Psoriasis

LAS VEGAS – Wet dressing, a technique forgotten in most places but in continual use at the Mayo Clinic for more than 80 years, knocks out intractable pruritus – whatever its cause – in children and adults, according to Dr. Mark Davis, chair of the division of clinical dermatology at the clinic in Rochester, Minn.

"It’s a simple technique that works extraordinarily well for any itchy condition from head to toe, and has virtually no side effects. It stops itching reliably, when nothing else has worked," including prednisone, methotrexate, phototherapy, and elimination diets, among other strategies, he said at Skin Disease Education Foundation’s annual Las Vegas dermatology seminar.

M. Alexander Otto/IMNG Medical Media

Even so, "there’s remarkably little on this in the literature, and what’s published is mostly just in kids, but in adults it works brilliantly, too, particularly for atopic dermatitis. We use it when people come in itching from anything, like psoriasis," he said (J. Am. Acad. Dermatol. 2009;60:792-800).

"The commonest question [we hear from people] is ‘I’ve been going to doctors for years. Why didn’t anybody tell me about this?’ " said Dr. Davis.

If their pruritus is severe enough, patients will be admitted to the Mayo Clinic and have wet cloths applied to wherever the itch happens to be – above the waist, below the waist, the feet, or even the entire body, including the face – with a dry blanket on top if needed to ward of the chill. Patients can get up from bed for a bathroom break when the dressings are changed every 3 hours.

Topical steroids are used with the dressings up to three times a day; 1% percent hydrocortisone for the face or genitals, 0.1% or 0.05% triamcinolone elsewhere. The Mayo Clinic has never had a case of hypothalamic-pituitary-adrenal axis suppression with the technique, and insurance usually covers the cost for 3 days, Dr. Davis said.

When outpatient treatment is sufficient, pruritic patients are instructed to put on wet pajamas or long johns, or hop into the shower in dry ones, and then leave them on for 30 minutes to an hour, 3-4 times a day. Nurses, with the help of handouts and videos, teach patients how to do this, and call them every 24 hours to see how they are getting along.

Hospital patients get the same instructions at discharge. "Initially, they have to do [it] at least once a day for a number of weeks, and then they can use [the technique] on an as-needed basis, maybe once or twice a week," Dr. Davis said.

"Wet dressings went out of favor" in most places because "they are just so much trouble," he said. At present, the technique is "largely unknown," as is the reason why it works, he added.

Dr. Davis has no relevant disclosures. SDEF and this news organization are owned by Frontline Medical Communications.

[email protected]

LAS VEGAS – Wet dressing, a technique forgotten in most places but in continual use at the Mayo Clinic for more than 80 years, knocks out intractable pruritus – whatever its cause – in children and adults, according to Dr. Mark Davis, chair of the division of clinical dermatology at the clinic in Rochester, Minn.

"It’s a simple technique that works extraordinarily well for any itchy condition from head to toe, and has virtually no side effects. It stops itching reliably, when nothing else has worked," including prednisone, methotrexate, phototherapy, and elimination diets, among other strategies, he said at Skin Disease Education Foundation’s annual Las Vegas dermatology seminar.

M. Alexander Otto/IMNG Medical Media

Even so, "there’s remarkably little on this in the literature, and what’s published is mostly just in kids, but in adults it works brilliantly, too, particularly for atopic dermatitis. We use it when people come in itching from anything, like psoriasis," he said (J. Am. Acad. Dermatol. 2009;60:792-800).

"The commonest question [we hear from people] is ‘I’ve been going to doctors for years. Why didn’t anybody tell me about this?’ " said Dr. Davis.

If their pruritus is severe enough, patients will be admitted to the Mayo Clinic and have wet cloths applied to wherever the itch happens to be – above the waist, below the waist, the feet, or even the entire body, including the face – with a dry blanket on top if needed to ward of the chill. Patients can get up from bed for a bathroom break when the dressings are changed every 3 hours.

Topical steroids are used with the dressings up to three times a day; 1% percent hydrocortisone for the face or genitals, 0.1% or 0.05% triamcinolone elsewhere. The Mayo Clinic has never had a case of hypothalamic-pituitary-adrenal axis suppression with the technique, and insurance usually covers the cost for 3 days, Dr. Davis said.

When outpatient treatment is sufficient, pruritic patients are instructed to put on wet pajamas or long johns, or hop into the shower in dry ones, and then leave them on for 30 minutes to an hour, 3-4 times a day. Nurses, with the help of handouts and videos, teach patients how to do this, and call them every 24 hours to see how they are getting along.

Hospital patients get the same instructions at discharge. "Initially, they have to do [it] at least once a day for a number of weeks, and then they can use [the technique] on an as-needed basis, maybe once or twice a week," Dr. Davis said.

"Wet dressings went out of favor" in most places because "they are just so much trouble," he said. At present, the technique is "largely unknown," as is the reason why it works, he added.

Dr. Davis has no relevant disclosures. SDEF and this news organization are owned by Frontline Medical Communications.

[email protected]

LAS VEGAS – Wet dressing, a technique forgotten in most places but in continual use at the Mayo Clinic for more than 80 years, knocks out intractable pruritus – whatever its cause – in children and adults, according to Dr. Mark Davis, chair of the division of clinical dermatology at the clinic in Rochester, Minn.

"It’s a simple technique that works extraordinarily well for any itchy condition from head to toe, and has virtually no side effects. It stops itching reliably, when nothing else has worked," including prednisone, methotrexate, phototherapy, and elimination diets, among other strategies, he said at Skin Disease Education Foundation’s annual Las Vegas dermatology seminar.

M. Alexander Otto/IMNG Medical Media

Even so, "there’s remarkably little on this in the literature, and what’s published is mostly just in kids, but in adults it works brilliantly, too, particularly for atopic dermatitis. We use it when people come in itching from anything, like psoriasis," he said (J. Am. Acad. Dermatol. 2009;60:792-800).

"The commonest question [we hear from people] is ‘I’ve been going to doctors for years. Why didn’t anybody tell me about this?’ " said Dr. Davis.

If their pruritus is severe enough, patients will be admitted to the Mayo Clinic and have wet cloths applied to wherever the itch happens to be – above the waist, below the waist, the feet, or even the entire body, including the face – with a dry blanket on top if needed to ward of the chill. Patients can get up from bed for a bathroom break when the dressings are changed every 3 hours.

Topical steroids are used with the dressings up to three times a day; 1% percent hydrocortisone for the face or genitals, 0.1% or 0.05% triamcinolone elsewhere. The Mayo Clinic has never had a case of hypothalamic-pituitary-adrenal axis suppression with the technique, and insurance usually covers the cost for 3 days, Dr. Davis said.

When outpatient treatment is sufficient, pruritic patients are instructed to put on wet pajamas or long johns, or hop into the shower in dry ones, and then leave them on for 30 minutes to an hour, 3-4 times a day. Nurses, with the help of handouts and videos, teach patients how to do this, and call them every 24 hours to see how they are getting along.

Hospital patients get the same instructions at discharge. "Initially, they have to do [it] at least once a day for a number of weeks, and then they can use [the technique] on an as-needed basis, maybe once or twice a week," Dr. Davis said.

"Wet dressings went out of favor" in most places because "they are just so much trouble," he said. At present, the technique is "largely unknown," as is the reason why it works, he added.

Dr. Davis has no relevant disclosures. SDEF and this news organization are owned by Frontline Medical Communications.

[email protected]

As evidence supporting an association between psoriasis and cardiovascular disease continues to mount, dermatologists may be the first line of defense in lowering heart failure risk.

"The increased risk of cardiovascular disease for patients with psoriasis may be of a similar magnitude as other well-described CV risk factors, such as uncontrolled hypertension," said Dr. Bruce E. Strober of the University of Connecticut, Farmington. "Further, epidemiological studies show that psoriasis patients have a shortened life expectancy, likely as a result of their experience with CV comorbitidies."

Patient education is essential, he noted at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar. "At the very least, dermatologists should alert patients of the link between psoriasis and CV disease, and remind these patients of the necessity of having a primary care physician who monitors conventional risk factors of CV disease. Patients should be reminded that psoriasis is ‘systemic disease of inflammation’ that creates risks beyond the skin and may shorten life expectancy."

"Dermatologists who care for moderate to severe psoriasis patients should measure blood pressure and draw baseline blood tests assessing for abnormalities of cholesterol, triglycerides, kidney function, liver function, and blood glucose. Abnormalities should prompt an appropriate referral to a primary care physician," he noted.

In a population-based Dutch study presented at the annual congress of the European Society of Cardiology in September, adults with mild psoriasis developed 4.02 cases of new-onset heart failure per 1,000 person-years of follow-up, compared with 4.50/1,000 person-years in patients with severe psoriasis; both of which were significantly higher than the rate of 2.27/1,000 person-years in the general population.

Data from a 2006 study found that diabetes, hypertension, hyperlipidemia, and obesity were more prevalent in psoriasis patients, when compared with controls (J. Am. Acad. Dermatol. 2006;55:829-35). Diabetes and obesity were significantly more prevalent in patients with severe psoriasis, compared with patients with mild psoriasis.

Although the reasons for the increased cardiovascular risk in psoriasis patients remain unknown, possible causes include the use of dyslipidemic therapies, including corticosteroids, acitretin, and cyclosporine, as well as uncontrolled inflammation that could lead to endothelial dysfunction and dyslipidemia, said Dr. Strober. The prevalence of other associated and/or independent risk factors including obesity, hypertension, smoking, and alcohol misuse in psoriasis patients, also could play a role.

Dr. Strober disclosed relationships with multiple pharmaceutical companies including Abbott, Amgen, Janssen, Pfizer, Novartis, and Celgene. SDEF and this news organization are owned by Frontline Medical Communications.

[email protected]

As evidence supporting an association between psoriasis and cardiovascular disease continues to mount, dermatologists may be the first line of defense in lowering heart failure risk.

"The increased risk of cardiovascular disease for patients with psoriasis may be of a similar magnitude as other well-described CV risk factors, such as uncontrolled hypertension," said Dr. Bruce E. Strober of the University of Connecticut, Farmington. "Further, epidemiological studies show that psoriasis patients have a shortened life expectancy, likely as a result of their experience with CV comorbitidies."

Patient education is essential, he noted at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar. "At the very least, dermatologists should alert patients of the link between psoriasis and CV disease, and remind these patients of the necessity of having a primary care physician who monitors conventional risk factors of CV disease. Patients should be reminded that psoriasis is ‘systemic disease of inflammation’ that creates risks beyond the skin and may shorten life expectancy."

"Dermatologists who care for moderate to severe psoriasis patients should measure blood pressure and draw baseline blood tests assessing for abnormalities of cholesterol, triglycerides, kidney function, liver function, and blood glucose. Abnormalities should prompt an appropriate referral to a primary care physician," he noted.

In a population-based Dutch study presented at the annual congress of the European Society of Cardiology in September, adults with mild psoriasis developed 4.02 cases of new-onset heart failure per 1,000 person-years of follow-up, compared with 4.50/1,000 person-years in patients with severe psoriasis; both of which were significantly higher than the rate of 2.27/1,000 person-years in the general population.

Data from a 2006 study found that diabetes, hypertension, hyperlipidemia, and obesity were more prevalent in psoriasis patients, when compared with controls (J. Am. Acad. Dermatol. 2006;55:829-35). Diabetes and obesity were significantly more prevalent in patients with severe psoriasis, compared with patients with mild psoriasis.

Although the reasons for the increased cardiovascular risk in psoriasis patients remain unknown, possible causes include the use of dyslipidemic therapies, including corticosteroids, acitretin, and cyclosporine, as well as uncontrolled inflammation that could lead to endothelial dysfunction and dyslipidemia, said Dr. Strober. The prevalence of other associated and/or independent risk factors including obesity, hypertension, smoking, and alcohol misuse in psoriasis patients, also could play a role.

Dr. Strober disclosed relationships with multiple pharmaceutical companies including Abbott, Amgen, Janssen, Pfizer, Novartis, and Celgene. SDEF and this news organization are owned by Frontline Medical Communications.

[email protected]

As evidence supporting an association between psoriasis and cardiovascular disease continues to mount, dermatologists may be the first line of defense in lowering heart failure risk.

"The increased risk of cardiovascular disease for patients with psoriasis may be of a similar magnitude as other well-described CV risk factors, such as uncontrolled hypertension," said Dr. Bruce E. Strober of the University of Connecticut, Farmington. "Further, epidemiological studies show that psoriasis patients have a shortened life expectancy, likely as a result of their experience with CV comorbitidies."

Patient education is essential, he noted at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar. "At the very least, dermatologists should alert patients of the link between psoriasis and CV disease, and remind these patients of the necessity of having a primary care physician who monitors conventional risk factors of CV disease. Patients should be reminded that psoriasis is ‘systemic disease of inflammation’ that creates risks beyond the skin and may shorten life expectancy."

"Dermatologists who care for moderate to severe psoriasis patients should measure blood pressure and draw baseline blood tests assessing for abnormalities of cholesterol, triglycerides, kidney function, liver function, and blood glucose. Abnormalities should prompt an appropriate referral to a primary care physician," he noted.

In a population-based Dutch study presented at the annual congress of the European Society of Cardiology in September, adults with mild psoriasis developed 4.02 cases of new-onset heart failure per 1,000 person-years of follow-up, compared with 4.50/1,000 person-years in patients with severe psoriasis; both of which were significantly higher than the rate of 2.27/1,000 person-years in the general population.

Data from a 2006 study found that diabetes, hypertension, hyperlipidemia, and obesity were more prevalent in psoriasis patients, when compared with controls (J. Am. Acad. Dermatol. 2006;55:829-35). Diabetes and obesity were significantly more prevalent in patients with severe psoriasis, compared with patients with mild psoriasis.

Although the reasons for the increased cardiovascular risk in psoriasis patients remain unknown, possible causes include the use of dyslipidemic therapies, including corticosteroids, acitretin, and cyclosporine, as well as uncontrolled inflammation that could lead to endothelial dysfunction and dyslipidemia, said Dr. Strober. The prevalence of other associated and/or independent risk factors including obesity, hypertension, smoking, and alcohol misuse in psoriasis patients, also could play a role.

Dr. Strober disclosed relationships with multiple pharmaceutical companies including Abbott, Amgen, Janssen, Pfizer, Novartis, and Celgene. SDEF and this news organization are owned by Frontline Medical Communications.

[email protected]

Cimzia

UCB, Inc, obtains US Food and Drug Administration approval of Cimzia (certolizumab pegol), a tumor necrosis factor blocker for the treatment of active psoriatic arthritis in adults. Cimzia also is indicated in adults for the treatment of moderate to severe rheumatoid arthritis and to reduce signs and symptoms of moderately to severely active Crohn disease. For more information, visit www.cimzia.com.

La Roche-Posay Antiaging Products

La Roche-Posay Laboratoire Dermatologique releases 3 antiaging products: Mela-D Deep Cleansing Brightening Foaming Cream, Redermic [R] Eyes, and Substiane [+] Serum. The Mela-D product is a deep-cleansing and brightening formula with lipohy-droxy acid that combats dark spots and gives the skin a clean and smooth appearance. Redermic [R] Eyes combines 0.01% pure retinol with a retinol booster complex and caffeine to reduce crow’s-feet and dark circles to rejuvenate the eye area. Substiane [+] Serum increases the volume and elasticity of the skin. All products are physician dispensed or available in select drugstores and online. For more information, visit www.laroche-posay.us.

Otrexup

Antares Pharma Inc obtains US Food and Drug Administration approval of Otrexup (methotrexate), a folate analog metabolic inhibitor for the treatment of severe, recalcitrant, disabling psoriasis in adults who have not responded to other therapies. Otrexup is self-administered subcutaneously once weekly via an easy-to-use, single-dose, disposable autoinjector, which utilizes Vibex Medi-Jet technology. Otrexup also is indicated for adults with severe active rheumatoid arthritis and for children with active polyarticular juvenile idiopathic arthritis. For more information, visit www.otrexup.com.

Valeant Partners With National Coalition Against Domestic

Violence Valeant Pharmaceuticals International, Inc, announces a partnership with the National Coalition Against Domestic Violence (NCADV) to help improve the lives of women. Valeant pledges to donate a portion of sales from Medicis and Obagi products to support the initiatives of the NCADV. For more information, visit enddomesticviolence.valeant.com.

If you would like your product included in Product News, please e-mail a press release to Melissa Steiger at [email protected].

Cimzia

UCB, Inc, obtains US Food and Drug Administration approval of Cimzia (certolizumab pegol), a tumor necrosis factor blocker for the treatment of active psoriatic arthritis in adults. Cimzia also is indicated in adults for the treatment of moderate to severe rheumatoid arthritis and to reduce signs and symptoms of moderately to severely active Crohn disease. For more information, visit www.cimzia.com.

La Roche-Posay Antiaging Products

La Roche-Posay Laboratoire Dermatologique releases 3 antiaging products: Mela-D Deep Cleansing Brightening Foaming Cream, Redermic [R] Eyes, and Substiane [+] Serum. The Mela-D product is a deep-cleansing and brightening formula with lipohy-droxy acid that combats dark spots and gives the skin a clean and smooth appearance. Redermic [R] Eyes combines 0.01% pure retinol with a retinol booster complex and caffeine to reduce crow’s-feet and dark circles to rejuvenate the eye area. Substiane [+] Serum increases the volume and elasticity of the skin. All products are physician dispensed or available in select drugstores and online. For more information, visit www.laroche-posay.us.

Otrexup

Antares Pharma Inc obtains US Food and Drug Administration approval of Otrexup (methotrexate), a folate analog metabolic inhibitor for the treatment of severe, recalcitrant, disabling psoriasis in adults who have not responded to other therapies. Otrexup is self-administered subcutaneously once weekly via an easy-to-use, single-dose, disposable autoinjector, which utilizes Vibex Medi-Jet technology. Otrexup also is indicated for adults with severe active rheumatoid arthritis and for children with active polyarticular juvenile idiopathic arthritis. For more information, visit www.otrexup.com.

Valeant Partners With National Coalition Against Domestic

Violence Valeant Pharmaceuticals International, Inc, announces a partnership with the National Coalition Against Domestic Violence (NCADV) to help improve the lives of women. Valeant pledges to donate a portion of sales from Medicis and Obagi products to support the initiatives of the NCADV. For more information, visit enddomesticviolence.valeant.com.

If you would like your product included in Product News, please e-mail a press release to Melissa Steiger at [email protected].

Cimzia

UCB, Inc, obtains US Food and Drug Administration approval of Cimzia (certolizumab pegol), a tumor necrosis factor blocker for the treatment of active psoriatic arthritis in adults. Cimzia also is indicated in adults for the treatment of moderate to severe rheumatoid arthritis and to reduce signs and symptoms of moderately to severely active Crohn disease. For more information, visit www.cimzia.com.

La Roche-Posay Antiaging Products

La Roche-Posay Laboratoire Dermatologique releases 3 antiaging products: Mela-D Deep Cleansing Brightening Foaming Cream, Redermic [R] Eyes, and Substiane [+] Serum. The Mela-D product is a deep-cleansing and brightening formula with lipohy-droxy acid that combats dark spots and gives the skin a clean and smooth appearance. Redermic [R] Eyes combines 0.01% pure retinol with a retinol booster complex and caffeine to reduce crow’s-feet and dark circles to rejuvenate the eye area. Substiane [+] Serum increases the volume and elasticity of the skin. All products are physician dispensed or available in select drugstores and online. For more information, visit www.laroche-posay.us.

Otrexup

Antares Pharma Inc obtains US Food and Drug Administration approval of Otrexup (methotrexate), a folate analog metabolic inhibitor for the treatment of severe, recalcitrant, disabling psoriasis in adults who have not responded to other therapies. Otrexup is self-administered subcutaneously once weekly via an easy-to-use, single-dose, disposable autoinjector, which utilizes Vibex Medi-Jet technology. Otrexup also is indicated for adults with severe active rheumatoid arthritis and for children with active polyarticular juvenile idiopathic arthritis. For more information, visit www.otrexup.com.

Valeant Partners With National Coalition Against Domestic

Violence Valeant Pharmaceuticals International, Inc, announces a partnership with the National Coalition Against Domestic Violence (NCADV) to help improve the lives of women. Valeant pledges to donate a portion of sales from Medicis and Obagi products to support the initiatives of the NCADV. For more information, visit enddomesticviolence.valeant.com.

If you would like your product included in Product News, please e-mail a press release to Melissa Steiger at [email protected].

LAS VEGAS – Dermatologists, like all physicians, play an important role not just in the treatment of disease, but also in the prevention of disease, and that means vaccinating patients when indicated, according to Dr. Stephen K. Tyring.

The varicella vaccines, including the chicken pox and shingles vaccines, and the human papillomavirus (HPV), hepatitis, and influenza virus vaccines are among those to consider offering to patients when appropriate, Dr. Tyring said at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar.

Concerns arise, however, when it comes to vaccinating psoriasis patients who are – or will be – treated with biologics.

Ideally, vaccination should be offered before treatment is initiated, he said, but for some patients – such as those who are under the age for which their insurance company will cover a vaccine (age 50 or 60 for the shingles vaccine, depending on the insurance company, for example) – this may not be possible. In those already taking a biologic drug, the question is how to vaccinate safely and without interfering with treatment efficacy, he said.

"What we usually do – and there’s no absolute golden rule – is ask the patient to stop the drug for one to two half-lives of the drug," said Dr. Tyring of the University of Texas, Houston. We suggest stopping one half-life for killed, subunit, or recombinant virus vaccines and stopping for two half-lives for live attenuated virus vaccines.

With the tumor necrosis factor (TNF) inhibitor etanercept (Enbrel), for example, that means skipping one to two weekly injections.

"That’s a little bit more than a half-life, but if a patient is using Enbrel once or twice a week, the next week, instead of injecting the Enbrel, they can just come in and get the shingles vaccine [Zostavax]," he said.

Adalimumab (Humira), another anti-TNF drug, has a longer half-life, so that has to be taken into account. Things get a little more complicated when it comes to patients treated with ustekinumab (Stelera), which has a particularly long half-life, he noted.

"It’s not quite as easy, because it’s not clear how long to wait after Stelera to give a vaccine. Most efficacy is seen in the first month, and when patients come back at 3 months, they often are starting to get a little psoriasis back. Therefore, 2 months following an injection of Stelera is about the right time to get the vaccine; that way you get the minimum immunosuppression and the maximum chance to respond," he said.

Similarly, with other vaccines like the Gardasil HPV vaccine and the hepatitis A and B vaccines that require a series of shots, the biologic should be stopped for a half-life. This will mean skipping biologic dosing multiple times, but in most cases this won’t be problematic, because it typically takes about 3 months for a patient who is clear to experience significant psoriasis recurrence.

"There’s really no danger in skipping," he said.

While some may advocate waiting two half-lives after vaccination, most experts agree that is unnecessary for killed, recombinant, or subunit (for example, injectable influenza) virus vaccines but is advisable for live attenuated virus vaccines like the intranasal influenza virus vaccine or the herpes zoster vaccine Zostavax, he said.

Dr. Tyring also noted during his presentation that in his experience, concerns about increased infection risk in patients taking TNF inhibitors have been unfounded. In fact, treatment appears to provide an unexpected benefit for those who do become infected with herpes zoster: a reduced risk of postherpetic neuralgia, even among older individuals who are generally at particularly high risk.

After noticing this benefit in his own patients, Dr. Tyring asked his colleagues and found that they, too, had noticed a similar pattern. In 2011, he and his colleagues published a retrospective study of 206 patients on TNF inhibitors who developed herpes zoster, and with only two exceptions involving patients on both a TNF inhibitor and methotrexate, patients universally experienced milder symptoms if they developed shingles while on a TNF inhibitor, he said, noting that this is much lower than rates reported in the literature in the general population (J. Med. Virol. 2011;83:2051-5).

SDEF and this news organization are owned by Frontline Medical Communications.

LAS VEGAS – Dermatologists, like all physicians, play an important role not just in the treatment of disease, but also in the prevention of disease, and that means vaccinating patients when indicated, according to Dr. Stephen K. Tyring.

The varicella vaccines, including the chicken pox and shingles vaccines, and the human papillomavirus (HPV), hepatitis, and influenza virus vaccines are among those to consider offering to patients when appropriate, Dr. Tyring said at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar.

Concerns arise, however, when it comes to vaccinating psoriasis patients who are – or will be – treated with biologics.

Ideally, vaccination should be offered before treatment is initiated, he said, but for some patients – such as those who are under the age for which their insurance company will cover a vaccine (age 50 or 60 for the shingles vaccine, depending on the insurance company, for example) – this may not be possible. In those already taking a biologic drug, the question is how to vaccinate safely and without interfering with treatment efficacy, he said.

"What we usually do – and there’s no absolute golden rule – is ask the patient to stop the drug for one to two half-lives of the drug," said Dr. Tyring of the University of Texas, Houston. We suggest stopping one half-life for killed, subunit, or recombinant virus vaccines and stopping for two half-lives for live attenuated virus vaccines.

With the tumor necrosis factor (TNF) inhibitor etanercept (Enbrel), for example, that means skipping one to two weekly injections.

"That’s a little bit more than a half-life, but if a patient is using Enbrel once or twice a week, the next week, instead of injecting the Enbrel, they can just come in and get the shingles vaccine [Zostavax]," he said.

Adalimumab (Humira), another anti-TNF drug, has a longer half-life, so that has to be taken into account. Things get a little more complicated when it comes to patients treated with ustekinumab (Stelera), which has a particularly long half-life, he noted.

"It’s not quite as easy, because it’s not clear how long to wait after Stelera to give a vaccine. Most efficacy is seen in the first month, and when patients come back at 3 months, they often are starting to get a little psoriasis back. Therefore, 2 months following an injection of Stelera is about the right time to get the vaccine; that way you get the minimum immunosuppression and the maximum chance to respond," he said.

Similarly, with other vaccines like the Gardasil HPV vaccine and the hepatitis A and B vaccines that require a series of shots, the biologic should be stopped for a half-life. This will mean skipping biologic dosing multiple times, but in most cases this won’t be problematic, because it typically takes about 3 months for a patient who is clear to experience significant psoriasis recurrence.

"There’s really no danger in skipping," he said.

While some may advocate waiting two half-lives after vaccination, most experts agree that is unnecessary for killed, recombinant, or subunit (for example, injectable influenza) virus vaccines but is advisable for live attenuated virus vaccines like the intranasal influenza virus vaccine or the herpes zoster vaccine Zostavax, he said.

Dr. Tyring also noted during his presentation that in his experience, concerns about increased infection risk in patients taking TNF inhibitors have been unfounded. In fact, treatment appears to provide an unexpected benefit for those who do become infected with herpes zoster: a reduced risk of postherpetic neuralgia, even among older individuals who are generally at particularly high risk.

After noticing this benefit in his own patients, Dr. Tyring asked his colleagues and found that they, too, had noticed a similar pattern. In 2011, he and his colleagues published a retrospective study of 206 patients on TNF inhibitors who developed herpes zoster, and with only two exceptions involving patients on both a TNF inhibitor and methotrexate, patients universally experienced milder symptoms if they developed shingles while on a TNF inhibitor, he said, noting that this is much lower than rates reported in the literature in the general population (J. Med. Virol. 2011;83:2051-5).

SDEF and this news organization are owned by Frontline Medical Communications.

LAS VEGAS – Dermatologists, like all physicians, play an important role not just in the treatment of disease, but also in the prevention of disease, and that means vaccinating patients when indicated, according to Dr. Stephen K. Tyring.

The varicella vaccines, including the chicken pox and shingles vaccines, and the human papillomavirus (HPV), hepatitis, and influenza virus vaccines are among those to consider offering to patients when appropriate, Dr. Tyring said at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar.

Concerns arise, however, when it comes to vaccinating psoriasis patients who are – or will be – treated with biologics.

Ideally, vaccination should be offered before treatment is initiated, he said, but for some patients – such as those who are under the age for which their insurance company will cover a vaccine (age 50 or 60 for the shingles vaccine, depending on the insurance company, for example) – this may not be possible. In those already taking a biologic drug, the question is how to vaccinate safely and without interfering with treatment efficacy, he said.

"What we usually do – and there’s no absolute golden rule – is ask the patient to stop the drug for one to two half-lives of the drug," said Dr. Tyring of the University of Texas, Houston. We suggest stopping one half-life for killed, subunit, or recombinant virus vaccines and stopping for two half-lives for live attenuated virus vaccines.

With the tumor necrosis factor (TNF) inhibitor etanercept (Enbrel), for example, that means skipping one to two weekly injections.

"That’s a little bit more than a half-life, but if a patient is using Enbrel once or twice a week, the next week, instead of injecting the Enbrel, they can just come in and get the shingles vaccine [Zostavax]," he said.

Adalimumab (Humira), another anti-TNF drug, has a longer half-life, so that has to be taken into account. Things get a little more complicated when it comes to patients treated with ustekinumab (Stelera), which has a particularly long half-life, he noted.

"It’s not quite as easy, because it’s not clear how long to wait after Stelera to give a vaccine. Most efficacy is seen in the first month, and when patients come back at 3 months, they often are starting to get a little psoriasis back. Therefore, 2 months following an injection of Stelera is about the right time to get the vaccine; that way you get the minimum immunosuppression and the maximum chance to respond," he said.

Similarly, with other vaccines like the Gardasil HPV vaccine and the hepatitis A and B vaccines that require a series of shots, the biologic should be stopped for a half-life. This will mean skipping biologic dosing multiple times, but in most cases this won’t be problematic, because it typically takes about 3 months for a patient who is clear to experience significant psoriasis recurrence.

"There’s really no danger in skipping," he said.

While some may advocate waiting two half-lives after vaccination, most experts agree that is unnecessary for killed, recombinant, or subunit (for example, injectable influenza) virus vaccines but is advisable for live attenuated virus vaccines like the intranasal influenza virus vaccine or the herpes zoster vaccine Zostavax, he said.

Dr. Tyring also noted during his presentation that in his experience, concerns about increased infection risk in patients taking TNF inhibitors have been unfounded. In fact, treatment appears to provide an unexpected benefit for those who do become infected with herpes zoster: a reduced risk of postherpetic neuralgia, even among older individuals who are generally at particularly high risk.

After noticing this benefit in his own patients, Dr. Tyring asked his colleagues and found that they, too, had noticed a similar pattern. In 2011, he and his colleagues published a retrospective study of 206 patients on TNF inhibitors who developed herpes zoster, and with only two exceptions involving patients on both a TNF inhibitor and methotrexate, patients universally experienced milder symptoms if they developed shingles while on a TNF inhibitor, he said, noting that this is much lower than rates reported in the literature in the general population (J. Med. Virol. 2011;83:2051-5).

SDEF and this news organization are owned by Frontline Medical Communications.

Biologics and systemic therapies command much of the spotlight for treating psoriasis, but topical therapy remains an effective option for many psoriasis patients, according to Dr. Linda Stein Gold.

In fact, up to 80% of psoriasis patients can be adequately treated with topical therapy (N. Engl. J. Med. 2005;352:1899-912), said Dr. Stein Gold at the Skin Disease Education Foundation’s (SDEF’s) annual Las Vegas dermatology seminar.

She offered several principles to help clinicians make the most of topical therapies by troubleshooting potential problems.

• Check the amount. One gram of most topical psoriasis products covers 4% of body surface area per application, so a 60-gram tube should treat 4% of body surface area for a month, said Dr. Stein Gold, citing guidelines developed by Dr. Alan Menter and his colleagues and approved by the American Academy of Dermatology in 2009.

• Don’t miss corticosteroid allergies. "We are missing this," said Dr. Stein Gold, director of dermatology research at Henry Ford Hospital in Detroit. Suspect a possible allergy if a patient returns with a worsening rash after using hydrocortisone, for example. Data have shown that between 0.2% and 5% of all dermatitis patients have a steroid allergy. "Allergy to the active molecule or to the vehicle should be suspected in all patients who don’t respond as expected to topical steroids," she noted.

• Visit (or revisit) vitamin D. Another plus for topical therapy is the usefulness of topical vitamin D for tricky areas, such as the forehead, armpit, groin, and the area behind the ears. Data from a randomized trial of 75 patients found calcitriol ointment to be significantly more effective against target lesions and better tolerated by patients than calcipotriene ointment (Br. J. Dermatol. 2003;148:326-33).

• Don’t forget coal tar. Simple, but effective, coal tar is a proven safe topical psoriasis treatment and is available in several vehicles, including solution and foam. Data from a study of more than 13,000 patients with psoriasis and eczema found that coal tar was safe, and that it did not increase the risk for skin cancer (J. Invest. Dermatol. 2010;130:953-61).

The future of topical psoriasis therapy is not static, said Dr. Stein Gold. New molecules – notably topical Janus kinase inhibitors and phosphodiesterase-4 inhibitors – are currently being explored in clinical trials.

Dr. Stein Gold disclosed relationships with Leo, Medicis, and other companies. SDEF and this news organization are owned by Frontline Medical Communications.

[email protected]

Biologics and systemic therapies command much of the spotlight for treating psoriasis, but topical therapy remains an effective option for many psoriasis patients, according to Dr. Linda Stein Gold.

In fact, up to 80% of psoriasis patients can be adequately treated with topical therapy (N. Engl. J. Med. 2005;352:1899-912), said Dr. Stein Gold at the Skin Disease Education Foundation’s (SDEF’s) annual Las Vegas dermatology seminar.

She offered several principles to help clinicians make the most of topical therapies by troubleshooting potential problems.

• Check the amount. One gram of most topical psoriasis products covers 4% of body surface area per application, so a 60-gram tube should treat 4% of body surface area for a month, said Dr. Stein Gold, citing guidelines developed by Dr. Alan Menter and his colleagues and approved by the American Academy of Dermatology in 2009.

• Don’t miss corticosteroid allergies. "We are missing this," said Dr. Stein Gold, director of dermatology research at Henry Ford Hospital in Detroit. Suspect a possible allergy if a patient returns with a worsening rash after using hydrocortisone, for example. Data have shown that between 0.2% and 5% of all dermatitis patients have a steroid allergy. "Allergy to the active molecule or to the vehicle should be suspected in all patients who don’t respond as expected to topical steroids," she noted.

• Visit (or revisit) vitamin D. Another plus for topical therapy is the usefulness of topical vitamin D for tricky areas, such as the forehead, armpit, groin, and the area behind the ears. Data from a randomized trial of 75 patients found calcitriol ointment to be significantly more effective against target lesions and better tolerated by patients than calcipotriene ointment (Br. J. Dermatol. 2003;148:326-33).

• Don’t forget coal tar. Simple, but effective, coal tar is a proven safe topical psoriasis treatment and is available in several vehicles, including solution and foam. Data from a study of more than 13,000 patients with psoriasis and eczema found that coal tar was safe, and that it did not increase the risk for skin cancer (J. Invest. Dermatol. 2010;130:953-61).

The future of topical psoriasis therapy is not static, said Dr. Stein Gold. New molecules – notably topical Janus kinase inhibitors and phosphodiesterase-4 inhibitors – are currently being explored in clinical trials.

Dr. Stein Gold disclosed relationships with Leo, Medicis, and other companies. SDEF and this news organization are owned by Frontline Medical Communications.

[email protected]

Biologics and systemic therapies command much of the spotlight for treating psoriasis, but topical therapy remains an effective option for many psoriasis patients, according to Dr. Linda Stein Gold.

In fact, up to 80% of psoriasis patients can be adequately treated with topical therapy (N. Engl. J. Med. 2005;352:1899-912), said Dr. Stein Gold at the Skin Disease Education Foundation’s (SDEF’s) annual Las Vegas dermatology seminar.

She offered several principles to help clinicians make the most of topical therapies by troubleshooting potential problems.

• Check the amount. One gram of most topical psoriasis products covers 4% of body surface area per application, so a 60-gram tube should treat 4% of body surface area for a month, said Dr. Stein Gold, citing guidelines developed by Dr. Alan Menter and his colleagues and approved by the American Academy of Dermatology in 2009.

• Don’t miss corticosteroid allergies. "We are missing this," said Dr. Stein Gold, director of dermatology research at Henry Ford Hospital in Detroit. Suspect a possible allergy if a patient returns with a worsening rash after using hydrocortisone, for example. Data have shown that between 0.2% and 5% of all dermatitis patients have a steroid allergy. "Allergy to the active molecule or to the vehicle should be suspected in all patients who don’t respond as expected to topical steroids," she noted.

• Visit (or revisit) vitamin D. Another plus for topical therapy is the usefulness of topical vitamin D for tricky areas, such as the forehead, armpit, groin, and the area behind the ears. Data from a randomized trial of 75 patients found calcitriol ointment to be significantly more effective against target lesions and better tolerated by patients than calcipotriene ointment (Br. J. Dermatol. 2003;148:326-33).

• Don’t forget coal tar. Simple, but effective, coal tar is a proven safe topical psoriasis treatment and is available in several vehicles, including solution and foam. Data from a study of more than 13,000 patients with psoriasis and eczema found that coal tar was safe, and that it did not increase the risk for skin cancer (J. Invest. Dermatol. 2010;130:953-61).

The future of topical psoriasis therapy is not static, said Dr. Stein Gold. New molecules – notably topical Janus kinase inhibitors and phosphodiesterase-4 inhibitors – are currently being explored in clinical trials.

Dr. Stein Gold disclosed relationships with Leo, Medicis, and other companies. SDEF and this news organization are owned by Frontline Medical Communications.

[email protected]

SAN DIEGO – Rheumatoid arthritis patients undergoing surgery who stayed on their antirheumatic medication perioperatively didn’t have a higher risk of early postoperative infection compared with those who temporarily stopped treatment before surgery, according to findings from a large national Veterans Affairs study.

Rheumatologists are frequently consulted about this issue. Evidence to guide practice has been scarce, however, and until now many rheumatologists and surgeons have taken a conservative approach, reasoning that the immunosuppressive drugs employed in controlling inflammation in rheumatoid arthritis might also increase the risk of surgical wound infection.

A common practice has been to have RA patients stop their medication a month ahead of elective surgery, or at least two drug half-lives beforehand, then start treatment again roughly a month after the operation, or when the wound has healed. The new Veterans Affairs (VA) study findings suggest this practice may be unnecessary, Dr. Zaki Abou Zahr said at the annual meeting of the American College of Rheumatology.

Dr. Bernard Ng, his senior coinvestigator in the study, added that temporarily stopping antirheumatic agents before surgery may actually be harmful in that it increases the risk of a flare of the RA, which in turn would impede postoperative rehabilitation.

But there is a major caveat regarding the VA study: Participation was restricted to RA patients on only a single conventional disease-modifying antirheumatic drug (DMARD) or biologic agent leading up to surgery. This restriction, imposed to make for a more clear-cut analysis, means that the study results can’t be extrapolated to patients on multidrug therapy. And multidrug therapy is quite common. Indeed, slightly more than half of RA patients in the VA health care system are on combination therapy, most often methotrexate plus a biologic agent, noted Dr. Ng, chief of rheumatology at the VA Puget Sound Health Care System, Seattle.

Dr. Abou Zahr presented the retrospective cohort study involving 6,548 RA patients in VA administrative databases, all of whom were on antirheumatic drug monotherapy prior to surgery. The surgery was of all types, including cardiothoracic, gastrointestinal, vascular, and orthopedic, as well as emergent and elective.

The primary endpoints were the rate of wound infections, both superficial and deep, within 30 days post surgery, and the general infection rate – including pneumonia, sepsis, and urinary tract infections – during the same time frame.

Sixty-two percent of the 1,480 RA patients on a single biologic agent did not stop taking it preoperatively. One key study finding was that neither their postoperative wound infection rate nor their general infection rate differed significantly from rates in patients who temporarily halted their biologic agent. The same held true among the 70% of patients on a single conventional DMARD who did not stop taking their medication preoperatively, according to Dr. Abou Zahr of Baylor College of Medicine, Houston.

Dr. Ng said the investigators plan to extend their work to include RA patients on multiple antirheumatic drugs that they do or don’t temporarily stop when undergoing surgery within the VA system. The researchers also plan to take a close look at patients undergoing specific types of surgery to see if the postoperative infection risk in patients who remain on treatment varies according to their operation.

Dr. Fehmida Zahabi, a rheumatologist from Plano, Tex., who chaired a press conference highlighting the VA study findings, said that while she’d like to see a confirmatory study, "I think we’re getting to the point where we’re saying we should cautiously keep these patients on their medications. That’s what the data suggest."

She noted that before the VA study, the very limited evidence available to guide practice in this area centered on a 12-year-old British randomized trial involving RA patients on methotrexate undergoing elective orthopedic surgery. Those assigned to stop the drug from 2 weeks before surgery to 2 weeks post surgery had significantly more infections, surgical complications, and RA flares within 6 weeks after surgery (Ann. Rheum. Dis. 2001;60:214-7).

As for patients on multidrug therapy who are scheduled for surgery, her inclination until evidence becomes available for guidance is to pare down the regimen preoperatively, while keeping the patient on one or two drugs.

The VA study was funded by the Department of Veterans Affairs. Dr. Abou Zahr and Dr. Ng reported having no conflicts of interest.

[email protected]

SAN DIEGO – Rheumatoid arthritis patients undergoing surgery who stayed on their antirheumatic medication perioperatively didn’t have a higher risk of early postoperative infection compared with those who temporarily stopped treatment before surgery, according to findings from a large national Veterans Affairs study.

Rheumatologists are frequently consulted about this issue. Evidence to guide practice has been scarce, however, and until now many rheumatologists and surgeons have taken a conservative approach, reasoning that the immunosuppressive drugs employed in controlling inflammation in rheumatoid arthritis might also increase the risk of surgical wound infection.

A common practice has been to have RA patients stop their medication a month ahead of elective surgery, or at least two drug half-lives beforehand, then start treatment again roughly a month after the operation, or when the wound has healed. The new Veterans Affairs (VA) study findings suggest this practice may be unnecessary, Dr. Zaki Abou Zahr said at the annual meeting of the American College of Rheumatology.

Dr. Bernard Ng, his senior coinvestigator in the study, added that temporarily stopping antirheumatic agents before surgery may actually be harmful in that it increases the risk of a flare of the RA, which in turn would impede postoperative rehabilitation.

But there is a major caveat regarding the VA study: Participation was restricted to RA patients on only a single conventional disease-modifying antirheumatic drug (DMARD) or biologic agent leading up to surgery. This restriction, imposed to make for a more clear-cut analysis, means that the study results can’t be extrapolated to patients on multidrug therapy. And multidrug therapy is quite common. Indeed, slightly more than half of RA patients in the VA health care system are on combination therapy, most often methotrexate plus a biologic agent, noted Dr. Ng, chief of rheumatology at the VA Puget Sound Health Care System, Seattle.

Dr. Abou Zahr presented the retrospective cohort study involving 6,548 RA patients in VA administrative databases, all of whom were on antirheumatic drug monotherapy prior to surgery. The surgery was of all types, including cardiothoracic, gastrointestinal, vascular, and orthopedic, as well as emergent and elective.

The primary endpoints were the rate of wound infections, both superficial and deep, within 30 days post surgery, and the general infection rate – including pneumonia, sepsis, and urinary tract infections – during the same time frame.

Sixty-two percent of the 1,480 RA patients on a single biologic agent did not stop taking it preoperatively. One key study finding was that neither their postoperative wound infection rate nor their general infection rate differed significantly from rates in patients who temporarily halted their biologic agent. The same held true among the 70% of patients on a single conventional DMARD who did not stop taking their medication preoperatively, according to Dr. Abou Zahr of Baylor College of Medicine, Houston.

Dr. Ng said the investigators plan to extend their work to include RA patients on multiple antirheumatic drugs that they do or don’t temporarily stop when undergoing surgery within the VA system. The researchers also plan to take a close look at patients undergoing specific types of surgery to see if the postoperative infection risk in patients who remain on treatment varies according to their operation.

Dr. Fehmida Zahabi, a rheumatologist from Plano, Tex., who chaired a press conference highlighting the VA study findings, said that while she’d like to see a confirmatory study, "I think we’re getting to the point where we’re saying we should cautiously keep these patients on their medications. That’s what the data suggest."

She noted that before the VA study, the very limited evidence available to guide practice in this area centered on a 12-year-old British randomized trial involving RA patients on methotrexate undergoing elective orthopedic surgery. Those assigned to stop the drug from 2 weeks before surgery to 2 weeks post surgery had significantly more infections, surgical complications, and RA flares within 6 weeks after surgery (Ann. Rheum. Dis. 2001;60:214-7).

As for patients on multidrug therapy who are scheduled for surgery, her inclination until evidence becomes available for guidance is to pare down the regimen preoperatively, while keeping the patient on one or two drugs.

The VA study was funded by the Department of Veterans Affairs. Dr. Abou Zahr and Dr. Ng reported having no conflicts of interest.

[email protected]

SAN DIEGO – Rheumatoid arthritis patients undergoing surgery who stayed on their antirheumatic medication perioperatively didn’t have a higher risk of early postoperative infection compared with those who temporarily stopped treatment before surgery, according to findings from a large national Veterans Affairs study.

Rheumatologists are frequently consulted about this issue. Evidence to guide practice has been scarce, however, and until now many rheumatologists and surgeons have taken a conservative approach, reasoning that the immunosuppressive drugs employed in controlling inflammation in rheumatoid arthritis might also increase the risk of surgical wound infection.

A common practice has been to have RA patients stop their medication a month ahead of elective surgery, or at least two drug half-lives beforehand, then start treatment again roughly a month after the operation, or when the wound has healed. The new Veterans Affairs (VA) study findings suggest this practice may be unnecessary, Dr. Zaki Abou Zahr said at the annual meeting of the American College of Rheumatology.

Dr. Bernard Ng, his senior coinvestigator in the study, added that temporarily stopping antirheumatic agents before surgery may actually be harmful in that it increases the risk of a flare of the RA, which in turn would impede postoperative rehabilitation.

But there is a major caveat regarding the VA study: Participation was restricted to RA patients on only a single conventional disease-modifying antirheumatic drug (DMARD) or biologic agent leading up to surgery. This restriction, imposed to make for a more clear-cut analysis, means that the study results can’t be extrapolated to patients on multidrug therapy. And multidrug therapy is quite common. Indeed, slightly more than half of RA patients in the VA health care system are on combination therapy, most often methotrexate plus a biologic agent, noted Dr. Ng, chief of rheumatology at the VA Puget Sound Health Care System, Seattle.

Dr. Abou Zahr presented the retrospective cohort study involving 6,548 RA patients in VA administrative databases, all of whom were on antirheumatic drug monotherapy prior to surgery. The surgery was of all types, including cardiothoracic, gastrointestinal, vascular, and orthopedic, as well as emergent and elective.

The primary endpoints were the rate of wound infections, both superficial and deep, within 30 days post surgery, and the general infection rate – including pneumonia, sepsis, and urinary tract infections – during the same time frame.

Sixty-two percent of the 1,480 RA patients on a single biologic agent did not stop taking it preoperatively. One key study finding was that neither their postoperative wound infection rate nor their general infection rate differed significantly from rates in patients who temporarily halted their biologic agent. The same held true among the 70% of patients on a single conventional DMARD who did not stop taking their medication preoperatively, according to Dr. Abou Zahr of Baylor College of Medicine, Houston.

Dr. Ng said the investigators plan to extend their work to include RA patients on multiple antirheumatic drugs that they do or don’t temporarily stop when undergoing surgery within the VA system. The researchers also plan to take a close look at patients undergoing specific types of surgery to see if the postoperative infection risk in patients who remain on treatment varies according to their operation.

Dr. Fehmida Zahabi, a rheumatologist from Plano, Tex., who chaired a press conference highlighting the VA study findings, said that while she’d like to see a confirmatory study, "I think we’re getting to the point where we’re saying we should cautiously keep these patients on their medications. That’s what the data suggest."

She noted that before the VA study, the very limited evidence available to guide practice in this area centered on a 12-year-old British randomized trial involving RA patients on methotrexate undergoing elective orthopedic surgery. Those assigned to stop the drug from 2 weeks before surgery to 2 weeks post surgery had significantly more infections, surgical complications, and RA flares within 6 weeks after surgery (Ann. Rheum. Dis. 2001;60:214-7).

As for patients on multidrug therapy who are scheduled for surgery, her inclination until evidence becomes available for guidance is to pare down the regimen preoperatively, while keeping the patient on one or two drugs.

The VA study was funded by the Department of Veterans Affairs. Dr. Abou Zahr and Dr. Ng reported having no conflicts of interest.

[email protected]

SAN DIEGO – Patients with systemic sclerosis are at greater than eightfold increased risk of having an acute myocardial infarction during the first year after diagnosis, compared with matched controls, according to the first large population-based cohort study to look at the issue.

After that first year, the MI risk drops off over time. Still, during years 1-5 post diagnosis the MI risk remains more than triple that of the matched general population, Dr. J. Antonio Avina-Zubieta reported at the annual meeting of the American College of Rheumatology.

"Our findings support increased vigilance in cardiovascular disease prevention, surveillance, and risk modification in patients with systemic sclerosis," declared Dr. Avina-Zubieta, a rheumatologist at the University of British Columbia, Vancouver.

He and his coinvestigators harnessed comprehensive provincial medical databases to identify all 1,245 adults diagnosed with rheumatologist-confirmed systemic sclerosis (SSc) in British Columbia during 1996-2010. The SSc patients averaged 53 years of age at the time of their rheumatologic diagnosis. Eighty-three percent were women.

During a mean follow-up period of 3.5 years following diagnosis of SSc, 89 patients experienced an acute MI, as did 289 controls. This translated to an incidence rate of 20.2 cases per 1,000 person-years among patients with SSc, compared with 5.3 per 1,000 among controls.

The risk was 8.2-fold greater in SSc patients than controls during the first year after diagnosis and 3.5 times greater during years 1-5 after diagnosis, but once patients got more than 5 years out from diagnosis there was no longer any significant increase in MI risk.

Patients with SSc who were in the 45- to 59-year-old age group were at greatest risk: They were 7.4 times more likely than controls to have an MI. SSc patients aged 60-74 years had a 4.4-fold greater risk of MI than did controls, and those aged 75 years and older were at 5.6-fold increased risk.

The SSc patients remained at a 4.3-fold increased risk of MI, compared with controls, in a multivariate analysis extensively adjusted for baseline chronic obstructive pulmonary disease, angina, obesity, hormone replacement therapy, Charlson Comorbidity Index, number of hospitalizations during the 12 months prior to diagnosis, and the use of NSAIDs, COX-2 inhibitors, glucocorticoids, lipid-lowering drugs, and antidiabetic medications.

It is well established that patients with rheumatoid arthritis or systemic lupus erythematosus have an increased risk of premature atherosclerotic disease. Up until now, however, information about the risk of major adverse cardiovascular events in patients with SSc has been scarce and has come from nondefinitive studies in selected populations or cross-sectional studies lacking adequate adjustment for potential confounding factors, according to Dr. Avina-Zubieta, who also is a research scientist at the Arthritis Research Centre of Canada in Richmond, B.C.

Why the sharp increase in MI risk during the first year after diagnosis of SSc? He offered two hypotheses. One is that this is a time of particularly great inflammatory load as physicians work to get the disease under control. Also, there is a phenomenon Dr. Avina-Zubieta called "the depletion of susceptibles," whereby, once the patients at higher risk have had their MI early on, those who remain aren’t at sufficient risk to stand out from the general population.

The study was sponsored by the Arthritis Centre of Canada. Dr. Avina-Zubieta reported having no financial conflicts of interest.

[email protected]

SAN DIEGO – Patients with systemic sclerosis are at greater than eightfold increased risk of having an acute myocardial infarction during the first year after diagnosis, compared with matched controls, according to the first large population-based cohort study to look at the issue.

After that first year, the MI risk drops off over time. Still, during years 1-5 post diagnosis the MI risk remains more than triple that of the matched general population, Dr. J. Antonio Avina-Zubieta reported at the annual meeting of the American College of Rheumatology.

"Our findings support increased vigilance in cardiovascular disease prevention, surveillance, and risk modification in patients with systemic sclerosis," declared Dr. Avina-Zubieta, a rheumatologist at the University of British Columbia, Vancouver.

He and his coinvestigators harnessed comprehensive provincial medical databases to identify all 1,245 adults diagnosed with rheumatologist-confirmed systemic sclerosis (SSc) in British Columbia during 1996-2010. The SSc patients averaged 53 years of age at the time of their rheumatologic diagnosis. Eighty-three percent were women.

During a mean follow-up period of 3.5 years following diagnosis of SSc, 89 patients experienced an acute MI, as did 289 controls. This translated to an incidence rate of 20.2 cases per 1,000 person-years among patients with SSc, compared with 5.3 per 1,000 among controls.

The risk was 8.2-fold greater in SSc patients than controls during the first year after diagnosis and 3.5 times greater during years 1-5 after diagnosis, but once patients got more than 5 years out from diagnosis there was no longer any significant increase in MI risk.

Patients with SSc who were in the 45- to 59-year-old age group were at greatest risk: They were 7.4 times more likely than controls to have an MI. SSc patients aged 60-74 years had a 4.4-fold greater risk of MI than did controls, and those aged 75 years and older were at 5.6-fold increased risk.

The SSc patients remained at a 4.3-fold increased risk of MI, compared with controls, in a multivariate analysis extensively adjusted for baseline chronic obstructive pulmonary disease, angina, obesity, hormone replacement therapy, Charlson Comorbidity Index, number of hospitalizations during the 12 months prior to diagnosis, and the use of NSAIDs, COX-2 inhibitors, glucocorticoids, lipid-lowering drugs, and antidiabetic medications.

It is well established that patients with rheumatoid arthritis or systemic lupus erythematosus have an increased risk of premature atherosclerotic disease. Up until now, however, information about the risk of major adverse cardiovascular events in patients with SSc has been scarce and has come from nondefinitive studies in selected populations or cross-sectional studies lacking adequate adjustment for potential confounding factors, according to Dr. Avina-Zubieta, who also is a research scientist at the Arthritis Research Centre of Canada in Richmond, B.C.

Why the sharp increase in MI risk during the first year after diagnosis of SSc? He offered two hypotheses. One is that this is a time of particularly great inflammatory load as physicians work to get the disease under control. Also, there is a phenomenon Dr. Avina-Zubieta called "the depletion of susceptibles," whereby, once the patients at higher risk have had their MI early on, those who remain aren’t at sufficient risk to stand out from the general population.

The study was sponsored by the Arthritis Centre of Canada. Dr. Avina-Zubieta reported having no financial conflicts of interest.

[email protected]

SAN DIEGO – Patients with systemic sclerosis are at greater than eightfold increased risk of having an acute myocardial infarction during the first year after diagnosis, compared with matched controls, according to the first large population-based cohort study to look at the issue.

After that first year, the MI risk drops off over time. Still, during years 1-5 post diagnosis the MI risk remains more than triple that of the matched general population, Dr. J. Antonio Avina-Zubieta reported at the annual meeting of the American College of Rheumatology.

"Our findings support increased vigilance in cardiovascular disease prevention, surveillance, and risk modification in patients with systemic sclerosis," declared Dr. Avina-Zubieta, a rheumatologist at the University of British Columbia, Vancouver.

He and his coinvestigators harnessed comprehensive provincial medical databases to identify all 1,245 adults diagnosed with rheumatologist-confirmed systemic sclerosis (SSc) in British Columbia during 1996-2010. The SSc patients averaged 53 years of age at the time of their rheumatologic diagnosis. Eighty-three percent were women.

During a mean follow-up period of 3.5 years following diagnosis of SSc, 89 patients experienced an acute MI, as did 289 controls. This translated to an incidence rate of 20.2 cases per 1,000 person-years among patients with SSc, compared with 5.3 per 1,000 among controls.

The risk was 8.2-fold greater in SSc patients than controls during the first year after diagnosis and 3.5 times greater during years 1-5 after diagnosis, but once patients got more than 5 years out from diagnosis there was no longer any significant increase in MI risk.

Patients with SSc who were in the 45- to 59-year-old age group were at greatest risk: They were 7.4 times more likely than controls to have an MI. SSc patients aged 60-74 years had a 4.4-fold greater risk of MI than did controls, and those aged 75 years and older were at 5.6-fold increased risk.

The SSc patients remained at a 4.3-fold increased risk of MI, compared with controls, in a multivariate analysis extensively adjusted for baseline chronic obstructive pulmonary disease, angina, obesity, hormone replacement therapy, Charlson Comorbidity Index, number of hospitalizations during the 12 months prior to diagnosis, and the use of NSAIDs, COX-2 inhibitors, glucocorticoids, lipid-lowering drugs, and antidiabetic medications.

It is well established that patients with rheumatoid arthritis or systemic lupus erythematosus have an increased risk of premature atherosclerotic disease. Up until now, however, information about the risk of major adverse cardiovascular events in patients with SSc has been scarce and has come from nondefinitive studies in selected populations or cross-sectional studies lacking adequate adjustment for potential confounding factors, according to Dr. Avina-Zubieta, who also is a research scientist at the Arthritis Research Centre of Canada in Richmond, B.C.

Why the sharp increase in MI risk during the first year after diagnosis of SSc? He offered two hypotheses. One is that this is a time of particularly great inflammatory load as physicians work to get the disease under control. Also, there is a phenomenon Dr. Avina-Zubieta called "the depletion of susceptibles," whereby, once the patients at higher risk have had their MI early on, those who remain aren’t at sufficient risk to stand out from the general population.

The study was sponsored by the Arthritis Centre of Canada. Dr. Avina-Zubieta reported having no financial conflicts of interest.

[email protected]

SAN DIEGO – Fewer than one in three Medicaid beneficiaries with systemic lupus erythematosus are adhering to their recommended treatment regimens at least 80% of the time, results from a large national analysis demonstrated.

"As a physician who spends my professional time taking care of people with lupus, these data are highly concerning," Dr. Jinoos Yazdany said in an interview prior to the annual meeting of the American College of Rheumatology, where the study was presented. "For many individuals with lupus, treatment is very effective and has a proven track record of preventing life-threatening complications and long-term organ damage such as kidney failure. The fact that less than one in three patients are adhering with treatment is alarming and should serve as a call to action for those of providing care to these patients."

Dr. Yazdany, associate director of the lupus clinic at the University of California-San Francisco Medical Center, and her colleagues used MAX (Medicaid Analytic eXtract) data from 2000 to 2006 to identify 23,187 patients with systemic lupus erythematosus (SLE) who were taking at least one immunosuppressive or antimalarial drug. They used pharmacy claims to assess adherence to drugs over a period of 180 days by calculating a medication possession ratio (MPR), defined as the proportion of days covered by the total days’ supply dispensed after the first claim for each drug. The researchers also evaluated the proportion of patients who had an MPR of 80% or greater. The oral drugs studied were hydroxychloroquine, azathioprine, methotrexate, mycophenolate mofetil, cyclosporine, tacrolimus, cyclophosphamide, and leflunomide.

The mean age of the 23,187 patients was 38 years, 94% were female, and the racial and ethnic makeup was diverse (40% black, 34% white, 16% Hispanic, 5% Asian, and 5% other). The highest proportion of SLE patients lived in the southern United States (36%).

Dr. Yazdany reported that the average MPR ranged from 31.1% for tacrolimus to 56% for hydroxychloroquine. In addition, for most drugs, fewer than one in three patients had an MPR of at least 80%. Overall adherence was poorest among those taking tacrolimus (14%) and highest among those taking mycophenolate mofetil (40%).

Across all medications, blacks had lower adherence, compared with whites, and adherence was highest for those residing in the Northeast.

"Our findings underscore the need to understand the reasons behind low adherence in this high-risk and vulnerable group of patients," Dr. Yazdany said. "And we urgently need to develop interventions to improve adherence. Physicians may be unaware of their patient’s adherence with medication, and patients may not be forthcoming about this issue. Concerns about side effects, inadequate understanding of the benefit, and the medication’s cost may be barriers for patients. Treatment-associated side effects may be another important barrier. We need better patient-physician communication around the issue of adherence."

The Medicaid administrative data allowed for an otherwise unobtainable nationwide view of adherence in SLE, but Dr. Yazdany acknowledged certain limitations of the study, including the fact that treatment "may be interrupted for clinically appropriate reasons, so the medication possession ratios in our study may underestimate actual adherence. Also, pharmacy claims are imperfect proxies for whether patients actually take medications that are dispensed, which might lead to an overestimation of adherence."

Dr. Yazdany disclosed that her research is funded by the National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases. She had no other relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Fewer than one in three Medicaid beneficiaries with systemic lupus erythematosus are adhering to their recommended treatment regimens at least 80% of the time, results from a large national analysis demonstrated.

"As a physician who spends my professional time taking care of people with lupus, these data are highly concerning," Dr. Jinoos Yazdany said in an interview prior to the annual meeting of the American College of Rheumatology, where the study was presented. "For many individuals with lupus, treatment is very effective and has a proven track record of preventing life-threatening complications and long-term organ damage such as kidney failure. The fact that less than one in three patients are adhering with treatment is alarming and should serve as a call to action for those of providing care to these patients."

Dr. Yazdany, associate director of the lupus clinic at the University of California-San Francisco Medical Center, and her colleagues used MAX (Medicaid Analytic eXtract) data from 2000 to 2006 to identify 23,187 patients with systemic lupus erythematosus (SLE) who were taking at least one immunosuppressive or antimalarial drug. They used pharmacy claims to assess adherence to drugs over a period of 180 days by calculating a medication possession ratio (MPR), defined as the proportion of days covered by the total days’ supply dispensed after the first claim for each drug. The researchers also evaluated the proportion of patients who had an MPR of 80% or greater. The oral drugs studied were hydroxychloroquine, azathioprine, methotrexate, mycophenolate mofetil, cyclosporine, tacrolimus, cyclophosphamide, and leflunomide.

The mean age of the 23,187 patients was 38 years, 94% were female, and the racial and ethnic makeup was diverse (40% black, 34% white, 16% Hispanic, 5% Asian, and 5% other). The highest proportion of SLE patients lived in the southern United States (36%).

Dr. Yazdany reported that the average MPR ranged from 31.1% for tacrolimus to 56% for hydroxychloroquine. In addition, for most drugs, fewer than one in three patients had an MPR of at least 80%. Overall adherence was poorest among those taking tacrolimus (14%) and highest among those taking mycophenolate mofetil (40%).

Across all medications, blacks had lower adherence, compared with whites, and adherence was highest for those residing in the Northeast.

"Our findings underscore the need to understand the reasons behind low adherence in this high-risk and vulnerable group of patients," Dr. Yazdany said. "And we urgently need to develop interventions to improve adherence. Physicians may be unaware of their patient’s adherence with medication, and patients may not be forthcoming about this issue. Concerns about side effects, inadequate understanding of the benefit, and the medication’s cost may be barriers for patients. Treatment-associated side effects may be another important barrier. We need better patient-physician communication around the issue of adherence."

The Medicaid administrative data allowed for an otherwise unobtainable nationwide view of adherence in SLE, but Dr. Yazdany acknowledged certain limitations of the study, including the fact that treatment "may be interrupted for clinically appropriate reasons, so the medication possession ratios in our study may underestimate actual adherence. Also, pharmacy claims are imperfect proxies for whether patients actually take medications that are dispensed, which might lead to an overestimation of adherence."

Dr. Yazdany disclosed that her research is funded by the National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases. She had no other relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Fewer than one in three Medicaid beneficiaries with systemic lupus erythematosus are adhering to their recommended treatment regimens at least 80% of the time, results from a large national analysis demonstrated.

"As a physician who spends my professional time taking care of people with lupus, these data are highly concerning," Dr. Jinoos Yazdany said in an interview prior to the annual meeting of the American College of Rheumatology, where the study was presented. "For many individuals with lupus, treatment is very effective and has a proven track record of preventing life-threatening complications and long-term organ damage such as kidney failure. The fact that less than one in three patients are adhering with treatment is alarming and should serve as a call to action for those of providing care to these patients."

Dr. Yazdany, associate director of the lupus clinic at the University of California-San Francisco Medical Center, and her colleagues used MAX (Medicaid Analytic eXtract) data from 2000 to 2006 to identify 23,187 patients with systemic lupus erythematosus (SLE) who were taking at least one immunosuppressive or antimalarial drug. They used pharmacy claims to assess adherence to drugs over a period of 180 days by calculating a medication possession ratio (MPR), defined as the proportion of days covered by the total days’ supply dispensed after the first claim for each drug. The researchers also evaluated the proportion of patients who had an MPR of 80% or greater. The oral drugs studied were hydroxychloroquine, azathioprine, methotrexate, mycophenolate mofetil, cyclosporine, tacrolimus, cyclophosphamide, and leflunomide.

The mean age of the 23,187 patients was 38 years, 94% were female, and the racial and ethnic makeup was diverse (40% black, 34% white, 16% Hispanic, 5% Asian, and 5% other). The highest proportion of SLE patients lived in the southern United States (36%).

Dr. Yazdany reported that the average MPR ranged from 31.1% for tacrolimus to 56% for hydroxychloroquine. In addition, for most drugs, fewer than one in three patients had an MPR of at least 80%. Overall adherence was poorest among those taking tacrolimus (14%) and highest among those taking mycophenolate mofetil (40%).

Across all medications, blacks had lower adherence, compared with whites, and adherence was highest for those residing in the Northeast.

"Our findings underscore the need to understand the reasons behind low adherence in this high-risk and vulnerable group of patients," Dr. Yazdany said. "And we urgently need to develop interventions to improve adherence. Physicians may be unaware of their patient’s adherence with medication, and patients may not be forthcoming about this issue. Concerns about side effects, inadequate understanding of the benefit, and the medication’s cost may be barriers for patients. Treatment-associated side effects may be another important barrier. We need better patient-physician communication around the issue of adherence."

The Medicaid administrative data allowed for an otherwise unobtainable nationwide view of adherence in SLE, but Dr. Yazdany acknowledged certain limitations of the study, including the fact that treatment "may be interrupted for clinically appropriate reasons, so the medication possession ratios in our study may underestimate actual adherence. Also, pharmacy claims are imperfect proxies for whether patients actually take medications that are dispensed, which might lead to an overestimation of adherence."

Dr. Yazdany disclosed that her research is funded by the National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases. She had no other relevant financial conflicts to disclose.

[email protected]

ISTANBUL, TURKEY – The investigational oral phosphodiesterase-4 inhibitor apremilast showed dramatic efficacy in the treatment of oral and genital ulcers of Behçet’s syndrome in a randomized, double-blind clinical trial.

The multicenter phase II study included 111 Behçet’s syndrome patients with active oral ulcers. They were randomized to 12 weeks of double-blind apremilast at 30 mg twice daily or placebo followed by an additional 12 weeks of open-label apremilast for all, then 4 weeks of post-treatment observation.

Participants had a mean of 2.8 oral ulcers at baseline. The primary study endpoint was the number present at week 12: a mean of 0.5 in the apremilast group, compared with 2.1 in controls, Dr. Gülen Hatemi reported at the annual congress of the European Academy of Dermatology and Venereology.

A total of 71% of patients in the apremilast group were oral ulcer–free at week 12, as were 29% of controls, added Dr. Hatemi, a rheumatologist at Istanbul (Turkey) University.

The benefit of apremilast occurred rapidly. The full response was seen at week 2 and was then maintained throughout the remainder of the 12 weeks of double-blind therapy and the following 12 weeks of open-label apremilast. However, oral ulcers returned in full force quickly after treatment cessation.

Pain from oral ulcers on a 0-100 visual analog scale plummeted in the apremilast group by a mean 44.7 points from a baseline of score of 54. In contrast, pain scores in the control group improved by 16 points, which is less than the 20-point threshold accepted as being clinically meaningful.

Behçet’s syndrome is an immune-mediated small-vessel vasculitis. Its mucocutaneous manifestations can be disabling and resistant to conventional therapies, Dr. Hatemi noted.

Only 16 patients had genital ulcers. All 10 randomized to apremilast were free of the ulcers at week 12, as were three of six affected patients in the control group.

Average scores on the Behçet’s Disease Activity Index dropped from 3.4 at baseline to 2.0 at 12 weeks in the apremilast arm while remaining unchanged in controls. Mean scores on the Behçet’s Disease Quality of Life instrument decreased by 4.5 points from a baseline of 12.6 in apremilast-treated patients, compared with a 1.6-point reduction in controls.

The investigators said no serious adverse events were related to apremilast.

Dr. Hatemi received a research grant from Celgene, the study sponsor, which is also developing the oral drug as a possible treatment for psoriasis, psoriatic arthritis, and ankylosing spondylitis.

[email protected]

ISTANBUL, TURKEY – The investigational oral phosphodiesterase-4 inhibitor apremilast showed dramatic efficacy in the treatment of oral and genital ulcers of Behçet’s syndrome in a randomized, double-blind clinical trial.

The multicenter phase II study included 111 Behçet’s syndrome patients with active oral ulcers. They were randomized to 12 weeks of double-blind apremilast at 30 mg twice daily or placebo followed by an additional 12 weeks of open-label apremilast for all, then 4 weeks of post-treatment observation.

Participants had a mean of 2.8 oral ulcers at baseline. The primary study endpoint was the number present at week 12: a mean of 0.5 in the apremilast group, compared with 2.1 in controls, Dr. Gülen Hatemi reported at the annual congress of the European Academy of Dermatology and Venereology.

A total of 71% of patients in the apremilast group were oral ulcer–free at week 12, as were 29% of controls, added Dr. Hatemi, a rheumatologist at Istanbul (Turkey) University.

The benefit of apremilast occurred rapidly. The full response was seen at week 2 and was then maintained throughout the remainder of the 12 weeks of double-blind therapy and the following 12 weeks of open-label apremilast. However, oral ulcers returned in full force quickly after treatment cessation.

Pain from oral ulcers on a 0-100 visual analog scale plummeted in the apremilast group by a mean 44.7 points from a baseline of score of 54. In contrast, pain scores in the control group improved by 16 points, which is less than the 20-point threshold accepted as being clinically meaningful.

Behçet’s syndrome is an immune-mediated small-vessel vasculitis. Its mucocutaneous manifestations can be disabling and resistant to conventional therapies, Dr. Hatemi noted.

Only 16 patients had genital ulcers. All 10 randomized to apremilast were free of the ulcers at week 12, as were three of six affected patients in the control group.

Average scores on the Behçet’s Disease Activity Index dropped from 3.4 at baseline to 2.0 at 12 weeks in the apremilast arm while remaining unchanged in controls. Mean scores on the Behçet’s Disease Quality of Life instrument decreased by 4.5 points from a baseline of 12.6 in apremilast-treated patients, compared with a 1.6-point reduction in controls.

The investigators said no serious adverse events were related to apremilast.

Dr. Hatemi received a research grant from Celgene, the study sponsor, which is also developing the oral drug as a possible treatment for psoriasis, psoriatic arthritis, and ankylosing spondylitis.

[email protected]

ISTANBUL, TURKEY – The investigational oral phosphodiesterase-4 inhibitor apremilast showed dramatic efficacy in the treatment of oral and genital ulcers of Behçet’s syndrome in a randomized, double-blind clinical trial.

The multicenter phase II study included 111 Behçet’s syndrome patients with active oral ulcers. They were randomized to 12 weeks of double-blind apremilast at 30 mg twice daily or placebo followed by an additional 12 weeks of open-label apremilast for all, then 4 weeks of post-treatment observation.

Participants had a mean of 2.8 oral ulcers at baseline. The primary study endpoint was the number present at week 12: a mean of 0.5 in the apremilast group, compared with 2.1 in controls, Dr. Gülen Hatemi reported at the annual congress of the European Academy of Dermatology and Venereology.

A total of 71% of patients in the apremilast group were oral ulcer–free at week 12, as were 29% of controls, added Dr. Hatemi, a rheumatologist at Istanbul (Turkey) University.

The benefit of apremilast occurred rapidly. The full response was seen at week 2 and was then maintained throughout the remainder of the 12 weeks of double-blind therapy and the following 12 weeks of open-label apremilast. However, oral ulcers returned in full force quickly after treatment cessation.

Pain from oral ulcers on a 0-100 visual analog scale plummeted in the apremilast group by a mean 44.7 points from a baseline of score of 54. In contrast, pain scores in the control group improved by 16 points, which is less than the 20-point threshold accepted as being clinically meaningful.

Behçet’s syndrome is an immune-mediated small-vessel vasculitis. Its mucocutaneous manifestations can be disabling and resistant to conventional therapies, Dr. Hatemi noted.

Only 16 patients had genital ulcers. All 10 randomized to apremilast were free of the ulcers at week 12, as were three of six affected patients in the control group.

Average scores on the Behçet’s Disease Activity Index dropped from 3.4 at baseline to 2.0 at 12 weeks in the apremilast arm while remaining unchanged in controls. Mean scores on the Behçet’s Disease Quality of Life instrument decreased by 4.5 points from a baseline of 12.6 in apremilast-treated patients, compared with a 1.6-point reduction in controls.

The investigators said no serious adverse events were related to apremilast.

Dr. Hatemi received a research grant from Celgene, the study sponsor, which is also developing the oral drug as a possible treatment for psoriasis, psoriatic arthritis, and ankylosing spondylitis.

[email protected]