KAUAI, HAWAII – Medical therapy alone is never sufficient in Hurley stage III hidradenitis suppurativa (HS), Iltefat H. Hamzavi, MD, observed at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

“Even with the advances in biologics and antibiotic therapy, you still have to excise once you’re in full-blown Hurley stage III disease. Surgery has to be part of your protocol,” according to Dr. Hamzavi, a dermatologist at Henry Ford Hospital in Detroit, which runs one of the nation’s largest hidradenitis suppurativa clinics, with roughly 1,600 patients.

Elsevier

He outlined the Henry Ford Hospital’s HS treatment algorithm. Where good evidence exists, the algorithm is evidence-based, and where evidence is lacking, it’s based upon expert opinion and considerable anecdotal experience.

“Of course we’re biased. But until the data can set us free, you’re stuck with me,” the dermatologist quipped.

A core principle of the Henry Ford algorithm is this: “Medical therapy [for patients with advanced HS] stabilizes them and reduces their draining and pain, then you try to bring them back to a lower stage with surgical options,” he explained.

Although other HS staging systems exist, Dr. Hamzavi and his colleagues rely on the Hurley staging system to guide their treatment. Basically, Hurley stage I consists of follicular nodules and abscesses. When the nodules connect to form sinus tracts with scarring, that’s stage II. And if the sinus tracts interconnect throughout an entire area, that’s stage III.

 

Hurley stage I

First-line treatment of localized Hurley stage I disease at Henry Ford is a 10% topical benzoyl peroxide wash left on for 5 minutes before bathing, followed by postbathing topical clindamycin 1% lotion or solution applied to the nodules. If this maintenance regimen isn’t sufficient to prevent formation of new and worsening nodules, Dr. Hamzavi supplements it with up to three once-monthly 1064-nm Nd:YAG laser sessions aimed at follicular ablation. It’s a laser application he and his colleagues pioneered (Dermatol Surg. 2009 Aug;35[8]:1188-98). They subsequently documented the histopathologic basis of the procedure’s efficacy, which entails selective thermolysis of follicles, destruction of inflammatory lesions in the superficial to mid-dermis, followed by fibrosis and scarring (Arch Dermatol. 2011 Jan;147[1]:21-8).

Bruce Jancin/MDedge News

“Our experience, and that of most people in the HS community, has been that, if you limit the hair follicles you limit the disease state,” said Dr. Hamzavi, who is the current president of the Hidradenitis Suppurativa Foundation.

In generalized Hurley stage I HS, the Henry Ford approach is to supplement the topical regimen and laser sessions with oral doxycycline at 100-150 mg daily for 1-6 months.

“The theory here is this is a dysbiotic event. The antibiotics reduce commensal bacteria, which ultimately reduces the reactive inflammatory response. But when you stop the antibiotics, the inflammatory response returns. So antibiotics can help stabilize the disease state but really can’t reverse the disease state. For that we have to turn to ablative treatment options: laser, surgery,” the dermatologist continued.

 

Hurley stage II

“At this point you’re looking at procedures,” according to Dr. Hamzavi. “Once you have sinus tracts it’s critical to remove them.”

The treatment backbone in stage II disease is 8-10 weeks of oral clindamycin and rifampin, both at 300 mg twice daily.

“This is one of the fundamental building blocks of HS clinics throughout the world,” he noted.

Clostridium difficile infection is exceedingly rare in HS patients on this regimen, for reasons still unclear.

If this dual-antibiotic regimen doesn’t dramatically reduce drainage and pain, he adds levofloxacin at 500 mg twice daily for up to 2 weeks in an effort to calm down unstable, decompensating disease.

 

Dapsone at 50-150 mg/day for up to 12 weeks is an additional option. It’s most useful in patients with nodules that are disproportionately painful, in Dr. Hamzavi’s experience.

Deroofing is a simple procedure that should be considered for all sinus tracts. It entails numbing the area with a ring block then introducing a curette or surgical probe into the sinus tract to open it up and get rid of the gelatinous material within. Dutch investigators have detailed the technique (J Am Acad Dermatol. 2010 Sep;63[3]:475-80).

Tumor necrosis factor–inhibitor therapy has been a major advance in Hurley stage II and III disease. “It doesn’t work in everybody, but a lot of patients can be stabilized,” Dr. Hamzavi observed.

Efficacy has been amply demonstrated for adalimumab (Humira) and infliximab (Remicade). In Dr. Hamzavi’s experience infliximab works better, probably because it offers more dosing options.

Assuming medical therapy has resulted in disease stabilization, CO₂ laser excision of sinus tracts under local anesthesia can then be employed as an office procedure to turn back the clock and return to an earlier stage of disease. Dermatologists at the Cleveland Clinic have described the technique in detail (Dermatol Surg. 2010 Feb;36[2]:208-13).

 

Hurley stage III

If biologic therapy doesn’t bring disease stabilization, the patient is likely headed for surgical excision using the CO₂ laser. The Henry Ford team favors a specific regimen of surgical preparation using wide-spectrum antibiotics. The program begins with 6 weeks of IV ertapenem at 1 g/day delivered by a peripherally inserted central catheter managed by infectious disease colleagues.

“IV ertapenem is a drug you may not know much about. We find it works really well as a great way to bridge patients towards surgery,” the dermatologist explained.

The IV ertapenem is followed by 6 weeks of oral triple therapy with rifampin, moxifloxacin, and metronidazole then another 6 weeks of rifampin plus moxifloxacin. Next it’s surgical excision time.

 

Lifestyle modification

Lifestyle modification deserves to be a major priority in all HS patients, regardless of Hurley stage. Smoking cessation results in significantly greater likelihood of favorable response to first-line therapy. In obese patients, greater than 15% weight loss has been associated with significant reduction in disease severity. A sartorial shift to loose-fitting clothing can quiet down skin lesions through decreased friction and pressure. And proper utilization of warm compression will rapidly decrease acute lesional pain.

Dr. Hamzavi and his coinvestigators have described the Henry Ford Hospital treatment algorithm in a review of HS published in an open-access journal meant to serve as a resource for patients and physicians alike (F1000Res. 2017 Jul 28;6:1272. doi: 10.12688/f1000research.11337.1. eCollection 2017).

He reported serving as a consultant to AbbVie, Incyte, and UCB.

The Global Academy for Medical Education/SDEF and this news organization are owned by the same parent company.

[email protected]

KAUAI, HAWAII – Medical therapy alone is never sufficient in Hurley stage III hidradenitis suppurativa (HS), Iltefat H. Hamzavi, MD, observed at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

“Even with the advances in biologics and antibiotic therapy, you still have to excise once you’re in full-blown Hurley stage III disease. Surgery has to be part of your protocol,” according to Dr. Hamzavi, a dermatologist at Henry Ford Hospital in Detroit, which runs one of the nation’s largest hidradenitis suppurativa clinics, with roughly 1,600 patients.

Elsevier

He outlined the Henry Ford Hospital’s HS treatment algorithm. Where good evidence exists, the algorithm is evidence-based, and where evidence is lacking, it’s based upon expert opinion and considerable anecdotal experience.

“Of course we’re biased. But until the data can set us free, you’re stuck with me,” the dermatologist quipped.

A core principle of the Henry Ford algorithm is this: “Medical therapy [for patients with advanced HS] stabilizes them and reduces their draining and pain, then you try to bring them back to a lower stage with surgical options,” he explained.

Although other HS staging systems exist, Dr. Hamzavi and his colleagues rely on the Hurley staging system to guide their treatment. Basically, Hurley stage I consists of follicular nodules and abscesses. When the nodules connect to form sinus tracts with scarring, that’s stage II. And if the sinus tracts interconnect throughout an entire area, that’s stage III.

 

Hurley stage I

First-line treatment of localized Hurley stage I disease at Henry Ford is a 10% topical benzoyl peroxide wash left on for 5 minutes before bathing, followed by postbathing topical clindamycin 1% lotion or solution applied to the nodules. If this maintenance regimen isn’t sufficient to prevent formation of new and worsening nodules, Dr. Hamzavi supplements it with up to three once-monthly 1064-nm Nd:YAG laser sessions aimed at follicular ablation. It’s a laser application he and his colleagues pioneered (Dermatol Surg. 2009 Aug;35[8]:1188-98). They subsequently documented the histopathologic basis of the procedure’s efficacy, which entails selective thermolysis of follicles, destruction of inflammatory lesions in the superficial to mid-dermis, followed by fibrosis and scarring (Arch Dermatol. 2011 Jan;147[1]:21-8).

Bruce Jancin/MDedge News

“Our experience, and that of most people in the HS community, has been that, if you limit the hair follicles you limit the disease state,” said Dr. Hamzavi, who is the current president of the Hidradenitis Suppurativa Foundation.

In generalized Hurley stage I HS, the Henry Ford approach is to supplement the topical regimen and laser sessions with oral doxycycline at 100-150 mg daily for 1-6 months.

“The theory here is this is a dysbiotic event. The antibiotics reduce commensal bacteria, which ultimately reduces the reactive inflammatory response. But when you stop the antibiotics, the inflammatory response returns. So antibiotics can help stabilize the disease state but really can’t reverse the disease state. For that we have to turn to ablative treatment options: laser, surgery,” the dermatologist continued.

 

Hurley stage II

“At this point you’re looking at procedures,” according to Dr. Hamzavi. “Once you have sinus tracts it’s critical to remove them.”

The treatment backbone in stage II disease is 8-10 weeks of oral clindamycin and rifampin, both at 300 mg twice daily.

“This is one of the fundamental building blocks of HS clinics throughout the world,” he noted.

Clostridium difficile infection is exceedingly rare in HS patients on this regimen, for reasons still unclear.

If this dual-antibiotic regimen doesn’t dramatically reduce drainage and pain, he adds levofloxacin at 500 mg twice daily for up to 2 weeks in an effort to calm down unstable, decompensating disease.

 

Dapsone at 50-150 mg/day for up to 12 weeks is an additional option. It’s most useful in patients with nodules that are disproportionately painful, in Dr. Hamzavi’s experience.

Deroofing is a simple procedure that should be considered for all sinus tracts. It entails numbing the area with a ring block then introducing a curette or surgical probe into the sinus tract to open it up and get rid of the gelatinous material within. Dutch investigators have detailed the technique (J Am Acad Dermatol. 2010 Sep;63[3]:475-80).

Tumor necrosis factor–inhibitor therapy has been a major advance in Hurley stage II and III disease. “It doesn’t work in everybody, but a lot of patients can be stabilized,” Dr. Hamzavi observed.

Efficacy has been amply demonstrated for adalimumab (Humira) and infliximab (Remicade). In Dr. Hamzavi’s experience infliximab works better, probably because it offers more dosing options.

Assuming medical therapy has resulted in disease stabilization, CO₂ laser excision of sinus tracts under local anesthesia can then be employed as an office procedure to turn back the clock and return to an earlier stage of disease. Dermatologists at the Cleveland Clinic have described the technique in detail (Dermatol Surg. 2010 Feb;36[2]:208-13).

 

Hurley stage III

If biologic therapy doesn’t bring disease stabilization, the patient is likely headed for surgical excision using the CO₂ laser. The Henry Ford team favors a specific regimen of surgical preparation using wide-spectrum antibiotics. The program begins with 6 weeks of IV ertapenem at 1 g/day delivered by a peripherally inserted central catheter managed by infectious disease colleagues.

“IV ertapenem is a drug you may not know much about. We find it works really well as a great way to bridge patients towards surgery,” the dermatologist explained.

The IV ertapenem is followed by 6 weeks of oral triple therapy with rifampin, moxifloxacin, and metronidazole then another 6 weeks of rifampin plus moxifloxacin. Next it’s surgical excision time.

 

Lifestyle modification

Lifestyle modification deserves to be a major priority in all HS patients, regardless of Hurley stage. Smoking cessation results in significantly greater likelihood of favorable response to first-line therapy. In obese patients, greater than 15% weight loss has been associated with significant reduction in disease severity. A sartorial shift to loose-fitting clothing can quiet down skin lesions through decreased friction and pressure. And proper utilization of warm compression will rapidly decrease acute lesional pain.

Dr. Hamzavi and his coinvestigators have described the Henry Ford Hospital treatment algorithm in a review of HS published in an open-access journal meant to serve as a resource for patients and physicians alike (F1000Res. 2017 Jul 28;6:1272. doi: 10.12688/f1000research.11337.1. eCollection 2017).

He reported serving as a consultant to AbbVie, Incyte, and UCB.

The Global Academy for Medical Education/SDEF and this news organization are owned by the same parent company.

[email protected]

KAUAI, HAWAII – Medical therapy alone is never sufficient in Hurley stage III hidradenitis suppurativa (HS), Iltefat H. Hamzavi, MD, observed at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

“Even with the advances in biologics and antibiotic therapy, you still have to excise once you’re in full-blown Hurley stage III disease. Surgery has to be part of your protocol,” according to Dr. Hamzavi, a dermatologist at Henry Ford Hospital in Detroit, which runs one of the nation’s largest hidradenitis suppurativa clinics, with roughly 1,600 patients.

Elsevier

He outlined the Henry Ford Hospital’s HS treatment algorithm. Where good evidence exists, the algorithm is evidence-based, and where evidence is lacking, it’s based upon expert opinion and considerable anecdotal experience.

“Of course we’re biased. But until the data can set us free, you’re stuck with me,” the dermatologist quipped.

A core principle of the Henry Ford algorithm is this: “Medical therapy [for patients with advanced HS] stabilizes them and reduces their draining and pain, then you try to bring them back to a lower stage with surgical options,” he explained.

Although other HS staging systems exist, Dr. Hamzavi and his colleagues rely on the Hurley staging system to guide their treatment. Basically, Hurley stage I consists of follicular nodules and abscesses. When the nodules connect to form sinus tracts with scarring, that’s stage II. And if the sinus tracts interconnect throughout an entire area, that’s stage III.

 

Hurley stage I

First-line treatment of localized Hurley stage I disease at Henry Ford is a 10% topical benzoyl peroxide wash left on for 5 minutes before bathing, followed by postbathing topical clindamycin 1% lotion or solution applied to the nodules. If this maintenance regimen isn’t sufficient to prevent formation of new and worsening nodules, Dr. Hamzavi supplements it with up to three once-monthly 1064-nm Nd:YAG laser sessions aimed at follicular ablation. It’s a laser application he and his colleagues pioneered (Dermatol Surg. 2009 Aug;35[8]:1188-98). They subsequently documented the histopathologic basis of the procedure’s efficacy, which entails selective thermolysis of follicles, destruction of inflammatory lesions in the superficial to mid-dermis, followed by fibrosis and scarring (Arch Dermatol. 2011 Jan;147[1]:21-8).

Bruce Jancin/MDedge News

“Our experience, and that of most people in the HS community, has been that, if you limit the hair follicles you limit the disease state,” said Dr. Hamzavi, who is the current president of the Hidradenitis Suppurativa Foundation.

In generalized Hurley stage I HS, the Henry Ford approach is to supplement the topical regimen and laser sessions with oral doxycycline at 100-150 mg daily for 1-6 months.

“The theory here is this is a dysbiotic event. The antibiotics reduce commensal bacteria, which ultimately reduces the reactive inflammatory response. But when you stop the antibiotics, the inflammatory response returns. So antibiotics can help stabilize the disease state but really can’t reverse the disease state. For that we have to turn to ablative treatment options: laser, surgery,” the dermatologist continued.

 

Hurley stage II

“At this point you’re looking at procedures,” according to Dr. Hamzavi. “Once you have sinus tracts it’s critical to remove them.”

The treatment backbone in stage II disease is 8-10 weeks of oral clindamycin and rifampin, both at 300 mg twice daily.

“This is one of the fundamental building blocks of HS clinics throughout the world,” he noted.

Clostridium difficile infection is exceedingly rare in HS patients on this regimen, for reasons still unclear.

If this dual-antibiotic regimen doesn’t dramatically reduce drainage and pain, he adds levofloxacin at 500 mg twice daily for up to 2 weeks in an effort to calm down unstable, decompensating disease.

 

Dapsone at 50-150 mg/day for up to 12 weeks is an additional option. It’s most useful in patients with nodules that are disproportionately painful, in Dr. Hamzavi’s experience.

Deroofing is a simple procedure that should be considered for all sinus tracts. It entails numbing the area with a ring block then introducing a curette or surgical probe into the sinus tract to open it up and get rid of the gelatinous material within. Dutch investigators have detailed the technique (J Am Acad Dermatol. 2010 Sep;63[3]:475-80).

Tumor necrosis factor–inhibitor therapy has been a major advance in Hurley stage II and III disease. “It doesn’t work in everybody, but a lot of patients can be stabilized,” Dr. Hamzavi observed.

Efficacy has been amply demonstrated for adalimumab (Humira) and infliximab (Remicade). In Dr. Hamzavi’s experience infliximab works better, probably because it offers more dosing options.

Assuming medical therapy has resulted in disease stabilization, CO₂ laser excision of sinus tracts under local anesthesia can then be employed as an office procedure to turn back the clock and return to an earlier stage of disease. Dermatologists at the Cleveland Clinic have described the technique in detail (Dermatol Surg. 2010 Feb;36[2]:208-13).

 

Hurley stage III

If biologic therapy doesn’t bring disease stabilization, the patient is likely headed for surgical excision using the CO₂ laser. The Henry Ford team favors a specific regimen of surgical preparation using wide-spectrum antibiotics. The program begins with 6 weeks of IV ertapenem at 1 g/day delivered by a peripherally inserted central catheter managed by infectious disease colleagues.

“IV ertapenem is a drug you may not know much about. We find it works really well as a great way to bridge patients towards surgery,” the dermatologist explained.

The IV ertapenem is followed by 6 weeks of oral triple therapy with rifampin, moxifloxacin, and metronidazole then another 6 weeks of rifampin plus moxifloxacin. Next it’s surgical excision time.

 

Lifestyle modification

Lifestyle modification deserves to be a major priority in all HS patients, regardless of Hurley stage. Smoking cessation results in significantly greater likelihood of favorable response to first-line therapy. In obese patients, greater than 15% weight loss has been associated with significant reduction in disease severity. A sartorial shift to loose-fitting clothing can quiet down skin lesions through decreased friction and pressure. And proper utilization of warm compression will rapidly decrease acute lesional pain.

Dr. Hamzavi and his coinvestigators have described the Henry Ford Hospital treatment algorithm in a review of HS published in an open-access journal meant to serve as a resource for patients and physicians alike (F1000Res. 2017 Jul 28;6:1272. doi: 10.12688/f1000research.11337.1. eCollection 2017).

He reported serving as a consultant to AbbVie, Incyte, and UCB.

The Global Academy for Medical Education/SDEF and this news organization are owned by the same parent company.

[email protected]

KAUAI, HAWAII – Physicians have become much more cognizant of severe diarrhea and nausea as potential side effects of apremilast since the Food and Drug Administration–approved change in the warnings and precautions section of the drug’s labeling in June 2017. Jashin J. Wu, MD, director of the psoriasis clinic at Kaiser Permanente Los Angeles Medical Center, has a tip for avoiding these problems: Delay up-titrating.

Bruce Jancin/Frontline Medical News

During the first 5 days patients are on apremilast (Otezla), they are supposed to titrate up from 10 mg/day to 50 mg on day 5 before starting full-dose therapy at 30 mg twice daily on day 6.

“In my opinion, that may be too quick of an up-titration. I tell patients that, if they feel the GI issues are still a problem for them on day 6, they should take 30 mg just once a day for the first 1-2 months. After that we’ll see how they’re doing, and if they feel they can make the jump to twice a day, then they can go for it. Of course, I also tell them that maybe their psoriasis will not clear as well as if they’d been on apremilast twice a day right from day 6, but if they’re able to tolerate it and can continue to take it, they can improve while they’re on it,” the dermatologist said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Dr. Wu presented an update on recent developments regarding the newest oral drugs for psoriasis and one of the oldest: apremilast and methotrexate, respectively.

Apremilast

The revised warning label highlighting the risks of severe diarrhea and nausea associated with the oral phosphodiesterase-4 inhibitor says that most such events have occurred within the first few weeks of therapy. The guidance also notes that patients who reduced the dosage or discontinued treatment outright generally improved rapidly.

“I see this in a lot of my patients. They have to go to the bathroom pretty often. It’s actually unusual for me for a patient not to have any GI issues at all,” according to Dr. Wu.

He shared a number of other fresh insights into apremilast’s safety and efficacy derived from recent studies.

 

Efficacy appears to increase at least out to 1 year

A report from the phase 3b, randomized, placebo-controlled, 250-patient LIBERATE trial showed that the week 16 PASI 75 response rate was 39.8% with apremilast, 48.2% with etanercept (Enbrel), and 11.9% with placebo. After week 16, everyone switched to apremilast. The PASI 75 rate in patients on apremilast all along climbed from 39.8% at week 16 to 52.7% at week 52. That result was in the same ballpark as the 57% rate in those switched from etanercept to apremilast and the 53.4% PASI 75 rate at week 52 in patients switched from placebo to apremilast (J Eur Acad Dermatol Venereol. 2017 Mar;31[3]:507-17).

“It was interesting to see that, as the study continued on for 1 year, the PASI 75 rate continued to improve. That’s worth noting: In general, I tell patients you have to be on a drug for about 3 months before we’re going to say if it worked or not, and that’s true even with drugs for other conditions, like doxycycline for acne. But this study seems to indicate that you have much better improvement at the 1-year point, and that’s not so much true for the biologics,” the dermatologist observed.

Safety to 3 years looks reassuringly good: 3-year follow-up of the 1,184-patient, phase 3, randomized, controlled ESTEEM 1 and 2 trials provided by far the longest look to date at apremilast’s safety. There were no surprises, no serious opportunistic infections, and no significant changes in laboratory values (J Am Acad Dermatol. 2017 Aug;77[2]:310-17.e1).

Of note, 21.9% of patients on apremilast lost more than 5% of their baseline body weight. Most of the weight loss occurred during year 1 of treatment and mostly in patients with a higher baseline body mass index.

 

“It seems like apremilast is definitely a good option if patients can tolerate the GI upset,” Dr. Wu said.

Apremilast can safely and effectively be combined with other psoriasis therapies: Dermatologists at the University of Toronto reported on a retrospective analysis of 81 biologic-naive psoriasis patients treated with apremilast in combination with methotrexate, acitretin (Soriatane), cyclosporine, narrowband UVB, etanercept, infliximab (Remicade), adalimumab (Humira), and/or ustekinumab (Stelara). Of these patients, 81% achieved a PASI 75 response at week 12 (J Cutan Med Surg. 2016 Jul;20[4]:313-6).

“That’s pretty good. It’s certainly better than apremilast by itself. So if you can get the payer to cover a combination of apremilast and something else, it may help get to PASI 75,” Dr. Wu noted.

Session chair Craig L. Leonardi, MD, said he hasn’t had any luck in going that route.

“The insurance industry just won’t give me apremilast in combination with a biologic drug. Even though it makes complete sense to use it in place of methotrexate with a biologic, I just can’t get it,” according to Dr. Leonardi, a dermatologist at Saint Louis University.

 

“I don’t have those limitations at Kaiser,” according to Dr. Wu. “I personally have only used apremilast and methotrexate and apremilast and acitretin in combination. I just want to be kind to Kaiser and not give two branded medications to a patient, but I certainly think it’s a feasible option.”

 

Methotrexate

A simple response prediction rule: Kenneth B. Gordon, MD, professor and chair of dermatology at the Medical College of Wisconsin in Milwaukee, and his coinvestigators at AbbVie developed a methotrexate response/nonresponse prediction rule using data on 110 participants in the phase 3 CHAMPION trial. Then they validated the rule in the phase 3 M10-255 trial. They found that a PASI 25 response to methotrexate at week 4 was associated with an 8.9-fold increased likelihood of a week-16 PASI 75 response. Patients with a predicted response probability of less than 30% were asked to discontinue the drug; their week 16 PASI 75 rate was only 21.1%, compared with a 65.8% response rate in patients with a prediction rating (J Am Acad Dermatol. 2017 Dec;77[6]:1030-7).

“Four weeks of methotrexate may be sufficient to determine the long-term response. It may not be necessary to put them on the drug for 3 months,” Dr. Wu commented.

Subcutaneous methotrexate: European investigators demonstrated that an intensified dosing schedule of subcutaneous methotrexate was safe and effective for treatment of moderate to severe plaque psoriasis in the 52-week, phase 3, randomized, 16-center, double-blind, 120-patient, placebo-controlled METOP study.

 

The intensified subcutaneous regimen consisted of 17.5 mg/week initially, escalated to 22.5 mg/week after 8 weeks if a patient hadn’t achieved at least a PASI 50 response at that point. The primary outcome, the PASI 75 response at week 16, was 41% in the subcutaneous methotrexate group and 10% in controls, with a maximum PASI 75 rate of 51% seen beginning at week 24. The week 4 and 8 PASI 50 rates were 50% and 58%, respectively, with methotrexate versus 3% and 17% in placebo-treated controls. The subcutaneous regimen was generally well tolerated, with no serious infections or malignancies arising during 52 weeks (Lancet. 2017 Feb 4;389[10068]:528-37).

Dr. Wu reported receiving research funding from AbbVie, Amgen, Eli Lilly, Janssen, Novartis, and Regeneron.

The Global Academy for Medical Education/SDEF and this news organization are owned by the same parent company.

[email protected]

KAUAI, HAWAII – Physicians have become much more cognizant of severe diarrhea and nausea as potential side effects of apremilast since the Food and Drug Administration–approved change in the warnings and precautions section of the drug’s labeling in June 2017. Jashin J. Wu, MD, director of the psoriasis clinic at Kaiser Permanente Los Angeles Medical Center, has a tip for avoiding these problems: Delay up-titrating.

Bruce Jancin/Frontline Medical News

During the first 5 days patients are on apremilast (Otezla), they are supposed to titrate up from 10 mg/day to 50 mg on day 5 before starting full-dose therapy at 30 mg twice daily on day 6.

“In my opinion, that may be too quick of an up-titration. I tell patients that, if they feel the GI issues are still a problem for them on day 6, they should take 30 mg just once a day for the first 1-2 months. After that we’ll see how they’re doing, and if they feel they can make the jump to twice a day, then they can go for it. Of course, I also tell them that maybe their psoriasis will not clear as well as if they’d been on apremilast twice a day right from day 6, but if they’re able to tolerate it and can continue to take it, they can improve while they’re on it,” the dermatologist said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Dr. Wu presented an update on recent developments regarding the newest oral drugs for psoriasis and one of the oldest: apremilast and methotrexate, respectively.

Apremilast

The revised warning label highlighting the risks of severe diarrhea and nausea associated with the oral phosphodiesterase-4 inhibitor says that most such events have occurred within the first few weeks of therapy. The guidance also notes that patients who reduced the dosage or discontinued treatment outright generally improved rapidly.

“I see this in a lot of my patients. They have to go to the bathroom pretty often. It’s actually unusual for me for a patient not to have any GI issues at all,” according to Dr. Wu.

He shared a number of other fresh insights into apremilast’s safety and efficacy derived from recent studies.

 

Efficacy appears to increase at least out to 1 year

A report from the phase 3b, randomized, placebo-controlled, 250-patient LIBERATE trial showed that the week 16 PASI 75 response rate was 39.8% with apremilast, 48.2% with etanercept (Enbrel), and 11.9% with placebo. After week 16, everyone switched to apremilast. The PASI 75 rate in patients on apremilast all along climbed from 39.8% at week 16 to 52.7% at week 52. That result was in the same ballpark as the 57% rate in those switched from etanercept to apremilast and the 53.4% PASI 75 rate at week 52 in patients switched from placebo to apremilast (J Eur Acad Dermatol Venereol. 2017 Mar;31[3]:507-17).

“It was interesting to see that, as the study continued on for 1 year, the PASI 75 rate continued to improve. That’s worth noting: In general, I tell patients you have to be on a drug for about 3 months before we’re going to say if it worked or not, and that’s true even with drugs for other conditions, like doxycycline for acne. But this study seems to indicate that you have much better improvement at the 1-year point, and that’s not so much true for the biologics,” the dermatologist observed.

Safety to 3 years looks reassuringly good: 3-year follow-up of the 1,184-patient, phase 3, randomized, controlled ESTEEM 1 and 2 trials provided by far the longest look to date at apremilast’s safety. There were no surprises, no serious opportunistic infections, and no significant changes in laboratory values (J Am Acad Dermatol. 2017 Aug;77[2]:310-17.e1).

Of note, 21.9% of patients on apremilast lost more than 5% of their baseline body weight. Most of the weight loss occurred during year 1 of treatment and mostly in patients with a higher baseline body mass index.

 

“It seems like apremilast is definitely a good option if patients can tolerate the GI upset,” Dr. Wu said.

Apremilast can safely and effectively be combined with other psoriasis therapies: Dermatologists at the University of Toronto reported on a retrospective analysis of 81 biologic-naive psoriasis patients treated with apremilast in combination with methotrexate, acitretin (Soriatane), cyclosporine, narrowband UVB, etanercept, infliximab (Remicade), adalimumab (Humira), and/or ustekinumab (Stelara). Of these patients, 81% achieved a PASI 75 response at week 12 (J Cutan Med Surg. 2016 Jul;20[4]:313-6).

“That’s pretty good. It’s certainly better than apremilast by itself. So if you can get the payer to cover a combination of apremilast and something else, it may help get to PASI 75,” Dr. Wu noted.

Session chair Craig L. Leonardi, MD, said he hasn’t had any luck in going that route.

“The insurance industry just won’t give me apremilast in combination with a biologic drug. Even though it makes complete sense to use it in place of methotrexate with a biologic, I just can’t get it,” according to Dr. Leonardi, a dermatologist at Saint Louis University.

 

“I don’t have those limitations at Kaiser,” according to Dr. Wu. “I personally have only used apremilast and methotrexate and apremilast and acitretin in combination. I just want to be kind to Kaiser and not give two branded medications to a patient, but I certainly think it’s a feasible option.”

 

Methotrexate

A simple response prediction rule: Kenneth B. Gordon, MD, professor and chair of dermatology at the Medical College of Wisconsin in Milwaukee, and his coinvestigators at AbbVie developed a methotrexate response/nonresponse prediction rule using data on 110 participants in the phase 3 CHAMPION trial. Then they validated the rule in the phase 3 M10-255 trial. They found that a PASI 25 response to methotrexate at week 4 was associated with an 8.9-fold increased likelihood of a week-16 PASI 75 response. Patients with a predicted response probability of less than 30% were asked to discontinue the drug; their week 16 PASI 75 rate was only 21.1%, compared with a 65.8% response rate in patients with a prediction rating (J Am Acad Dermatol. 2017 Dec;77[6]:1030-7).

“Four weeks of methotrexate may be sufficient to determine the long-term response. It may not be necessary to put them on the drug for 3 months,” Dr. Wu commented.

Subcutaneous methotrexate: European investigators demonstrated that an intensified dosing schedule of subcutaneous methotrexate was safe and effective for treatment of moderate to severe plaque psoriasis in the 52-week, phase 3, randomized, 16-center, double-blind, 120-patient, placebo-controlled METOP study.

 

The intensified subcutaneous regimen consisted of 17.5 mg/week initially, escalated to 22.5 mg/week after 8 weeks if a patient hadn’t achieved at least a PASI 50 response at that point. The primary outcome, the PASI 75 response at week 16, was 41% in the subcutaneous methotrexate group and 10% in controls, with a maximum PASI 75 rate of 51% seen beginning at week 24. The week 4 and 8 PASI 50 rates were 50% and 58%, respectively, with methotrexate versus 3% and 17% in placebo-treated controls. The subcutaneous regimen was generally well tolerated, with no serious infections or malignancies arising during 52 weeks (Lancet. 2017 Feb 4;389[10068]:528-37).

Dr. Wu reported receiving research funding from AbbVie, Amgen, Eli Lilly, Janssen, Novartis, and Regeneron.

The Global Academy for Medical Education/SDEF and this news organization are owned by the same parent company.

[email protected]

KAUAI, HAWAII – Physicians have become much more cognizant of severe diarrhea and nausea as potential side effects of apremilast since the Food and Drug Administration–approved change in the warnings and precautions section of the drug’s labeling in June 2017. Jashin J. Wu, MD, director of the psoriasis clinic at Kaiser Permanente Los Angeles Medical Center, has a tip for avoiding these problems: Delay up-titrating.

Bruce Jancin/Frontline Medical News

During the first 5 days patients are on apremilast (Otezla), they are supposed to titrate up from 10 mg/day to 50 mg on day 5 before starting full-dose therapy at 30 mg twice daily on day 6.

“In my opinion, that may be too quick of an up-titration. I tell patients that, if they feel the GI issues are still a problem for them on day 6, they should take 30 mg just once a day for the first 1-2 months. After that we’ll see how they’re doing, and if they feel they can make the jump to twice a day, then they can go for it. Of course, I also tell them that maybe their psoriasis will not clear as well as if they’d been on apremilast twice a day right from day 6, but if they’re able to tolerate it and can continue to take it, they can improve while they’re on it,” the dermatologist said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Dr. Wu presented an update on recent developments regarding the newest oral drugs for psoriasis and one of the oldest: apremilast and methotrexate, respectively.

Apremilast

The revised warning label highlighting the risks of severe diarrhea and nausea associated with the oral phosphodiesterase-4 inhibitor says that most such events have occurred within the first few weeks of therapy. The guidance also notes that patients who reduced the dosage or discontinued treatment outright generally improved rapidly.

“I see this in a lot of my patients. They have to go to the bathroom pretty often. It’s actually unusual for me for a patient not to have any GI issues at all,” according to Dr. Wu.

He shared a number of other fresh insights into apremilast’s safety and efficacy derived from recent studies.

 

Efficacy appears to increase at least out to 1 year

A report from the phase 3b, randomized, placebo-controlled, 250-patient LIBERATE trial showed that the week 16 PASI 75 response rate was 39.8% with apremilast, 48.2% with etanercept (Enbrel), and 11.9% with placebo. After week 16, everyone switched to apremilast. The PASI 75 rate in patients on apremilast all along climbed from 39.8% at week 16 to 52.7% at week 52. That result was in the same ballpark as the 57% rate in those switched from etanercept to apremilast and the 53.4% PASI 75 rate at week 52 in patients switched from placebo to apremilast (J Eur Acad Dermatol Venereol. 2017 Mar;31[3]:507-17).

“It was interesting to see that, as the study continued on for 1 year, the PASI 75 rate continued to improve. That’s worth noting: In general, I tell patients you have to be on a drug for about 3 months before we’re going to say if it worked or not, and that’s true even with drugs for other conditions, like doxycycline for acne. But this study seems to indicate that you have much better improvement at the 1-year point, and that’s not so much true for the biologics,” the dermatologist observed.

Safety to 3 years looks reassuringly good: 3-year follow-up of the 1,184-patient, phase 3, randomized, controlled ESTEEM 1 and 2 trials provided by far the longest look to date at apremilast’s safety. There were no surprises, no serious opportunistic infections, and no significant changes in laboratory values (J Am Acad Dermatol. 2017 Aug;77[2]:310-17.e1).

Of note, 21.9% of patients on apremilast lost more than 5% of their baseline body weight. Most of the weight loss occurred during year 1 of treatment and mostly in patients with a higher baseline body mass index.

 

“It seems like apremilast is definitely a good option if patients can tolerate the GI upset,” Dr. Wu said.

Apremilast can safely and effectively be combined with other psoriasis therapies: Dermatologists at the University of Toronto reported on a retrospective analysis of 81 biologic-naive psoriasis patients treated with apremilast in combination with methotrexate, acitretin (Soriatane), cyclosporine, narrowband UVB, etanercept, infliximab (Remicade), adalimumab (Humira), and/or ustekinumab (Stelara). Of these patients, 81% achieved a PASI 75 response at week 12 (J Cutan Med Surg. 2016 Jul;20[4]:313-6).

“That’s pretty good. It’s certainly better than apremilast by itself. So if you can get the payer to cover a combination of apremilast and something else, it may help get to PASI 75,” Dr. Wu noted.

Session chair Craig L. Leonardi, MD, said he hasn’t had any luck in going that route.

“The insurance industry just won’t give me apremilast in combination with a biologic drug. Even though it makes complete sense to use it in place of methotrexate with a biologic, I just can’t get it,” according to Dr. Leonardi, a dermatologist at Saint Louis University.

 

“I don’t have those limitations at Kaiser,” according to Dr. Wu. “I personally have only used apremilast and methotrexate and apremilast and acitretin in combination. I just want to be kind to Kaiser and not give two branded medications to a patient, but I certainly think it’s a feasible option.”

 

Methotrexate

A simple response prediction rule: Kenneth B. Gordon, MD, professor and chair of dermatology at the Medical College of Wisconsin in Milwaukee, and his coinvestigators at AbbVie developed a methotrexate response/nonresponse prediction rule using data on 110 participants in the phase 3 CHAMPION trial. Then they validated the rule in the phase 3 M10-255 trial. They found that a PASI 25 response to methotrexate at week 4 was associated with an 8.9-fold increased likelihood of a week-16 PASI 75 response. Patients with a predicted response probability of less than 30% were asked to discontinue the drug; their week 16 PASI 75 rate was only 21.1%, compared with a 65.8% response rate in patients with a prediction rating (J Am Acad Dermatol. 2017 Dec;77[6]:1030-7).

“Four weeks of methotrexate may be sufficient to determine the long-term response. It may not be necessary to put them on the drug for 3 months,” Dr. Wu commented.

Subcutaneous methotrexate: European investigators demonstrated that an intensified dosing schedule of subcutaneous methotrexate was safe and effective for treatment of moderate to severe plaque psoriasis in the 52-week, phase 3, randomized, 16-center, double-blind, 120-patient, placebo-controlled METOP study.

 

The intensified subcutaneous regimen consisted of 17.5 mg/week initially, escalated to 22.5 mg/week after 8 weeks if a patient hadn’t achieved at least a PASI 50 response at that point. The primary outcome, the PASI 75 response at week 16, was 41% in the subcutaneous methotrexate group and 10% in controls, with a maximum PASI 75 rate of 51% seen beginning at week 24. The week 4 and 8 PASI 50 rates were 50% and 58%, respectively, with methotrexate versus 3% and 17% in placebo-treated controls. The subcutaneous regimen was generally well tolerated, with no serious infections or malignancies arising during 52 weeks (Lancet. 2017 Feb 4;389[10068]:528-37).

Dr. Wu reported receiving research funding from AbbVie, Amgen, Eli Lilly, Janssen, Novartis, and Regeneron.

The Global Academy for Medical Education/SDEF and this news organization are owned by the same parent company.

[email protected]

Papulopustular rosacea (PPR) and rosacea-like demodicosis may be the same disease, according to the authors of a retrospective study.

Currently, there is a lack of consensus among physicians and health care organizations on how Demodex mites affect the development of rosacea. Many experts separate rosacea into two camps: PPR not caused by Demodex and rosacea-like demodicosis caused by Demodex.

Rosacea.org

To address this confusion, Fabienne Forton, MD, a dermatologist in Brussels, and Viviane de Maertelaer, PhD, of the Université Libre de Bruxelles conducted this study to determine the role that Demodex mites play in the development of PPR and rosacea-like demodicosis, which are surprisingly similar. Building off of a previous study of 254 patients with central facial papulopustules, the researchers conducted a secondary analysis of 242 patients; 215 of these patients had central facial papulopustules and persistent erthyema (both considered diagnostic of PPR), and 27 had central facial papulopustules but lacked persistent erythema.

During each evaluation session, each patient underwent two consecutive standardized skin surface biopsies (SSSBs), a small 1 square centimeter sample of the horny skin layer and the follicular content, on each cheek. The first sample, SSSB1, was a superficial sample, and SSSB2, the second sample, was a deep sample. The sum of the two samples, SSSB1+2, also was noted.

During the same session, patients had Demodex densities (Dds) measured. To avoid any confounding factors that could affect facial skin symptoms, Dr. Forton and Dr. de Maertelaer evaluated a subgroup of 132 patients who had not been treated in the previous 3 months and had no other facial dermatoses, such as acne vulgaris and seborrheic dermatitis.

The study revealed that, among the 242 patients in the primary analysis group, those with persistent erythema had higher Dds than did those without and the differences were statistically significant when comparing SSSB2 (208 D/cm² vs. 130 D/cm²; P = 0.031) and SSB1+2 (298 D/cm² vs. 191 D/cm²; P = 0.025), respectively.

 

This pattern of greater Dds density among patients with persistent erythema, compared with patients without, also held true among the subgroup of 132 patients who had not received any recent dermatological treatments, but the difference was not statistically significant. Nonetheless, patients with follicular scales did have greater SSSBs than did those without follicular scales.

As part of the study, Dr. Forton and Dr. de Maertelaer analyzed the findings of a case report of a 19-year-old woman who had a facial papulopustular eruption that had been present for 1 year. She had two SSSBs taken on each cheek: the right had follicular scales and papulopustules, and the left was clinically normal. This revealed that she had much higher Dds on the affected cheek than on the clinically normal one (108 and 216 D/cm² vs. 12 and 20 D/cm2). She was subsequently diagnosed with rosacea-like demodicosis.

After treating the areas with acaricidal ointment, the symptoms improved. But 27 months after stopping maintenance treatments, the facial eruptions reappeared, and the papulopustules were larger than during her original consultation, leading to the diagnosis of PPR. This time, the Dds was high on both cheeks but responded to acaricidal treatment, which indicates that her eruptions were caused Demodex mites.

“All our observations, therefore, highlight the nosological confusion that persists between PPR and rosacea-like demodicosis and the need to update the consensus concerning the definition and classification of rosacea. Moreover, they suggest that PPR and rosacea-like demodicosis may be phenotypes of the same disease,” wrote Dr. Forton and Dr. de Maertelaer. “This concept is supported by our case report, with many features indicating that the second presentation was an evolution of the first.”

 

They cautioned that their research is not definitive but should provide strong evidence that PPR and rosacea-like demodicosis are the same disease.

“While our observations do not prove a causative role of Demodex in rosacea, they nevertheless support the idea that PPR and rosacea-like demodicosis should no longer be considered as two separate entities but, rather, as two phenotypes of the same disease,” they wrote. “As such, the definition of rosacea subtype II (PPR) should be reconsidered and simplified to include all patients with central face papulopustules – with or without persistent erythema – and thus also patients with ‘rosacea-like demodicosis,’ which is a term that should therefore disappear.”

This study received no external funding. Dr. Forton works for Galderma as a consultant. Dr. de Maertelaer had no conflicts of interest to declare.

[email protected]

SOURCE: Forton F et al. J Eur Acad Dermatol Venereol. 2018 Feb 25. doi: 10.1111/jdv.14885.

Papulopustular rosacea (PPR) and rosacea-like demodicosis may be the same disease, according to the authors of a retrospective study.

Currently, there is a lack of consensus among physicians and health care organizations on how Demodex mites affect the development of rosacea. Many experts separate rosacea into two camps: PPR not caused by Demodex and rosacea-like demodicosis caused by Demodex.

Rosacea.org

To address this confusion, Fabienne Forton, MD, a dermatologist in Brussels, and Viviane de Maertelaer, PhD, of the Université Libre de Bruxelles conducted this study to determine the role that Demodex mites play in the development of PPR and rosacea-like demodicosis, which are surprisingly similar. Building off of a previous study of 254 patients with central facial papulopustules, the researchers conducted a secondary analysis of 242 patients; 215 of these patients had central facial papulopustules and persistent erthyema (both considered diagnostic of PPR), and 27 had central facial papulopustules but lacked persistent erythema.

During each evaluation session, each patient underwent two consecutive standardized skin surface biopsies (SSSBs), a small 1 square centimeter sample of the horny skin layer and the follicular content, on each cheek. The first sample, SSSB1, was a superficial sample, and SSSB2, the second sample, was a deep sample. The sum of the two samples, SSSB1+2, also was noted.

During the same session, patients had Demodex densities (Dds) measured. To avoid any confounding factors that could affect facial skin symptoms, Dr. Forton and Dr. de Maertelaer evaluated a subgroup of 132 patients who had not been treated in the previous 3 months and had no other facial dermatoses, such as acne vulgaris and seborrheic dermatitis.

The study revealed that, among the 242 patients in the primary analysis group, those with persistent erythema had higher Dds than did those without and the differences were statistically significant when comparing SSSB2 (208 D/cm² vs. 130 D/cm²; P = 0.031) and SSB1+2 (298 D/cm² vs. 191 D/cm²; P = 0.025), respectively.

 

This pattern of greater Dds density among patients with persistent erythema, compared with patients without, also held true among the subgroup of 132 patients who had not received any recent dermatological treatments, but the difference was not statistically significant. Nonetheless, patients with follicular scales did have greater SSSBs than did those without follicular scales.

As part of the study, Dr. Forton and Dr. de Maertelaer analyzed the findings of a case report of a 19-year-old woman who had a facial papulopustular eruption that had been present for 1 year. She had two SSSBs taken on each cheek: the right had follicular scales and papulopustules, and the left was clinically normal. This revealed that she had much higher Dds on the affected cheek than on the clinically normal one (108 and 216 D/cm² vs. 12 and 20 D/cm2). She was subsequently diagnosed with rosacea-like demodicosis.

After treating the areas with acaricidal ointment, the symptoms improved. But 27 months after stopping maintenance treatments, the facial eruptions reappeared, and the papulopustules were larger than during her original consultation, leading to the diagnosis of PPR. This time, the Dds was high on both cheeks but responded to acaricidal treatment, which indicates that her eruptions were caused Demodex mites.

“All our observations, therefore, highlight the nosological confusion that persists between PPR and rosacea-like demodicosis and the need to update the consensus concerning the definition and classification of rosacea. Moreover, they suggest that PPR and rosacea-like demodicosis may be phenotypes of the same disease,” wrote Dr. Forton and Dr. de Maertelaer. “This concept is supported by our case report, with many features indicating that the second presentation was an evolution of the first.”

 

They cautioned that their research is not definitive but should provide strong evidence that PPR and rosacea-like demodicosis are the same disease.

“While our observations do not prove a causative role of Demodex in rosacea, they nevertheless support the idea that PPR and rosacea-like demodicosis should no longer be considered as two separate entities but, rather, as two phenotypes of the same disease,” they wrote. “As such, the definition of rosacea subtype II (PPR) should be reconsidered and simplified to include all patients with central face papulopustules – with or without persistent erythema – and thus also patients with ‘rosacea-like demodicosis,’ which is a term that should therefore disappear.”

This study received no external funding. Dr. Forton works for Galderma as a consultant. Dr. de Maertelaer had no conflicts of interest to declare.

[email protected]

SOURCE: Forton F et al. J Eur Acad Dermatol Venereol. 2018 Feb 25. doi: 10.1111/jdv.14885.

Papulopustular rosacea (PPR) and rosacea-like demodicosis may be the same disease, according to the authors of a retrospective study.

Currently, there is a lack of consensus among physicians and health care organizations on how Demodex mites affect the development of rosacea. Many experts separate rosacea into two camps: PPR not caused by Demodex and rosacea-like demodicosis caused by Demodex.

Rosacea.org

To address this confusion, Fabienne Forton, MD, a dermatologist in Brussels, and Viviane de Maertelaer, PhD, of the Université Libre de Bruxelles conducted this study to determine the role that Demodex mites play in the development of PPR and rosacea-like demodicosis, which are surprisingly similar. Building off of a previous study of 254 patients with central facial papulopustules, the researchers conducted a secondary analysis of 242 patients; 215 of these patients had central facial papulopustules and persistent erthyema (both considered diagnostic of PPR), and 27 had central facial papulopustules but lacked persistent erythema.

During each evaluation session, each patient underwent two consecutive standardized skin surface biopsies (SSSBs), a small 1 square centimeter sample of the horny skin layer and the follicular content, on each cheek. The first sample, SSSB1, was a superficial sample, and SSSB2, the second sample, was a deep sample. The sum of the two samples, SSSB1+2, also was noted.

During the same session, patients had Demodex densities (Dds) measured. To avoid any confounding factors that could affect facial skin symptoms, Dr. Forton and Dr. de Maertelaer evaluated a subgroup of 132 patients who had not been treated in the previous 3 months and had no other facial dermatoses, such as acne vulgaris and seborrheic dermatitis.

The study revealed that, among the 242 patients in the primary analysis group, those with persistent erythema had higher Dds than did those without and the differences were statistically significant when comparing SSSB2 (208 D/cm² vs. 130 D/cm²; P = 0.031) and SSB1+2 (298 D/cm² vs. 191 D/cm²; P = 0.025), respectively.

 

This pattern of greater Dds density among patients with persistent erythema, compared with patients without, also held true among the subgroup of 132 patients who had not received any recent dermatological treatments, but the difference was not statistically significant. Nonetheless, patients with follicular scales did have greater SSSBs than did those without follicular scales.

As part of the study, Dr. Forton and Dr. de Maertelaer analyzed the findings of a case report of a 19-year-old woman who had a facial papulopustular eruption that had been present for 1 year. She had two SSSBs taken on each cheek: the right had follicular scales and papulopustules, and the left was clinically normal. This revealed that she had much higher Dds on the affected cheek than on the clinically normal one (108 and 216 D/cm² vs. 12 and 20 D/cm2). She was subsequently diagnosed with rosacea-like demodicosis.

After treating the areas with acaricidal ointment, the symptoms improved. But 27 months after stopping maintenance treatments, the facial eruptions reappeared, and the papulopustules were larger than during her original consultation, leading to the diagnosis of PPR. This time, the Dds was high on both cheeks but responded to acaricidal treatment, which indicates that her eruptions were caused Demodex mites.

“All our observations, therefore, highlight the nosological confusion that persists between PPR and rosacea-like demodicosis and the need to update the consensus concerning the definition and classification of rosacea. Moreover, they suggest that PPR and rosacea-like demodicosis may be phenotypes of the same disease,” wrote Dr. Forton and Dr. de Maertelaer. “This concept is supported by our case report, with many features indicating that the second presentation was an evolution of the first.”

 

They cautioned that their research is not definitive but should provide strong evidence that PPR and rosacea-like demodicosis are the same disease.

“While our observations do not prove a causative role of Demodex in rosacea, they nevertheless support the idea that PPR and rosacea-like demodicosis should no longer be considered as two separate entities but, rather, as two phenotypes of the same disease,” they wrote. “As such, the definition of rosacea subtype II (PPR) should be reconsidered and simplified to include all patients with central face papulopustules – with or without persistent erythema – and thus also patients with ‘rosacea-like demodicosis,’ which is a term that should therefore disappear.”

This study received no external funding. Dr. Forton works for Galderma as a consultant. Dr. de Maertelaer had no conflicts of interest to declare.

[email protected]

SOURCE: Forton F et al. J Eur Acad Dermatol Venereol. 2018 Feb 25. doi: 10.1111/jdv.14885.

KAUAI, HAWAII – Current or recent use of hormonal contraception is associated with an increased risk of breast cancer, although the limited magnitude and duration of breast cancer risk are such that one acne expert says he’s not inclined to change his regimen of care in response to the Danish study findings.

“The data looks clear. It’s not a big risk, but it’s clearly a higher risk,” Lawrence F. Eichenfield, MD, said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce Jancin/MDedge News

“I generally will mention it very briefly to my patients. But it hasn’t changed where I use niche hormonal therapy for my patients,” said Dr. Eichenfield, chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego and a professor of dermatology and pediatrics at the University of California, San Diego.

Investigators at the University of Copenhagen conducted a prospective cohort study among all 1.8 million Danish women aged 15-49 years who had not had cancer, venous thromboembolism, or treatment for infertility. Comprehensive nationwide registries were used to follow the women for an average of 10.9 years, which represents 19.6 million person-years of follow-up.

During that time, 11,517 cases of invasive breast cancer occurred in the study population. The relative risk was 1.2-fold greater in current or recent users of hormonal contraception, compared with never users of oral estrogen/progestin contraceptives or progestin-containing intrauterine devices. The risk rose with duration of use: from 1.09-fold with less than 1 year of exposure to 1.38-fold with more than 10 years of hormonal contraception.

From a population standpoint, there were 13 additional breast cancers diagnosed per 100,000 person-years of hormonal contraception use. That worked out to one extra breast cancer for every 7,690 women using hormonal contraception for 1 year (N Engl J Med. 2017 Dec 7;377[23]:2228-39).

 

Dr. Eichenfield pointed out that among Danish patients who used an oral contraceptive for less than 5 years, the excess risk of breast cancer went away within a year of stopping the medication. If patients used hormonal contraception for more than 5 years, the excess breast cancer risk lasted for 5 years after stopping.

He noted that the antiandrogen spironolactone, widely used off-label to treat adult female acne, has been shown to be free of any increased breast cancer risk.

He reported serving as a consultant to and/or recipient of research grants from more than a dozen pharmaceutical companies.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company..

[email protected]

KAUAI, HAWAII – Current or recent use of hormonal contraception is associated with an increased risk of breast cancer, although the limited magnitude and duration of breast cancer risk are such that one acne expert says he’s not inclined to change his regimen of care in response to the Danish study findings.

“The data looks clear. It’s not a big risk, but it’s clearly a higher risk,” Lawrence F. Eichenfield, MD, said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce Jancin/MDedge News

“I generally will mention it very briefly to my patients. But it hasn’t changed where I use niche hormonal therapy for my patients,” said Dr. Eichenfield, chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego and a professor of dermatology and pediatrics at the University of California, San Diego.

Investigators at the University of Copenhagen conducted a prospective cohort study among all 1.8 million Danish women aged 15-49 years who had not had cancer, venous thromboembolism, or treatment for infertility. Comprehensive nationwide registries were used to follow the women for an average of 10.9 years, which represents 19.6 million person-years of follow-up.

During that time, 11,517 cases of invasive breast cancer occurred in the study population. The relative risk was 1.2-fold greater in current or recent users of hormonal contraception, compared with never users of oral estrogen/progestin contraceptives or progestin-containing intrauterine devices. The risk rose with duration of use: from 1.09-fold with less than 1 year of exposure to 1.38-fold with more than 10 years of hormonal contraception.

From a population standpoint, there were 13 additional breast cancers diagnosed per 100,000 person-years of hormonal contraception use. That worked out to one extra breast cancer for every 7,690 women using hormonal contraception for 1 year (N Engl J Med. 2017 Dec 7;377[23]:2228-39).

 

Dr. Eichenfield pointed out that among Danish patients who used an oral contraceptive for less than 5 years, the excess risk of breast cancer went away within a year of stopping the medication. If patients used hormonal contraception for more than 5 years, the excess breast cancer risk lasted for 5 years after stopping.

He noted that the antiandrogen spironolactone, widely used off-label to treat adult female acne, has been shown to be free of any increased breast cancer risk.

He reported serving as a consultant to and/or recipient of research grants from more than a dozen pharmaceutical companies.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company..

[email protected]

KAUAI, HAWAII – Current or recent use of hormonal contraception is associated with an increased risk of breast cancer, although the limited magnitude and duration of breast cancer risk are such that one acne expert says he’s not inclined to change his regimen of care in response to the Danish study findings.

“The data looks clear. It’s not a big risk, but it’s clearly a higher risk,” Lawrence F. Eichenfield, MD, said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce Jancin/MDedge News

“I generally will mention it very briefly to my patients. But it hasn’t changed where I use niche hormonal therapy for my patients,” said Dr. Eichenfield, chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego and a professor of dermatology and pediatrics at the University of California, San Diego.

Investigators at the University of Copenhagen conducted a prospective cohort study among all 1.8 million Danish women aged 15-49 years who had not had cancer, venous thromboembolism, or treatment for infertility. Comprehensive nationwide registries were used to follow the women for an average of 10.9 years, which represents 19.6 million person-years of follow-up.

During that time, 11,517 cases of invasive breast cancer occurred in the study population. The relative risk was 1.2-fold greater in current or recent users of hormonal contraception, compared with never users of oral estrogen/progestin contraceptives or progestin-containing intrauterine devices. The risk rose with duration of use: from 1.09-fold with less than 1 year of exposure to 1.38-fold with more than 10 years of hormonal contraception.

From a population standpoint, there were 13 additional breast cancers diagnosed per 100,000 person-years of hormonal contraception use. That worked out to one extra breast cancer for every 7,690 women using hormonal contraception for 1 year (N Engl J Med. 2017 Dec 7;377[23]:2228-39).

 

Dr. Eichenfield pointed out that among Danish patients who used an oral contraceptive for less than 5 years, the excess risk of breast cancer went away within a year of stopping the medication. If patients used hormonal contraception for more than 5 years, the excess breast cancer risk lasted for 5 years after stopping.

He noted that the antiandrogen spironolactone, widely used off-label to treat adult female acne, has been shown to be free of any increased breast cancer risk.

He reported serving as a consultant to and/or recipient of research grants from more than a dozen pharmaceutical companies.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company..

[email protected]

DALLAS – Most physicians do not report adverse events related to noninvasive body contouring devices to the Food and Drug Administration, a database review showed.

“The FDA mandates that manufacturers and device operators disclose medical device reports to monitor suspected injuries and device malfunctions to the Manufacturer and User Facility Device Experience [MAUDE] database,” study author Adam J. Wulkan, MD, said at the annual conference of the American Society for Laser Medicine and Surgery. “Given the rapid growth in the noninvasive fat reduction market, it is essential physicians be aware of associated adverse events.”

In what is believed to be the first study of its kind, Dr. Wulkan, a dermatologist at Massachusetts General Hospital, Boston, and his associates performed a search of complications of noninvasive fat reduction and cellulite reduction devices reported to the MAUDE database from January 2014 to October 2017. The search yielded 98 medical device reports (MDRs), most of which were submitted by patients.

“Given that this is the largest database for adverse events, I was surprised how few reports were done by physicians,” Dr. Wulkan said in an interview.

He reported results from 83 of the 98 MDRs. A total of 26 MDRs reported on cryolipolysis and included newly diagnosed or exacerbation of prior umbilical hernias (10), neuropathies (5), paradoxical fat hyperplasias (4), blisters (3), rashes (1), flu-like symptoms (1), gastroenteritis (1), and prolapsed bladder/uterus/rectum (1). Of the 11 MDRs for radio-frequency devices, 10 were burns/blisters and 1 fire.

Dr. Wulkan went on to note that 17 MDRs were reported for 1060-nm laser lipolysis, including burns/blisters (5), nodules (4), pain (3), cellulitis/abscesses (2), excessive swelling (1), neuropathy (1), and vomiting (1). There were four cases of burns on MDRs from focused/pulsed ultrasound procedures. One was on a non–FDA approved body site and another after combination radio-frequency/infrared treatment for cellulite reduction.

There were eight MDRs reported with 1440-nm laser cellulite reduction, including burn (5), unacceptable cosmesis (2), and faulty power supply (1). In addition, there were 12 MDRs reported on high-frequency ultrasound, including burns/blisters (9), subcutaneous nodules (2), and excoriation (1). Finally, vacuum-assisted submission was associated with five MDRs, including festooning/unacceptable cosmesis (2), seroma/hematoma (1), laceration (1), and nodules (1).

 

Dr. Wulkan acknowledged certain limitations of the study, including the fact that not all MDRs are reported to MAUDE, and that the reliability of patient reporting can be questionable. “We have to figure out if there is a natural causation between the adverse event and the treatment itself,” he said at the meeting. “The number of MDRs for any given device must be correlated to the number of procedures performed before we jump to conclusions about the safety of any given device.”

He reported having no financial disclosures. One study coauthor holds positions on advisory boards of, is a consultant for, and has intellectual property and/or stock options with various industry companies, such as Soliton and Allergan.

[email protected]

SOURCE: Wulkan et. al., ASLMS 2018.

DALLAS – Most physicians do not report adverse events related to noninvasive body contouring devices to the Food and Drug Administration, a database review showed.

“The FDA mandates that manufacturers and device operators disclose medical device reports to monitor suspected injuries and device malfunctions to the Manufacturer and User Facility Device Experience [MAUDE] database,” study author Adam J. Wulkan, MD, said at the annual conference of the American Society for Laser Medicine and Surgery. “Given the rapid growth in the noninvasive fat reduction market, it is essential physicians be aware of associated adverse events.”

In what is believed to be the first study of its kind, Dr. Wulkan, a dermatologist at Massachusetts General Hospital, Boston, and his associates performed a search of complications of noninvasive fat reduction and cellulite reduction devices reported to the MAUDE database from January 2014 to October 2017. The search yielded 98 medical device reports (MDRs), most of which were submitted by patients.

“Given that this is the largest database for adverse events, I was surprised how few reports were done by physicians,” Dr. Wulkan said in an interview.

He reported results from 83 of the 98 MDRs. A total of 26 MDRs reported on cryolipolysis and included newly diagnosed or exacerbation of prior umbilical hernias (10), neuropathies (5), paradoxical fat hyperplasias (4), blisters (3), rashes (1), flu-like symptoms (1), gastroenteritis (1), and prolapsed bladder/uterus/rectum (1). Of the 11 MDRs for radio-frequency devices, 10 were burns/blisters and 1 fire.

Dr. Wulkan went on to note that 17 MDRs were reported for 1060-nm laser lipolysis, including burns/blisters (5), nodules (4), pain (3), cellulitis/abscesses (2), excessive swelling (1), neuropathy (1), and vomiting (1). There were four cases of burns on MDRs from focused/pulsed ultrasound procedures. One was on a non–FDA approved body site and another after combination radio-frequency/infrared treatment for cellulite reduction.

There were eight MDRs reported with 1440-nm laser cellulite reduction, including burn (5), unacceptable cosmesis (2), and faulty power supply (1). In addition, there were 12 MDRs reported on high-frequency ultrasound, including burns/blisters (9), subcutaneous nodules (2), and excoriation (1). Finally, vacuum-assisted submission was associated with five MDRs, including festooning/unacceptable cosmesis (2), seroma/hematoma (1), laceration (1), and nodules (1).

 

Dr. Wulkan acknowledged certain limitations of the study, including the fact that not all MDRs are reported to MAUDE, and that the reliability of patient reporting can be questionable. “We have to figure out if there is a natural causation between the adverse event and the treatment itself,” he said at the meeting. “The number of MDRs for any given device must be correlated to the number of procedures performed before we jump to conclusions about the safety of any given device.”

He reported having no financial disclosures. One study coauthor holds positions on advisory boards of, is a consultant for, and has intellectual property and/or stock options with various industry companies, such as Soliton and Allergan.

[email protected]

SOURCE: Wulkan et. al., ASLMS 2018.

DALLAS – Most physicians do not report adverse events related to noninvasive body contouring devices to the Food and Drug Administration, a database review showed.

“The FDA mandates that manufacturers and device operators disclose medical device reports to monitor suspected injuries and device malfunctions to the Manufacturer and User Facility Device Experience [MAUDE] database,” study author Adam J. Wulkan, MD, said at the annual conference of the American Society for Laser Medicine and Surgery. “Given the rapid growth in the noninvasive fat reduction market, it is essential physicians be aware of associated adverse events.”

In what is believed to be the first study of its kind, Dr. Wulkan, a dermatologist at Massachusetts General Hospital, Boston, and his associates performed a search of complications of noninvasive fat reduction and cellulite reduction devices reported to the MAUDE database from January 2014 to October 2017. The search yielded 98 medical device reports (MDRs), most of which were submitted by patients.

“Given that this is the largest database for adverse events, I was surprised how few reports were done by physicians,” Dr. Wulkan said in an interview.

He reported results from 83 of the 98 MDRs. A total of 26 MDRs reported on cryolipolysis and included newly diagnosed or exacerbation of prior umbilical hernias (10), neuropathies (5), paradoxical fat hyperplasias (4), blisters (3), rashes (1), flu-like symptoms (1), gastroenteritis (1), and prolapsed bladder/uterus/rectum (1). Of the 11 MDRs for radio-frequency devices, 10 were burns/blisters and 1 fire.

Dr. Wulkan went on to note that 17 MDRs were reported for 1060-nm laser lipolysis, including burns/blisters (5), nodules (4), pain (3), cellulitis/abscesses (2), excessive swelling (1), neuropathy (1), and vomiting (1). There were four cases of burns on MDRs from focused/pulsed ultrasound procedures. One was on a non–FDA approved body site and another after combination radio-frequency/infrared treatment for cellulite reduction.

There were eight MDRs reported with 1440-nm laser cellulite reduction, including burn (5), unacceptable cosmesis (2), and faulty power supply (1). In addition, there were 12 MDRs reported on high-frequency ultrasound, including burns/blisters (9), subcutaneous nodules (2), and excoriation (1). Finally, vacuum-assisted submission was associated with five MDRs, including festooning/unacceptable cosmesis (2), seroma/hematoma (1), laceration (1), and nodules (1).

 

Dr. Wulkan acknowledged certain limitations of the study, including the fact that not all MDRs are reported to MAUDE, and that the reliability of patient reporting can be questionable. “We have to figure out if there is a natural causation between the adverse event and the treatment itself,” he said at the meeting. “The number of MDRs for any given device must be correlated to the number of procedures performed before we jump to conclusions about the safety of any given device.”

He reported having no financial disclosures. One study coauthor holds positions on advisory boards of, is a consultant for, and has intellectual property and/or stock options with various industry companies, such as Soliton and Allergan.

[email protected]

SOURCE: Wulkan et. al., ASLMS 2018.

DALLAS – Laser treatment of port wine stains in infancy is both safe and effective, with no incidence of scarring or pigmentary changes, according to results from a single-center analysis.

“Early intervention allows for treatment without general anesthesia, with faster and more complete clearance than what has been reported for treatments begun at older ages,” Hana Jeon, MD, said at the annual conference of the American Society for Laser Medicine and Surgery.

Courtesy RegionalDerm.com

A recent Food and Drug Administration Drug Safety Communication warned that “repeated or lengthy used of general anesthetic and sedation drugs during surgeries or procedures in children younger than 3 years or in pregnant women during their third trimester may affect the development of children’s brains.” Dr. Jeon, a dermatologist in private practice in New York, noted that the FDA warning “places a greater importance on the already controversial topic of when to initiate port wine stain [PWS] treatments in pediatric patients, which requires repeated treatments and are often performed with general anesthesia. Without treatment, these lesions tend to get larger and thicker with time. Starting the treatment during infancy has the potential to limit the use of general anesthesia and to facilitate clearing.”

In what she said is the largest retrospective study of its kind to date, Dr. Jeon and her associates evaluated the success and safety of treating PWSs with a pulsed dye laser at the age of 1 year or younger in the office setting without general anesthesia. The patients received their first PWS treatment at their center during 2000-2017. They reviewed the charts of 197 patients to extract relevant data, including demographic information, age at the time of procedure, and treatment dates. The data cutoff was at 1 year following the initial treatment. Four physicians independently reviewed before and after photos and used the visual analogue scale to grade them.

The pulsed dye laser with dynamic cooling spray was used to minimize patient discomfort. No topical, local, or general anesthesia was used. Patients were immobilized by ancillary staff with parents present in most cases. Ocular shields were placed to allow treatment of periocular lesions.

Of the 197 patients, 63% were female, 90.1% had Fitzpatrick skin types I-III, 8.1% had type IV skin, and the rest had type V-VI skin. Most of the lesions were facial (75.6%), and 41.1% had periocular involvement. The average lesion size was 61 cm².

 

The treatment settings for the pulsed dye laser were a 10-12 mm spot size delivered at a fluence of 6.5-9 J/cm² in a pulse duration of 0.45-1.5 milliseconds. The average age at the time of first treatment was 3.4 months (range, 5-355 days), and the average number of treatments was 9.8 (range, 2-23). Most of the patients (116) were aged 0-3 months at the time of first treatment, followed by 51 aged 3-6 months, 19 aged 6-9 months, and 11 aged 9-12 months.

According to the averaged scores on the visual analogue scale assigned by physicians, 27.4% showed a 100% clearance, 39.1% showed 76%-99% improvement, 15.1% showed 51%-75% improvement, 10.7% showed 26%-50% improvement, and 7.7% showed 0%-25% improvement. No scarring or pigmentary changes were observed.

An analysis of dermatomal distribution revealed that the presence of a V1 lesion was a statistically significant predictor of a higher clearance rate, while the presence of a V3 lesion was a statistically significant predictor of a low clearance rate. “Regardless of where the lesion was, all patients did well,” she said.

Given the small proportion of patients who received their first treatment between the ages of 6 and 12 months of age, Dr. Jeon said that “further studies would be needed to elucidate whether earlier intervention helps to achieve better results.”*

 

Advantages of early treatment, she said, include the ability to “treat lesions before they get larger and thicker, which also decreases the risk of spontaneous bleeding. Thinner skin allows for better penetration of the laser beam, and we can also avoid using general anesthesia. Psychologically, if we’re able to clear these lesions, it can result in improved quality of life and self-esteem; not just for the patient but for the family as well.”

Dr. Jeon acknowledged certain limitations of the study, including its retrospective design, variable follow-up times, and non-standardization of photographs.

She reported having no financial disclosures.

[email protected]

SOURCE: Jeon H et al. ASLMS 2018.

Correction, 4/18/18: An earlier version of this article misstated the age range of the study participants.

DALLAS – Laser treatment of port wine stains in infancy is both safe and effective, with no incidence of scarring or pigmentary changes, according to results from a single-center analysis.

“Early intervention allows for treatment without general anesthesia, with faster and more complete clearance than what has been reported for treatments begun at older ages,” Hana Jeon, MD, said at the annual conference of the American Society for Laser Medicine and Surgery.

Courtesy RegionalDerm.com

A recent Food and Drug Administration Drug Safety Communication warned that “repeated or lengthy used of general anesthetic and sedation drugs during surgeries or procedures in children younger than 3 years or in pregnant women during their third trimester may affect the development of children’s brains.” Dr. Jeon, a dermatologist in private practice in New York, noted that the FDA warning “places a greater importance on the already controversial topic of when to initiate port wine stain [PWS] treatments in pediatric patients, which requires repeated treatments and are often performed with general anesthesia. Without treatment, these lesions tend to get larger and thicker with time. Starting the treatment during infancy has the potential to limit the use of general anesthesia and to facilitate clearing.”

In what she said is the largest retrospective study of its kind to date, Dr. Jeon and her associates evaluated the success and safety of treating PWSs with a pulsed dye laser at the age of 1 year or younger in the office setting without general anesthesia. The patients received their first PWS treatment at their center during 2000-2017. They reviewed the charts of 197 patients to extract relevant data, including demographic information, age at the time of procedure, and treatment dates. The data cutoff was at 1 year following the initial treatment. Four physicians independently reviewed before and after photos and used the visual analogue scale to grade them.

The pulsed dye laser with dynamic cooling spray was used to minimize patient discomfort. No topical, local, or general anesthesia was used. Patients were immobilized by ancillary staff with parents present in most cases. Ocular shields were placed to allow treatment of periocular lesions.

Of the 197 patients, 63% were female, 90.1% had Fitzpatrick skin types I-III, 8.1% had type IV skin, and the rest had type V-VI skin. Most of the lesions were facial (75.6%), and 41.1% had periocular involvement. The average lesion size was 61 cm².

 

The treatment settings for the pulsed dye laser were a 10-12 mm spot size delivered at a fluence of 6.5-9 J/cm² in a pulse duration of 0.45-1.5 milliseconds. The average age at the time of first treatment was 3.4 months (range, 5-355 days), and the average number of treatments was 9.8 (range, 2-23). Most of the patients (116) were aged 0-3 months at the time of first treatment, followed by 51 aged 3-6 months, 19 aged 6-9 months, and 11 aged 9-12 months.

According to the averaged scores on the visual analogue scale assigned by physicians, 27.4% showed a 100% clearance, 39.1% showed 76%-99% improvement, 15.1% showed 51%-75% improvement, 10.7% showed 26%-50% improvement, and 7.7% showed 0%-25% improvement. No scarring or pigmentary changes were observed.

An analysis of dermatomal distribution revealed that the presence of a V1 lesion was a statistically significant predictor of a higher clearance rate, while the presence of a V3 lesion was a statistically significant predictor of a low clearance rate. “Regardless of where the lesion was, all patients did well,” she said.

Given the small proportion of patients who received their first treatment between the ages of 6 and 12 months of age, Dr. Jeon said that “further studies would be needed to elucidate whether earlier intervention helps to achieve better results.”*

 

Advantages of early treatment, she said, include the ability to “treat lesions before they get larger and thicker, which also decreases the risk of spontaneous bleeding. Thinner skin allows for better penetration of the laser beam, and we can also avoid using general anesthesia. Psychologically, if we’re able to clear these lesions, it can result in improved quality of life and self-esteem; not just for the patient but for the family as well.”

Dr. Jeon acknowledged certain limitations of the study, including its retrospective design, variable follow-up times, and non-standardization of photographs.

She reported having no financial disclosures.

[email protected]

SOURCE: Jeon H et al. ASLMS 2018.

Correction, 4/18/18: An earlier version of this article misstated the age range of the study participants.

DALLAS – Laser treatment of port wine stains in infancy is both safe and effective, with no incidence of scarring or pigmentary changes, according to results from a single-center analysis.

“Early intervention allows for treatment without general anesthesia, with faster and more complete clearance than what has been reported for treatments begun at older ages,” Hana Jeon, MD, said at the annual conference of the American Society for Laser Medicine and Surgery.

Courtesy RegionalDerm.com

A recent Food and Drug Administration Drug Safety Communication warned that “repeated or lengthy used of general anesthetic and sedation drugs during surgeries or procedures in children younger than 3 years or in pregnant women during their third trimester may affect the development of children’s brains.” Dr. Jeon, a dermatologist in private practice in New York, noted that the FDA warning “places a greater importance on the already controversial topic of when to initiate port wine stain [PWS] treatments in pediatric patients, which requires repeated treatments and are often performed with general anesthesia. Without treatment, these lesions tend to get larger and thicker with time. Starting the treatment during infancy has the potential to limit the use of general anesthesia and to facilitate clearing.”

In what she said is the largest retrospective study of its kind to date, Dr. Jeon and her associates evaluated the success and safety of treating PWSs with a pulsed dye laser at the age of 1 year or younger in the office setting without general anesthesia. The patients received their first PWS treatment at their center during 2000-2017. They reviewed the charts of 197 patients to extract relevant data, including demographic information, age at the time of procedure, and treatment dates. The data cutoff was at 1 year following the initial treatment. Four physicians independently reviewed before and after photos and used the visual analogue scale to grade them.

The pulsed dye laser with dynamic cooling spray was used to minimize patient discomfort. No topical, local, or general anesthesia was used. Patients were immobilized by ancillary staff with parents present in most cases. Ocular shields were placed to allow treatment of periocular lesions.

Of the 197 patients, 63% were female, 90.1% had Fitzpatrick skin types I-III, 8.1% had type IV skin, and the rest had type V-VI skin. Most of the lesions were facial (75.6%), and 41.1% had periocular involvement. The average lesion size was 61 cm².

 

The treatment settings for the pulsed dye laser were a 10-12 mm spot size delivered at a fluence of 6.5-9 J/cm² in a pulse duration of 0.45-1.5 milliseconds. The average age at the time of first treatment was 3.4 months (range, 5-355 days), and the average number of treatments was 9.8 (range, 2-23). Most of the patients (116) were aged 0-3 months at the time of first treatment, followed by 51 aged 3-6 months, 19 aged 6-9 months, and 11 aged 9-12 months.

According to the averaged scores on the visual analogue scale assigned by physicians, 27.4% showed a 100% clearance, 39.1% showed 76%-99% improvement, 15.1% showed 51%-75% improvement, 10.7% showed 26%-50% improvement, and 7.7% showed 0%-25% improvement. No scarring or pigmentary changes were observed.

An analysis of dermatomal distribution revealed that the presence of a V1 lesion was a statistically significant predictor of a higher clearance rate, while the presence of a V3 lesion was a statistically significant predictor of a low clearance rate. “Regardless of where the lesion was, all patients did well,” she said.

Given the small proportion of patients who received their first treatment between the ages of 6 and 12 months of age, Dr. Jeon said that “further studies would be needed to elucidate whether earlier intervention helps to achieve better results.”*

 

Advantages of early treatment, she said, include the ability to “treat lesions before they get larger and thicker, which also decreases the risk of spontaneous bleeding. Thinner skin allows for better penetration of the laser beam, and we can also avoid using general anesthesia. Psychologically, if we’re able to clear these lesions, it can result in improved quality of life and self-esteem; not just for the patient but for the family as well.”

Dr. Jeon acknowledged certain limitations of the study, including its retrospective design, variable follow-up times, and non-standardization of photographs.

She reported having no financial disclosures.

[email protected]

SOURCE: Jeon H et al. ASLMS 2018.

Correction, 4/18/18: An earlier version of this article misstated the age range of the study participants.

CHICAGO – Use of an enhanced recovery protocol for oncology patients has been shown to improve outcomes in colorectal surgery but has been largely unproven in other types of major oncology operations. That prompted researchers at the University of Texas MD Anderson Cancer Center in Houston to investigate enhanced recovery protocols in multispecialty, major oncologic procedures. They found that the enhanced recovery protocol led to a reduction in complication rates and a decrease in hospital stay with no increase in readmissions, according to an analysis of more than 3,000 oncologic operations presented at the Society of Surgical Oncology Annual Cancer Symposium here.

lyosha_nazarenko/Thinkstock

“Patients treated with enhanced recovery did better,” Rebecca Marcus, MD, said in reporting the results. “There were decreased rates of perioperative transfusions, decreased rates of surgical site infections, decreased rates of complications, including severe complications such as wound dehiscence, pneumonia, renal failure, and unintended returns to the operating room.” She noted that the shorter hospital stays – 4 days for patients on the enhanced recovery protocol versus 5 days for those on the traditional postoperative protocol – did not result in increased readmissions.

The study reviewed 3,256 operations performed during 2011-2016 in the MD Anderson institutional American College of Surgeons National Surgical Quality Improvement Program database. The operations were colorectal (20.4%), gynecologic (19.5%), hepatobiliary (8.9%), thoracic (41.9%) and urologic (9.3%). Most employed the traditional postoperative protocol (53.4%). Colorectal and thoracic/vascular surgery were early adopters of the enhanced recovery protocol at MD Anderson.

Dr. Marcus noted that the overall complication rates were 21.9% for those treated with enhanced recovery–protocol versus 33.9% for those treated with traditional postoperative protocol (P less than .0001). The group treated with enhanced recovery protocol also had lower rates of severe complications: 8.7% vs. 11.7% (P =.0048). The study also noted a trend toward reduced National Surgical Quality Improvement Program 30-day mortality with the enhanced recover protocol (0.4% vs. 0.86%; P = .097). Readmission rates were similar between the two groups: 8.3% for enhanced recovery protocol versus 8.9% for traditional postoperative protocol.

 

The researchers performed a subanalysis of high-magnitude cases that had a relative value unit of 30 or more and involved operations of greater complexity, which constituted 38% of the study population. “In this group, we still saw the benefit of having treatment with an enhanced recovery protocol with decreased rates of preoperative transfusions, complications, and shorter length of stay without any recent readmission,” Dr. Marcus said. Complication rates in the high-magnitude group were 19% for the enhanced recovery protocol versus 26% for the traditional postoperative protocol in colorectal cases, 21% vs. 40% in gynecology, and 19% vs. 28% in thoracic/vascular.

“The beneficial impact of enhanced recovery appears to be maintained across all specialties and to be independent of case magnitude,” Dr. Marcus said.

She said future research of enhanced recovery in surgical oncology should focus on more long-term outcomes, “such as oncologic benefits of these protocols, especially given the known detrimental effect of the delayed return to adjuvant therapy for this patient population.”

Dr. Marcus and her coauthors reported having no financial disclosures.

SOURCE: Marcus RK et al. SSO 2018, Abstract 21.

CHICAGO – Use of an enhanced recovery protocol for oncology patients has been shown to improve outcomes in colorectal surgery but has been largely unproven in other types of major oncology operations. That prompted researchers at the University of Texas MD Anderson Cancer Center in Houston to investigate enhanced recovery protocols in multispecialty, major oncologic procedures. They found that the enhanced recovery protocol led to a reduction in complication rates and a decrease in hospital stay with no increase in readmissions, according to an analysis of more than 3,000 oncologic operations presented at the Society of Surgical Oncology Annual Cancer Symposium here.

lyosha_nazarenko/Thinkstock

“Patients treated with enhanced recovery did better,” Rebecca Marcus, MD, said in reporting the results. “There were decreased rates of perioperative transfusions, decreased rates of surgical site infections, decreased rates of complications, including severe complications such as wound dehiscence, pneumonia, renal failure, and unintended returns to the operating room.” She noted that the shorter hospital stays – 4 days for patients on the enhanced recovery protocol versus 5 days for those on the traditional postoperative protocol – did not result in increased readmissions.

The study reviewed 3,256 operations performed during 2011-2016 in the MD Anderson institutional American College of Surgeons National Surgical Quality Improvement Program database. The operations were colorectal (20.4%), gynecologic (19.5%), hepatobiliary (8.9%), thoracic (41.9%) and urologic (9.3%). Most employed the traditional postoperative protocol (53.4%). Colorectal and thoracic/vascular surgery were early adopters of the enhanced recovery protocol at MD Anderson.

Dr. Marcus noted that the overall complication rates were 21.9% for those treated with enhanced recovery–protocol versus 33.9% for those treated with traditional postoperative protocol (P less than .0001). The group treated with enhanced recovery protocol also had lower rates of severe complications: 8.7% vs. 11.7% (P =.0048). The study also noted a trend toward reduced National Surgical Quality Improvement Program 30-day mortality with the enhanced recover protocol (0.4% vs. 0.86%; P = .097). Readmission rates were similar between the two groups: 8.3% for enhanced recovery protocol versus 8.9% for traditional postoperative protocol.

 

The researchers performed a subanalysis of high-magnitude cases that had a relative value unit of 30 or more and involved operations of greater complexity, which constituted 38% of the study population. “In this group, we still saw the benefit of having treatment with an enhanced recovery protocol with decreased rates of preoperative transfusions, complications, and shorter length of stay without any recent readmission,” Dr. Marcus said. Complication rates in the high-magnitude group were 19% for the enhanced recovery protocol versus 26% for the traditional postoperative protocol in colorectal cases, 21% vs. 40% in gynecology, and 19% vs. 28% in thoracic/vascular.

“The beneficial impact of enhanced recovery appears to be maintained across all specialties and to be independent of case magnitude,” Dr. Marcus said.

She said future research of enhanced recovery in surgical oncology should focus on more long-term outcomes, “such as oncologic benefits of these protocols, especially given the known detrimental effect of the delayed return to adjuvant therapy for this patient population.”

Dr. Marcus and her coauthors reported having no financial disclosures.

SOURCE: Marcus RK et al. SSO 2018, Abstract 21.

CHICAGO – Use of an enhanced recovery protocol for oncology patients has been shown to improve outcomes in colorectal surgery but has been largely unproven in other types of major oncology operations. That prompted researchers at the University of Texas MD Anderson Cancer Center in Houston to investigate enhanced recovery protocols in multispecialty, major oncologic procedures. They found that the enhanced recovery protocol led to a reduction in complication rates and a decrease in hospital stay with no increase in readmissions, according to an analysis of more than 3,000 oncologic operations presented at the Society of Surgical Oncology Annual Cancer Symposium here.

lyosha_nazarenko/Thinkstock

“Patients treated with enhanced recovery did better,” Rebecca Marcus, MD, said in reporting the results. “There were decreased rates of perioperative transfusions, decreased rates of surgical site infections, decreased rates of complications, including severe complications such as wound dehiscence, pneumonia, renal failure, and unintended returns to the operating room.” She noted that the shorter hospital stays – 4 days for patients on the enhanced recovery protocol versus 5 days for those on the traditional postoperative protocol – did not result in increased readmissions.

The study reviewed 3,256 operations performed during 2011-2016 in the MD Anderson institutional American College of Surgeons National Surgical Quality Improvement Program database. The operations were colorectal (20.4%), gynecologic (19.5%), hepatobiliary (8.9%), thoracic (41.9%) and urologic (9.3%). Most employed the traditional postoperative protocol (53.4%). Colorectal and thoracic/vascular surgery were early adopters of the enhanced recovery protocol at MD Anderson.

Dr. Marcus noted that the overall complication rates were 21.9% for those treated with enhanced recovery–protocol versus 33.9% for those treated with traditional postoperative protocol (P less than .0001). The group treated with enhanced recovery protocol also had lower rates of severe complications: 8.7% vs. 11.7% (P =.0048). The study also noted a trend toward reduced National Surgical Quality Improvement Program 30-day mortality with the enhanced recover protocol (0.4% vs. 0.86%; P = .097). Readmission rates were similar between the two groups: 8.3% for enhanced recovery protocol versus 8.9% for traditional postoperative protocol.

 

The researchers performed a subanalysis of high-magnitude cases that had a relative value unit of 30 or more and involved operations of greater complexity, which constituted 38% of the study population. “In this group, we still saw the benefit of having treatment with an enhanced recovery protocol with decreased rates of preoperative transfusions, complications, and shorter length of stay without any recent readmission,” Dr. Marcus said. Complication rates in the high-magnitude group were 19% for the enhanced recovery protocol versus 26% for the traditional postoperative protocol in colorectal cases, 21% vs. 40% in gynecology, and 19% vs. 28% in thoracic/vascular.

“The beneficial impact of enhanced recovery appears to be maintained across all specialties and to be independent of case magnitude,” Dr. Marcus said.

She said future research of enhanced recovery in surgical oncology should focus on more long-term outcomes, “such as oncologic benefits of these protocols, especially given the known detrimental effect of the delayed return to adjuvant therapy for this patient population.”

Dr. Marcus and her coauthors reported having no financial disclosures.

SOURCE: Marcus RK et al. SSO 2018, Abstract 21.

SALT LAKE CITY – Recipients of hematopoietic cell transplant with umbilical cord blood CD34+ cells expanded with an aryl hydrocarbon receptor (AHR) antagonist had a significantly higher rate of engraftment and comparable survival to a historical cohort of umbilical cord blood recipients.

The robust expansion of donor umbilical cord blood seen with the new technique opens the door for better use of umbilical cord blood inventory with superior human leukocyte antigen (HLA) matching, John Wagner, MD, said at a top abstracts session of the combined annual meetings of the Center for International Blood & Marrow Transplant Research and the American Society for Blood and Marrow Transplantation.

The new technique still shared the benefits of low rates of graft-versus-host disease (GVHD) and high survival that have been seen in previous umbilical cord blood transplants, with no significant difference in overall survival, relapse, or acute or chronic GVHD.

Compared to historical controls (n = 151), patients receiving the AHR antagonist–expanded umbilical cord blood (UCB) cells with myeloablative conditioning (n = 9) saw complete and more rapid engraftment (100% vs. 89% engraftment at a median 14 days vs. 23 days; P less than .01), reported Dr. Wagner of the University of Minnesota, Minneapolis.

These and other results came from two arms of a phase 2 trial of MGTA-456 (the working name of the AHR-expanded UCB cells). Twenty patients were to receive MGTA-456 derived from partially matched umbilical cord blood units after either myeloablative or nonmyeloablative conditioning; one patient in each arm had low expansion of UCB, so a total of 18 patients received MGTA-456. Each intervention arm was compared with a historical control arm that had received conventional UCB units.

In the myeloablative arm, patient demographics and disease characteristics were similar to the control cohort except that the MGTA-456 patients were significantly heavier (93.8 kg vs. 66.7 kg; P less than .04).

 

Platelet recovery also rebounded faster with MGTA-456 plus myeloablative conditioning than it did with historical controls: 89% of patients had platelet recovery by a median 46 days, compared with 71% with platelet recovery by a median 64 days in the historical cohort (P less than .01).

Patients achieved rapid complete chimerism if they received myeloablative conditioning, and they had rapid rebound of CD4 counts to at least 200 by 2-3 months posttransplant, Dr. Wagner reported.

The nonmyeloablative arm had a historical control cohort of 132 patients. Characteristics were similar between the two groups except that the MGTA-456 patients were older and more likely to have high-risk disease.

Again, all patients had rapid neutrophil recovery and saw 100% engraftment with MGTA-456. Median time to engraftment was 7 days with MGTA-456 and 15 days for the historical controls (P less than .01). Platelet recovery took longer for the MGTA-456 (median of 47 vs. 107 days), but the difference was not statistically significant.

 

Complete chimerism was achieved rapidly with the nonmyeloablative regimen as well, and CD4 recovery was brisk, as had been seen with myeloablative conditioning before MGTA-456 transplantation.

Compared with historical controls, “MGTA-456 retains the benefits of low chronic-graft-versus host disease and high survival despite higher disease risk and age” in the study group, Dr. Wagner said. There were no significant differences between the intervention and historical control arms of the nonmyeloablative study in acute or chronic GVHD, relapse, or overall survival.

The use of MGTA-456 occurs against the backdrop of a history of high survival rates with UCB transplantation – about 70% at 5 years, Dr. Wagner said. However, when conventional culture and expansion methods for UCB were used, the median time to engraftment had been reported to be 25 days with a 79% engraftment rate. This contrasts with the mean 13 days to engraftment for peripheral blood transplants and 18 days for bone marrow transplants. All of these transplant sources, regardless of whether the transplant was matched or mismatched, have engraftment rates of 92%-96%, said Dr. Wagner (Lancet Oncol. 2010; 11[7]:653-60).

When an AHR antagonist is used for UCB expansion, hematopoietic stem cell renewal is upped because cell differentiation is blocked, which means expansion is all driven toward hematopoietic stem cell self-renewal, Dr. Wagner said. Of the 36 available samples, MGTA-456 achieved a median 327-fold expansion of CD34+ cells, which enabled investigators to deliver a median CD34+ dose of 17.5 X 10⁶ cells/kg.

 

The downstream effect of the robust expansion rates is that more cord blood will be available for transplantation, and HLA matches will improve, Dr. Wagner said. Using current expansion techniques, fewer than 5% of cord blood units have a total nucleated cell count sufficient for an adult 80 kg recipient, he said, adding that use of MGTA-456 could make more than 80% of cord blood units available for adults.

According to the UCB transplant history at the University of Minnesota – where Dr. Wagner directs the pediatric blood and marrow transplantation program – of the patients who received 4/6 HLA-matched cord blood, 63% would move to a 5/6 match, and 8% would move to a full HLA match with the MGTA-456 technique. Of patients who received 5/6-matched transplants, almost one in four (23%) would move to a full 6/6 match.

Dr. Wagner and his colleagues had previously shown that adding an AHR antagonist resulted in enhanced T-cell recovery and rapid and sustained engraftment (Science. 2010;329:1345-8).

The researchers then proceeded to a phase 1-2, first-in-human trial of MGTA-456 that used a myeloablative conditioning regimen that met its primary safety endpoint of a lack of infusional toxicity or primary/secondary graft failure (Cell Stem Cell. 2016;18:144-55).

 

For reasons of safety, this earlier study used a double-transplant platform in which one infusion was uncultured umbilical cord blood and the other was MGTA-456. This study showed rapid neutrophil recovery when MGTA-456 was infused, with median 10.5 days to recovery, compared with a median 26.5 days for historical controls (P less than .001).

Additionally, the study showed a 19-day decrease in duration of the initial hospitalization, and all patients who received MGTA-456 had successful engraftment, Dr. Wagner said. On the strength of these results, the current trials of MGTA-456 alone – with both nonmyeloablative and myeloablative conditioning – were approved.

Multicenter clinical trials of MGTA-456 transplantation are now planned for both malignant and nonmalignant diseases. Enrollment is currently open for a phase 2 clinical trial of MGTA for inherited metabolic disorders (NCT03406962).

The study was funded by Novartis and Magenta Therapeutics. Dr. Wagner reported no other relevant disclosures.
 

[email protected]

SOURCE: Wagner J et al. 2018 BMT Tandem Meetings, Abstract 4.

SALT LAKE CITY – Recipients of hematopoietic cell transplant with umbilical cord blood CD34+ cells expanded with an aryl hydrocarbon receptor (AHR) antagonist had a significantly higher rate of engraftment and comparable survival to a historical cohort of umbilical cord blood recipients.

The robust expansion of donor umbilical cord blood seen with the new technique opens the door for better use of umbilical cord blood inventory with superior human leukocyte antigen (HLA) matching, John Wagner, MD, said at a top abstracts session of the combined annual meetings of the Center for International Blood & Marrow Transplant Research and the American Society for Blood and Marrow Transplantation.

The new technique still shared the benefits of low rates of graft-versus-host disease (GVHD) and high survival that have been seen in previous umbilical cord blood transplants, with no significant difference in overall survival, relapse, or acute or chronic GVHD.

Compared to historical controls (n = 151), patients receiving the AHR antagonist–expanded umbilical cord blood (UCB) cells with myeloablative conditioning (n = 9) saw complete and more rapid engraftment (100% vs. 89% engraftment at a median 14 days vs. 23 days; P less than .01), reported Dr. Wagner of the University of Minnesota, Minneapolis.

These and other results came from two arms of a phase 2 trial of MGTA-456 (the working name of the AHR-expanded UCB cells). Twenty patients were to receive MGTA-456 derived from partially matched umbilical cord blood units after either myeloablative or nonmyeloablative conditioning; one patient in each arm had low expansion of UCB, so a total of 18 patients received MGTA-456. Each intervention arm was compared with a historical control arm that had received conventional UCB units.

In the myeloablative arm, patient demographics and disease characteristics were similar to the control cohort except that the MGTA-456 patients were significantly heavier (93.8 kg vs. 66.7 kg; P less than .04).

 

Platelet recovery also rebounded faster with MGTA-456 plus myeloablative conditioning than it did with historical controls: 89% of patients had platelet recovery by a median 46 days, compared with 71% with platelet recovery by a median 64 days in the historical cohort (P less than .01).

Patients achieved rapid complete chimerism if they received myeloablative conditioning, and they had rapid rebound of CD4 counts to at least 200 by 2-3 months posttransplant, Dr. Wagner reported.

The nonmyeloablative arm had a historical control cohort of 132 patients. Characteristics were similar between the two groups except that the MGTA-456 patients were older and more likely to have high-risk disease.

Again, all patients had rapid neutrophil recovery and saw 100% engraftment with MGTA-456. Median time to engraftment was 7 days with MGTA-456 and 15 days for the historical controls (P less than .01). Platelet recovery took longer for the MGTA-456 (median of 47 vs. 107 days), but the difference was not statistically significant.

 

Complete chimerism was achieved rapidly with the nonmyeloablative regimen as well, and CD4 recovery was brisk, as had been seen with myeloablative conditioning before MGTA-456 transplantation.

Compared with historical controls, “MGTA-456 retains the benefits of low chronic-graft-versus host disease and high survival despite higher disease risk and age” in the study group, Dr. Wagner said. There were no significant differences between the intervention and historical control arms of the nonmyeloablative study in acute or chronic GVHD, relapse, or overall survival.

The use of MGTA-456 occurs against the backdrop of a history of high survival rates with UCB transplantation – about 70% at 5 years, Dr. Wagner said. However, when conventional culture and expansion methods for UCB were used, the median time to engraftment had been reported to be 25 days with a 79% engraftment rate. This contrasts with the mean 13 days to engraftment for peripheral blood transplants and 18 days for bone marrow transplants. All of these transplant sources, regardless of whether the transplant was matched or mismatched, have engraftment rates of 92%-96%, said Dr. Wagner (Lancet Oncol. 2010; 11[7]:653-60).

When an AHR antagonist is used for UCB expansion, hematopoietic stem cell renewal is upped because cell differentiation is blocked, which means expansion is all driven toward hematopoietic stem cell self-renewal, Dr. Wagner said. Of the 36 available samples, MGTA-456 achieved a median 327-fold expansion of CD34+ cells, which enabled investigators to deliver a median CD34+ dose of 17.5 X 10⁶ cells/kg.

 

The downstream effect of the robust expansion rates is that more cord blood will be available for transplantation, and HLA matches will improve, Dr. Wagner said. Using current expansion techniques, fewer than 5% of cord blood units have a total nucleated cell count sufficient for an adult 80 kg recipient, he said, adding that use of MGTA-456 could make more than 80% of cord blood units available for adults.

According to the UCB transplant history at the University of Minnesota – where Dr. Wagner directs the pediatric blood and marrow transplantation program – of the patients who received 4/6 HLA-matched cord blood, 63% would move to a 5/6 match, and 8% would move to a full HLA match with the MGTA-456 technique. Of patients who received 5/6-matched transplants, almost one in four (23%) would move to a full 6/6 match.

Dr. Wagner and his colleagues had previously shown that adding an AHR antagonist resulted in enhanced T-cell recovery and rapid and sustained engraftment (Science. 2010;329:1345-8).

The researchers then proceeded to a phase 1-2, first-in-human trial of MGTA-456 that used a myeloablative conditioning regimen that met its primary safety endpoint of a lack of infusional toxicity or primary/secondary graft failure (Cell Stem Cell. 2016;18:144-55).

 

For reasons of safety, this earlier study used a double-transplant platform in which one infusion was uncultured umbilical cord blood and the other was MGTA-456. This study showed rapid neutrophil recovery when MGTA-456 was infused, with median 10.5 days to recovery, compared with a median 26.5 days for historical controls (P less than .001).

Additionally, the study showed a 19-day decrease in duration of the initial hospitalization, and all patients who received MGTA-456 had successful engraftment, Dr. Wagner said. On the strength of these results, the current trials of MGTA-456 alone – with both nonmyeloablative and myeloablative conditioning – were approved.

Multicenter clinical trials of MGTA-456 transplantation are now planned for both malignant and nonmalignant diseases. Enrollment is currently open for a phase 2 clinical trial of MGTA for inherited metabolic disorders (NCT03406962).

The study was funded by Novartis and Magenta Therapeutics. Dr. Wagner reported no other relevant disclosures.
 

[email protected]

SOURCE: Wagner J et al. 2018 BMT Tandem Meetings, Abstract 4.

SALT LAKE CITY – Recipients of hematopoietic cell transplant with umbilical cord blood CD34+ cells expanded with an aryl hydrocarbon receptor (AHR) antagonist had a significantly higher rate of engraftment and comparable survival to a historical cohort of umbilical cord blood recipients.

The robust expansion of donor umbilical cord blood seen with the new technique opens the door for better use of umbilical cord blood inventory with superior human leukocyte antigen (HLA) matching, John Wagner, MD, said at a top abstracts session of the combined annual meetings of the Center for International Blood & Marrow Transplant Research and the American Society for Blood and Marrow Transplantation.

The new technique still shared the benefits of low rates of graft-versus-host disease (GVHD) and high survival that have been seen in previous umbilical cord blood transplants, with no significant difference in overall survival, relapse, or acute or chronic GVHD.

Compared to historical controls (n = 151), patients receiving the AHR antagonist–expanded umbilical cord blood (UCB) cells with myeloablative conditioning (n = 9) saw complete and more rapid engraftment (100% vs. 89% engraftment at a median 14 days vs. 23 days; P less than .01), reported Dr. Wagner of the University of Minnesota, Minneapolis.

These and other results came from two arms of a phase 2 trial of MGTA-456 (the working name of the AHR-expanded UCB cells). Twenty patients were to receive MGTA-456 derived from partially matched umbilical cord blood units after either myeloablative or nonmyeloablative conditioning; one patient in each arm had low expansion of UCB, so a total of 18 patients received MGTA-456. Each intervention arm was compared with a historical control arm that had received conventional UCB units.

In the myeloablative arm, patient demographics and disease characteristics were similar to the control cohort except that the MGTA-456 patients were significantly heavier (93.8 kg vs. 66.7 kg; P less than .04).

 

Platelet recovery also rebounded faster with MGTA-456 plus myeloablative conditioning than it did with historical controls: 89% of patients had platelet recovery by a median 46 days, compared with 71% with platelet recovery by a median 64 days in the historical cohort (P less than .01).

Patients achieved rapid complete chimerism if they received myeloablative conditioning, and they had rapid rebound of CD4 counts to at least 200 by 2-3 months posttransplant, Dr. Wagner reported.

The nonmyeloablative arm had a historical control cohort of 132 patients. Characteristics were similar between the two groups except that the MGTA-456 patients were older and more likely to have high-risk disease.

Again, all patients had rapid neutrophil recovery and saw 100% engraftment with MGTA-456. Median time to engraftment was 7 days with MGTA-456 and 15 days for the historical controls (P less than .01). Platelet recovery took longer for the MGTA-456 (median of 47 vs. 107 days), but the difference was not statistically significant.

 

Complete chimerism was achieved rapidly with the nonmyeloablative regimen as well, and CD4 recovery was brisk, as had been seen with myeloablative conditioning before MGTA-456 transplantation.

Compared with historical controls, “MGTA-456 retains the benefits of low chronic-graft-versus host disease and high survival despite higher disease risk and age” in the study group, Dr. Wagner said. There were no significant differences between the intervention and historical control arms of the nonmyeloablative study in acute or chronic GVHD, relapse, or overall survival.

The use of MGTA-456 occurs against the backdrop of a history of high survival rates with UCB transplantation – about 70% at 5 years, Dr. Wagner said. However, when conventional culture and expansion methods for UCB were used, the median time to engraftment had been reported to be 25 days with a 79% engraftment rate. This contrasts with the mean 13 days to engraftment for peripheral blood transplants and 18 days for bone marrow transplants. All of these transplant sources, regardless of whether the transplant was matched or mismatched, have engraftment rates of 92%-96%, said Dr. Wagner (Lancet Oncol. 2010; 11[7]:653-60).

When an AHR antagonist is used for UCB expansion, hematopoietic stem cell renewal is upped because cell differentiation is blocked, which means expansion is all driven toward hematopoietic stem cell self-renewal, Dr. Wagner said. Of the 36 available samples, MGTA-456 achieved a median 327-fold expansion of CD34+ cells, which enabled investigators to deliver a median CD34+ dose of 17.5 X 10⁶ cells/kg.

 

The downstream effect of the robust expansion rates is that more cord blood will be available for transplantation, and HLA matches will improve, Dr. Wagner said. Using current expansion techniques, fewer than 5% of cord blood units have a total nucleated cell count sufficient for an adult 80 kg recipient, he said, adding that use of MGTA-456 could make more than 80% of cord blood units available for adults.

According to the UCB transplant history at the University of Minnesota – where Dr. Wagner directs the pediatric blood and marrow transplantation program – of the patients who received 4/6 HLA-matched cord blood, 63% would move to a 5/6 match, and 8% would move to a full HLA match with the MGTA-456 technique. Of patients who received 5/6-matched transplants, almost one in four (23%) would move to a full 6/6 match.

Dr. Wagner and his colleagues had previously shown that adding an AHR antagonist resulted in enhanced T-cell recovery and rapid and sustained engraftment (Science. 2010;329:1345-8).

The researchers then proceeded to a phase 1-2, first-in-human trial of MGTA-456 that used a myeloablative conditioning regimen that met its primary safety endpoint of a lack of infusional toxicity or primary/secondary graft failure (Cell Stem Cell. 2016;18:144-55).

 

For reasons of safety, this earlier study used a double-transplant platform in which one infusion was uncultured umbilical cord blood and the other was MGTA-456. This study showed rapid neutrophil recovery when MGTA-456 was infused, with median 10.5 days to recovery, compared with a median 26.5 days for historical controls (P less than .001).

Additionally, the study showed a 19-day decrease in duration of the initial hospitalization, and all patients who received MGTA-456 had successful engraftment, Dr. Wagner said. On the strength of these results, the current trials of MGTA-456 alone – with both nonmyeloablative and myeloablative conditioning – were approved.

Multicenter clinical trials of MGTA-456 transplantation are now planned for both malignant and nonmalignant diseases. Enrollment is currently open for a phase 2 clinical trial of MGTA for inherited metabolic disorders (NCT03406962).

The study was funded by Novartis and Magenta Therapeutics. Dr. Wagner reported no other relevant disclosures.
 

[email protected]

SOURCE: Wagner J et al. 2018 BMT Tandem Meetings, Abstract 4.

Photo by Rhoda Baer

Adding an experimental compound to chemotherapy is a “promising” treatment approach for certain patients with acute myeloid leukemia (AML), according to researchers.

They tested the compound, CPI-613, in combination with high-dose cytarabine and mitoxantrone in a phase 1 trial of patients with relapsed or refractory AML.

The combination produced similar response rates in the overall patient population (50%), patients age 60 and older (47%), and those with poor-risk cytogenetics (46%).

The most common grade 3/4 adverse events (AEs) were hematologic toxicities, and there was 1 fatal AE—hypotension.

Mortality rates in this trial were similar to those observed in historical controls treated with high-dose cytarabine, mitoxantrone, and asparaginase.

“These data are very encouraging, especially for patients 60 years of age or older who have historically done very poorly with this disease,” said Timothy Pardee, MD, PhD, a professor at Wake Forest Baptist Health in Winston-Salem, North Carolina, and chief medical officer of Rafael Pharmaceuticals, Inc., the company developing CPI-613.

Dr Pardee and his colleagues reported these results in Clinical Cancer Research.

The researchers noted that CPI-613 is designed to target mitochondrial metabolism in cancer cells, and preclinical research showed that CPI-613 sensitized AML cells to chemotherapy.

To investigate this further, the team tested CPI-613 in combination with high-dose cytarabine and mitoxantrone in the phase 1 trial. The study included 66 patients with relapsed or refractory AML, as well as a patient with advanced-phase chronic myeloid leukemia (CML) who was mistakenly enrolled.

The patients’ median age was 60 (range, 21-79), and 54% were age 60 and older. Their median percentage of marrow blasts was 43%. Forty percent of patients had poor-risk cytogenetics, and 49% had intermediate-risk cytogenetics.

Most patients (72%) had no prior salvage therapy, 13% had 1 prior line of salvage, 10% had 2 prior lines, and 4% had more than 2. Thirty-one percent of patients had refractory disease.

Seven percent of patients had previously received high-dose cytarabine and mitoxantrone, and 25% had previous salvage including high-dose or intermediate-dose cytarabine.

Treatment

Patients received CPI-613, given over 2 hours, on days 1 to 5 of cycle 1. Doses ranged from 500 mg/m² to 2750 mg/m².

Starting on day 3, patients received 5 doses of cytarabine at 3 gm/m² (for patients younger than 60) or 1.5 gm/m² (for older patients) in 500 mL normal saline, over 3 hours, every 12 hours.

Patients also received 3 daily doses of mitoxantrone at 6 mg/m² in 50 mL normal saline, given over 15 minutes, after the first, third, and fifth doses of cytarabine.

Patients were initially assigned to receive 1 cycle of treatment. Those with at least 5% blasts after the first cycle could receive a second course—either a full course or a 3-day course. And patients who responded to the first course could receive up to 2 cycles of the 3-day course.

Safety

There were 2 dose-limiting toxicities when CPI-613 was given at the 2750 mg/m² dose. One of these toxicities was grade 3 diarrhea that didn’t respond to anti-diarrheals, and the other was grade 3 nausea that didn’t respond to antiemetics.

Because of these events, 2500 mg/m² was deemed the maximum-tolerated dose. However, the recommended phase 2 dose is 2000 mg/m².

The most common AEs—occurring in at least 50% of all patients who received CPI-613 (n=67)—included hemoglobin decrease (67%), hyperglycemia (67%), neutropenia (67%), thrombocytopenia (67%), hypomagnesemia (66%), leukopenia (66%), lymphopenia (66%), hypoalbuminemia (65%), hypokalemia (60%), hypocalcemia (57%), and diarrhea (55%).

All cases of neutropenia, thrombocytopenia, leukopenia, and lymphopenia were grade 3/4. Other common grade 3/4 AEs (occurring in at least 20% of patients) included hemoglobin decrease (62%), febrile neutropenia (28%), hypophosphatemia (24%), and hypokalemia (23%).

 

The only grade 5 AE was hypotension.

The mortality rate was 12% (n=8) at 30 days and 19% (n=13) at 60 days. The researchers said this was similar to the historical experience with high-dose cytarabine, mitoxantrone, and asparaginase. Mortality rates with this regimen were 13% at 30 days and 22% at 60 days.

Efficacy

Sixty-two patients were evaluable for response. Of the 5 patients who were not evaluable, 1 didn’t complete the first cycle of treatment, 1 was the CML patient, and 3 died before assessment.

The overall response rate was 50% (31/62). This included 26 patients with a complete response (CR) and 5 patients who had a CR with incomplete count recovery (CRi).

The rate of CR/CRi was 47% (15/32) in patients older than 60 years of age, 46% (11/24) in patients who had poor-risk cytogenetics, and 53% (8/15) when CPI-613 was given at the recommended phase 2 dose—2000 mg/m².

The median overall survival (OS) was 6.7 months for all evaluable patients and 13.2 months for patients who achieved a CR/CRi.

The median OS was 6.9 months for patients age 60 and older, which was not significantly different from the median OS in younger patients (P=0.9642).

This study was sponsored by Wake Forest University Health Sciences and the National Cancer Institute.

Photo by Rhoda Baer

Adding an experimental compound to chemotherapy is a “promising” treatment approach for certain patients with acute myeloid leukemia (AML), according to researchers.

They tested the compound, CPI-613, in combination with high-dose cytarabine and mitoxantrone in a phase 1 trial of patients with relapsed or refractory AML.

The combination produced similar response rates in the overall patient population (50%), patients age 60 and older (47%), and those with poor-risk cytogenetics (46%).

The most common grade 3/4 adverse events (AEs) were hematologic toxicities, and there was 1 fatal AE—hypotension.

Mortality rates in this trial were similar to those observed in historical controls treated with high-dose cytarabine, mitoxantrone, and asparaginase.

“These data are very encouraging, especially for patients 60 years of age or older who have historically done very poorly with this disease,” said Timothy Pardee, MD, PhD, a professor at Wake Forest Baptist Health in Winston-Salem, North Carolina, and chief medical officer of Rafael Pharmaceuticals, Inc., the company developing CPI-613.

Dr Pardee and his colleagues reported these results in Clinical Cancer Research.

The researchers noted that CPI-613 is designed to target mitochondrial metabolism in cancer cells, and preclinical research showed that CPI-613 sensitized AML cells to chemotherapy.

To investigate this further, the team tested CPI-613 in combination with high-dose cytarabine and mitoxantrone in the phase 1 trial. The study included 66 patients with relapsed or refractory AML, as well as a patient with advanced-phase chronic myeloid leukemia (CML) who was mistakenly enrolled.

The patients’ median age was 60 (range, 21-79), and 54% were age 60 and older. Their median percentage of marrow blasts was 43%. Forty percent of patients had poor-risk cytogenetics, and 49% had intermediate-risk cytogenetics.

Most patients (72%) had no prior salvage therapy, 13% had 1 prior line of salvage, 10% had 2 prior lines, and 4% had more than 2. Thirty-one percent of patients had refractory disease.

Seven percent of patients had previously received high-dose cytarabine and mitoxantrone, and 25% had previous salvage including high-dose or intermediate-dose cytarabine.

Treatment

Patients received CPI-613, given over 2 hours, on days 1 to 5 of cycle 1. Doses ranged from 500 mg/m² to 2750 mg/m².

Starting on day 3, patients received 5 doses of cytarabine at 3 gm/m² (for patients younger than 60) or 1.5 gm/m² (for older patients) in 500 mL normal saline, over 3 hours, every 12 hours.

Patients also received 3 daily doses of mitoxantrone at 6 mg/m² in 50 mL normal saline, given over 15 minutes, after the first, third, and fifth doses of cytarabine.

Patients were initially assigned to receive 1 cycle of treatment. Those with at least 5% blasts after the first cycle could receive a second course—either a full course or a 3-day course. And patients who responded to the first course could receive up to 2 cycles of the 3-day course.

Safety

There were 2 dose-limiting toxicities when CPI-613 was given at the 2750 mg/m² dose. One of these toxicities was grade 3 diarrhea that didn’t respond to anti-diarrheals, and the other was grade 3 nausea that didn’t respond to antiemetics.

Because of these events, 2500 mg/m² was deemed the maximum-tolerated dose. However, the recommended phase 2 dose is 2000 mg/m².

The most common AEs—occurring in at least 50% of all patients who received CPI-613 (n=67)—included hemoglobin decrease (67%), hyperglycemia (67%), neutropenia (67%), thrombocytopenia (67%), hypomagnesemia (66%), leukopenia (66%), lymphopenia (66%), hypoalbuminemia (65%), hypokalemia (60%), hypocalcemia (57%), and diarrhea (55%).

All cases of neutropenia, thrombocytopenia, leukopenia, and lymphopenia were grade 3/4. Other common grade 3/4 AEs (occurring in at least 20% of patients) included hemoglobin decrease (62%), febrile neutropenia (28%), hypophosphatemia (24%), and hypokalemia (23%).

 

The only grade 5 AE was hypotension.

The mortality rate was 12% (n=8) at 30 days and 19% (n=13) at 60 days. The researchers said this was similar to the historical experience with high-dose cytarabine, mitoxantrone, and asparaginase. Mortality rates with this regimen were 13% at 30 days and 22% at 60 days.

Efficacy

Sixty-two patients were evaluable for response. Of the 5 patients who were not evaluable, 1 didn’t complete the first cycle of treatment, 1 was the CML patient, and 3 died before assessment.

The overall response rate was 50% (31/62). This included 26 patients with a complete response (CR) and 5 patients who had a CR with incomplete count recovery (CRi).

The rate of CR/CRi was 47% (15/32) in patients older than 60 years of age, 46% (11/24) in patients who had poor-risk cytogenetics, and 53% (8/15) when CPI-613 was given at the recommended phase 2 dose—2000 mg/m².

The median overall survival (OS) was 6.7 months for all evaluable patients and 13.2 months for patients who achieved a CR/CRi.

The median OS was 6.9 months for patients age 60 and older, which was not significantly different from the median OS in younger patients (P=0.9642).

This study was sponsored by Wake Forest University Health Sciences and the National Cancer Institute.

Photo by Rhoda Baer

Adding an experimental compound to chemotherapy is a “promising” treatment approach for certain patients with acute myeloid leukemia (AML), according to researchers.

They tested the compound, CPI-613, in combination with high-dose cytarabine and mitoxantrone in a phase 1 trial of patients with relapsed or refractory AML.

The combination produced similar response rates in the overall patient population (50%), patients age 60 and older (47%), and those with poor-risk cytogenetics (46%).

The most common grade 3/4 adverse events (AEs) were hematologic toxicities, and there was 1 fatal AE—hypotension.

Mortality rates in this trial were similar to those observed in historical controls treated with high-dose cytarabine, mitoxantrone, and asparaginase.

“These data are very encouraging, especially for patients 60 years of age or older who have historically done very poorly with this disease,” said Timothy Pardee, MD, PhD, a professor at Wake Forest Baptist Health in Winston-Salem, North Carolina, and chief medical officer of Rafael Pharmaceuticals, Inc., the company developing CPI-613.

Dr Pardee and his colleagues reported these results in Clinical Cancer Research.

The researchers noted that CPI-613 is designed to target mitochondrial metabolism in cancer cells, and preclinical research showed that CPI-613 sensitized AML cells to chemotherapy.

To investigate this further, the team tested CPI-613 in combination with high-dose cytarabine and mitoxantrone in the phase 1 trial. The study included 66 patients with relapsed or refractory AML, as well as a patient with advanced-phase chronic myeloid leukemia (CML) who was mistakenly enrolled.

The patients’ median age was 60 (range, 21-79), and 54% were age 60 and older. Their median percentage of marrow blasts was 43%. Forty percent of patients had poor-risk cytogenetics, and 49% had intermediate-risk cytogenetics.

Most patients (72%) had no prior salvage therapy, 13% had 1 prior line of salvage, 10% had 2 prior lines, and 4% had more than 2. Thirty-one percent of patients had refractory disease.

Seven percent of patients had previously received high-dose cytarabine and mitoxantrone, and 25% had previous salvage including high-dose or intermediate-dose cytarabine.

Treatment

Patients received CPI-613, given over 2 hours, on days 1 to 5 of cycle 1. Doses ranged from 500 mg/m² to 2750 mg/m².

Starting on day 3, patients received 5 doses of cytarabine at 3 gm/m² (for patients younger than 60) or 1.5 gm/m² (for older patients) in 500 mL normal saline, over 3 hours, every 12 hours.

Patients also received 3 daily doses of mitoxantrone at 6 mg/m² in 50 mL normal saline, given over 15 minutes, after the first, third, and fifth doses of cytarabine.

Patients were initially assigned to receive 1 cycle of treatment. Those with at least 5% blasts after the first cycle could receive a second course—either a full course or a 3-day course. And patients who responded to the first course could receive up to 2 cycles of the 3-day course.

Safety

There were 2 dose-limiting toxicities when CPI-613 was given at the 2750 mg/m² dose. One of these toxicities was grade 3 diarrhea that didn’t respond to anti-diarrheals, and the other was grade 3 nausea that didn’t respond to antiemetics.

Because of these events, 2500 mg/m² was deemed the maximum-tolerated dose. However, the recommended phase 2 dose is 2000 mg/m².

The most common AEs—occurring in at least 50% of all patients who received CPI-613 (n=67)—included hemoglobin decrease (67%), hyperglycemia (67%), neutropenia (67%), thrombocytopenia (67%), hypomagnesemia (66%), leukopenia (66%), lymphopenia (66%), hypoalbuminemia (65%), hypokalemia (60%), hypocalcemia (57%), and diarrhea (55%).

All cases of neutropenia, thrombocytopenia, leukopenia, and lymphopenia were grade 3/4. Other common grade 3/4 AEs (occurring in at least 20% of patients) included hemoglobin decrease (62%), febrile neutropenia (28%), hypophosphatemia (24%), and hypokalemia (23%).

 

The only grade 5 AE was hypotension.

The mortality rate was 12% (n=8) at 30 days and 19% (n=13) at 60 days. The researchers said this was similar to the historical experience with high-dose cytarabine, mitoxantrone, and asparaginase. Mortality rates with this regimen were 13% at 30 days and 22% at 60 days.

Efficacy

Sixty-two patients were evaluable for response. Of the 5 patients who were not evaluable, 1 didn’t complete the first cycle of treatment, 1 was the CML patient, and 3 died before assessment.

The overall response rate was 50% (31/62). This included 26 patients with a complete response (CR) and 5 patients who had a CR with incomplete count recovery (CRi).

The rate of CR/CRi was 47% (15/32) in patients older than 60 years of age, 46% (11/24) in patients who had poor-risk cytogenetics, and 53% (8/15) when CPI-613 was given at the recommended phase 2 dose—2000 mg/m².

The median overall survival (OS) was 6.7 months for all evaluable patients and 13.2 months for patients who achieved a CR/CRi.

The median OS was 6.9 months for patients age 60 and older, which was not significantly different from the median OS in younger patients (P=0.9642).

This study was sponsored by Wake Forest University Health Sciences and the National Cancer Institute.

 

KAUAI, HAWAII – Dermatologists don’t ordinarily peruse the ophthalmology literature. So they may be unaware that the American Academy of Ophthalmology has issued revised recommendations on weight-based dosing of hydroxychloroquine in order to minimize retinopathy risk, Erik J. Stratman, MD, noted at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

Most dermatologists routinely dose hydroxychloroquine at 400 mg/day, regardless of body weight. The former AAO recommendation, which dates back to 2011, called for dosing at up to 6.5 mg/kg of ideal body weight or 400 mg/day, whichever is lower. However, the AAO recommendation has changed in light of a large, retrospective case-control study that suggested this practice may be overdosing thin patients – thereby exposing them to increased risk of retinal toxicity and other drug-related adverse events – while at the same time possibly underdosing some obese patients, said Dr. Stratman, chairman of the department of dermatology at the Marshfield (Wisc.) Clinic.

This was one of two dermatology practice gaps he highlighted involving suboptimal medication management, the other being most dermatologists’ failure to protect their patients’ gut when prescribing prednisone.

“I think the push over the last 5 years has been ‘protect the bones, protect the bones, protect the bones.’ We’ve done better and better about protecting the bones and getting that into our conversations with patients on prednisone. But we’re not thinking so much about the gut,” the dermatologist said.

Hydroxychloroquine dosing

The former AAO recommendation was revised in response to a retrospective case-control study of retinal toxicity rates in 2,361 patients on the drug continuously for longer than 5 years. The study demonstrated that the risk of retinopathy jumped 5.7-fold with daily consumption of hydroxychloroquine at more than 5.0 mg/kg (JAMA Ophthalmol. 2014 Dec;132[12]:1453-60).

The current AAO recommendation (Ophthalmology. 2016 Jun;123[6]:1386-94) is to dose hydroxychloroquine at a daily maximum of 5.0 mg/kg of real weight, which correlated better with retinopathy risk in the case-control study than did ideal body weight. Hydroxychloroquine doesn’t accumulate well in fat.

Until now, most dermatologists have not routinely measured patients’ body weight in the office or calculated their body mass index. But Dr. Stratman advised against reliance upon a patient’s self-reported body weight, which may diverge substantially from reality. “Get yourself a good office scale – they’re not that expensive – and use it when prescribing drugs with a tight therapeutic window,” he urged.

 

Another key to minimizing retinopathy risk in patients on hydroxychloroquine is to pay careful attention to how long they’ve been on the drug. As the years go by in patients being treated for cutaneous lupus or other dermatologic disorders where decades-long therapy is often a mainstay, it’s important to check with patients and make sure they’re getting annual ophthalmologic screening for irreversible retinal toxicity by both threshold visual fields and spectral domain optical coherence tomography. In the large, practice-changing retrospective study, patients on hydroxychloroquine at 4.0-5.0 mg/kg daily had a prevalence of retinopathy of less than 2% during the first 10 years of therapy, but the rate shot up to nearly 20% after 20 years of use, Dr. Stratman observed.

He highlighted as helpful an updated review of the use of hydroxychloroquine in dermatology recently published by Anthony P. Fernandez, MD, PhD, of the department of dermatology at the Cleveland Clinic (J Am Acad Dermatol. 2017 Jun;76[6]:1176-82).

Dr. Fernandez recommends following the AAO guidance to dose the drug at 5.0 mg/kg or less of actual body weight in thin or normal-weight patients; however, he departed from the ophthalmologists with regard to treatment of obese patients. Because dosing based on actual weight could potentially lead to relative overdosing in obese patients, in that growing population he recommends calculating the dose based upon 5.0 mg/kg of actual body weight, as well as the dose based on 6.5 mg/kg of ideal body weight, then prescribing the lower of the two, up to a maximum of 400 mg/day.

“The current recommendation is really about not overdosing thin patients. Basically, dosing is not so difficult for obese people because if you weigh more than 175 pounds, you’re going to get 400 mg/day,” Dr. Stratman explained.

That 400 mg/day ceiling is not cast in stone, he continued. The guideline recommends that, if a patient is a nonresponder to several months of hydroxychloroquine at 400 mg/day, it’s worthwhile to order a drug blood level. If it’s not above the efficacy threshold of more than 750 ng/mL, it’s appropriate to titrate up.

 

Protecting against prednisone-induced gastritis

“We underprotect the gut,” Dr. Stratman asserted.

He referred to a recent comprehensive dermatologic review of the prevention and management of glucocorticoid-related side effects, especially the part on peptic ulcer disease (J Am Acad Dermatol. 2017 Jan;76[1]:11-6). This is an issue that heretofore hadn’t been much emphasized in the dermatology literature.

“I read this and thought, ‘Gosh, I’m not really having a conversation with my patients about a review of systems for gut protection as I should. And I certainly haven’t been thinking about prescribing PPIs [proton pump inhibitors] for my patients,’” he recalled.

Dr. Stratman polled his Hawaii Dermatology Seminar audience as to who had ever prescribed a PPI. Most indicated with their electronic clickers that they had never done so.

“This is what a practice gap is,” he commented. “You read the literature and you say, ‘Oh, I guess that makes sense. Maybe I should be doing that more often, or making sure it gets done.’”

“I don’t want to come across as saying, ‘For everybody we put on prednisone we should be giving vitamin D, calcium, and a PPI.’ That’s not the message. The message is, assess your patient – or make sure your patient is being assessed – for risk of peptic ulcer disease. And if you don’t feel comfortable prescribing a PPI, please get the patient connected with their primary care provider, who should,” Dr. Stratman said.

 

The authors of the dermatology review made a case for screening for GI risk factors in every patient who is going to receive an oral glucocorticoid. The ones who absolutely should be prescribed a PPI unless contraindicated include patients who are taking daily aspirin or NSAIDs for an essential reason, such as cardiovascular protection or significant arthritic pain. The authors suggest consideration of a PPI in patients with other, less potent risk factors for peptic ulcer disease, including a history of ulcer disease, gastroesophageal reflux disease, Barrett’s esophagus, heavy smoking, heavy alcohol consumption, age greater than 65, and concomitant use of other medications with an associated risk of peptic ulcer disease – such as bisphosphonates, “which you may have just put them on to protect their bones,” Dr. Stratman noted.

Of course, PPIs come with side effects of their own, including increased fracture risk, Clostridium difficile infections, and rebound acid secretion.

Dr. Stratman reported having no financial conflicts regarding his presentation.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]

 

KAUAI, HAWAII – Dermatologists don’t ordinarily peruse the ophthalmology literature. So they may be unaware that the American Academy of Ophthalmology has issued revised recommendations on weight-based dosing of hydroxychloroquine in order to minimize retinopathy risk, Erik J. Stratman, MD, noted at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

Most dermatologists routinely dose hydroxychloroquine at 400 mg/day, regardless of body weight. The former AAO recommendation, which dates back to 2011, called for dosing at up to 6.5 mg/kg of ideal body weight or 400 mg/day, whichever is lower. However, the AAO recommendation has changed in light of a large, retrospective case-control study that suggested this practice may be overdosing thin patients – thereby exposing them to increased risk of retinal toxicity and other drug-related adverse events – while at the same time possibly underdosing some obese patients, said Dr. Stratman, chairman of the department of dermatology at the Marshfield (Wisc.) Clinic.

This was one of two dermatology practice gaps he highlighted involving suboptimal medication management, the other being most dermatologists’ failure to protect their patients’ gut when prescribing prednisone.

“I think the push over the last 5 years has been ‘protect the bones, protect the bones, protect the bones.’ We’ve done better and better about protecting the bones and getting that into our conversations with patients on prednisone. But we’re not thinking so much about the gut,” the dermatologist said.

Hydroxychloroquine dosing

The former AAO recommendation was revised in response to a retrospective case-control study of retinal toxicity rates in 2,361 patients on the drug continuously for longer than 5 years. The study demonstrated that the risk of retinopathy jumped 5.7-fold with daily consumption of hydroxychloroquine at more than 5.0 mg/kg (JAMA Ophthalmol. 2014 Dec;132[12]:1453-60).

The current AAO recommendation (Ophthalmology. 2016 Jun;123[6]:1386-94) is to dose hydroxychloroquine at a daily maximum of 5.0 mg/kg of real weight, which correlated better with retinopathy risk in the case-control study than did ideal body weight. Hydroxychloroquine doesn’t accumulate well in fat.

Until now, most dermatologists have not routinely measured patients’ body weight in the office or calculated their body mass index. But Dr. Stratman advised against reliance upon a patient’s self-reported body weight, which may diverge substantially from reality. “Get yourself a good office scale – they’re not that expensive – and use it when prescribing drugs with a tight therapeutic window,” he urged.

 

Another key to minimizing retinopathy risk in patients on hydroxychloroquine is to pay careful attention to how long they’ve been on the drug. As the years go by in patients being treated for cutaneous lupus or other dermatologic disorders where decades-long therapy is often a mainstay, it’s important to check with patients and make sure they’re getting annual ophthalmologic screening for irreversible retinal toxicity by both threshold visual fields and spectral domain optical coherence tomography. In the large, practice-changing retrospective study, patients on hydroxychloroquine at 4.0-5.0 mg/kg daily had a prevalence of retinopathy of less than 2% during the first 10 years of therapy, but the rate shot up to nearly 20% after 20 years of use, Dr. Stratman observed.

He highlighted as helpful an updated review of the use of hydroxychloroquine in dermatology recently published by Anthony P. Fernandez, MD, PhD, of the department of dermatology at the Cleveland Clinic (J Am Acad Dermatol. 2017 Jun;76[6]:1176-82).

Dr. Fernandez recommends following the AAO guidance to dose the drug at 5.0 mg/kg or less of actual body weight in thin or normal-weight patients; however, he departed from the ophthalmologists with regard to treatment of obese patients. Because dosing based on actual weight could potentially lead to relative overdosing in obese patients, in that growing population he recommends calculating the dose based upon 5.0 mg/kg of actual body weight, as well as the dose based on 6.5 mg/kg of ideal body weight, then prescribing the lower of the two, up to a maximum of 400 mg/day.

“The current recommendation is really about not overdosing thin patients. Basically, dosing is not so difficult for obese people because if you weigh more than 175 pounds, you’re going to get 400 mg/day,” Dr. Stratman explained.

That 400 mg/day ceiling is not cast in stone, he continued. The guideline recommends that, if a patient is a nonresponder to several months of hydroxychloroquine at 400 mg/day, it’s worthwhile to order a drug blood level. If it’s not above the efficacy threshold of more than 750 ng/mL, it’s appropriate to titrate up.

 

Protecting against prednisone-induced gastritis

“We underprotect the gut,” Dr. Stratman asserted.

He referred to a recent comprehensive dermatologic review of the prevention and management of glucocorticoid-related side effects, especially the part on peptic ulcer disease (J Am Acad Dermatol. 2017 Jan;76[1]:11-6). This is an issue that heretofore hadn’t been much emphasized in the dermatology literature.

“I read this and thought, ‘Gosh, I’m not really having a conversation with my patients about a review of systems for gut protection as I should. And I certainly haven’t been thinking about prescribing PPIs [proton pump inhibitors] for my patients,’” he recalled.

Dr. Stratman polled his Hawaii Dermatology Seminar audience as to who had ever prescribed a PPI. Most indicated with their electronic clickers that they had never done so.

“This is what a practice gap is,” he commented. “You read the literature and you say, ‘Oh, I guess that makes sense. Maybe I should be doing that more often, or making sure it gets done.’”

“I don’t want to come across as saying, ‘For everybody we put on prednisone we should be giving vitamin D, calcium, and a PPI.’ That’s not the message. The message is, assess your patient – or make sure your patient is being assessed – for risk of peptic ulcer disease. And if you don’t feel comfortable prescribing a PPI, please get the patient connected with their primary care provider, who should,” Dr. Stratman said.

 

The authors of the dermatology review made a case for screening for GI risk factors in every patient who is going to receive an oral glucocorticoid. The ones who absolutely should be prescribed a PPI unless contraindicated include patients who are taking daily aspirin or NSAIDs for an essential reason, such as cardiovascular protection or significant arthritic pain. The authors suggest consideration of a PPI in patients with other, less potent risk factors for peptic ulcer disease, including a history of ulcer disease, gastroesophageal reflux disease, Barrett’s esophagus, heavy smoking, heavy alcohol consumption, age greater than 65, and concomitant use of other medications with an associated risk of peptic ulcer disease – such as bisphosphonates, “which you may have just put them on to protect their bones,” Dr. Stratman noted.

Of course, PPIs come with side effects of their own, including increased fracture risk, Clostridium difficile infections, and rebound acid secretion.

Dr. Stratman reported having no financial conflicts regarding his presentation.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]

 

KAUAI, HAWAII – Dermatologists don’t ordinarily peruse the ophthalmology literature. So they may be unaware that the American Academy of Ophthalmology has issued revised recommendations on weight-based dosing of hydroxychloroquine in order to minimize retinopathy risk, Erik J. Stratman, MD, noted at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

Most dermatologists routinely dose hydroxychloroquine at 400 mg/day, regardless of body weight. The former AAO recommendation, which dates back to 2011, called for dosing at up to 6.5 mg/kg of ideal body weight or 400 mg/day, whichever is lower. However, the AAO recommendation has changed in light of a large, retrospective case-control study that suggested this practice may be overdosing thin patients – thereby exposing them to increased risk of retinal toxicity and other drug-related adverse events – while at the same time possibly underdosing some obese patients, said Dr. Stratman, chairman of the department of dermatology at the Marshfield (Wisc.) Clinic.

This was one of two dermatology practice gaps he highlighted involving suboptimal medication management, the other being most dermatologists’ failure to protect their patients’ gut when prescribing prednisone.

“I think the push over the last 5 years has been ‘protect the bones, protect the bones, protect the bones.’ We’ve done better and better about protecting the bones and getting that into our conversations with patients on prednisone. But we’re not thinking so much about the gut,” the dermatologist said.

Hydroxychloroquine dosing

The former AAO recommendation was revised in response to a retrospective case-control study of retinal toxicity rates in 2,361 patients on the drug continuously for longer than 5 years. The study demonstrated that the risk of retinopathy jumped 5.7-fold with daily consumption of hydroxychloroquine at more than 5.0 mg/kg (JAMA Ophthalmol. 2014 Dec;132[12]:1453-60).

The current AAO recommendation (Ophthalmology. 2016 Jun;123[6]:1386-94) is to dose hydroxychloroquine at a daily maximum of 5.0 mg/kg of real weight, which correlated better with retinopathy risk in the case-control study than did ideal body weight. Hydroxychloroquine doesn’t accumulate well in fat.

Until now, most dermatologists have not routinely measured patients’ body weight in the office or calculated their body mass index. But Dr. Stratman advised against reliance upon a patient’s self-reported body weight, which may diverge substantially from reality. “Get yourself a good office scale – they’re not that expensive – and use it when prescribing drugs with a tight therapeutic window,” he urged.

 

Another key to minimizing retinopathy risk in patients on hydroxychloroquine is to pay careful attention to how long they’ve been on the drug. As the years go by in patients being treated for cutaneous lupus or other dermatologic disorders where decades-long therapy is often a mainstay, it’s important to check with patients and make sure they’re getting annual ophthalmologic screening for irreversible retinal toxicity by both threshold visual fields and spectral domain optical coherence tomography. In the large, practice-changing retrospective study, patients on hydroxychloroquine at 4.0-5.0 mg/kg daily had a prevalence of retinopathy of less than 2% during the first 10 years of therapy, but the rate shot up to nearly 20% after 20 years of use, Dr. Stratman observed.

He highlighted as helpful an updated review of the use of hydroxychloroquine in dermatology recently published by Anthony P. Fernandez, MD, PhD, of the department of dermatology at the Cleveland Clinic (J Am Acad Dermatol. 2017 Jun;76[6]:1176-82).

Dr. Fernandez recommends following the AAO guidance to dose the drug at 5.0 mg/kg or less of actual body weight in thin or normal-weight patients; however, he departed from the ophthalmologists with regard to treatment of obese patients. Because dosing based on actual weight could potentially lead to relative overdosing in obese patients, in that growing population he recommends calculating the dose based upon 5.0 mg/kg of actual body weight, as well as the dose based on 6.5 mg/kg of ideal body weight, then prescribing the lower of the two, up to a maximum of 400 mg/day.

“The current recommendation is really about not overdosing thin patients. Basically, dosing is not so difficult for obese people because if you weigh more than 175 pounds, you’re going to get 400 mg/day,” Dr. Stratman explained.

That 400 mg/day ceiling is not cast in stone, he continued. The guideline recommends that, if a patient is a nonresponder to several months of hydroxychloroquine at 400 mg/day, it’s worthwhile to order a drug blood level. If it’s not above the efficacy threshold of more than 750 ng/mL, it’s appropriate to titrate up.

 

Protecting against prednisone-induced gastritis

“We underprotect the gut,” Dr. Stratman asserted.

He referred to a recent comprehensive dermatologic review of the prevention and management of glucocorticoid-related side effects, especially the part on peptic ulcer disease (J Am Acad Dermatol. 2017 Jan;76[1]:11-6). This is an issue that heretofore hadn’t been much emphasized in the dermatology literature.

“I read this and thought, ‘Gosh, I’m not really having a conversation with my patients about a review of systems for gut protection as I should. And I certainly haven’t been thinking about prescribing PPIs [proton pump inhibitors] for my patients,’” he recalled.

Dr. Stratman polled his Hawaii Dermatology Seminar audience as to who had ever prescribed a PPI. Most indicated with their electronic clickers that they had never done so.

“This is what a practice gap is,” he commented. “You read the literature and you say, ‘Oh, I guess that makes sense. Maybe I should be doing that more often, or making sure it gets done.’”

“I don’t want to come across as saying, ‘For everybody we put on prednisone we should be giving vitamin D, calcium, and a PPI.’ That’s not the message. The message is, assess your patient – or make sure your patient is being assessed – for risk of peptic ulcer disease. And if you don’t feel comfortable prescribing a PPI, please get the patient connected with their primary care provider, who should,” Dr. Stratman said.

 

The authors of the dermatology review made a case for screening for GI risk factors in every patient who is going to receive an oral glucocorticoid. The ones who absolutely should be prescribed a PPI unless contraindicated include patients who are taking daily aspirin or NSAIDs for an essential reason, such as cardiovascular protection or significant arthritic pain. The authors suggest consideration of a PPI in patients with other, less potent risk factors for peptic ulcer disease, including a history of ulcer disease, gastroesophageal reflux disease, Barrett’s esophagus, heavy smoking, heavy alcohol consumption, age greater than 65, and concomitant use of other medications with an associated risk of peptic ulcer disease – such as bisphosphonates, “which you may have just put them on to protect their bones,” Dr. Stratman noted.

Of course, PPIs come with side effects of their own, including increased fracture risk, Clostridium difficile infections, and rebound acid secretion.

Dr. Stratman reported having no financial conflicts regarding his presentation.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]