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Using oral and topical cosmeceuticals to prevent and treat skin aging, Part I
It is important for dermatologists to recognize patients at an increased risk of skin aging early enough to initiate countermeasures. “Wrinkle-prone” skin types can be identified easily through use of the Baumann Skin Type Indicator Questionnaire.1 The wrinkle-prone Baumann skin type is associated with age or with lifestyle factors that increase the risk for promoting skin aging.2 Prevention and treatment of numerous signs of cutaneous aging can be achieved through consistent daily use of oral and topical products suited to the identified specifically wrinkle-prone Baumann skin type.
Skin aging
The numerous causes of skin aging can be divided into two broad categories: intrinsic and extrinsic. Intrinsic aging results from cellular processes that occur over time and is influenced by genetics. Such aging is characterized by decreased function of keratinocytes and fibroblasts, intra- and extracellular accumulation of by-products, reduced function of sirtuins (proteins that regulate cell metabolism and aging), mitochondrial damage, and loss of telomeres.
Extrinsic aging results from environmental exposures that engender cell damage, including UV light, infrared and radiation exposure, air pollution, smoking, tanning beds, alcohol and drug usage, stress, and poor diet. Extrinsic aging occurs as a result of intersecting processes caused by free radicals, DNA damage, glycation, inflammation, and other actions by the immune system. Generally, these factors can be partially mitigated through behavioral change. As much as 80% of facial aging can be ascribed to sun exposure.4 Several mechanisms through which sun exposure promotes aging have been well characterized. DNA damage results when UV light induces covalent bonds between nucleic acid base pairs and forms thymine dimers, which can alter tumor suppressor gene p53 function, thereby increasing the risk of cutaneous cancers and aging.5 UV exposure also yields free radicals that create damaging oxidative stress,6 which can activate the arachidonic acid pathway resulting in inflammation.7 Other skin aging mechanisms are not as well understood.
The cellular role in aging: Keratinocytes and fibroblasts
Keratinocyte cells found in layers that resemble the brick-and-mortar structure of a brick wall compose the epidermis. Each epidermal layer exhibits specific functional roles and characteristics. The top layer of the epidermis, known as the stratum corneum, is notable because it forms the skin barrier. This protective barrier contains cross-linked proteins for strength, antioxidants to protect the cells from free radicals, a bilayer lipid membrane layer to prevent water evaporation from the cells surface, immune cells, antimicrobial peptides, and a natural microbiome. Damage to any layer of the epidermis can unleash a cascade of events that can lead to increased cutaneous aging.
The dermis is composed of fibroblast cells, which synthesize collagen, elastin, hyaluronic acid, heparan sulfate, and other glycosaminoglycans that keep the skin smooth, strong, and healthy. Collagen confers strength, elastin provides elasticity, and the glycosaminoglycans such as hyaluronic acid, heparan sulfate, and dermatan sulfate bind water, impart volume to the skin, and provide support for important cell-to-cell communication.
When keratinocytes and fibroblasts age, they may no longer respond to cellular signals such as growth factors. The primary aim of any antiaging skin care regimen is to protect and rejuvenate these key skin cells.
Cellular damage that contributes to skin aging
The accumulated damage from intrinsic and extrinsic factors yields keratinocytes and fibroblasts that fail to produce important cellular components as well as they did when they were younger. Cellular factors that age cells include nuclear DNA damage, mitochondrial DNA damage, diminished lysosomal function, structural impairment of proteins, and damage to cell membranes. This harm occurs because of the direct effects of UV radiation, pollution, toxins, free radicals (oxidation), glycation, and inflammation.
Preventing and treating DNA damage
DNA damage presents as thymine-thymine dimers, pyrimidine-pyrimidine dimers, impaired telomeres, or other mutations. Broad-spectrum sunscreens and sun avoidance are important steps in preventing DNA damage induced from exposure to UV radiation. Other cosmeceutical agents have been designed to hinder the effects of UV radiation or to foster DNA repair. Besides sunscreen, the key members of the dermatologic armamentarium against DNA damage are various antioxidants. Data have been gathered over the last few decades that support the protective effects of antioxidants such as polypodium leucotomos,ascorbic acid, and green tea. Other antioxidants are associated with less data, but hypothetically should deliver similar benefits.
Polypodium leucotomos (PL), an oral extract derived from ferns, has been demonstrated to display photoprotective effects at an oral dose of 7.5 mg. PL has consistently exhibited antitumor and skin protective effects.8 A 2004 study in humans revealed that two oral doses of PL contributed to a significant reduction in DNA damage after UV exposure,9 and a 2017 study showed that PL protected skin DNA from UVB.10 Although PL has been linked to topical benefits, it is the oral form that is most often used to protect skin.
Ascorbic acid, also known as vitamin C, has been amply demonstrated to confer benefits when given both orally and topically. An acidic environment is necessary for optimal absorption. Topical application of ascorbic acid, along with vitamin E and ferulic acid, has been demonstrated to decrease the formation of thymine dimers.11 Unlike other antioxidants, ascorbic acid also stimulates procollagen genes in fibroblasts to increase collagen synthesis.12
EpiGalloCatechin-3-O-Gallate (also known as EGCG), the primary active constituent of green tea, has been demonstrated to induce IL-12 to increase the production of enzymes that repair UV-induced DNA damage.15 The proven photoprotective effects of topical and oral green tea include reducing UV-induced erythema, decreasing sunburn cell formation, and attenuating DNA damage.16
Preventing and treating mitochondrial DNA damage
UV radiation elicits mitochondrial DNA damage known as the “common deletion.”17 Damaged mitochondria produce harmful free radicals known as reactive oxygen species. Mitochondria damage caused by ROS decreases the mitochondria’s ability to generate ATP energy, which is necessary for DNA repair and other cellular processes.
Free radicals and UV radiation damage mitochondria, as does normal cellular metabolism. The range of damage includes mitochondrial DNA impairment, loss of mitochondrial enzymes, and decreased ATP production. This leads to less energy for DNA repair and other reparative processes. While there is no established way to reduce mitochondrial damage once it has occurred, several research initiatives to achieve this end are underway. Currently, protecting the mitochondria from harm with sunscreens and antioxidants is the best option.
Antioxidants are effective in preventing the damaging effects of free radicals on vulnerable mitochondria. As a component of the mitochondrial respiratory chain and an antioxidant itself, coenzyme Q10 is particularly useful in this role. CoQ10 is available in both oral and topical formulations. Oral forms should be taken only in the morning because of a caffeine-like effect. Topical forms of CoQ10 have a dark yellow color that may be unappealing to patients. Polypodium leucotomos has been shown to lower the number of common deletions found in the mitochondria of irradiated keratinocytes and fibroblasts.18 The oral form is recommended. Another potent antioxidant, curcumin, is being studied for mitochondrial protective properties.19 Its strong yellow color and smell render it better suited for oral use although many companies are trying to develop cosmetically elegant topical formulations.
Scavenging free radicals
Ultraviolet light, pollution, and other insults engender free radical formation. Even sunscreen use has been linked to increased production of free radicals. Free radicals, also known as reactive oxygen species, harm cells in many ways including mitochondrial damage, DNA mutations, glycation, lysosomal damage, and oxidation of important lipids and other cellular components such as proteins. Antioxidants present various beneficial effects including scavenging free radicals, decreasing activation of mitogen-activated protein kinases, chelation of copper required by tyrosinase, and suppression of inflammatory factors, such as nuclear factor (NF)-
In summary, skin aging has many causes. Although they are not all understood, some of the processes have been elucidated. Next month, this column will focus on the prevention and treatment of inflammation and glycation, as well as reversing the effects of aging on skin cells.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014). She also wrote a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
References
1. Baumann, Leslie S. “Cosmeceuticals and cosmetic ingredients” (New York: McGraw-Hill Education / Medical, 2014).
2. Baumann, Leslie S. The Baumann Skin Typing System in “Textbook of Aging Skin” (New York: Springer-Verlag Berlin Heidelberg, 2017). pp. 1579-94.
3. Storm A et al. J Am Acad Dermatol. 2008 Dec;59(6):975-80.
4. Uitto J. N Engl J Med. 1997 Nov 13;337(20):1463-5.
5. Tornaletti S et al. Science. 1994;263(5152):1436-8.
6. Bickers D et al. J. Investig. Dermatol. 2006;126(12):2565-75.
7. Yaar M et al. Br J Dermatol. 2007 Nov;157(5):874-87.
8. Parrado C et al. Int J Mol Sci. 2016 Jun 29;17(7). pii: E1026.
9. Middelkamp-Hup MA et al. J Am Acad Dermatol. 2004 Dec;51(6):910-8.
10. Kohli I et al. J Am Acad Dermatol. 2017 Jul;77(1):33-41.
11. Murray JC et al. J Am Acad Dermatol. 2008;59(3):418-25.
12. Geesin JC et al. J Invest Dermatol. 1988 Apr;90(4):420-4.
13. Thompson BC et al. PLoS One. 2015 Feb 6;10(2):e0117491.
14. Surjana D et al. Carcinogenesis. 2013 May;34(5):1144-9.
15. Meeran SM et al. Cancer Res. 2006 May 15;66(10):5512-20.
16. Elmets CA et al. J Am Acad Dermatol. 2001 Mar;44(3):425-32.
17. Berneburg M et al. J Invest Dermatol. 2004 May;122(5):1277-83.
18. Villa A et al. J Am Acad Dermatol. 2010 Mar;62(3):511-3.
19. Trujillo J et al. Arch Pharm Chem Life Sci. 2014. doi: 10.1002/ardp.2014002662014.
20. Muthusam V et al. Arch Dermatol Res. 2010 Jan;302(1):5-17.
It is important for dermatologists to recognize patients at an increased risk of skin aging early enough to initiate countermeasures. “Wrinkle-prone” skin types can be identified easily through use of the Baumann Skin Type Indicator Questionnaire.1 The wrinkle-prone Baumann skin type is associated with age or with lifestyle factors that increase the risk for promoting skin aging.2 Prevention and treatment of numerous signs of cutaneous aging can be achieved through consistent daily use of oral and topical products suited to the identified specifically wrinkle-prone Baumann skin type.
Skin aging
The numerous causes of skin aging can be divided into two broad categories: intrinsic and extrinsic. Intrinsic aging results from cellular processes that occur over time and is influenced by genetics. Such aging is characterized by decreased function of keratinocytes and fibroblasts, intra- and extracellular accumulation of by-products, reduced function of sirtuins (proteins that regulate cell metabolism and aging), mitochondrial damage, and loss of telomeres.
Extrinsic aging results from environmental exposures that engender cell damage, including UV light, infrared and radiation exposure, air pollution, smoking, tanning beds, alcohol and drug usage, stress, and poor diet. Extrinsic aging occurs as a result of intersecting processes caused by free radicals, DNA damage, glycation, inflammation, and other actions by the immune system. Generally, these factors can be partially mitigated through behavioral change. As much as 80% of facial aging can be ascribed to sun exposure.4 Several mechanisms through which sun exposure promotes aging have been well characterized. DNA damage results when UV light induces covalent bonds between nucleic acid base pairs and forms thymine dimers, which can alter tumor suppressor gene p53 function, thereby increasing the risk of cutaneous cancers and aging.5 UV exposure also yields free radicals that create damaging oxidative stress,6 which can activate the arachidonic acid pathway resulting in inflammation.7 Other skin aging mechanisms are not as well understood.
The cellular role in aging: Keratinocytes and fibroblasts
Keratinocyte cells found in layers that resemble the brick-and-mortar structure of a brick wall compose the epidermis. Each epidermal layer exhibits specific functional roles and characteristics. The top layer of the epidermis, known as the stratum corneum, is notable because it forms the skin barrier. This protective barrier contains cross-linked proteins for strength, antioxidants to protect the cells from free radicals, a bilayer lipid membrane layer to prevent water evaporation from the cells surface, immune cells, antimicrobial peptides, and a natural microbiome. Damage to any layer of the epidermis can unleash a cascade of events that can lead to increased cutaneous aging.
The dermis is composed of fibroblast cells, which synthesize collagen, elastin, hyaluronic acid, heparan sulfate, and other glycosaminoglycans that keep the skin smooth, strong, and healthy. Collagen confers strength, elastin provides elasticity, and the glycosaminoglycans such as hyaluronic acid, heparan sulfate, and dermatan sulfate bind water, impart volume to the skin, and provide support for important cell-to-cell communication.
When keratinocytes and fibroblasts age, they may no longer respond to cellular signals such as growth factors. The primary aim of any antiaging skin care regimen is to protect and rejuvenate these key skin cells.
Cellular damage that contributes to skin aging
The accumulated damage from intrinsic and extrinsic factors yields keratinocytes and fibroblasts that fail to produce important cellular components as well as they did when they were younger. Cellular factors that age cells include nuclear DNA damage, mitochondrial DNA damage, diminished lysosomal function, structural impairment of proteins, and damage to cell membranes. This harm occurs because of the direct effects of UV radiation, pollution, toxins, free radicals (oxidation), glycation, and inflammation.
Preventing and treating DNA damage
DNA damage presents as thymine-thymine dimers, pyrimidine-pyrimidine dimers, impaired telomeres, or other mutations. Broad-spectrum sunscreens and sun avoidance are important steps in preventing DNA damage induced from exposure to UV radiation. Other cosmeceutical agents have been designed to hinder the effects of UV radiation or to foster DNA repair. Besides sunscreen, the key members of the dermatologic armamentarium against DNA damage are various antioxidants. Data have been gathered over the last few decades that support the protective effects of antioxidants such as polypodium leucotomos,ascorbic acid, and green tea. Other antioxidants are associated with less data, but hypothetically should deliver similar benefits.
Polypodium leucotomos (PL), an oral extract derived from ferns, has been demonstrated to display photoprotective effects at an oral dose of 7.5 mg. PL has consistently exhibited antitumor and skin protective effects.8 A 2004 study in humans revealed that two oral doses of PL contributed to a significant reduction in DNA damage after UV exposure,9 and a 2017 study showed that PL protected skin DNA from UVB.10 Although PL has been linked to topical benefits, it is the oral form that is most often used to protect skin.
Ascorbic acid, also known as vitamin C, has been amply demonstrated to confer benefits when given both orally and topically. An acidic environment is necessary for optimal absorption. Topical application of ascorbic acid, along with vitamin E and ferulic acid, has been demonstrated to decrease the formation of thymine dimers.11 Unlike other antioxidants, ascorbic acid also stimulates procollagen genes in fibroblasts to increase collagen synthesis.12
EpiGalloCatechin-3-O-Gallate (also known as EGCG), the primary active constituent of green tea, has been demonstrated to induce IL-12 to increase the production of enzymes that repair UV-induced DNA damage.15 The proven photoprotective effects of topical and oral green tea include reducing UV-induced erythema, decreasing sunburn cell formation, and attenuating DNA damage.16
Preventing and treating mitochondrial DNA damage
UV radiation elicits mitochondrial DNA damage known as the “common deletion.”17 Damaged mitochondria produce harmful free radicals known as reactive oxygen species. Mitochondria damage caused by ROS decreases the mitochondria’s ability to generate ATP energy, which is necessary for DNA repair and other cellular processes.
Free radicals and UV radiation damage mitochondria, as does normal cellular metabolism. The range of damage includes mitochondrial DNA impairment, loss of mitochondrial enzymes, and decreased ATP production. This leads to less energy for DNA repair and other reparative processes. While there is no established way to reduce mitochondrial damage once it has occurred, several research initiatives to achieve this end are underway. Currently, protecting the mitochondria from harm with sunscreens and antioxidants is the best option.
Antioxidants are effective in preventing the damaging effects of free radicals on vulnerable mitochondria. As a component of the mitochondrial respiratory chain and an antioxidant itself, coenzyme Q10 is particularly useful in this role. CoQ10 is available in both oral and topical formulations. Oral forms should be taken only in the morning because of a caffeine-like effect. Topical forms of CoQ10 have a dark yellow color that may be unappealing to patients. Polypodium leucotomos has been shown to lower the number of common deletions found in the mitochondria of irradiated keratinocytes and fibroblasts.18 The oral form is recommended. Another potent antioxidant, curcumin, is being studied for mitochondrial protective properties.19 Its strong yellow color and smell render it better suited for oral use although many companies are trying to develop cosmetically elegant topical formulations.
Scavenging free radicals
Ultraviolet light, pollution, and other insults engender free radical formation. Even sunscreen use has been linked to increased production of free radicals. Free radicals, also known as reactive oxygen species, harm cells in many ways including mitochondrial damage, DNA mutations, glycation, lysosomal damage, and oxidation of important lipids and other cellular components such as proteins. Antioxidants present various beneficial effects including scavenging free radicals, decreasing activation of mitogen-activated protein kinases, chelation of copper required by tyrosinase, and suppression of inflammatory factors, such as nuclear factor (NF)-
In summary, skin aging has many causes. Although they are not all understood, some of the processes have been elucidated. Next month, this column will focus on the prevention and treatment of inflammation and glycation, as well as reversing the effects of aging on skin cells.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014). She also wrote a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
References
1. Baumann, Leslie S. “Cosmeceuticals and cosmetic ingredients” (New York: McGraw-Hill Education / Medical, 2014).
2. Baumann, Leslie S. The Baumann Skin Typing System in “Textbook of Aging Skin” (New York: Springer-Verlag Berlin Heidelberg, 2017). pp. 1579-94.
3. Storm A et al. J Am Acad Dermatol. 2008 Dec;59(6):975-80.
4. Uitto J. N Engl J Med. 1997 Nov 13;337(20):1463-5.
5. Tornaletti S et al. Science. 1994;263(5152):1436-8.
6. Bickers D et al. J. Investig. Dermatol. 2006;126(12):2565-75.
7. Yaar M et al. Br J Dermatol. 2007 Nov;157(5):874-87.
8. Parrado C et al. Int J Mol Sci. 2016 Jun 29;17(7). pii: E1026.
9. Middelkamp-Hup MA et al. J Am Acad Dermatol. 2004 Dec;51(6):910-8.
10. Kohli I et al. J Am Acad Dermatol. 2017 Jul;77(1):33-41.
11. Murray JC et al. J Am Acad Dermatol. 2008;59(3):418-25.
12. Geesin JC et al. J Invest Dermatol. 1988 Apr;90(4):420-4.
13. Thompson BC et al. PLoS One. 2015 Feb 6;10(2):e0117491.
14. Surjana D et al. Carcinogenesis. 2013 May;34(5):1144-9.
15. Meeran SM et al. Cancer Res. 2006 May 15;66(10):5512-20.
16. Elmets CA et al. J Am Acad Dermatol. 2001 Mar;44(3):425-32.
17. Berneburg M et al. J Invest Dermatol. 2004 May;122(5):1277-83.
18. Villa A et al. J Am Acad Dermatol. 2010 Mar;62(3):511-3.
19. Trujillo J et al. Arch Pharm Chem Life Sci. 2014. doi: 10.1002/ardp.2014002662014.
20. Muthusam V et al. Arch Dermatol Res. 2010 Jan;302(1):5-17.
It is important for dermatologists to recognize patients at an increased risk of skin aging early enough to initiate countermeasures. “Wrinkle-prone” skin types can be identified easily through use of the Baumann Skin Type Indicator Questionnaire.1 The wrinkle-prone Baumann skin type is associated with age or with lifestyle factors that increase the risk for promoting skin aging.2 Prevention and treatment of numerous signs of cutaneous aging can be achieved through consistent daily use of oral and topical products suited to the identified specifically wrinkle-prone Baumann skin type.
Skin aging
The numerous causes of skin aging can be divided into two broad categories: intrinsic and extrinsic. Intrinsic aging results from cellular processes that occur over time and is influenced by genetics. Such aging is characterized by decreased function of keratinocytes and fibroblasts, intra- and extracellular accumulation of by-products, reduced function of sirtuins (proteins that regulate cell metabolism and aging), mitochondrial damage, and loss of telomeres.
Extrinsic aging results from environmental exposures that engender cell damage, including UV light, infrared and radiation exposure, air pollution, smoking, tanning beds, alcohol and drug usage, stress, and poor diet. Extrinsic aging occurs as a result of intersecting processes caused by free radicals, DNA damage, glycation, inflammation, and other actions by the immune system. Generally, these factors can be partially mitigated through behavioral change. As much as 80% of facial aging can be ascribed to sun exposure.4 Several mechanisms through which sun exposure promotes aging have been well characterized. DNA damage results when UV light induces covalent bonds between nucleic acid base pairs and forms thymine dimers, which can alter tumor suppressor gene p53 function, thereby increasing the risk of cutaneous cancers and aging.5 UV exposure also yields free radicals that create damaging oxidative stress,6 which can activate the arachidonic acid pathway resulting in inflammation.7 Other skin aging mechanisms are not as well understood.
The cellular role in aging: Keratinocytes and fibroblasts
Keratinocyte cells found in layers that resemble the brick-and-mortar structure of a brick wall compose the epidermis. Each epidermal layer exhibits specific functional roles and characteristics. The top layer of the epidermis, known as the stratum corneum, is notable because it forms the skin barrier. This protective barrier contains cross-linked proteins for strength, antioxidants to protect the cells from free radicals, a bilayer lipid membrane layer to prevent water evaporation from the cells surface, immune cells, antimicrobial peptides, and a natural microbiome. Damage to any layer of the epidermis can unleash a cascade of events that can lead to increased cutaneous aging.
The dermis is composed of fibroblast cells, which synthesize collagen, elastin, hyaluronic acid, heparan sulfate, and other glycosaminoglycans that keep the skin smooth, strong, and healthy. Collagen confers strength, elastin provides elasticity, and the glycosaminoglycans such as hyaluronic acid, heparan sulfate, and dermatan sulfate bind water, impart volume to the skin, and provide support for important cell-to-cell communication.
When keratinocytes and fibroblasts age, they may no longer respond to cellular signals such as growth factors. The primary aim of any antiaging skin care regimen is to protect and rejuvenate these key skin cells.
Cellular damage that contributes to skin aging
The accumulated damage from intrinsic and extrinsic factors yields keratinocytes and fibroblasts that fail to produce important cellular components as well as they did when they were younger. Cellular factors that age cells include nuclear DNA damage, mitochondrial DNA damage, diminished lysosomal function, structural impairment of proteins, and damage to cell membranes. This harm occurs because of the direct effects of UV radiation, pollution, toxins, free radicals (oxidation), glycation, and inflammation.
Preventing and treating DNA damage
DNA damage presents as thymine-thymine dimers, pyrimidine-pyrimidine dimers, impaired telomeres, or other mutations. Broad-spectrum sunscreens and sun avoidance are important steps in preventing DNA damage induced from exposure to UV radiation. Other cosmeceutical agents have been designed to hinder the effects of UV radiation or to foster DNA repair. Besides sunscreen, the key members of the dermatologic armamentarium against DNA damage are various antioxidants. Data have been gathered over the last few decades that support the protective effects of antioxidants such as polypodium leucotomos,ascorbic acid, and green tea. Other antioxidants are associated with less data, but hypothetically should deliver similar benefits.
Polypodium leucotomos (PL), an oral extract derived from ferns, has been demonstrated to display photoprotective effects at an oral dose of 7.5 mg. PL has consistently exhibited antitumor and skin protective effects.8 A 2004 study in humans revealed that two oral doses of PL contributed to a significant reduction in DNA damage after UV exposure,9 and a 2017 study showed that PL protected skin DNA from UVB.10 Although PL has been linked to topical benefits, it is the oral form that is most often used to protect skin.
Ascorbic acid, also known as vitamin C, has been amply demonstrated to confer benefits when given both orally and topically. An acidic environment is necessary for optimal absorption. Topical application of ascorbic acid, along with vitamin E and ferulic acid, has been demonstrated to decrease the formation of thymine dimers.11 Unlike other antioxidants, ascorbic acid also stimulates procollagen genes in fibroblasts to increase collagen synthesis.12
EpiGalloCatechin-3-O-Gallate (also known as EGCG), the primary active constituent of green tea, has been demonstrated to induce IL-12 to increase the production of enzymes that repair UV-induced DNA damage.15 The proven photoprotective effects of topical and oral green tea include reducing UV-induced erythema, decreasing sunburn cell formation, and attenuating DNA damage.16
Preventing and treating mitochondrial DNA damage
UV radiation elicits mitochondrial DNA damage known as the “common deletion.”17 Damaged mitochondria produce harmful free radicals known as reactive oxygen species. Mitochondria damage caused by ROS decreases the mitochondria’s ability to generate ATP energy, which is necessary for DNA repair and other cellular processes.
Free radicals and UV radiation damage mitochondria, as does normal cellular metabolism. The range of damage includes mitochondrial DNA impairment, loss of mitochondrial enzymes, and decreased ATP production. This leads to less energy for DNA repair and other reparative processes. While there is no established way to reduce mitochondrial damage once it has occurred, several research initiatives to achieve this end are underway. Currently, protecting the mitochondria from harm with sunscreens and antioxidants is the best option.
Antioxidants are effective in preventing the damaging effects of free radicals on vulnerable mitochondria. As a component of the mitochondrial respiratory chain and an antioxidant itself, coenzyme Q10 is particularly useful in this role. CoQ10 is available in both oral and topical formulations. Oral forms should be taken only in the morning because of a caffeine-like effect. Topical forms of CoQ10 have a dark yellow color that may be unappealing to patients. Polypodium leucotomos has been shown to lower the number of common deletions found in the mitochondria of irradiated keratinocytes and fibroblasts.18 The oral form is recommended. Another potent antioxidant, curcumin, is being studied for mitochondrial protective properties.19 Its strong yellow color and smell render it better suited for oral use although many companies are trying to develop cosmetically elegant topical formulations.
Scavenging free radicals
Ultraviolet light, pollution, and other insults engender free radical formation. Even sunscreen use has been linked to increased production of free radicals. Free radicals, also known as reactive oxygen species, harm cells in many ways including mitochondrial damage, DNA mutations, glycation, lysosomal damage, and oxidation of important lipids and other cellular components such as proteins. Antioxidants present various beneficial effects including scavenging free radicals, decreasing activation of mitogen-activated protein kinases, chelation of copper required by tyrosinase, and suppression of inflammatory factors, such as nuclear factor (NF)-
In summary, skin aging has many causes. Although they are not all understood, some of the processes have been elucidated. Next month, this column will focus on the prevention and treatment of inflammation and glycation, as well as reversing the effects of aging on skin cells.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014). She also wrote a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
References
1. Baumann, Leslie S. “Cosmeceuticals and cosmetic ingredients” (New York: McGraw-Hill Education / Medical, 2014).
2. Baumann, Leslie S. The Baumann Skin Typing System in “Textbook of Aging Skin” (New York: Springer-Verlag Berlin Heidelberg, 2017). pp. 1579-94.
3. Storm A et al. J Am Acad Dermatol. 2008 Dec;59(6):975-80.
4. Uitto J. N Engl J Med. 1997 Nov 13;337(20):1463-5.
5. Tornaletti S et al. Science. 1994;263(5152):1436-8.
6. Bickers D et al. J. Investig. Dermatol. 2006;126(12):2565-75.
7. Yaar M et al. Br J Dermatol. 2007 Nov;157(5):874-87.
8. Parrado C et al. Int J Mol Sci. 2016 Jun 29;17(7). pii: E1026.
9. Middelkamp-Hup MA et al. J Am Acad Dermatol. 2004 Dec;51(6):910-8.
10. Kohli I et al. J Am Acad Dermatol. 2017 Jul;77(1):33-41.
11. Murray JC et al. J Am Acad Dermatol. 2008;59(3):418-25.
12. Geesin JC et al. J Invest Dermatol. 1988 Apr;90(4):420-4.
13. Thompson BC et al. PLoS One. 2015 Feb 6;10(2):e0117491.
14. Surjana D et al. Carcinogenesis. 2013 May;34(5):1144-9.
15. Meeran SM et al. Cancer Res. 2006 May 15;66(10):5512-20.
16. Elmets CA et al. J Am Acad Dermatol. 2001 Mar;44(3):425-32.
17. Berneburg M et al. J Invest Dermatol. 2004 May;122(5):1277-83.
18. Villa A et al. J Am Acad Dermatol. 2010 Mar;62(3):511-3.
19. Trujillo J et al. Arch Pharm Chem Life Sci. 2014. doi: 10.1002/ardp.2014002662014.
20. Muthusam V et al. Arch Dermatol Res. 2010 Jan;302(1):5-17.
Elevated CRP and mortality risk differs by gender, race
LOS ANGELES – The relationship between elevated C-reactive protein concentrations and increased all-cause mortality risk varies by gender and by race/ethnicity, an analysis of national data showed.
“Opportunities exist to discuss the importance of this marker and the relationship with mortality risk,” study author M. Ryan Richardson said in an interview following the World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease. “Although we do not fully understand all of the mechanisms that underlie this harmful relationship, our results add to the limited evidence available to those working within the clinical setting.”
A total of 4,383 adults between the ages of 30 and 79 years were included in the analysis. After the researchers adjusted for age, race, education, smoking, alcohol consumption, cardiovascular disease, waist circumference, and aerobic physical activity, they observed a significantly higher risk for all-cause mortality in non-Hispanic black males (hazard ratio, 2.04) and Mexican-American females (HR, 2.24). “We were surprised that this relationship was also independent of measured waist circumference and any volume of reported aerobic physical activity, which are both acknowledged as strong mediator variables in this relationship,” Mr. Richardson said. The HR in non-Hispanic white males approached but did not reach statistical significance (HR, 1.32).
He acknowledged certain limitations of the study, including its cross-sectional design. “We cannot make causal inferences based on this data,” he said.
The researchers reported having no financial disclosures.
SOURCE: M. Ryan Richardson et al.
LOS ANGELES – The relationship between elevated C-reactive protein concentrations and increased all-cause mortality risk varies by gender and by race/ethnicity, an analysis of national data showed.
“Opportunities exist to discuss the importance of this marker and the relationship with mortality risk,” study author M. Ryan Richardson said in an interview following the World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease. “Although we do not fully understand all of the mechanisms that underlie this harmful relationship, our results add to the limited evidence available to those working within the clinical setting.”
A total of 4,383 adults between the ages of 30 and 79 years were included in the analysis. After the researchers adjusted for age, race, education, smoking, alcohol consumption, cardiovascular disease, waist circumference, and aerobic physical activity, they observed a significantly higher risk for all-cause mortality in non-Hispanic black males (hazard ratio, 2.04) and Mexican-American females (HR, 2.24). “We were surprised that this relationship was also independent of measured waist circumference and any volume of reported aerobic physical activity, which are both acknowledged as strong mediator variables in this relationship,” Mr. Richardson said. The HR in non-Hispanic white males approached but did not reach statistical significance (HR, 1.32).
He acknowledged certain limitations of the study, including its cross-sectional design. “We cannot make causal inferences based on this data,” he said.
The researchers reported having no financial disclosures.
SOURCE: M. Ryan Richardson et al.
LOS ANGELES – The relationship between elevated C-reactive protein concentrations and increased all-cause mortality risk varies by gender and by race/ethnicity, an analysis of national data showed.
“Opportunities exist to discuss the importance of this marker and the relationship with mortality risk,” study author M. Ryan Richardson said in an interview following the World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease. “Although we do not fully understand all of the mechanisms that underlie this harmful relationship, our results add to the limited evidence available to those working within the clinical setting.”
A total of 4,383 adults between the ages of 30 and 79 years were included in the analysis. After the researchers adjusted for age, race, education, smoking, alcohol consumption, cardiovascular disease, waist circumference, and aerobic physical activity, they observed a significantly higher risk for all-cause mortality in non-Hispanic black males (hazard ratio, 2.04) and Mexican-American females (HR, 2.24). “We were surprised that this relationship was also independent of measured waist circumference and any volume of reported aerobic physical activity, which are both acknowledged as strong mediator variables in this relationship,” Mr. Richardson said. The HR in non-Hispanic white males approached but did not reach statistical significance (HR, 1.32).
He acknowledged certain limitations of the study, including its cross-sectional design. “We cannot make causal inferences based on this data,” he said.
The researchers reported having no financial disclosures.
SOURCE: M. Ryan Richardson et al.
REPORTING FROM WCIRDC 2017
Key clinical point:
Major finding: The risk for all-cause mortality was significantly higher in non-Hispanic black men and in Mexican-American females (HR of 2.04 and 2.24, respectively).
Study details: An analysis of 4,383 adults who participated in NHANES 1999-2006.
Disclosures: The researchers reported having no financial disclosures.
Source: M. Ryan Richardson et al.
Novel metabolic biomarkers linked to CHD
ANAHEIM, CALIF. – Low levels of four phosphatidylcholines – essential components of cell membranes – predict the risk of incident coronary heart disease about as well as body mass index does, according to an analysis presented at the American Heart Association scientific sessions.
The findings come from the BiomarCaRE consortium (Biomarker for Cardiovascular Risk Assessment in Europe), a European Union–funded effort to evaluate the predictive value of new and existing biomarkers for cardiovascular disease.
The new findings “demonstrate the value of metabolomics for biomarker discovery and improved risk stratification,” said lead investigator Tanja Zeller, PhD, of the department of general and interventional cardiology, University Heart Center Hamburg (Germany).
A total of 141 metabolites were detected by mass spectrometry using the Biocrates Absolute IDQ p180 assay. After adjustment for body mass index, blood pressure, cholesterol level, hypertension, and other known coronary heart disease (CHD) risk factors, four metabolites – all phosphatidylcholines (PCs) – showed independent predictive value for incident CHD, with low levels associated with higher CHD risk. The effect was greatest among women.
Phosphatidylcholines are a class of phospholipids derived from egg yolks, soybeans, and other foods that play an essential role in cell membrane function, among other things. They are thought to have anti-inflammatory effects, Dr. Zeller said.
The investigators found that lower levels of four in particular – PC ae C40:6; PC ae C38:6; PC aa C38:5; and PC aa C38:6 – increase the risk of incident CHD, with statistically significant hazard ratios ranging from 1.09 to 1.13, similar to body mass index, but lower than for diabetes and total cholesterol level.
Dr. Zeller said the team couldn’t adjust for lipid-lowering medications and diet, both of which might have affected levels, because information was not available for the subjects. There have been suggestions in the literature that higher levels of PCs are associated with a lower risk of Alzheimer’s disease, cognitive impairment, diabetes, and other diseases, but supplementation trials have been mostly negative.
BiomarCaRE is funded by the European Union. The investigators had no relevant financial disclosures.
BiomarCaRE and other studies offer us a unique opportunity to integrate metabolomics with genetic and other biomarkers to really understand the systems biology of disease.
But there are many questions to answer before we start measuring phosphatidylcholines. How do these biomarkers add to clinical risk prediction in our patients? While the magnitude of effect was good for a biomarker, it did not meet the strength of strong cardiovascular risk factors, including total cholesterol. Also, the investigators were careful to adjust for confounders and were able to show independent association, but they did not address incremental risk prediction.
And would measuring these metabolites change what we do for our patients? Are these pathways modifiable? In the absence of something to modify the pathway, risk prediction may be less significant.
Even so, metabolomics holds great promise in identifying biological pathways and understanding heterogeneity in medication and other effects, and advancing our efforts in precision medicine and patient care.
Svati Shah, MD , is with the department of cardiology at Duke University, Durham, N.C. She holds a patent on an unrelated metabolomics finding, and a research grant from Bristol-Myers Squibb. She also is an adviser for Biosense Webster. Dr. Shah was the discussant for the study presentation.
BiomarCaRE and other studies offer us a unique opportunity to integrate metabolomics with genetic and other biomarkers to really understand the systems biology of disease.
But there are many questions to answer before we start measuring phosphatidylcholines. How do these biomarkers add to clinical risk prediction in our patients? While the magnitude of effect was good for a biomarker, it did not meet the strength of strong cardiovascular risk factors, including total cholesterol. Also, the investigators were careful to adjust for confounders and were able to show independent association, but they did not address incremental risk prediction.
And would measuring these metabolites change what we do for our patients? Are these pathways modifiable? In the absence of something to modify the pathway, risk prediction may be less significant.
Even so, metabolomics holds great promise in identifying biological pathways and understanding heterogeneity in medication and other effects, and advancing our efforts in precision medicine and patient care.
Svati Shah, MD , is with the department of cardiology at Duke University, Durham, N.C. She holds a patent on an unrelated metabolomics finding, and a research grant from Bristol-Myers Squibb. She also is an adviser for Biosense Webster. Dr. Shah was the discussant for the study presentation.
BiomarCaRE and other studies offer us a unique opportunity to integrate metabolomics with genetic and other biomarkers to really understand the systems biology of disease.
But there are many questions to answer before we start measuring phosphatidylcholines. How do these biomarkers add to clinical risk prediction in our patients? While the magnitude of effect was good for a biomarker, it did not meet the strength of strong cardiovascular risk factors, including total cholesterol. Also, the investigators were careful to adjust for confounders and were able to show independent association, but they did not address incremental risk prediction.
And would measuring these metabolites change what we do for our patients? Are these pathways modifiable? In the absence of something to modify the pathway, risk prediction may be less significant.
Even so, metabolomics holds great promise in identifying biological pathways and understanding heterogeneity in medication and other effects, and advancing our efforts in precision medicine and patient care.
Svati Shah, MD , is with the department of cardiology at Duke University, Durham, N.C. She holds a patent on an unrelated metabolomics finding, and a research grant from Bristol-Myers Squibb. She also is an adviser for Biosense Webster. Dr. Shah was the discussant for the study presentation.
ANAHEIM, CALIF. – Low levels of four phosphatidylcholines – essential components of cell membranes – predict the risk of incident coronary heart disease about as well as body mass index does, according to an analysis presented at the American Heart Association scientific sessions.
The findings come from the BiomarCaRE consortium (Biomarker for Cardiovascular Risk Assessment in Europe), a European Union–funded effort to evaluate the predictive value of new and existing biomarkers for cardiovascular disease.
The new findings “demonstrate the value of metabolomics for biomarker discovery and improved risk stratification,” said lead investigator Tanja Zeller, PhD, of the department of general and interventional cardiology, University Heart Center Hamburg (Germany).
A total of 141 metabolites were detected by mass spectrometry using the Biocrates Absolute IDQ p180 assay. After adjustment for body mass index, blood pressure, cholesterol level, hypertension, and other known coronary heart disease (CHD) risk factors, four metabolites – all phosphatidylcholines (PCs) – showed independent predictive value for incident CHD, with low levels associated with higher CHD risk. The effect was greatest among women.
Phosphatidylcholines are a class of phospholipids derived from egg yolks, soybeans, and other foods that play an essential role in cell membrane function, among other things. They are thought to have anti-inflammatory effects, Dr. Zeller said.
The investigators found that lower levels of four in particular – PC ae C40:6; PC ae C38:6; PC aa C38:5; and PC aa C38:6 – increase the risk of incident CHD, with statistically significant hazard ratios ranging from 1.09 to 1.13, similar to body mass index, but lower than for diabetes and total cholesterol level.
Dr. Zeller said the team couldn’t adjust for lipid-lowering medications and diet, both of which might have affected levels, because information was not available for the subjects. There have been suggestions in the literature that higher levels of PCs are associated with a lower risk of Alzheimer’s disease, cognitive impairment, diabetes, and other diseases, but supplementation trials have been mostly negative.
BiomarCaRE is funded by the European Union. The investigators had no relevant financial disclosures.
ANAHEIM, CALIF. – Low levels of four phosphatidylcholines – essential components of cell membranes – predict the risk of incident coronary heart disease about as well as body mass index does, according to an analysis presented at the American Heart Association scientific sessions.
The findings come from the BiomarCaRE consortium (Biomarker for Cardiovascular Risk Assessment in Europe), a European Union–funded effort to evaluate the predictive value of new and existing biomarkers for cardiovascular disease.
The new findings “demonstrate the value of metabolomics for biomarker discovery and improved risk stratification,” said lead investigator Tanja Zeller, PhD, of the department of general and interventional cardiology, University Heart Center Hamburg (Germany).
A total of 141 metabolites were detected by mass spectrometry using the Biocrates Absolute IDQ p180 assay. After adjustment for body mass index, blood pressure, cholesterol level, hypertension, and other known coronary heart disease (CHD) risk factors, four metabolites – all phosphatidylcholines (PCs) – showed independent predictive value for incident CHD, with low levels associated with higher CHD risk. The effect was greatest among women.
Phosphatidylcholines are a class of phospholipids derived from egg yolks, soybeans, and other foods that play an essential role in cell membrane function, among other things. They are thought to have anti-inflammatory effects, Dr. Zeller said.
The investigators found that lower levels of four in particular – PC ae C40:6; PC ae C38:6; PC aa C38:5; and PC aa C38:6 – increase the risk of incident CHD, with statistically significant hazard ratios ranging from 1.09 to 1.13, similar to body mass index, but lower than for diabetes and total cholesterol level.
Dr. Zeller said the team couldn’t adjust for lipid-lowering medications and diet, both of which might have affected levels, because information was not available for the subjects. There have been suggestions in the literature that higher levels of PCs are associated with a lower risk of Alzheimer’s disease, cognitive impairment, diabetes, and other diseases, but supplementation trials have been mostly negative.
BiomarCaRE is funded by the European Union. The investigators had no relevant financial disclosures.
AT THE AHA SCIENTIFIC SESSIONS
Key clinical point:
Major finding: Lower levels of four in particular – PC ae C40:6; PC ae C38:6; PC aa C38:5; and PC aa C38:6 – increase the risk of incident CHD, with hazard ratios ranging from 1.09 to 1.13.
Data source: More than 10,000 subjects in the BiomarCaRE consortium.
Disclosures: BiomarCaRE is funded by the European Union. The investigators had no relevant financial disclosures.
FDA approves first follow-on short-acting insulin product using abbreviated approval pathway
aged 3 years and older with type 1 and type 2 diabetes mellitus, according to a news release from the FDA.
Insulin lispro injections are to be administered subcutaneously by injection, infusion via an insulin pump, or intravenously. Doses should be individualized based on route of administration and patients’ individual metabolic needs. All diabetes patients should regularly monitor their blood sugar levels and insulin regimens should be exclusively modified under medical supervision.
“With today’s approval, we are providing an important short-acting insulin option for patients that meets our standards for safety and effectiveness,” Mary T. Thanh Hai, MD, deputy director of the Office of New Drug Evaluation II in the FDA’s Center for Drug Evaluation and Research, said in a statement.
Admelog, a biosimilar to Eli Lilly’s Humalog, was approved as a follow-on product based on the prior approval of Humalog. This allowed insulin lispro injections to be passed through the abbreviated approval pathway under the Federal Food, Drug, and Cosmetic Act, formally known as the 505(b)(2) pathway. The makers of insulin lispro found it was scientifically justified to use the previous safety and effectiveness data from the approval of Humalog to support the approval of insulin lispro injections. In addition to the Humalog data, the insulin lispro injection data included findings from two phase 3 clinical trials, each of which comprised about 500 diabetes patients. Using this abbreviated pathway can reduce the costs of drug development significantly, allowing new products to be offered to patients at lower prices.
“One of my key policy efforts is increasing competition in the market for prescription drugs and helping facilitate the entry of lower-cost alternatives. This is particularly important for drugs like insulin that are taken by millions of Americans every day for a patient’s lifetime to manage a chronic disease,” FDA Commissioner Scott Gottlieb, MD, said in a statement “In the coming months, we’ll be taking additional policy steps to help to make sure patients continue to benefit from improved access to lower cost, safe and effective alternatives to brand name drugs approved through the agency’s abbreviated pathways.”
Insulin lispro injections are short-acting insulin products that can help improve blood sugar levels in diabetes patients. This can be useful in controlling blood sugar levels after eating. This contrasts with long-acting insulin products, which are intended to control background insulin levels between meals. The blood sugar control needs of type 1 and type 2 diabetes patients are unique. Type 1 patients require both short- and long-term controls, while some type 2 patients may never need a short-acting insulin product. Because of these differences, providing insulin lispro injections as a blood sugar control method may be particularly useful to type 1 diabetes patients who need to control mealtime blood sugar levels.
aged 3 years and older with type 1 and type 2 diabetes mellitus, according to a news release from the FDA.
Insulin lispro injections are to be administered subcutaneously by injection, infusion via an insulin pump, or intravenously. Doses should be individualized based on route of administration and patients’ individual metabolic needs. All diabetes patients should regularly monitor their blood sugar levels and insulin regimens should be exclusively modified under medical supervision.
“With today’s approval, we are providing an important short-acting insulin option for patients that meets our standards for safety and effectiveness,” Mary T. Thanh Hai, MD, deputy director of the Office of New Drug Evaluation II in the FDA’s Center for Drug Evaluation and Research, said in a statement.
Admelog, a biosimilar to Eli Lilly’s Humalog, was approved as a follow-on product based on the prior approval of Humalog. This allowed insulin lispro injections to be passed through the abbreviated approval pathway under the Federal Food, Drug, and Cosmetic Act, formally known as the 505(b)(2) pathway. The makers of insulin lispro found it was scientifically justified to use the previous safety and effectiveness data from the approval of Humalog to support the approval of insulin lispro injections. In addition to the Humalog data, the insulin lispro injection data included findings from two phase 3 clinical trials, each of which comprised about 500 diabetes patients. Using this abbreviated pathway can reduce the costs of drug development significantly, allowing new products to be offered to patients at lower prices.
“One of my key policy efforts is increasing competition in the market for prescription drugs and helping facilitate the entry of lower-cost alternatives. This is particularly important for drugs like insulin that are taken by millions of Americans every day for a patient’s lifetime to manage a chronic disease,” FDA Commissioner Scott Gottlieb, MD, said in a statement “In the coming months, we’ll be taking additional policy steps to help to make sure patients continue to benefit from improved access to lower cost, safe and effective alternatives to brand name drugs approved through the agency’s abbreviated pathways.”
Insulin lispro injections are short-acting insulin products that can help improve blood sugar levels in diabetes patients. This can be useful in controlling blood sugar levels after eating. This contrasts with long-acting insulin products, which are intended to control background insulin levels between meals. The blood sugar control needs of type 1 and type 2 diabetes patients are unique. Type 1 patients require both short- and long-term controls, while some type 2 patients may never need a short-acting insulin product. Because of these differences, providing insulin lispro injections as a blood sugar control method may be particularly useful to type 1 diabetes patients who need to control mealtime blood sugar levels.
aged 3 years and older with type 1 and type 2 diabetes mellitus, according to a news release from the FDA.
Insulin lispro injections are to be administered subcutaneously by injection, infusion via an insulin pump, or intravenously. Doses should be individualized based on route of administration and patients’ individual metabolic needs. All diabetes patients should regularly monitor their blood sugar levels and insulin regimens should be exclusively modified under medical supervision.
“With today’s approval, we are providing an important short-acting insulin option for patients that meets our standards for safety and effectiveness,” Mary T. Thanh Hai, MD, deputy director of the Office of New Drug Evaluation II in the FDA’s Center for Drug Evaluation and Research, said in a statement.
Admelog, a biosimilar to Eli Lilly’s Humalog, was approved as a follow-on product based on the prior approval of Humalog. This allowed insulin lispro injections to be passed through the abbreviated approval pathway under the Federal Food, Drug, and Cosmetic Act, formally known as the 505(b)(2) pathway. The makers of insulin lispro found it was scientifically justified to use the previous safety and effectiveness data from the approval of Humalog to support the approval of insulin lispro injections. In addition to the Humalog data, the insulin lispro injection data included findings from two phase 3 clinical trials, each of which comprised about 500 diabetes patients. Using this abbreviated pathway can reduce the costs of drug development significantly, allowing new products to be offered to patients at lower prices.
“One of my key policy efforts is increasing competition in the market for prescription drugs and helping facilitate the entry of lower-cost alternatives. This is particularly important for drugs like insulin that are taken by millions of Americans every day for a patient’s lifetime to manage a chronic disease,” FDA Commissioner Scott Gottlieb, MD, said in a statement “In the coming months, we’ll be taking additional policy steps to help to make sure patients continue to benefit from improved access to lower cost, safe and effective alternatives to brand name drugs approved through the agency’s abbreviated pathways.”
Insulin lispro injections are short-acting insulin products that can help improve blood sugar levels in diabetes patients. This can be useful in controlling blood sugar levels after eating. This contrasts with long-acting insulin products, which are intended to control background insulin levels between meals. The blood sugar control needs of type 1 and type 2 diabetes patients are unique. Type 1 patients require both short- and long-term controls, while some type 2 patients may never need a short-acting insulin product. Because of these differences, providing insulin lispro injections as a blood sugar control method may be particularly useful to type 1 diabetes patients who need to control mealtime blood sugar levels.
Clinical trial: The Role of the Robotic Platform in Inguinal Hernia Repair Surgery
The Role of the Robotic Platform in Inguinal Hernia Repair Surgery is an interventional trial currently recruiting patients who require inguinal hernia repair surgery.
The trial will compare postoperative pain in patients undergoing laparoscopic inguinal hernia surgery repair or robotic inguinal hernia repair surgery. The laparoscopic approach has been used frequently and has several advantages. However, it has several disadvantages that the robotic approach may address. As such, the study investigators have hypothesized that the robotic approach will result in less postoperative pain than the laparoscopic approach.
The primary outcome measure is the difference in postoperative pain between patients who undergo robotic inguinal hernia repair and those who undergo laparoscopic inguinal hernia repair during the 2 years following surgery. Secondary outcome measures include differences in surgeon ergonomics between the two approaches, institution cost analysis, and long-term recurrence rate differences, all within 2 years of surgery.
The study will end in May 2019. About 100 people are expected to be included in the final analysis.
Find more information on the study page at Clinicaltrials.gov.
SOURCE: Clinicaltrials.gov. NCT02816658.
The Role of the Robotic Platform in Inguinal Hernia Repair Surgery is an interventional trial currently recruiting patients who require inguinal hernia repair surgery.
The trial will compare postoperative pain in patients undergoing laparoscopic inguinal hernia surgery repair or robotic inguinal hernia repair surgery. The laparoscopic approach has been used frequently and has several advantages. However, it has several disadvantages that the robotic approach may address. As such, the study investigators have hypothesized that the robotic approach will result in less postoperative pain than the laparoscopic approach.
The primary outcome measure is the difference in postoperative pain between patients who undergo robotic inguinal hernia repair and those who undergo laparoscopic inguinal hernia repair during the 2 years following surgery. Secondary outcome measures include differences in surgeon ergonomics between the two approaches, institution cost analysis, and long-term recurrence rate differences, all within 2 years of surgery.
The study will end in May 2019. About 100 people are expected to be included in the final analysis.
Find more information on the study page at Clinicaltrials.gov.
SOURCE: Clinicaltrials.gov. NCT02816658.
The Role of the Robotic Platform in Inguinal Hernia Repair Surgery is an interventional trial currently recruiting patients who require inguinal hernia repair surgery.
The trial will compare postoperative pain in patients undergoing laparoscopic inguinal hernia surgery repair or robotic inguinal hernia repair surgery. The laparoscopic approach has been used frequently and has several advantages. However, it has several disadvantages that the robotic approach may address. As such, the study investigators have hypothesized that the robotic approach will result in less postoperative pain than the laparoscopic approach.
The primary outcome measure is the difference in postoperative pain between patients who undergo robotic inguinal hernia repair and those who undergo laparoscopic inguinal hernia repair during the 2 years following surgery. Secondary outcome measures include differences in surgeon ergonomics between the two approaches, institution cost analysis, and long-term recurrence rate differences, all within 2 years of surgery.
The study will end in May 2019. About 100 people are expected to be included in the final analysis.
Find more information on the study page at Clinicaltrials.gov.
SOURCE: Clinicaltrials.gov. NCT02816658.
FROM CLINICALTRIALS.GOV
Quick Byte: Take a seat
A survey of 305 inpatients showed that patients who reported that at least one provider sat down while caring for them were more likely to feel that their provider spent appropriate time with them and that their provider kept them well informed. The authors concluded that sitting down at a patient’s bedside improves some aspects of patients’ and families’ experience of their hospital care, and should be included in hospital efforts to improve the patient experience.
Reference
1. Adebusuyi OA et al. Does sitting enhance patient satisfaction in the hospital? [abstract]. J Hosp Med. 2017; 12 (suppl 2). Accessed Aug. 7, 2017.
A survey of 305 inpatients showed that patients who reported that at least one provider sat down while caring for them were more likely to feel that their provider spent appropriate time with them and that their provider kept them well informed. The authors concluded that sitting down at a patient’s bedside improves some aspects of patients’ and families’ experience of their hospital care, and should be included in hospital efforts to improve the patient experience.
Reference
1. Adebusuyi OA et al. Does sitting enhance patient satisfaction in the hospital? [abstract]. J Hosp Med. 2017; 12 (suppl 2). Accessed Aug. 7, 2017.
A survey of 305 inpatients showed that patients who reported that at least one provider sat down while caring for them were more likely to feel that their provider spent appropriate time with them and that their provider kept them well informed. The authors concluded that sitting down at a patient’s bedside improves some aspects of patients’ and families’ experience of their hospital care, and should be included in hospital efforts to improve the patient experience.
Reference
1. Adebusuyi OA et al. Does sitting enhance patient satisfaction in the hospital? [abstract]. J Hosp Med. 2017; 12 (suppl 2). Accessed Aug. 7, 2017.
VIDEO: Venetoclax/rituximab prolongs PFS in relapsed/refractory CLL
ATLANTA – Relapsed or refractory chronic lymphocytic leukemia (CLL) often has a suboptimal response to conventional chemotherapy, because of adverse biological features that can accumulate in cells.
The combination of bendamustine (Treanda) and rituximab has been associated with about 60% overall responses rates, median progression-free survival of approximately 15 months, and overall survival of nearly 3 years in patients with CLL, and there is now evidence that substituting venetoclax (Venclexta) for bendamustine could improve outcomes even further.
In a video interview at the annual meeting of the American Society of Hematology, comparing bendamustine plus rituximab with venetoclax plus rituximab in patients with relapsed/refractory CLL.
Venetoclax/rituximab was superior to bendamustine/rituximab for prolonging progression-free survival, with effects consistent across subgroups, regardless of mutation status, and for having a clinically meaningful improvement in overall survival.
The MURANO trial was funded by AbbVie. Dr. Seymour reported honoraria, research funding, and advisory committee and speakers bureau participation for AbbVie and other companies.
ATLANTA – Relapsed or refractory chronic lymphocytic leukemia (CLL) often has a suboptimal response to conventional chemotherapy, because of adverse biological features that can accumulate in cells.
The combination of bendamustine (Treanda) and rituximab has been associated with about 60% overall responses rates, median progression-free survival of approximately 15 months, and overall survival of nearly 3 years in patients with CLL, and there is now evidence that substituting venetoclax (Venclexta) for bendamustine could improve outcomes even further.
In a video interview at the annual meeting of the American Society of Hematology, comparing bendamustine plus rituximab with venetoclax plus rituximab in patients with relapsed/refractory CLL.
Venetoclax/rituximab was superior to bendamustine/rituximab for prolonging progression-free survival, with effects consistent across subgroups, regardless of mutation status, and for having a clinically meaningful improvement in overall survival.
The MURANO trial was funded by AbbVie. Dr. Seymour reported honoraria, research funding, and advisory committee and speakers bureau participation for AbbVie and other companies.
ATLANTA – Relapsed or refractory chronic lymphocytic leukemia (CLL) often has a suboptimal response to conventional chemotherapy, because of adverse biological features that can accumulate in cells.
The combination of bendamustine (Treanda) and rituximab has been associated with about 60% overall responses rates, median progression-free survival of approximately 15 months, and overall survival of nearly 3 years in patients with CLL, and there is now evidence that substituting venetoclax (Venclexta) for bendamustine could improve outcomes even further.
In a video interview at the annual meeting of the American Society of Hematology, comparing bendamustine plus rituximab with venetoclax plus rituximab in patients with relapsed/refractory CLL.
Venetoclax/rituximab was superior to bendamustine/rituximab for prolonging progression-free survival, with effects consistent across subgroups, regardless of mutation status, and for having a clinically meaningful improvement in overall survival.
The MURANO trial was funded by AbbVie. Dr. Seymour reported honoraria, research funding, and advisory committee and speakers bureau participation for AbbVie and other companies.
REPORTING FROM ASH 2017
Don’t choose hormones to protect postmenopausal women
Hormone therapy should not be used to prevent chronic conditions in postmenopausal women, according to updated recommendations from the U.S. Preventive Services Task Force. The recommendations were published online Dec. 12 in JAMA.
In the latest recommendation statement, the USPSTF issued D recommendations against using combination estrogen and progestin to prevent chronic conditions in postmenopausal women and against using estrogen only to prevent chronic conditions in postmenopausal women who have undergone hysterectomies (JAMA. 2017 Dec 12. doi: 10.1001/jama.2017.18261). A grade D recommendation is defined as “The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.”
In response to public comments, the USPSTF team made several changes including adjusting the language to clarify that the recommendations apply only to postmenopausal women, and adding tables showing estimates of increased or decreased risk of various outcomes for postmenopausal women receiving different hormone therapies.
Approximately 40,000 women aged 53-79 years were included in an evidence report from Gerald Gartlehner, MD, of the University of North Carolina, Chapel Hill, and his colleagues that accompanied the recommendations (JAMA. 2017 Dec 12. doi: 10.1001/jama.2017.16952).
The researchers found that women taking estrogen alone had significantly lower risk of breast cancer, diabetes, and osteoporotic fractures, but significantly higher risk of gallbladder disease, stroke, urinary incontinence, and venous thromboembolism, compared with women taking placebo. In addition, women using a combination of estrogen and progestin had significantly lower risk of colorectal cancer, diabetes, and osteoporotic fractures, but significantly higher risk of breast cancer, probable dementia, gallbladder disease, stroke, urinary incontinence, and venous thromboembolism, compared with women taking placebo.
“Hormone therapy for the primary prevention of chronic conditions in menopausal women is associated with some beneficial effects but also with a substantial increase of risks for harms,” and the current evidence for the risks and benefits of hormone therapy is inconclusive, the researchers said.
The final recommendation remains consistent with the USPSTF draft statement issued earlier in 2017 and with the final recommendation statements issued in 2012.
The researchers had no relevant financial conflicts to disclose.
Twenty-five years ago, the U.S. Preventive Services Task Force advised clinicians to consider hormone therapy for the prevention of disease in all women, particularly those at risk for coronary heart disease, Deborah Grady, MD, wrote in an editorial (JAMA Intern Med. 2017 Dec 12. doi: 10.1001/jamainternmed.2017.7861). Dr. Grady was one of the coauthors of a literature review supporting the American College of Physicians’ recommendation to counsel asymptomatic postmenopausal women about hormone therapy based on data from observational studies. “No randomized trials with clinical outcomes had been conducted,” Dr. Grady said. By 2002, data from three large randomized trials told a different story, and the Task Force recommended against using estrogen alone as a strategy to prevent chronic conditions in postmenopausal women, she noted.
“I believe that the fear of hormone therapy is overblown,” Dr. Grady wrote. “When adequately informed, women with moderate to severe symptoms and without contraindications should be able to take such small risks if hormone therapy improves symptoms and quality of life,” she said.
In fact, professional societies, including the North American Menopause Society, the American College of Obstetricians and Gynecologists, and the Endocrine Society support hormone therapy for symptomatic women who are recently menopausal, said Dr. Grady. However, a key lesson learned from the ongoing research on hormone therapy is the importance of conducting clinical trials that are large enough to identify serious adverse effects, she added.
Dr. Grady is affiliated with the University of California, San Francisco. She had no financial conflicts to disclose.
Twenty-five years ago, the U.S. Preventive Services Task Force advised clinicians to consider hormone therapy for the prevention of disease in all women, particularly those at risk for coronary heart disease, Deborah Grady, MD, wrote in an editorial (JAMA Intern Med. 2017 Dec 12. doi: 10.1001/jamainternmed.2017.7861). Dr. Grady was one of the coauthors of a literature review supporting the American College of Physicians’ recommendation to counsel asymptomatic postmenopausal women about hormone therapy based on data from observational studies. “No randomized trials with clinical outcomes had been conducted,” Dr. Grady said. By 2002, data from three large randomized trials told a different story, and the Task Force recommended against using estrogen alone as a strategy to prevent chronic conditions in postmenopausal women, she noted.
“I believe that the fear of hormone therapy is overblown,” Dr. Grady wrote. “When adequately informed, women with moderate to severe symptoms and without contraindications should be able to take such small risks if hormone therapy improves symptoms and quality of life,” she said.
In fact, professional societies, including the North American Menopause Society, the American College of Obstetricians and Gynecologists, and the Endocrine Society support hormone therapy for symptomatic women who are recently menopausal, said Dr. Grady. However, a key lesson learned from the ongoing research on hormone therapy is the importance of conducting clinical trials that are large enough to identify serious adverse effects, she added.
Dr. Grady is affiliated with the University of California, San Francisco. She had no financial conflicts to disclose.
Twenty-five years ago, the U.S. Preventive Services Task Force advised clinicians to consider hormone therapy for the prevention of disease in all women, particularly those at risk for coronary heart disease, Deborah Grady, MD, wrote in an editorial (JAMA Intern Med. 2017 Dec 12. doi: 10.1001/jamainternmed.2017.7861). Dr. Grady was one of the coauthors of a literature review supporting the American College of Physicians’ recommendation to counsel asymptomatic postmenopausal women about hormone therapy based on data from observational studies. “No randomized trials with clinical outcomes had been conducted,” Dr. Grady said. By 2002, data from three large randomized trials told a different story, and the Task Force recommended against using estrogen alone as a strategy to prevent chronic conditions in postmenopausal women, she noted.
“I believe that the fear of hormone therapy is overblown,” Dr. Grady wrote. “When adequately informed, women with moderate to severe symptoms and without contraindications should be able to take such small risks if hormone therapy improves symptoms and quality of life,” she said.
In fact, professional societies, including the North American Menopause Society, the American College of Obstetricians and Gynecologists, and the Endocrine Society support hormone therapy for symptomatic women who are recently menopausal, said Dr. Grady. However, a key lesson learned from the ongoing research on hormone therapy is the importance of conducting clinical trials that are large enough to identify serious adverse effects, she added.
Dr. Grady is affiliated with the University of California, San Francisco. She had no financial conflicts to disclose.
Hormone therapy should not be used to prevent chronic conditions in postmenopausal women, according to updated recommendations from the U.S. Preventive Services Task Force. The recommendations were published online Dec. 12 in JAMA.
In the latest recommendation statement, the USPSTF issued D recommendations against using combination estrogen and progestin to prevent chronic conditions in postmenopausal women and against using estrogen only to prevent chronic conditions in postmenopausal women who have undergone hysterectomies (JAMA. 2017 Dec 12. doi: 10.1001/jama.2017.18261). A grade D recommendation is defined as “The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.”
In response to public comments, the USPSTF team made several changes including adjusting the language to clarify that the recommendations apply only to postmenopausal women, and adding tables showing estimates of increased or decreased risk of various outcomes for postmenopausal women receiving different hormone therapies.
Approximately 40,000 women aged 53-79 years were included in an evidence report from Gerald Gartlehner, MD, of the University of North Carolina, Chapel Hill, and his colleagues that accompanied the recommendations (JAMA. 2017 Dec 12. doi: 10.1001/jama.2017.16952).
The researchers found that women taking estrogen alone had significantly lower risk of breast cancer, diabetes, and osteoporotic fractures, but significantly higher risk of gallbladder disease, stroke, urinary incontinence, and venous thromboembolism, compared with women taking placebo. In addition, women using a combination of estrogen and progestin had significantly lower risk of colorectal cancer, diabetes, and osteoporotic fractures, but significantly higher risk of breast cancer, probable dementia, gallbladder disease, stroke, urinary incontinence, and venous thromboembolism, compared with women taking placebo.
“Hormone therapy for the primary prevention of chronic conditions in menopausal women is associated with some beneficial effects but also with a substantial increase of risks for harms,” and the current evidence for the risks and benefits of hormone therapy is inconclusive, the researchers said.
The final recommendation remains consistent with the USPSTF draft statement issued earlier in 2017 and with the final recommendation statements issued in 2012.
The researchers had no relevant financial conflicts to disclose.
Hormone therapy should not be used to prevent chronic conditions in postmenopausal women, according to updated recommendations from the U.S. Preventive Services Task Force. The recommendations were published online Dec. 12 in JAMA.
In the latest recommendation statement, the USPSTF issued D recommendations against using combination estrogen and progestin to prevent chronic conditions in postmenopausal women and against using estrogen only to prevent chronic conditions in postmenopausal women who have undergone hysterectomies (JAMA. 2017 Dec 12. doi: 10.1001/jama.2017.18261). A grade D recommendation is defined as “The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.”
In response to public comments, the USPSTF team made several changes including adjusting the language to clarify that the recommendations apply only to postmenopausal women, and adding tables showing estimates of increased or decreased risk of various outcomes for postmenopausal women receiving different hormone therapies.
Approximately 40,000 women aged 53-79 years were included in an evidence report from Gerald Gartlehner, MD, of the University of North Carolina, Chapel Hill, and his colleagues that accompanied the recommendations (JAMA. 2017 Dec 12. doi: 10.1001/jama.2017.16952).
The researchers found that women taking estrogen alone had significantly lower risk of breast cancer, diabetes, and osteoporotic fractures, but significantly higher risk of gallbladder disease, stroke, urinary incontinence, and venous thromboembolism, compared with women taking placebo. In addition, women using a combination of estrogen and progestin had significantly lower risk of colorectal cancer, diabetes, and osteoporotic fractures, but significantly higher risk of breast cancer, probable dementia, gallbladder disease, stroke, urinary incontinence, and venous thromboembolism, compared with women taking placebo.
“Hormone therapy for the primary prevention of chronic conditions in menopausal women is associated with some beneficial effects but also with a substantial increase of risks for harms,” and the current evidence for the risks and benefits of hormone therapy is inconclusive, the researchers said.
The final recommendation remains consistent with the USPSTF draft statement issued earlier in 2017 and with the final recommendation statements issued in 2012.
The researchers had no relevant financial conflicts to disclose.
FROM JAMA
Study supports methotrexate monotherapy with TNF inhibitor rescue for early RA treatment
For patients with early rheumatoid arthritis, starting with methotrexate and adding adalimumab after 26 weeks if needed led to clinical and functional outcomes similar to those of starting with a dual adalimumab-methotrexate regimen, according to a study published in Annals of the Rheumatic Diseases.
Although upfront adalimumab-methotrexate led to about a 14% decrease in the likelihood of radiographic progression, nearly one in four patients did well over more than a year of follow-up without ever needing to add a biologic disease-modifying antirheumatic drug (DMARD), said Arthur Kavanaugh, MD, of the University of California at San Diego, La Jolla, Calif., and his associates.
At week 26, patients who had achieved stable low disease activity (LDA; 28-joint modified Disease Activity Score of less than 3.2, based on C-reactive protein) on dual therapy were re-randomized to either stay on or withdraw from adalimumab. Patients who achieved stable LDA on methotrexate alone stayed on it. Patients who did not achieve stable LDA by week 26 either stayed on methotrexate-adalimumab or received adalimumab rescue. For the current post hoc study, Dr. Kavanaugh and his associates compared longer-term outcomes between patients who received adalimumab-methotrexate at baseline and patients who started with methotrexate only. In addition to stable LDA, the investigators assessed normal function (Health Assessment Questionnaire Disability Index less than 0.5) and radiographic nonprogression (no more than 0.5 change in modified total Sharp score).
Patients who started on adalimumab-methotrexate instead of methotrexate monotherapy were significantly more likely to achieve stable LDA (53% vs. 30%), good function (45% vs. 33%), and radiographic nonprogression (87% vs. 72%) at week 26 (Ann Rheum Dis. 2013;72:64-71). However, as-needed rescue treatment with adalimumab at week 26 achieved very similar clinical and functional outcomes compared with initial treatment with methotrexate-adalimumab. At week 52, 62% and 65% of patients in these two groups had stable LDA, and 44% and 47% had normal function, respectively. At week 78, 65% of patients in both groups had stable LDA and 45% and 48% had normal function, respectively. However, initial therapy with adalimumab-methotrexate was associated with lower chances of radiographic progression compared with methotrexate monotherapy (86% and 72% at both time points, respectively).
This is the first study to assess whether rapidly adding a TNFi improves disease outcomes compared with starting treatment with both adalimumab and methotrexate in patients with early RA, the researchers said. Importantly, 24% of patients who started on methotrexate alone never needed to add a biological DMARD, experiencing “little to no radiographic progression and mostly good physical function thereafter,” they reported. The study supports current guidelines and a stepwise treat-to-target strategy can prevent overtreatment in about one in four patients with early RA, they concluded.
AbbVie makes adalimumab, sponsored the study, and was involved in its design, analysis, writeup, and review. Dr. Kavanaugh disclosed ties to AbbVie through his institution. Nine coinvestigators disclosed ties to AbbVie; five of the nine reported current or former employment with the company.
SOURCE: Ann Rheum Dis. 2017 Nov 16. doi: 10.1136/annrheumdis-2017-211871
This study is of general interest and its design is complex, with double-blind, open re-randomization, and open-label extension arms.
There are a number of points to highlight:
1. Both methotrexate-adalimumab arms eventuate in a small advantage with respect to radiographs, with less accrued damage than with methotrexate alone. As in multiple other studies, the radiographic differences, although statistically significant, are not clinically important during this short study. However, if extended over a number of years, they could become clinically important, and that should not be ignored.
2. The authors state that methotrexate monotherapy patients who later added adalimumab achieved symptomatic and functional relief equivalent to starting on methotrexate-adalimumab – which I fully agree with – but the authors pointed out that there may well be some bias in that conclusion because the “add-on” patients did so during an open-label phase of the study. The complex design of the study makes this a bit hard to dissect.
4. Also, this study design did not allow corticosteroids. While I am a staunch advocate of minimizing steroids, some clinicians would have used steroids early on to improve early response, thus mitigating the early differential effect of methotrexate monotherapy.
So what is the bottom line? In my mind, this study supports that methotrexate-adalimumab decreases the rate of bony damage (not a new finding among biologics plus methotrexate in RA) and gently advocates that using methotrexate alone as the first DMARD is appropriate.
The data actually do not clarify the potentially important symptomatic/functional differences during the early months between the group that went from methotrexate monotherapy to methotrexate-adalimumab vs. the group that received immediate methotrexate-adalimumab, where the “immediate” methotrexate-adalimumab patients probably felt better faster. Still, one needs to consider potential toxicity and cost of the immediate methotrexate-adalimumab group, and that is not well addressed here.
When faced with a patient, I always ask how bad are the symptoms (worse leaning me toward immediate methotrexate-adalimumab) vs. how frail is the patient (more frail leaning me toward first using methotrexate) and how good is their insurance (sadly a consideration in the United States, with better insurance leaning me toward the “immediate” combo because I think other data show this yields a faster response).
Daniel E. Furst, MD, is professor of rheumatology at the University of California, Los Angeles (emeritus), at the University of Washington, Seattle, and at the University of Florence (Italy). He reported receiving grant/research support from Bristol-Myers-Squibb, Pfizer, and Roche/Genentech. He is also a consultant to AbbVie, Novartis, Pfizer, and Roche/Genentech.
This study is of general interest and its design is complex, with double-blind, open re-randomization, and open-label extension arms.
There are a number of points to highlight:
1. Both methotrexate-adalimumab arms eventuate in a small advantage with respect to radiographs, with less accrued damage than with methotrexate alone. As in multiple other studies, the radiographic differences, although statistically significant, are not clinically important during this short study. However, if extended over a number of years, they could become clinically important, and that should not be ignored.
2. The authors state that methotrexate monotherapy patients who later added adalimumab achieved symptomatic and functional relief equivalent to starting on methotrexate-adalimumab – which I fully agree with – but the authors pointed out that there may well be some bias in that conclusion because the “add-on” patients did so during an open-label phase of the study. The complex design of the study makes this a bit hard to dissect.
4. Also, this study design did not allow corticosteroids. While I am a staunch advocate of minimizing steroids, some clinicians would have used steroids early on to improve early response, thus mitigating the early differential effect of methotrexate monotherapy.
So what is the bottom line? In my mind, this study supports that methotrexate-adalimumab decreases the rate of bony damage (not a new finding among biologics plus methotrexate in RA) and gently advocates that using methotrexate alone as the first DMARD is appropriate.
The data actually do not clarify the potentially important symptomatic/functional differences during the early months between the group that went from methotrexate monotherapy to methotrexate-adalimumab vs. the group that received immediate methotrexate-adalimumab, where the “immediate” methotrexate-adalimumab patients probably felt better faster. Still, one needs to consider potential toxicity and cost of the immediate methotrexate-adalimumab group, and that is not well addressed here.
When faced with a patient, I always ask how bad are the symptoms (worse leaning me toward immediate methotrexate-adalimumab) vs. how frail is the patient (more frail leaning me toward first using methotrexate) and how good is their insurance (sadly a consideration in the United States, with better insurance leaning me toward the “immediate” combo because I think other data show this yields a faster response).
Daniel E. Furst, MD, is professor of rheumatology at the University of California, Los Angeles (emeritus), at the University of Washington, Seattle, and at the University of Florence (Italy). He reported receiving grant/research support from Bristol-Myers-Squibb, Pfizer, and Roche/Genentech. He is also a consultant to AbbVie, Novartis, Pfizer, and Roche/Genentech.
This study is of general interest and its design is complex, with double-blind, open re-randomization, and open-label extension arms.
There are a number of points to highlight:
1. Both methotrexate-adalimumab arms eventuate in a small advantage with respect to radiographs, with less accrued damage than with methotrexate alone. As in multiple other studies, the radiographic differences, although statistically significant, are not clinically important during this short study. However, if extended over a number of years, they could become clinically important, and that should not be ignored.
2. The authors state that methotrexate monotherapy patients who later added adalimumab achieved symptomatic and functional relief equivalent to starting on methotrexate-adalimumab – which I fully agree with – but the authors pointed out that there may well be some bias in that conclusion because the “add-on” patients did so during an open-label phase of the study. The complex design of the study makes this a bit hard to dissect.
4. Also, this study design did not allow corticosteroids. While I am a staunch advocate of minimizing steroids, some clinicians would have used steroids early on to improve early response, thus mitigating the early differential effect of methotrexate monotherapy.
So what is the bottom line? In my mind, this study supports that methotrexate-adalimumab decreases the rate of bony damage (not a new finding among biologics plus methotrexate in RA) and gently advocates that using methotrexate alone as the first DMARD is appropriate.
The data actually do not clarify the potentially important symptomatic/functional differences during the early months between the group that went from methotrexate monotherapy to methotrexate-adalimumab vs. the group that received immediate methotrexate-adalimumab, where the “immediate” methotrexate-adalimumab patients probably felt better faster. Still, one needs to consider potential toxicity and cost of the immediate methotrexate-adalimumab group, and that is not well addressed here.
When faced with a patient, I always ask how bad are the symptoms (worse leaning me toward immediate methotrexate-adalimumab) vs. how frail is the patient (more frail leaning me toward first using methotrexate) and how good is their insurance (sadly a consideration in the United States, with better insurance leaning me toward the “immediate” combo because I think other data show this yields a faster response).
Daniel E. Furst, MD, is professor of rheumatology at the University of California, Los Angeles (emeritus), at the University of Washington, Seattle, and at the University of Florence (Italy). He reported receiving grant/research support from Bristol-Myers-Squibb, Pfizer, and Roche/Genentech. He is also a consultant to AbbVie, Novartis, Pfizer, and Roche/Genentech.
For patients with early rheumatoid arthritis, starting with methotrexate and adding adalimumab after 26 weeks if needed led to clinical and functional outcomes similar to those of starting with a dual adalimumab-methotrexate regimen, according to a study published in Annals of the Rheumatic Diseases.
Although upfront adalimumab-methotrexate led to about a 14% decrease in the likelihood of radiographic progression, nearly one in four patients did well over more than a year of follow-up without ever needing to add a biologic disease-modifying antirheumatic drug (DMARD), said Arthur Kavanaugh, MD, of the University of California at San Diego, La Jolla, Calif., and his associates.
At week 26, patients who had achieved stable low disease activity (LDA; 28-joint modified Disease Activity Score of less than 3.2, based on C-reactive protein) on dual therapy were re-randomized to either stay on or withdraw from adalimumab. Patients who achieved stable LDA on methotrexate alone stayed on it. Patients who did not achieve stable LDA by week 26 either stayed on methotrexate-adalimumab or received adalimumab rescue. For the current post hoc study, Dr. Kavanaugh and his associates compared longer-term outcomes between patients who received adalimumab-methotrexate at baseline and patients who started with methotrexate only. In addition to stable LDA, the investigators assessed normal function (Health Assessment Questionnaire Disability Index less than 0.5) and radiographic nonprogression (no more than 0.5 change in modified total Sharp score).
Patients who started on adalimumab-methotrexate instead of methotrexate monotherapy were significantly more likely to achieve stable LDA (53% vs. 30%), good function (45% vs. 33%), and radiographic nonprogression (87% vs. 72%) at week 26 (Ann Rheum Dis. 2013;72:64-71). However, as-needed rescue treatment with adalimumab at week 26 achieved very similar clinical and functional outcomes compared with initial treatment with methotrexate-adalimumab. At week 52, 62% and 65% of patients in these two groups had stable LDA, and 44% and 47% had normal function, respectively. At week 78, 65% of patients in both groups had stable LDA and 45% and 48% had normal function, respectively. However, initial therapy with adalimumab-methotrexate was associated with lower chances of radiographic progression compared with methotrexate monotherapy (86% and 72% at both time points, respectively).
This is the first study to assess whether rapidly adding a TNFi improves disease outcomes compared with starting treatment with both adalimumab and methotrexate in patients with early RA, the researchers said. Importantly, 24% of patients who started on methotrexate alone never needed to add a biological DMARD, experiencing “little to no radiographic progression and mostly good physical function thereafter,” they reported. The study supports current guidelines and a stepwise treat-to-target strategy can prevent overtreatment in about one in four patients with early RA, they concluded.
AbbVie makes adalimumab, sponsored the study, and was involved in its design, analysis, writeup, and review. Dr. Kavanaugh disclosed ties to AbbVie through his institution. Nine coinvestigators disclosed ties to AbbVie; five of the nine reported current or former employment with the company.
SOURCE: Ann Rheum Dis. 2017 Nov 16. doi: 10.1136/annrheumdis-2017-211871
For patients with early rheumatoid arthritis, starting with methotrexate and adding adalimumab after 26 weeks if needed led to clinical and functional outcomes similar to those of starting with a dual adalimumab-methotrexate regimen, according to a study published in Annals of the Rheumatic Diseases.
Although upfront adalimumab-methotrexate led to about a 14% decrease in the likelihood of radiographic progression, nearly one in four patients did well over more than a year of follow-up without ever needing to add a biologic disease-modifying antirheumatic drug (DMARD), said Arthur Kavanaugh, MD, of the University of California at San Diego, La Jolla, Calif., and his associates.
At week 26, patients who had achieved stable low disease activity (LDA; 28-joint modified Disease Activity Score of less than 3.2, based on C-reactive protein) on dual therapy were re-randomized to either stay on or withdraw from adalimumab. Patients who achieved stable LDA on methotrexate alone stayed on it. Patients who did not achieve stable LDA by week 26 either stayed on methotrexate-adalimumab or received adalimumab rescue. For the current post hoc study, Dr. Kavanaugh and his associates compared longer-term outcomes between patients who received adalimumab-methotrexate at baseline and patients who started with methotrexate only. In addition to stable LDA, the investigators assessed normal function (Health Assessment Questionnaire Disability Index less than 0.5) and radiographic nonprogression (no more than 0.5 change in modified total Sharp score).
Patients who started on adalimumab-methotrexate instead of methotrexate monotherapy were significantly more likely to achieve stable LDA (53% vs. 30%), good function (45% vs. 33%), and radiographic nonprogression (87% vs. 72%) at week 26 (Ann Rheum Dis. 2013;72:64-71). However, as-needed rescue treatment with adalimumab at week 26 achieved very similar clinical and functional outcomes compared with initial treatment with methotrexate-adalimumab. At week 52, 62% and 65% of patients in these two groups had stable LDA, and 44% and 47% had normal function, respectively. At week 78, 65% of patients in both groups had stable LDA and 45% and 48% had normal function, respectively. However, initial therapy with adalimumab-methotrexate was associated with lower chances of radiographic progression compared with methotrexate monotherapy (86% and 72% at both time points, respectively).
This is the first study to assess whether rapidly adding a TNFi improves disease outcomes compared with starting treatment with both adalimumab and methotrexate in patients with early RA, the researchers said. Importantly, 24% of patients who started on methotrexate alone never needed to add a biological DMARD, experiencing “little to no radiographic progression and mostly good physical function thereafter,” they reported. The study supports current guidelines and a stepwise treat-to-target strategy can prevent overtreatment in about one in four patients with early RA, they concluded.
AbbVie makes adalimumab, sponsored the study, and was involved in its design, analysis, writeup, and review. Dr. Kavanaugh disclosed ties to AbbVie through his institution. Nine coinvestigators disclosed ties to AbbVie; five of the nine reported current or former employment with the company.
SOURCE: Ann Rheum Dis. 2017 Nov 16. doi: 10.1136/annrheumdis-2017-211871
FROM ANNALS OF THE RHEUMATIC DISEASES
Key clinical point:
Major finding: Adding adalimumab as rescue therapy at 26 weeks achieved outcomes at 78 weeks similar to those of starting treatment with adalimumab-methotrexate.
Data source: A post hoc analysis of a 78-week, randomized, double-blind, phase 4 study of 926 methotrexate-naive patients with a less than 1-year history of active RA.
Disclosures: AbbVie makes adalimumab, sponsored the study, and was involved in its design, analysis, writeup, and review. Dr. Kavanaugh disclosed ties to AbbVie through his institution. Nine coinvestigators disclosed ties to AbbVie; five of the nine reported current or former employment with the company.
Source: Ann Rheum Dis. 2017 Nov 16. doi: 10.1136/annrheumdis-2017-211871
Gene silencer reduces mutant huntingtin protein in early-stage Huntington’s patients
An investigational gene-silencing molecule safely and dose-dependently reduced production of the mutant huntingtin protein in people with early-stage Huntington’s disease in a small, early-phase study, according to an announcement from the drug’s developer, Ionis Pharmaceuticals.
The antisense oligonucleotide IONIS-HTTRx – the first potentially disease-modifying drug for Huntington’s – will now go forward in a larger study to determine whether lowering mutant huntingtin protein (mHTT) confers any clinical benefits upon patients with the fatal neurodegenerative disease.
IONIS-HTTRx reduced mHTT by fractions that “exceeded expectations” set for the 46-person trial, C. Frank Bennett, PhD, senior vice president of research at Ionis, said in a press statement.
“The results of this trial are of groundbreaking importance for Huntington’s disease patients and families,” said Dr. Tabrizi, director of the Huntington’s Disease Centre at University College London. “For the first time a drug has lowered the level of the toxic disease-causing protein in the nervous system, and the drug was safe and well tolerated. The key now is to move quickly to a larger trial to test whether the drug slows disease progression.”
Upon receiving the positive data, Roche Pharma exercised its $45 million option to license the molecule. Roche now takes all regulatory and clinical development responsibility for IONIS-HTTRx.
There are few publicly available data on the IONIS-HTTRx study. It enrolled 46 patients with early-stage Huntington’s who were recruited from nine sites in the United Kingdom, Germany, and Canada. They were randomized to placebo or to four ascending doses of IONIS-HTTRx. The primary outcomes were mHTT levels in spinal fluid, safety, and tolerability. It produced significant, dose-dependent reductions of mHTT without concerning or dose-limiting safety signals, the press statement noted.
A larger study with clinical endpoints is next up, according to a statement Ionis and Roche jointly issued to the Huntington’s Disease Society of America.
“The next step for this program will be to conduct a safety and efficacy study to investigate if decreasing mutant huntingtin protein with IONIS-HTTRx can benefit people with Huntington’s disease,” the statement noted. “Future studies for the program will be conducted globally, including in the U.S. Roche will announce details about future studies, including eligibility criteria and planned start dates, as this information becomes available. All relevant information on upcoming studies will also be posted on HDTrialFinder.org and ClinicalTrials.gov.”
Huntington’s disease is caused by an expansion of at least 36 repeats of the CAG trinucleotide sequence in the huntingtin gene. The resulting mHTT is toxic and gradually damages neurons. IONIS-HTTRx interrupts the messenger RNA that fuels this toxic protein buildup, and it is the only drug that has ever attacked the disease at this level. This development is “a historic moment in the fight against Huntington’s, as it represents the successful completion of the first trial to treat the underlying cause of Huntington’s disease, the genetic mutation itself,” according to a statement by Louise Vetter, president of the Huntington’s Disease Society of America.
“The fact that levels of mutant huntingtin were reduced in correlation to the dose of IONIS-HTTRx that was given is significant, and the fact that participants in this first Phase 1/2a study are able to continue on the drug through an open-label extension gives us optimism regarding its safety,” Ms. Vetter said.
In January 2016, the Food and Drug Administration granted orphan drug status to IONIS-HTTRX; the European Medicines Agency had previously granted it similar status.
The press release from Ionis Pharmaceuticals sounds very promising. There is reason to believe that lowering mHTT protein might prevent or delay Huntington’s disease, and this antisense molecule appears to be safe and to lower mHTT in cerebrospinal fluid. However, there are several caveats.
First, it is unclear whether lowering mHTT protein might help those who already have clinical Huntington’s disease.
Third, no information is given in the press release about the degree of reduction of mHTT observed and whether there is evidence that this lowering might be sufficient for a therapeutic effect.
Fourth, neurotoxicity may not only result from the mHTT protein but also directly from the mRNA itself. The contribution of mutant mRNA to pathogenesis is a key open question in the study of Huntington’s disease and other related “repeat disorders.”
Michael Wolfe, PhD , is the Mathias P. Mertes Professor of Medicinal Chemistry at the University of Kansas, Lawrence. He has no relevant disclosures.
The press release from Ionis Pharmaceuticals sounds very promising. There is reason to believe that lowering mHTT protein might prevent or delay Huntington’s disease, and this antisense molecule appears to be safe and to lower mHTT in cerebrospinal fluid. However, there are several caveats.
First, it is unclear whether lowering mHTT protein might help those who already have clinical Huntington’s disease.
Third, no information is given in the press release about the degree of reduction of mHTT observed and whether there is evidence that this lowering might be sufficient for a therapeutic effect.
Fourth, neurotoxicity may not only result from the mHTT protein but also directly from the mRNA itself. The contribution of mutant mRNA to pathogenesis is a key open question in the study of Huntington’s disease and other related “repeat disorders.”
Michael Wolfe, PhD , is the Mathias P. Mertes Professor of Medicinal Chemistry at the University of Kansas, Lawrence. He has no relevant disclosures.
The press release from Ionis Pharmaceuticals sounds very promising. There is reason to believe that lowering mHTT protein might prevent or delay Huntington’s disease, and this antisense molecule appears to be safe and to lower mHTT in cerebrospinal fluid. However, there are several caveats.
First, it is unclear whether lowering mHTT protein might help those who already have clinical Huntington’s disease.
Third, no information is given in the press release about the degree of reduction of mHTT observed and whether there is evidence that this lowering might be sufficient for a therapeutic effect.
Fourth, neurotoxicity may not only result from the mHTT protein but also directly from the mRNA itself. The contribution of mutant mRNA to pathogenesis is a key open question in the study of Huntington’s disease and other related “repeat disorders.”
Michael Wolfe, PhD , is the Mathias P. Mertes Professor of Medicinal Chemistry at the University of Kansas, Lawrence. He has no relevant disclosures.
An investigational gene-silencing molecule safely and dose-dependently reduced production of the mutant huntingtin protein in people with early-stage Huntington’s disease in a small, early-phase study, according to an announcement from the drug’s developer, Ionis Pharmaceuticals.
The antisense oligonucleotide IONIS-HTTRx – the first potentially disease-modifying drug for Huntington’s – will now go forward in a larger study to determine whether lowering mutant huntingtin protein (mHTT) confers any clinical benefits upon patients with the fatal neurodegenerative disease.
IONIS-HTTRx reduced mHTT by fractions that “exceeded expectations” set for the 46-person trial, C. Frank Bennett, PhD, senior vice president of research at Ionis, said in a press statement.
“The results of this trial are of groundbreaking importance for Huntington’s disease patients and families,” said Dr. Tabrizi, director of the Huntington’s Disease Centre at University College London. “For the first time a drug has lowered the level of the toxic disease-causing protein in the nervous system, and the drug was safe and well tolerated. The key now is to move quickly to a larger trial to test whether the drug slows disease progression.”
Upon receiving the positive data, Roche Pharma exercised its $45 million option to license the molecule. Roche now takes all regulatory and clinical development responsibility for IONIS-HTTRx.
There are few publicly available data on the IONIS-HTTRx study. It enrolled 46 patients with early-stage Huntington’s who were recruited from nine sites in the United Kingdom, Germany, and Canada. They were randomized to placebo or to four ascending doses of IONIS-HTTRx. The primary outcomes were mHTT levels in spinal fluid, safety, and tolerability. It produced significant, dose-dependent reductions of mHTT without concerning or dose-limiting safety signals, the press statement noted.
A larger study with clinical endpoints is next up, according to a statement Ionis and Roche jointly issued to the Huntington’s Disease Society of America.
“The next step for this program will be to conduct a safety and efficacy study to investigate if decreasing mutant huntingtin protein with IONIS-HTTRx can benefit people with Huntington’s disease,” the statement noted. “Future studies for the program will be conducted globally, including in the U.S. Roche will announce details about future studies, including eligibility criteria and planned start dates, as this information becomes available. All relevant information on upcoming studies will also be posted on HDTrialFinder.org and ClinicalTrials.gov.”
Huntington’s disease is caused by an expansion of at least 36 repeats of the CAG trinucleotide sequence in the huntingtin gene. The resulting mHTT is toxic and gradually damages neurons. IONIS-HTTRx interrupts the messenger RNA that fuels this toxic protein buildup, and it is the only drug that has ever attacked the disease at this level. This development is “a historic moment in the fight against Huntington’s, as it represents the successful completion of the first trial to treat the underlying cause of Huntington’s disease, the genetic mutation itself,” according to a statement by Louise Vetter, president of the Huntington’s Disease Society of America.
“The fact that levels of mutant huntingtin were reduced in correlation to the dose of IONIS-HTTRx that was given is significant, and the fact that participants in this first Phase 1/2a study are able to continue on the drug through an open-label extension gives us optimism regarding its safety,” Ms. Vetter said.
In January 2016, the Food and Drug Administration granted orphan drug status to IONIS-HTTRX; the European Medicines Agency had previously granted it similar status.
An investigational gene-silencing molecule safely and dose-dependently reduced production of the mutant huntingtin protein in people with early-stage Huntington’s disease in a small, early-phase study, according to an announcement from the drug’s developer, Ionis Pharmaceuticals.
The antisense oligonucleotide IONIS-HTTRx – the first potentially disease-modifying drug for Huntington’s – will now go forward in a larger study to determine whether lowering mutant huntingtin protein (mHTT) confers any clinical benefits upon patients with the fatal neurodegenerative disease.
IONIS-HTTRx reduced mHTT by fractions that “exceeded expectations” set for the 46-person trial, C. Frank Bennett, PhD, senior vice president of research at Ionis, said in a press statement.
“The results of this trial are of groundbreaking importance for Huntington’s disease patients and families,” said Dr. Tabrizi, director of the Huntington’s Disease Centre at University College London. “For the first time a drug has lowered the level of the toxic disease-causing protein in the nervous system, and the drug was safe and well tolerated. The key now is to move quickly to a larger trial to test whether the drug slows disease progression.”
Upon receiving the positive data, Roche Pharma exercised its $45 million option to license the molecule. Roche now takes all regulatory and clinical development responsibility for IONIS-HTTRx.
There are few publicly available data on the IONIS-HTTRx study. It enrolled 46 patients with early-stage Huntington’s who were recruited from nine sites in the United Kingdom, Germany, and Canada. They were randomized to placebo or to four ascending doses of IONIS-HTTRx. The primary outcomes were mHTT levels in spinal fluid, safety, and tolerability. It produced significant, dose-dependent reductions of mHTT without concerning or dose-limiting safety signals, the press statement noted.
A larger study with clinical endpoints is next up, according to a statement Ionis and Roche jointly issued to the Huntington’s Disease Society of America.
“The next step for this program will be to conduct a safety and efficacy study to investigate if decreasing mutant huntingtin protein with IONIS-HTTRx can benefit people with Huntington’s disease,” the statement noted. “Future studies for the program will be conducted globally, including in the U.S. Roche will announce details about future studies, including eligibility criteria and planned start dates, as this information becomes available. All relevant information on upcoming studies will also be posted on HDTrialFinder.org and ClinicalTrials.gov.”
Huntington’s disease is caused by an expansion of at least 36 repeats of the CAG trinucleotide sequence in the huntingtin gene. The resulting mHTT is toxic and gradually damages neurons. IONIS-HTTRx interrupts the messenger RNA that fuels this toxic protein buildup, and it is the only drug that has ever attacked the disease at this level. This development is “a historic moment in the fight against Huntington’s, as it represents the successful completion of the first trial to treat the underlying cause of Huntington’s disease, the genetic mutation itself,” according to a statement by Louise Vetter, president of the Huntington’s Disease Society of America.
“The fact that levels of mutant huntingtin were reduced in correlation to the dose of IONIS-HTTRx that was given is significant, and the fact that participants in this first Phase 1/2a study are able to continue on the drug through an open-label extension gives us optimism regarding its safety,” Ms. Vetter said.
In January 2016, the Food and Drug Administration granted orphan drug status to IONIS-HTTRX; the European Medicines Agency had previously granted it similar status.