-term low-dose warfarin (international normalized ratio [INR], 1.5-1.9) was more effective than placebo for prevention of DVT (hazard ratio=0.36; 95% confidence interval [CI], 0.19-0.67).¹

A double-blind randomized controlled trial of 738 patients demonstrated that conventional-intensity warfarin therapy (INR=2.0-3.0) was more effective than low-intensity therapy (INR=1.5-1.9) in prevention of recurrent DVT. There were 1.9 vs 0.7 DVTs per 100 person-years in the low-intensity vs conventional-intensity therapy groups (hazard ratio=2.8; 95% CI, 1.1-7.0; number needed to treat [NNT]=37). No significant difference was seen in the frequency of bleeding complications between the groups.² This and other studies suggest that low-intensity warfarin therapy reduces the relative risk of thrombosis by about 75%, and conventional-intensity therapy reduces this risk by over 90%.²

Several studies have examined the duration of warfarin therapy. A meta-analysis found treatment with warfarin for 12 to 24 weeks decreased DVT recurrence compared with 2- to 6-week regimens (relative risk [RR]=0.60; 95% CI, 0.45-0.79; NNT=21).³ A multicenter randomized controlled trial found extending warfarin treatment for 12 months vs 3 months resulted in a 95% relative risk reduction (RRR) in risk of DVT recurrence (95% CI, 63-99; NNT=5).⁴ A multicenter randomized trial showed similar results, but risk for recurrence was the same after treatment was stopped, regardless of the length of treatment.⁵

In patients with cancer, warfarin was shown to be more effective than placebo in prevention of DVT. In a trial of 311 breast cancer patients receiving chemotherapy, treatment with very-low-dose warfarin (INR=1.3-1.9) decreased thrombotic events compared with placebo, with no increase in bleeding complications (RRR=85%; P=.031; NNT=27).⁶ A later cost analysis showed that very-low-dose warfarin can be used in prevention of DVT in breast cancer patients on chemotherapy without an increase in health care costs.⁷

Although immobilized patients are at high risk for DVT, no randomized controlled trials exist for the use of warfarin in these patients. A few small studies suggest that warfarin reduces DVT rates in spinal-cord-injured patients.⁸ A small trial randomized stroke patients undergoing rehabilitation to placebo or fixed 1- or 2-mg doses of warfarin. This underpowered study showed a nonsignificant decrease in the risk of development of DVT (RR=0.39; 95% CI, 0.13-1.37).⁸

Recommendations from others

The 6th American College of Chest Physicians Consensus Conference on Antithrombotic Therapy makes these recommendations:⁹

Prior DVT: Oral anticoagulation therapy (INR=2.0-3.0) is indicated for at least 3 months for patients with proximal DVT or for at least 6 months in those with idiopathic proximal vein thrombosis or recurrent venous thrombosis. Indefinite anticoagulation is indicated for patients with more than 1 episode of idiopathic proximal vein thrombosis or pulmonary embolus.

Malignancy: Indefinite anticoagulation (INR= 2.0-3.0) is indicated for patients with thrombosis complicating malignancy. Prophylaxis with low-intensity warfarin in ambulatory patients with cancer to prevent initial DVT warrants further study.

Acute spinal cord injuries: Low-molecular-weight heparin or switch to full-dose oral anti-coagulation (INR=2.0-3.0) for the duration of the rehabilitation phase.

Evidence summary

Warfarin, at both low and conventional doses, has been shown to be effective in preventing recurrence of DVT. A large, 4-year placebo-controlled randomized controlled trial showed that long-term low-dose warfarin (international normalized ratio [INR], 1.5-1.9) was more effective than placebo for prevention of DVT (hazard ratio=0.36; 95% confidence interval [CI], 0.19-0.67).¹

A double-blind randomized controlled trial of 738 patients demonstrated that conventional-intensity warfarin therapy (INR=2.0-3.0) was more effective than low-intensity therapy (INR=1.5-1.9) in prevention of recurrent DVT. There were 1.9 vs 0.7 DVTs per 100 person-years in the low-intensity vs conventional-intensity therapy groups (hazard ratio=2.8; 95% CI, 1.1-7.0; number needed to treat [NNT]=37). No significant difference was seen in the frequency of bleeding complications between the groups.² This and other studies suggest that low-intensity warfarin therapy reduces the relative risk of thrombosis by about 75%, and conventional-intensity therapy reduces this risk by over 90%.²

Several studies have examined the duration of warfarin therapy. A meta-analysis found treatment with warfarin for 12 to 24 weeks decreased DVT recurrence compared with 2- to 6-week regimens (relative risk [RR]=0.60; 95% CI, 0.45-0.79; NNT=21).³ A multicenter randomized controlled trial found extending warfarin treatment for 12 months vs 3 months resulted in a 95% relative risk reduction (RRR) in risk of DVT recurrence (95% CI, 63-99; NNT=5).⁴ A multicenter randomized trial showed similar results, but risk for recurrence was the same after treatment was stopped, regardless of the length of treatment.⁵

In patients with cancer, warfarin was shown to be more effective than placebo in prevention of DVT. In a trial of 311 breast cancer patients receiving chemotherapy, treatment with very-low-dose warfarin (INR=1.3-1.9) decreased thrombotic events compared with placebo, with no increase in bleeding complications (RRR=85%; P=.031; NNT=27).⁶ A later cost analysis showed that very-low-dose warfarin can be used in prevention of DVT in breast cancer patients on chemotherapy without an increase in health care costs.⁷

Although immobilized patients are at high risk for DVT, no randomized controlled trials exist for the use of warfarin in these patients. A few small studies suggest that warfarin reduces DVT rates in spinal-cord-injured patients.⁸ A small trial randomized stroke patients undergoing rehabilitation to placebo or fixed 1- or 2-mg doses of warfarin. This underpowered study showed a nonsignificant decrease in the risk of development of DVT (RR=0.39; 95% CI, 0.13-1.37).⁸

Recommendations from others

The 6th American College of Chest Physicians Consensus Conference on Antithrombotic Therapy makes these recommendations:⁹

Prior DVT: Oral anticoagulation therapy (INR=2.0-3.0) is indicated for at least 3 months for patients with proximal DVT or for at least 6 months in those with idiopathic proximal vein thrombosis or recurrent venous thrombosis. Indefinite anticoagulation is indicated for patients with more than 1 episode of idiopathic proximal vein thrombosis or pulmonary embolus.

Malignancy: Indefinite anticoagulation (INR= 2.0-3.0) is indicated for patients with thrombosis complicating malignancy. Prophylaxis with low-intensity warfarin in ambulatory patients with cancer to prevent initial DVT warrants further study.

Acute spinal cord injuries: Low-molecular-weight heparin or switch to full-dose oral anti-coagulation (INR=2.0-3.0) for the duration of the rehabilitation phase.

For several years our residency program had been considering the purchase of an electronic medicalrecord (EMR). We had seen demonstrations of the products and were aware that a few practices in our area were using full EMRs. We knew of their many advantages, as delineated in several recent articles.^1-3

Our faculty had 3 major concerns about the purchase of an EMR. The first was price. The cost of implementation cited in the literature varies widely; one source estimates $15,000 per full-time physician.¹ There is disagreement as to whether the operating expenses of paperless EMR systems are less than traditional paper systems.⁴ The savings in dictation and filing are often offset by fees for service agreements and technical support. Thus, it seemed unlikely that an EMR would significantly decrease our operating costs in the immediate future.

Our second concern was the potential for physician dissatisfaction and disruption of clinical flow. At least 10 residency programs had purchased commercial EMRs and discontinued using them.^5-7 Our clinic was running smoothly, so we believed that the advantages of a full EMR would not compensate for the inconveniences and frustrations that seem to accompany a commercial product. Our third concern was the apparent lack of a dominant EMR vendor. A recent survey of the industry revealed tremendous turnover,⁸ and a survey of family medicine residencies reported that no vendor had more than 25% of the market.⁵ Consequently, we feared investing in a product when its vendor might go out of business.

Our foremost goal was quality improvement (QI). This should include electronic reminders for due prevention items, the ability to display our completion rates for key prevention items without the time and expense of pulling charts, and the ability to check on critical combinations of diagnoses and medications (eg, congestive heart failure and ß-blocker usage). Second, we wanted to improve the legibility and accessibility of key parts of a patient’s chart, particularly medications and chronic diagnoses. The ability to access the full chart electronically and to change our current dictation of daily SOAP Notes (SpeechStudio; Portland, Ore) were less important to us.

Development

Since we did not believe a commercial program would meet our goals, we decided to create our own partial or miniature electronic medical record (mini EMR). Several reports in the literature have described the value of mini EMRs.^9,10 One of the authors with previous programming experience (R.D.C.) began writing the first version in May 1999. We found a formulary database, Multum (Multum Information Services, Denver, Colo) from which we could import generic and trade medication names and categories. We also created a list of 700 primary care International Classification of Diseases–9th revision (ICD-9) codes common in our practice.

Current Use

Starting in May 2000, all of our 6.5 full-time equivalent physicians began using the mini EMR. Our patients’ demographic data were initially imported from our billing program into the mini EMR from a delimited text file. This same method is used to update phone numbers monthly. We had traditionally placed a preprinted sheet of paper for notes and orders on the front of each patient’s chart at each visit. This sheet was replaced with a printout from the mini EMR that included current ICD-9 codes, medications, and reminders for age- and sex-appropriate due prevention items. Front sheets are batch-printed each morning, then placed in the patient’s chart where it remains until the next visit, to be replaced by the most current printed version. When dictating the visit, the physician also updates the mini EMR entry for that patient on the computer. It takes approximately 30 seconds to call up a patient record and enter or change several diagnoses or medications or to add prevention item dates. This is not additional time, since most physicians would otherwise have to update the problem and medication lists in the paper chart. However, it does require that the physician be at a computer terminal. Physicians or nurses also update the mini EMR as data from Papanicolaou tests, laboratory values, and so forth, become available.

Microsoft Access has proved to be very stable, and we have not experienced any system crashes or lockups. Security issues are addressed in 3 ways. First, Access allows group and individual log-in names and passwords for both individual and networked computers. Second, it can generate an audit trail for any changes made to the database. Finally, the database should be used on a standalone network or behind a firewall.

Six months after full implementation of the mini EMR, more than 75% of our patients older than 50 years (N=1912) had been entered into the mini EMR. Acceptance has been very high, even by care providers who were admittedly computer phobic. Since we can easily query the mini EMR and determine our adherence rates for prevention items and medication usage, we are planning a number of QI projects, including improving mammography rates, using β-blockers in patients with congestive heart failure, and lowering low-density lipoprotein levels.

Using the Mini EMR in Other Practices

There are several lessons we learned from developing and implementing the mini EMR. The first is to start with a subset of your most committed practitioners. This group will be most forgiving of the inevitable growing pains associated with adopting a new system. Such an approach may also induce nonuser envy. Second, the development of a sense of ownership of the program was very important. We believe implementing users’ suggestions increased acceptance.

Although a general purpose relational database may be inappropriate for practice networks with many providers and locations, adopting the mini EMR in a smaller practice should be relatively easy. A person with good knowledge of Access would be required for initial setup, for the link to your current computer system, and for any desired modifications. A small network can easily be created, as described by Levin.¹¹ Although we have not attempted to import data from the mini EMR into a commercial EMR, the widespread use of Access should make interfacing with a commercial EMR relatively simple.

Conclusions

The mini EMR has given our practice many of the advantages of a full EMR with few of the accompanying disruptions and at a much lower price. The simplicity of the design, coupled with the many attributes of Microsoft Access, make it easy to maintain and modify. We believe this program will serve our practice well for several years and then act as a bridge to a full commercial EMR once that software market has matured.

For several years our residency program had been considering the purchase of an electronic medicalrecord (EMR). We had seen demonstrations of the products and were aware that a few practices in our area were using full EMRs. We knew of their many advantages, as delineated in several recent articles.^1-3

Our faculty had 3 major concerns about the purchase of an EMR. The first was price. The cost of implementation cited in the literature varies widely; one source estimates $15,000 per full-time physician.¹ There is disagreement as to whether the operating expenses of paperless EMR systems are less than traditional paper systems.⁴ The savings in dictation and filing are often offset by fees for service agreements and technical support. Thus, it seemed unlikely that an EMR would significantly decrease our operating costs in the immediate future.

Our second concern was the potential for physician dissatisfaction and disruption of clinical flow. At least 10 residency programs had purchased commercial EMRs and discontinued using them.^5-7 Our clinic was running smoothly, so we believed that the advantages of a full EMR would not compensate for the inconveniences and frustrations that seem to accompany a commercial product. Our third concern was the apparent lack of a dominant EMR vendor. A recent survey of the industry revealed tremendous turnover,⁸ and a survey of family medicine residencies reported that no vendor had more than 25% of the market.⁵ Consequently, we feared investing in a product when its vendor might go out of business.

Our foremost goal was quality improvement (QI). This should include electronic reminders for due prevention items, the ability to display our completion rates for key prevention items without the time and expense of pulling charts, and the ability to check on critical combinations of diagnoses and medications (eg, congestive heart failure and ß-blocker usage). Second, we wanted to improve the legibility and accessibility of key parts of a patient’s chart, particularly medications and chronic diagnoses. The ability to access the full chart electronically and to change our current dictation of daily SOAP Notes (SpeechStudio; Portland, Ore) were less important to us.

Development

Since we did not believe a commercial program would meet our goals, we decided to create our own partial or miniature electronic medical record (mini EMR). Several reports in the literature have described the value of mini EMRs.^9,10 One of the authors with previous programming experience (R.D.C.) began writing the first version in May 1999. We found a formulary database, Multum (Multum Information Services, Denver, Colo) from which we could import generic and trade medication names and categories. We also created a list of 700 primary care International Classification of Diseases–9th revision (ICD-9) codes common in our practice.

Current Use

Starting in May 2000, all of our 6.5 full-time equivalent physicians began using the mini EMR. Our patients’ demographic data were initially imported from our billing program into the mini EMR from a delimited text file. This same method is used to update phone numbers monthly. We had traditionally placed a preprinted sheet of paper for notes and orders on the front of each patient’s chart at each visit. This sheet was replaced with a printout from the mini EMR that included current ICD-9 codes, medications, and reminders for age- and sex-appropriate due prevention items. Front sheets are batch-printed each morning, then placed in the patient’s chart where it remains until the next visit, to be replaced by the most current printed version. When dictating the visit, the physician also updates the mini EMR entry for that patient on the computer. It takes approximately 30 seconds to call up a patient record and enter or change several diagnoses or medications or to add prevention item dates. This is not additional time, since most physicians would otherwise have to update the problem and medication lists in the paper chart. However, it does require that the physician be at a computer terminal. Physicians or nurses also update the mini EMR as data from Papanicolaou tests, laboratory values, and so forth, become available.

Microsoft Access has proved to be very stable, and we have not experienced any system crashes or lockups. Security issues are addressed in 3 ways. First, Access allows group and individual log-in names and passwords for both individual and networked computers. Second, it can generate an audit trail for any changes made to the database. Finally, the database should be used on a standalone network or behind a firewall.

Six months after full implementation of the mini EMR, more than 75% of our patients older than 50 years (N=1912) had been entered into the mini EMR. Acceptance has been very high, even by care providers who were admittedly computer phobic. Since we can easily query the mini EMR and determine our adherence rates for prevention items and medication usage, we are planning a number of QI projects, including improving mammography rates, using β-blockers in patients with congestive heart failure, and lowering low-density lipoprotein levels.

Using the Mini EMR in Other Practices

There are several lessons we learned from developing and implementing the mini EMR. The first is to start with a subset of your most committed practitioners. This group will be most forgiving of the inevitable growing pains associated with adopting a new system. Such an approach may also induce nonuser envy. Second, the development of a sense of ownership of the program was very important. We believe implementing users’ suggestions increased acceptance.

Although a general purpose relational database may be inappropriate for practice networks with many providers and locations, adopting the mini EMR in a smaller practice should be relatively easy. A person with good knowledge of Access would be required for initial setup, for the link to your current computer system, and for any desired modifications. A small network can easily be created, as described by Levin.¹¹ Although we have not attempted to import data from the mini EMR into a commercial EMR, the widespread use of Access should make interfacing with a commercial EMR relatively simple.

Conclusions

The mini EMR has given our practice many of the advantages of a full EMR with few of the accompanying disruptions and at a much lower price. The simplicity of the design, coupled with the many attributes of Microsoft Access, make it easy to maintain and modify. We believe this program will serve our practice well for several years and then act as a bridge to a full commercial EMR once that software market has matured.

For several years our residency program had been considering the purchase of an electronic medicalrecord (EMR). We had seen demonstrations of the products and were aware that a few practices in our area were using full EMRs. We knew of their many advantages, as delineated in several recent articles.^1-3

Our faculty had 3 major concerns about the purchase of an EMR. The first was price. The cost of implementation cited in the literature varies widely; one source estimates $15,000 per full-time physician.¹ There is disagreement as to whether the operating expenses of paperless EMR systems are less than traditional paper systems.⁴ The savings in dictation and filing are often offset by fees for service agreements and technical support. Thus, it seemed unlikely that an EMR would significantly decrease our operating costs in the immediate future.

Our second concern was the potential for physician dissatisfaction and disruption of clinical flow. At least 10 residency programs had purchased commercial EMRs and discontinued using them.^5-7 Our clinic was running smoothly, so we believed that the advantages of a full EMR would not compensate for the inconveniences and frustrations that seem to accompany a commercial product. Our third concern was the apparent lack of a dominant EMR vendor. A recent survey of the industry revealed tremendous turnover,⁸ and a survey of family medicine residencies reported that no vendor had more than 25% of the market.⁵ Consequently, we feared investing in a product when its vendor might go out of business.

Our foremost goal was quality improvement (QI). This should include electronic reminders for due prevention items, the ability to display our completion rates for key prevention items without the time and expense of pulling charts, and the ability to check on critical combinations of diagnoses and medications (eg, congestive heart failure and ß-blocker usage). Second, we wanted to improve the legibility and accessibility of key parts of a patient’s chart, particularly medications and chronic diagnoses. The ability to access the full chart electronically and to change our current dictation of daily SOAP Notes (SpeechStudio; Portland, Ore) were less important to us.

Development

Since we did not believe a commercial program would meet our goals, we decided to create our own partial or miniature electronic medical record (mini EMR). Several reports in the literature have described the value of mini EMRs.^9,10 One of the authors with previous programming experience (R.D.C.) began writing the first version in May 1999. We found a formulary database, Multum (Multum Information Services, Denver, Colo) from which we could import generic and trade medication names and categories. We also created a list of 700 primary care International Classification of Diseases–9th revision (ICD-9) codes common in our practice.

Current Use

Starting in May 2000, all of our 6.5 full-time equivalent physicians began using the mini EMR. Our patients’ demographic data were initially imported from our billing program into the mini EMR from a delimited text file. This same method is used to update phone numbers monthly. We had traditionally placed a preprinted sheet of paper for notes and orders on the front of each patient’s chart at each visit. This sheet was replaced with a printout from the mini EMR that included current ICD-9 codes, medications, and reminders for age- and sex-appropriate due prevention items. Front sheets are batch-printed each morning, then placed in the patient’s chart where it remains until the next visit, to be replaced by the most current printed version. When dictating the visit, the physician also updates the mini EMR entry for that patient on the computer. It takes approximately 30 seconds to call up a patient record and enter or change several diagnoses or medications or to add prevention item dates. This is not additional time, since most physicians would otherwise have to update the problem and medication lists in the paper chart. However, it does require that the physician be at a computer terminal. Physicians or nurses also update the mini EMR as data from Papanicolaou tests, laboratory values, and so forth, become available.

Microsoft Access has proved to be very stable, and we have not experienced any system crashes or lockups. Security issues are addressed in 3 ways. First, Access allows group and individual log-in names and passwords for both individual and networked computers. Second, it can generate an audit trail for any changes made to the database. Finally, the database should be used on a standalone network or behind a firewall.

Six months after full implementation of the mini EMR, more than 75% of our patients older than 50 years (N=1912) had been entered into the mini EMR. Acceptance has been very high, even by care providers who were admittedly computer phobic. Since we can easily query the mini EMR and determine our adherence rates for prevention items and medication usage, we are planning a number of QI projects, including improving mammography rates, using β-blockers in patients with congestive heart failure, and lowering low-density lipoprotein levels.

Using the Mini EMR in Other Practices

There are several lessons we learned from developing and implementing the mini EMR. The first is to start with a subset of your most committed practitioners. This group will be most forgiving of the inevitable growing pains associated with adopting a new system. Such an approach may also induce nonuser envy. Second, the development of a sense of ownership of the program was very important. We believe implementing users’ suggestions increased acceptance.

Although a general purpose relational database may be inappropriate for practice networks with many providers and locations, adopting the mini EMR in a smaller practice should be relatively easy. A person with good knowledge of Access would be required for initial setup, for the link to your current computer system, and for any desired modifications. A small network can easily be created, as described by Levin.¹¹ Although we have not attempted to import data from the mini EMR into a commercial EMR, the widespread use of Access should make interfacing with a commercial EMR relatively simple.

Conclusions

The mini EMR has given our practice many of the advantages of a full EMR with few of the accompanying disruptions and at a much lower price. The simplicity of the design, coupled with the many attributes of Microsoft Access, make it easy to maintain and modify. We believe this program will serve our practice well for several years and then act as a bridge to a full commercial EMR once that software market has matured.

Recommendations From Others

Major pediatric and infectious disease textbooks continue to recommend griseofulvin as first-line therapy for tinea capitis but recognize that other safe and effective treatments exist.^1-4 A recent practice guideline from the British Association of Dermatologists did not recommend any oral antifungal agent as clearly superior.⁵

Evidence Summary

Tinea capitis is one of the most common dermatophyte infections in the pediatric population, affecting up to 4% of all children. The peak age is 4 to 6 years; infection is rare after puberty. Systemic therapy is generally required.6 The exact efficacy of any agent is difficult to determine, because most studies were small, used different doses and definitions of cure, and were conducted in different populations. With the exception of ketoconazole, all agents seem to have roughly similar efficacy and cure rates of approximately 70% to 80%. None of these agents require laboratory monitoring at the recommended lengths of treatment for tinea capitis Table.⁷

Griseofulvin’s safety and long history of use in children are its best assets. Recommended dosages and treatment duration have been increased because of fears of developing resistance.⁸ Tablets are approximately one third the cost of the liquid preparations.

Ketoconazole was one of the first “-azoles” studied for the treatment of tinea in children. It is not as efficacious or as safe as other available treatments, making it unsuitable for the treatment of tinea capitis in children.⁵

Itraconazole has been associated with several abnormalities of bone and soft tissue at doses exceeding normal human exposure. Additionally, at more normal doses a component of the liquid formulation causes pancreatic adenocarcinoma in rats.⁶ It has had mixed efficacy in clinical trials, with cure rates ranging from 40% to 89%.^9-11

Fluconazole is another broad-spectrum antifungal in the triazole class. It has been approved by the Food and Drug Administration (FDA) for use in children with systemic fungal infections. The safety profile is very good; it has no known significant carcinogenic potential. Fluconazole is available in both tablet and liquid formulations that make dosing in young children convenient. There are very few clinical studies comparing fluconazole with other antifungal drugs, and no head-to-head prospective randomized controlled trials with griseofulvin have been published to date.⁵

Terbinafine is an allyamine antifungal drug that has a very good safety profile. Unfortunately, there is no liquid formulation of terbinafine, but tablets may be hidden in food.¹² Although terbinafine is efficacious against Trichophyton tonsurans and Trichophyton violaceum, it does not work as well against Microsporum canis, which accounts for approximately 3% of the infections.^12-15 Terbinafine is the most attractively priced treatment for tinea capitis, particularly if a short course is used.

Recommendations From Others

Major pediatric and infectious disease textbooks continue to recommend griseofulvin as first-line therapy for tinea capitis but recognize that other safe and effective treatments exist.^1-4 A recent practice guideline from the British Association of Dermatologists did not recommend any oral antifungal agent as clearly superior.⁵

Evidence Summary

Tinea capitis is one of the most common dermatophyte infections in the pediatric population, affecting up to 4% of all children. The peak age is 4 to 6 years; infection is rare after puberty. Systemic therapy is generally required.6 The exact efficacy of any agent is difficult to determine, because most studies were small, used different doses and definitions of cure, and were conducted in different populations. With the exception of ketoconazole, all agents seem to have roughly similar efficacy and cure rates of approximately 70% to 80%. None of these agents require laboratory monitoring at the recommended lengths of treatment for tinea capitis Table.⁷

Griseofulvin’s safety and long history of use in children are its best assets. Recommended dosages and treatment duration have been increased because of fears of developing resistance.⁸ Tablets are approximately one third the cost of the liquid preparations.

Ketoconazole was one of the first “-azoles” studied for the treatment of tinea in children. It is not as efficacious or as safe as other available treatments, making it unsuitable for the treatment of tinea capitis in children.⁵

Itraconazole has been associated with several abnormalities of bone and soft tissue at doses exceeding normal human exposure. Additionally, at more normal doses a component of the liquid formulation causes pancreatic adenocarcinoma in rats.⁶ It has had mixed efficacy in clinical trials, with cure rates ranging from 40% to 89%.^9-11

Fluconazole is another broad-spectrum antifungal in the triazole class. It has been approved by the Food and Drug Administration (FDA) for use in children with systemic fungal infections. The safety profile is very good; it has no known significant carcinogenic potential. Fluconazole is available in both tablet and liquid formulations that make dosing in young children convenient. There are very few clinical studies comparing fluconazole with other antifungal drugs, and no head-to-head prospective randomized controlled trials with griseofulvin have been published to date.⁵

Terbinafine is an allyamine antifungal drug that has a very good safety profile. Unfortunately, there is no liquid formulation of terbinafine, but tablets may be hidden in food.¹² Although terbinafine is efficacious against Trichophyton tonsurans and Trichophyton violaceum, it does not work as well against Microsporum canis, which accounts for approximately 3% of the infections.^12-15 Terbinafine is the most attractively priced treatment for tinea capitis, particularly if a short course is used.

Recommendations From Others

Major pediatric and infectious disease textbooks continue to recommend griseofulvin as first-line therapy for tinea capitis but recognize that other safe and effective treatments exist.^1-4 A recent practice guideline from the British Association of Dermatologists did not recommend any oral antifungal agent as clearly superior.⁵

Evidence Summary

Tinea capitis is one of the most common dermatophyte infections in the pediatric population, affecting up to 4% of all children. The peak age is 4 to 6 years; infection is rare after puberty. Systemic therapy is generally required.6 The exact efficacy of any agent is difficult to determine, because most studies were small, used different doses and definitions of cure, and were conducted in different populations. With the exception of ketoconazole, all agents seem to have roughly similar efficacy and cure rates of approximately 70% to 80%. None of these agents require laboratory monitoring at the recommended lengths of treatment for tinea capitis Table.⁷

Griseofulvin’s safety and long history of use in children are its best assets. Recommended dosages and treatment duration have been increased because of fears of developing resistance.⁸ Tablets are approximately one third the cost of the liquid preparations.

Ketoconazole was one of the first “-azoles” studied for the treatment of tinea in children. It is not as efficacious or as safe as other available treatments, making it unsuitable for the treatment of tinea capitis in children.⁵

Itraconazole has been associated with several abnormalities of bone and soft tissue at doses exceeding normal human exposure. Additionally, at more normal doses a component of the liquid formulation causes pancreatic adenocarcinoma in rats.⁶ It has had mixed efficacy in clinical trials, with cure rates ranging from 40% to 89%.^9-11

Fluconazole is another broad-spectrum antifungal in the triazole class. It has been approved by the Food and Drug Administration (FDA) for use in children with systemic fungal infections. The safety profile is very good; it has no known significant carcinogenic potential. Fluconazole is available in both tablet and liquid formulations that make dosing in young children convenient. There are very few clinical studies comparing fluconazole with other antifungal drugs, and no head-to-head prospective randomized controlled trials with griseofulvin have been published to date.⁵

Terbinafine is an allyamine antifungal drug that has a very good safety profile. Unfortunately, there is no liquid formulation of terbinafine, but tablets may be hidden in food.¹² Although terbinafine is efficacious against Trichophyton tonsurans and Trichophyton violaceum, it does not work as well against Microsporum canis, which accounts for approximately 3% of the infections.^12-15 Terbinafine is the most attractively priced treatment for tinea capitis, particularly if a short course is used.