User login
Managing asthma in children: Pets don’t always have to go
SAN ANTONIO – It may not always be necessary to tell parents of children with asthma to get rid of the household pet, a recent study suggests.
Children with had significant improvements in a variety of asthma measures, regardless of whether parents reported pets or smoking at home, according to results of the 4-year, 471-patient prospective study.
Those results suggest that clinicians should be working to make sure the guidelines are being closely followed before, for example, telling parents they need to consider getting rid of the family pet, said Shahid Sheikh, MD, FCCP, of Nationwide Children’s Hospital, Columbus, Ohio.
“As the guidelines still work, we need to focus and develop the connections with the family to make sure the patients are on the right treatment, and that they’re getting the medications,” Dr. Sheikh said in an interview at the annual meeting of the American College of Chest Physicians.
The prospective cohort study by Dr. Sheikh and his colleagues, presented in a poster session, included children referred to a pediatric asthma center with the diagnosis of uncontrolled asthma. All patients received asthma care according to National Asthma Education and Prevention Program Expert Panel Report 3 guidelines.
Medications were changed as needed, and the asthma action plan was revised accordingly and reviewed with the family at each visit, Dr. Sheikh reported. After a baseline evaluation, clinic visits for the study occurred at 3 months, 6 months, and then at 1, 2, 3, and 4 years.
Out of 471 patients, 258 had pets, and 125 were in homes where smoking took place, according to parent reports.
Asthma control test scores were 15.1 at baseline for children in no-pet households, and 16.5 for those with pets; by the 3-month visit, scores increased to 20.1 and 20.3 for the no-pet and pet groups, and at 4 years, those scores had edged up to 22.2 and 22.7 (P = .371), Dr. Sheikh reported.
Similarly, after care was started, there was no significant difference between the no-pet and pet groups in mean percent of predicted forced expiratory volume in 1 second (FEV1), wheezing, nighttime cough, albuterol use, and other factors over the 4 years of follow-up, he said.
Likewise, looking at the data by nonsmoking vs. smoking households, asthma control test scores at baseline were 16.1 and 15.1, respectively, and at 4 years they were 22.2 and 22.3 (P = .078), with a similar lack of difference in predicted FEV1, wheezing, and all other factors evaluated.
Getting rid of the family pet may need to be a consideration for some families, but based on these data, that might not be necessary for the majority of families, Dr. Sheikh said in the interview.
“On the other hand, we are not saying that if you are smoking, you should continue to smoke,” he added.
“What we are saying is that smoking is bad, but if your child is not getting better, I don’t want to blame your smoking for it. There may be something else which may be more important than smoking which we are missing – the child may not be getting the medicine, or may not be on the right medicine, or may have other comorbidities.”
Dr. Sheikh and his coinvestigators disclosed that they had no relationships relevant to the study.
SOURCE: Sheikh S et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.666.
SAN ANTONIO – It may not always be necessary to tell parents of children with asthma to get rid of the household pet, a recent study suggests.
Children with had significant improvements in a variety of asthma measures, regardless of whether parents reported pets or smoking at home, according to results of the 4-year, 471-patient prospective study.
Those results suggest that clinicians should be working to make sure the guidelines are being closely followed before, for example, telling parents they need to consider getting rid of the family pet, said Shahid Sheikh, MD, FCCP, of Nationwide Children’s Hospital, Columbus, Ohio.
“As the guidelines still work, we need to focus and develop the connections with the family to make sure the patients are on the right treatment, and that they’re getting the medications,” Dr. Sheikh said in an interview at the annual meeting of the American College of Chest Physicians.
The prospective cohort study by Dr. Sheikh and his colleagues, presented in a poster session, included children referred to a pediatric asthma center with the diagnosis of uncontrolled asthma. All patients received asthma care according to National Asthma Education and Prevention Program Expert Panel Report 3 guidelines.
Medications were changed as needed, and the asthma action plan was revised accordingly and reviewed with the family at each visit, Dr. Sheikh reported. After a baseline evaluation, clinic visits for the study occurred at 3 months, 6 months, and then at 1, 2, 3, and 4 years.
Out of 471 patients, 258 had pets, and 125 were in homes where smoking took place, according to parent reports.
Asthma control test scores were 15.1 at baseline for children in no-pet households, and 16.5 for those with pets; by the 3-month visit, scores increased to 20.1 and 20.3 for the no-pet and pet groups, and at 4 years, those scores had edged up to 22.2 and 22.7 (P = .371), Dr. Sheikh reported.
Similarly, after care was started, there was no significant difference between the no-pet and pet groups in mean percent of predicted forced expiratory volume in 1 second (FEV1), wheezing, nighttime cough, albuterol use, and other factors over the 4 years of follow-up, he said.
Likewise, looking at the data by nonsmoking vs. smoking households, asthma control test scores at baseline were 16.1 and 15.1, respectively, and at 4 years they were 22.2 and 22.3 (P = .078), with a similar lack of difference in predicted FEV1, wheezing, and all other factors evaluated.
Getting rid of the family pet may need to be a consideration for some families, but based on these data, that might not be necessary for the majority of families, Dr. Sheikh said in the interview.
“On the other hand, we are not saying that if you are smoking, you should continue to smoke,” he added.
“What we are saying is that smoking is bad, but if your child is not getting better, I don’t want to blame your smoking for it. There may be something else which may be more important than smoking which we are missing – the child may not be getting the medicine, or may not be on the right medicine, or may have other comorbidities.”
Dr. Sheikh and his coinvestigators disclosed that they had no relationships relevant to the study.
SOURCE: Sheikh S et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.666.
SAN ANTONIO – It may not always be necessary to tell parents of children with asthma to get rid of the household pet, a recent study suggests.
Children with had significant improvements in a variety of asthma measures, regardless of whether parents reported pets or smoking at home, according to results of the 4-year, 471-patient prospective study.
Those results suggest that clinicians should be working to make sure the guidelines are being closely followed before, for example, telling parents they need to consider getting rid of the family pet, said Shahid Sheikh, MD, FCCP, of Nationwide Children’s Hospital, Columbus, Ohio.
“As the guidelines still work, we need to focus and develop the connections with the family to make sure the patients are on the right treatment, and that they’re getting the medications,” Dr. Sheikh said in an interview at the annual meeting of the American College of Chest Physicians.
The prospective cohort study by Dr. Sheikh and his colleagues, presented in a poster session, included children referred to a pediatric asthma center with the diagnosis of uncontrolled asthma. All patients received asthma care according to National Asthma Education and Prevention Program Expert Panel Report 3 guidelines.
Medications were changed as needed, and the asthma action plan was revised accordingly and reviewed with the family at each visit, Dr. Sheikh reported. After a baseline evaluation, clinic visits for the study occurred at 3 months, 6 months, and then at 1, 2, 3, and 4 years.
Out of 471 patients, 258 had pets, and 125 were in homes where smoking took place, according to parent reports.
Asthma control test scores were 15.1 at baseline for children in no-pet households, and 16.5 for those with pets; by the 3-month visit, scores increased to 20.1 and 20.3 for the no-pet and pet groups, and at 4 years, those scores had edged up to 22.2 and 22.7 (P = .371), Dr. Sheikh reported.
Similarly, after care was started, there was no significant difference between the no-pet and pet groups in mean percent of predicted forced expiratory volume in 1 second (FEV1), wheezing, nighttime cough, albuterol use, and other factors over the 4 years of follow-up, he said.
Likewise, looking at the data by nonsmoking vs. smoking households, asthma control test scores at baseline were 16.1 and 15.1, respectively, and at 4 years they were 22.2 and 22.3 (P = .078), with a similar lack of difference in predicted FEV1, wheezing, and all other factors evaluated.
Getting rid of the family pet may need to be a consideration for some families, but based on these data, that might not be necessary for the majority of families, Dr. Sheikh said in the interview.
“On the other hand, we are not saying that if you are smoking, you should continue to smoke,” he added.
“What we are saying is that smoking is bad, but if your child is not getting better, I don’t want to blame your smoking for it. There may be something else which may be more important than smoking which we are missing – the child may not be getting the medicine, or may not be on the right medicine, or may have other comorbidities.”
Dr. Sheikh and his coinvestigators disclosed that they had no relationships relevant to the study.
SOURCE: Sheikh S et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.666.
REPORTING FROM CHEST 2018
Key clinical point: Exposure to pets and tobacco smoke may have very little effect on the improvement of asthma in children who are being managed according to guidelines.
Major finding: ACT scores were 15.1 and 16.5 at baseline for children in no-pet and pet households, respectively, and were 22.2 and 22.7 at the 4-year evaluation.
Study details: A 4-year prospective cohort study of 471 children with uncontrolled asthma seen in a pediatric asthma center.
Disclosures: The study authors had no disclosures.
Source: Sheikh S et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.666.
New guidelines for idiopathic multicentric Castleman disease
The anti-IL-6 antibody siltuximab is central to first-line treatment of idiopathic multicentric Castleman disease (iMCD), according to new guidelines on iMCD published in Blood.
The guidelines also say that early intervention with combination chemotherapy may prevent a fatal outcome in patients with severe iMCD.
To create these guidelines, 42 experts from 10 countries reviewed the published literature and a series of 344 clinical cases.
The guidelines should help clinicians select therapy, evaluate response, and thereby improve outcomes for this difficult-to-treat disease, according to author David C. Fajgenbaum, MD, an assistant professor at the University of Pennsylvania in Philadelphia and an iMCD patient himself.
“Right now, we recommend siltuximab first-line for everyone,” Dr. Fajgenbaum said, “but if we continue to dig deeper, it may be that there are clinical cases within idiopathic MCD that we think are even better candidates than others, and there may be alternative therapies for other patients.”
Treating iMCD is challenging because of the rarity and heterogeneity of the disease, among other factors, Dr. Fajgenbaum noted.
Some 6,000 to 7,000 cases of Castleman disease are diagnosed yearly, and of those, only about 1,000 cases are iMCD, according to Dr. Fajgenbaum.
“Even within idiopathic MCD, there is some heterogeneity,” he said. “Some patients present in the intensive care unit with life-threatening multiple organ failure and will die within weeks of presentation, whereas others will have a slower presentation and certainly not nearly as aggressive presentation.”
Although the exact etiology of iMCD is unknown, human IL-6 is the most common pathological driver, the experts said in the guidelines.
Siltuximab and tocilizumab are two IL-6–directed therapies used to treat MCD, with siltuximab targeting IL-6 itself and tocilizumab targeting the IL-6 receptor. Siltuximab is recommended as the first choice because of rigorous data supporting its use, including randomized clinical trial data, while tocilizumab is recommended if siltuximab is not available.
However, clinicians need to carefully monitor laboratory results and clinical features for patients on these drugs because about 50% of iMCD patients don’t have a satisfactory response to first-line anti–IL-6 treatments, Dr. Fajgenbaum said.
“Once you get to second-line therapies, that’s really where the level of evidence is lower,” he said.
Second-line therapy should include rituximab, and immunomodulatory/immunosuppressive agents or steroids may be added, according to the guidelines.
Third-line therapy is “less well defined,” according to the guidelines, and experts generally recommended immunomodulatory/immunosuppressive agents such as cyclosporine A, sirolimus, thalidomide, and lenalidomide.
Cytotoxic chemotherapy has a high response rate but also a high rate of relapse and significant toxicities, according to the data analysis conducted as part of the guideline development process. Based on that, the experts said to avoid it unless the patient progresses to severe iMCD.
“Patients who are literally dying in the intensive care unit, given the right combination chemotherapy, can improve within days to weeks and can even leave the hospital,” Dr. Fajgenbaum said. “It’s not necessarily going to be the answer long-term, but it can be life-saving in the short term. So we recommended a really quite aggressive approach for these patients.”
To bolster the evidence base, investigators in the Castleman Disease Collaborative Network (CDCN) set up an international registry to collect treatment and outcome data for 500 patients. After the first year and a half, 150 patients were enrolled, and the investigators have identified more than 30 drugs that have been used off-label to treat iMCD, according to Dr. Fajgenbaum.
“Some of the drugs are demonstrating efficacy in small numbers,” he said. “With the goal of 500 patients total, we can certainly hope to see some trends.”
Dr. Fajgenbaum was diagnosed with iMCD as a medical student.
“That certainly served as a very strong personal motivator for me to get involved in the disease,” he said. “But as I’ve gotten more and more involved, I’ve obviously met a lot of other patients, and that really is a huge motivator for all members of the CDCN. We want more options for more patients more quickly so we can help as many people as possible.”
Dr. Fajgenbaum reported research funding from Janssen. Coauthors reported disclosures related to Janssen, Bristol-Myers Squibb, Genentech, Merck, Celgene, Incyte, Pfizer, Sequenom, and Foundation Medicine, among others.
The anti-IL-6 antibody siltuximab is central to first-line treatment of idiopathic multicentric Castleman disease (iMCD), according to new guidelines on iMCD published in Blood.
The guidelines also say that early intervention with combination chemotherapy may prevent a fatal outcome in patients with severe iMCD.
To create these guidelines, 42 experts from 10 countries reviewed the published literature and a series of 344 clinical cases.
The guidelines should help clinicians select therapy, evaluate response, and thereby improve outcomes for this difficult-to-treat disease, according to author David C. Fajgenbaum, MD, an assistant professor at the University of Pennsylvania in Philadelphia and an iMCD patient himself.
“Right now, we recommend siltuximab first-line for everyone,” Dr. Fajgenbaum said, “but if we continue to dig deeper, it may be that there are clinical cases within idiopathic MCD that we think are even better candidates than others, and there may be alternative therapies for other patients.”
Treating iMCD is challenging because of the rarity and heterogeneity of the disease, among other factors, Dr. Fajgenbaum noted.
Some 6,000 to 7,000 cases of Castleman disease are diagnosed yearly, and of those, only about 1,000 cases are iMCD, according to Dr. Fajgenbaum.
“Even within idiopathic MCD, there is some heterogeneity,” he said. “Some patients present in the intensive care unit with life-threatening multiple organ failure and will die within weeks of presentation, whereas others will have a slower presentation and certainly not nearly as aggressive presentation.”
Although the exact etiology of iMCD is unknown, human IL-6 is the most common pathological driver, the experts said in the guidelines.
Siltuximab and tocilizumab are two IL-6–directed therapies used to treat MCD, with siltuximab targeting IL-6 itself and tocilizumab targeting the IL-6 receptor. Siltuximab is recommended as the first choice because of rigorous data supporting its use, including randomized clinical trial data, while tocilizumab is recommended if siltuximab is not available.
However, clinicians need to carefully monitor laboratory results and clinical features for patients on these drugs because about 50% of iMCD patients don’t have a satisfactory response to first-line anti–IL-6 treatments, Dr. Fajgenbaum said.
“Once you get to second-line therapies, that’s really where the level of evidence is lower,” he said.
Second-line therapy should include rituximab, and immunomodulatory/immunosuppressive agents or steroids may be added, according to the guidelines.
Third-line therapy is “less well defined,” according to the guidelines, and experts generally recommended immunomodulatory/immunosuppressive agents such as cyclosporine A, sirolimus, thalidomide, and lenalidomide.
Cytotoxic chemotherapy has a high response rate but also a high rate of relapse and significant toxicities, according to the data analysis conducted as part of the guideline development process. Based on that, the experts said to avoid it unless the patient progresses to severe iMCD.
“Patients who are literally dying in the intensive care unit, given the right combination chemotherapy, can improve within days to weeks and can even leave the hospital,” Dr. Fajgenbaum said. “It’s not necessarily going to be the answer long-term, but it can be life-saving in the short term. So we recommended a really quite aggressive approach for these patients.”
To bolster the evidence base, investigators in the Castleman Disease Collaborative Network (CDCN) set up an international registry to collect treatment and outcome data for 500 patients. After the first year and a half, 150 patients were enrolled, and the investigators have identified more than 30 drugs that have been used off-label to treat iMCD, according to Dr. Fajgenbaum.
“Some of the drugs are demonstrating efficacy in small numbers,” he said. “With the goal of 500 patients total, we can certainly hope to see some trends.”
Dr. Fajgenbaum was diagnosed with iMCD as a medical student.
“That certainly served as a very strong personal motivator for me to get involved in the disease,” he said. “But as I’ve gotten more and more involved, I’ve obviously met a lot of other patients, and that really is a huge motivator for all members of the CDCN. We want more options for more patients more quickly so we can help as many people as possible.”
Dr. Fajgenbaum reported research funding from Janssen. Coauthors reported disclosures related to Janssen, Bristol-Myers Squibb, Genentech, Merck, Celgene, Incyte, Pfizer, Sequenom, and Foundation Medicine, among others.
The anti-IL-6 antibody siltuximab is central to first-line treatment of idiopathic multicentric Castleman disease (iMCD), according to new guidelines on iMCD published in Blood.
The guidelines also say that early intervention with combination chemotherapy may prevent a fatal outcome in patients with severe iMCD.
To create these guidelines, 42 experts from 10 countries reviewed the published literature and a series of 344 clinical cases.
The guidelines should help clinicians select therapy, evaluate response, and thereby improve outcomes for this difficult-to-treat disease, according to author David C. Fajgenbaum, MD, an assistant professor at the University of Pennsylvania in Philadelphia and an iMCD patient himself.
“Right now, we recommend siltuximab first-line for everyone,” Dr. Fajgenbaum said, “but if we continue to dig deeper, it may be that there are clinical cases within idiopathic MCD that we think are even better candidates than others, and there may be alternative therapies for other patients.”
Treating iMCD is challenging because of the rarity and heterogeneity of the disease, among other factors, Dr. Fajgenbaum noted.
Some 6,000 to 7,000 cases of Castleman disease are diagnosed yearly, and of those, only about 1,000 cases are iMCD, according to Dr. Fajgenbaum.
“Even within idiopathic MCD, there is some heterogeneity,” he said. “Some patients present in the intensive care unit with life-threatening multiple organ failure and will die within weeks of presentation, whereas others will have a slower presentation and certainly not nearly as aggressive presentation.”
Although the exact etiology of iMCD is unknown, human IL-6 is the most common pathological driver, the experts said in the guidelines.
Siltuximab and tocilizumab are two IL-6–directed therapies used to treat MCD, with siltuximab targeting IL-6 itself and tocilizumab targeting the IL-6 receptor. Siltuximab is recommended as the first choice because of rigorous data supporting its use, including randomized clinical trial data, while tocilizumab is recommended if siltuximab is not available.
However, clinicians need to carefully monitor laboratory results and clinical features for patients on these drugs because about 50% of iMCD patients don’t have a satisfactory response to first-line anti–IL-6 treatments, Dr. Fajgenbaum said.
“Once you get to second-line therapies, that’s really where the level of evidence is lower,” he said.
Second-line therapy should include rituximab, and immunomodulatory/immunosuppressive agents or steroids may be added, according to the guidelines.
Third-line therapy is “less well defined,” according to the guidelines, and experts generally recommended immunomodulatory/immunosuppressive agents such as cyclosporine A, sirolimus, thalidomide, and lenalidomide.
Cytotoxic chemotherapy has a high response rate but also a high rate of relapse and significant toxicities, according to the data analysis conducted as part of the guideline development process. Based on that, the experts said to avoid it unless the patient progresses to severe iMCD.
“Patients who are literally dying in the intensive care unit, given the right combination chemotherapy, can improve within days to weeks and can even leave the hospital,” Dr. Fajgenbaum said. “It’s not necessarily going to be the answer long-term, but it can be life-saving in the short term. So we recommended a really quite aggressive approach for these patients.”
To bolster the evidence base, investigators in the Castleman Disease Collaborative Network (CDCN) set up an international registry to collect treatment and outcome data for 500 patients. After the first year and a half, 150 patients were enrolled, and the investigators have identified more than 30 drugs that have been used off-label to treat iMCD, according to Dr. Fajgenbaum.
“Some of the drugs are demonstrating efficacy in small numbers,” he said. “With the goal of 500 patients total, we can certainly hope to see some trends.”
Dr. Fajgenbaum was diagnosed with iMCD as a medical student.
“That certainly served as a very strong personal motivator for me to get involved in the disease,” he said. “But as I’ve gotten more and more involved, I’ve obviously met a lot of other patients, and that really is a huge motivator for all members of the CDCN. We want more options for more patients more quickly so we can help as many people as possible.”
Dr. Fajgenbaum reported research funding from Janssen. Coauthors reported disclosures related to Janssen, Bristol-Myers Squibb, Genentech, Merck, Celgene, Incyte, Pfizer, Sequenom, and Foundation Medicine, among others.
Obesity paradox extends to PE patients
SAN ANTONIO – compared with those who are not obese, according to results of a retrospective analysis covering 13 years and nearly 2 million PE discharges.
The obese patients in the analysis had a lower mortality risk, despite receiving more thrombolytics and mechanical intubation, said investigator Zubair Khan, MD, an internal medicine resident at the University of Toledo (Ohio) Medical Center.
“Surprisingly, the mortality of PE was significantly less in obese patients,” Dr. Khan said in a podium presentation at the annual meeting of the American College of Chest Physicians. “When we initiated the study, we did not expect this result.”
The association between obesity and lower mortality, sometimes called the “obesity paradox,” has been observed in studies of other chronic health conditions including stable heart failure, coronary artery disease, unstable angina, MI, and also in some PE studies, Dr. Khan said.
The study by Dr. Khan and his colleagues, based on the National Inpatient Sample (NIS) database, included adults with a primary discharge diagnosis of PE between 2002 and 2014. They included 1,959,018 PE discharges, of which 312,770 (16%) had an underlying obesity diagnosis.
Obese PE patients had more risk factors and more severe disease but had an overall mortality of 2.2%, compared with 3.7% in PE patients without obesity (P less than .001), Dr. Khan reported.
Hypertension was significantly more prevalent in the obese PE patients (65% vs. 50.5%; P less than .001), as was chronic lung disease and chronic liver disease, he noted in his presentation.
Obese patients more often received thrombolytics (3.6% vs. 1.9%; P less than .001) and mechanical ventilation (5.8% vs. 4%; P less than .001), and more frequently had cardiogenic shock (0.65% vs. 0.45%; P less than .001), he said.
The obese PE patients were more often female, black, and younger than 65 years of age, it was reported.
Notably, the prevalence of obesity in PE patients more than doubled over the course of the study period, from 10.2% in 2002 to 22.6% in 2014, Dr. Khan added.
The paradoxically lower mortality in obese patients might be explained by increased levels of endocannabinoids, which have shown protective effects in rat and mouse studies, Dr. Khan told attendees at the meeting.
“I think it’s a rich area for more and further research, especially in basic science,” Dr. Khan said.
Dr. Khan and his coauthors disclosed that they had no relationships relevant to the study.
SOURCE: Khan Z et al. CHEST. 2018 Oct. doi: 10.1016/j.chest.2018.08.919.
SAN ANTONIO – compared with those who are not obese, according to results of a retrospective analysis covering 13 years and nearly 2 million PE discharges.
The obese patients in the analysis had a lower mortality risk, despite receiving more thrombolytics and mechanical intubation, said investigator Zubair Khan, MD, an internal medicine resident at the University of Toledo (Ohio) Medical Center.
“Surprisingly, the mortality of PE was significantly less in obese patients,” Dr. Khan said in a podium presentation at the annual meeting of the American College of Chest Physicians. “When we initiated the study, we did not expect this result.”
The association between obesity and lower mortality, sometimes called the “obesity paradox,” has been observed in studies of other chronic health conditions including stable heart failure, coronary artery disease, unstable angina, MI, and also in some PE studies, Dr. Khan said.
The study by Dr. Khan and his colleagues, based on the National Inpatient Sample (NIS) database, included adults with a primary discharge diagnosis of PE between 2002 and 2014. They included 1,959,018 PE discharges, of which 312,770 (16%) had an underlying obesity diagnosis.
Obese PE patients had more risk factors and more severe disease but had an overall mortality of 2.2%, compared with 3.7% in PE patients without obesity (P less than .001), Dr. Khan reported.
Hypertension was significantly more prevalent in the obese PE patients (65% vs. 50.5%; P less than .001), as was chronic lung disease and chronic liver disease, he noted in his presentation.
Obese patients more often received thrombolytics (3.6% vs. 1.9%; P less than .001) and mechanical ventilation (5.8% vs. 4%; P less than .001), and more frequently had cardiogenic shock (0.65% vs. 0.45%; P less than .001), he said.
The obese PE patients were more often female, black, and younger than 65 years of age, it was reported.
Notably, the prevalence of obesity in PE patients more than doubled over the course of the study period, from 10.2% in 2002 to 22.6% in 2014, Dr. Khan added.
The paradoxically lower mortality in obese patients might be explained by increased levels of endocannabinoids, which have shown protective effects in rat and mouse studies, Dr. Khan told attendees at the meeting.
“I think it’s a rich area for more and further research, especially in basic science,” Dr. Khan said.
Dr. Khan and his coauthors disclosed that they had no relationships relevant to the study.
SOURCE: Khan Z et al. CHEST. 2018 Oct. doi: 10.1016/j.chest.2018.08.919.
SAN ANTONIO – compared with those who are not obese, according to results of a retrospective analysis covering 13 years and nearly 2 million PE discharges.
The obese patients in the analysis had a lower mortality risk, despite receiving more thrombolytics and mechanical intubation, said investigator Zubair Khan, MD, an internal medicine resident at the University of Toledo (Ohio) Medical Center.
“Surprisingly, the mortality of PE was significantly less in obese patients,” Dr. Khan said in a podium presentation at the annual meeting of the American College of Chest Physicians. “When we initiated the study, we did not expect this result.”
The association between obesity and lower mortality, sometimes called the “obesity paradox,” has been observed in studies of other chronic health conditions including stable heart failure, coronary artery disease, unstable angina, MI, and also in some PE studies, Dr. Khan said.
The study by Dr. Khan and his colleagues, based on the National Inpatient Sample (NIS) database, included adults with a primary discharge diagnosis of PE between 2002 and 2014. They included 1,959,018 PE discharges, of which 312,770 (16%) had an underlying obesity diagnosis.
Obese PE patients had more risk factors and more severe disease but had an overall mortality of 2.2%, compared with 3.7% in PE patients without obesity (P less than .001), Dr. Khan reported.
Hypertension was significantly more prevalent in the obese PE patients (65% vs. 50.5%; P less than .001), as was chronic lung disease and chronic liver disease, he noted in his presentation.
Obese patients more often received thrombolytics (3.6% vs. 1.9%; P less than .001) and mechanical ventilation (5.8% vs. 4%; P less than .001), and more frequently had cardiogenic shock (0.65% vs. 0.45%; P less than .001), he said.
The obese PE patients were more often female, black, and younger than 65 years of age, it was reported.
Notably, the prevalence of obesity in PE patients more than doubled over the course of the study period, from 10.2% in 2002 to 22.6% in 2014, Dr. Khan added.
The paradoxically lower mortality in obese patients might be explained by increased levels of endocannabinoids, which have shown protective effects in rat and mouse studies, Dr. Khan told attendees at the meeting.
“I think it’s a rich area for more and further research, especially in basic science,” Dr. Khan said.
Dr. Khan and his coauthors disclosed that they had no relationships relevant to the study.
SOURCE: Khan Z et al. CHEST. 2018 Oct. doi: 10.1016/j.chest.2018.08.919.
REPORTING FROM CHEST 2018
Key clinical point: The obesity paradox observed in other chronic conditions held true in this study of patients with pulmonary embolism (PE).
Major finding: Obese PE patients had more risk factors and more severe disease, but an overall mortality of 2.2% vs 3.7% in nonobese PE patients.
Study details: Retrospective analysis of the National Inpatient Sample (NIS) database including almost 2 million individuals with a primary discharge diagnosis of PE.
Disclosures: Study authors had no disclosures.
Source: Khan Z et al. CHEST. 2018 Oct. doi: 10.1016/j.chest.2018.08.919.
Planning for ventilator-dependent patients during natural disasters
SAN ANTONIO – For patients with neuromuscular disorders, the stress and danger from natural disasters such Hurricane Harvey are best avoided by leaving the area as soon as possible, according to Venessa A. Holland, MD, FCCP, of Houston Methodist Hospital.
While none of Dr. Holland’s patients died during this catastrophic hurricane, there were considerable challenges, particularly for those trapped by the many trillion gallons of water fell on Texas and Louisiana in August 2017. Houston was flooded, and hospitals and other medical facilities were hit hard. The vulnerability of ventilator-dependent and incapacitated patients was of particular concern.
In one case, a ventilator-dependent patient trapped by flood waters at home became diaphoretic and hypotensive. The patient was treated with electrolyte-replacement sports drink administered via percutaneous endoscopic gastrostomy (PEG) tube, Dr. Holland told attendees at the annual meeting of the American College of Chest Physicians.
Dr. Holland spoke in a video interview about how neuromuscular disorder patients fared during Hurricane Harvey and her recommendations for the next natural disaster.
Dr. Holland disclosed that she previously served as a consultant to Hill-Rom.
SAN ANTONIO – For patients with neuromuscular disorders, the stress and danger from natural disasters such Hurricane Harvey are best avoided by leaving the area as soon as possible, according to Venessa A. Holland, MD, FCCP, of Houston Methodist Hospital.
While none of Dr. Holland’s patients died during this catastrophic hurricane, there were considerable challenges, particularly for those trapped by the many trillion gallons of water fell on Texas and Louisiana in August 2017. Houston was flooded, and hospitals and other medical facilities were hit hard. The vulnerability of ventilator-dependent and incapacitated patients was of particular concern.
In one case, a ventilator-dependent patient trapped by flood waters at home became diaphoretic and hypotensive. The patient was treated with electrolyte-replacement sports drink administered via percutaneous endoscopic gastrostomy (PEG) tube, Dr. Holland told attendees at the annual meeting of the American College of Chest Physicians.
Dr. Holland spoke in a video interview about how neuromuscular disorder patients fared during Hurricane Harvey and her recommendations for the next natural disaster.
Dr. Holland disclosed that she previously served as a consultant to Hill-Rom.
SAN ANTONIO – For patients with neuromuscular disorders, the stress and danger from natural disasters such Hurricane Harvey are best avoided by leaving the area as soon as possible, according to Venessa A. Holland, MD, FCCP, of Houston Methodist Hospital.
While none of Dr. Holland’s patients died during this catastrophic hurricane, there were considerable challenges, particularly for those trapped by the many trillion gallons of water fell on Texas and Louisiana in August 2017. Houston was flooded, and hospitals and other medical facilities were hit hard. The vulnerability of ventilator-dependent and incapacitated patients was of particular concern.
In one case, a ventilator-dependent patient trapped by flood waters at home became diaphoretic and hypotensive. The patient was treated with electrolyte-replacement sports drink administered via percutaneous endoscopic gastrostomy (PEG) tube, Dr. Holland told attendees at the annual meeting of the American College of Chest Physicians.
Dr. Holland spoke in a video interview about how neuromuscular disorder patients fared during Hurricane Harvey and her recommendations for the next natural disaster.
Dr. Holland disclosed that she previously served as a consultant to Hill-Rom.
REPORTING FROM CHEST 2018
Latest clinical trials advance COPD management
SAN ANTONIO – Recent studies have shown that the use of a long-acting beta2-agonist/long-acting muscarinic antagonist (LABA/LAMA) combination is superior to LAMA alone in endpoints including exacerbation, Nicola A. Hanania, MD, FCCP, said in a panel discussion session at the annual meeting of the American College of Chest Physicians.
Other recent evidence has shown that the use of LABA/LAMA has cardiovascular benefits in hyperinflated patients with COPD, according to Dr. Hanania, director of the Airways Clinical Research Center at Baylor College of Medicine, Houston.
Meanwhile, emerging data in patients with advanced COPD have demonstrated the benefits of single-inhaler triple therapy with inhaled corticosteroid (ICS)/LABA/LAMA versus LABA/LAMA or ICS/LABA combinations, Dr. Hanania said in an interview.
The past year also has brought news that ICS de-escalation is possible in patients with moderate COPD with no exacerbation risk, though it may not be possible in patients with high baseline blood eosinophils, he added.
Recent developments have not all been about drug therapy. The Zephyr endobronchial valve improved outcomes in patients with little to no collateral ventilation in target lobes, Dr. Hanania said. However, the therapy comes with a potential risk of pneumothorax, so patients need to be monitored in the hospital.
Dr. Hanania provided disclosures related to Roche (Genentech), AstraZeneca, Boehringer Ingelheim, Novartis, GlaxoSmithKline, and Sanofi/Regeneron, as well as institutional research grant support from the National Heart, Lung, and Blood Institute and the American Lung Association.
SAN ANTONIO – Recent studies have shown that the use of a long-acting beta2-agonist/long-acting muscarinic antagonist (LABA/LAMA) combination is superior to LAMA alone in endpoints including exacerbation, Nicola A. Hanania, MD, FCCP, said in a panel discussion session at the annual meeting of the American College of Chest Physicians.
Other recent evidence has shown that the use of LABA/LAMA has cardiovascular benefits in hyperinflated patients with COPD, according to Dr. Hanania, director of the Airways Clinical Research Center at Baylor College of Medicine, Houston.
Meanwhile, emerging data in patients with advanced COPD have demonstrated the benefits of single-inhaler triple therapy with inhaled corticosteroid (ICS)/LABA/LAMA versus LABA/LAMA or ICS/LABA combinations, Dr. Hanania said in an interview.
The past year also has brought news that ICS de-escalation is possible in patients with moderate COPD with no exacerbation risk, though it may not be possible in patients with high baseline blood eosinophils, he added.
Recent developments have not all been about drug therapy. The Zephyr endobronchial valve improved outcomes in patients with little to no collateral ventilation in target lobes, Dr. Hanania said. However, the therapy comes with a potential risk of pneumothorax, so patients need to be monitored in the hospital.
Dr. Hanania provided disclosures related to Roche (Genentech), AstraZeneca, Boehringer Ingelheim, Novartis, GlaxoSmithKline, and Sanofi/Regeneron, as well as institutional research grant support from the National Heart, Lung, and Blood Institute and the American Lung Association.
SAN ANTONIO – Recent studies have shown that the use of a long-acting beta2-agonist/long-acting muscarinic antagonist (LABA/LAMA) combination is superior to LAMA alone in endpoints including exacerbation, Nicola A. Hanania, MD, FCCP, said in a panel discussion session at the annual meeting of the American College of Chest Physicians.
Other recent evidence has shown that the use of LABA/LAMA has cardiovascular benefits in hyperinflated patients with COPD, according to Dr. Hanania, director of the Airways Clinical Research Center at Baylor College of Medicine, Houston.
Meanwhile, emerging data in patients with advanced COPD have demonstrated the benefits of single-inhaler triple therapy with inhaled corticosteroid (ICS)/LABA/LAMA versus LABA/LAMA or ICS/LABA combinations, Dr. Hanania said in an interview.
The past year also has brought news that ICS de-escalation is possible in patients with moderate COPD with no exacerbation risk, though it may not be possible in patients with high baseline blood eosinophils, he added.
Recent developments have not all been about drug therapy. The Zephyr endobronchial valve improved outcomes in patients with little to no collateral ventilation in target lobes, Dr. Hanania said. However, the therapy comes with a potential risk of pneumothorax, so patients need to be monitored in the hospital.
Dr. Hanania provided disclosures related to Roche (Genentech), AstraZeneca, Boehringer Ingelheim, Novartis, GlaxoSmithKline, and Sanofi/Regeneron, as well as institutional research grant support from the National Heart, Lung, and Blood Institute and the American Lung Association.
REPORTING FROM CHEST 2018
Precision medicine poised to improve IPF management
SAN ANTONIO – Although the research is in early phases, (IPF), Justin Oldham, MD, said in a plenary presentation at the annual meeting of the American College of Chest Physicians.
“IPF is a highly variable disease,” said Dr. Oldham, director of the Interstitial Lung Disease Program at the University of California, Davis. “Some patients have more rapidly progressive disease than others, and so using precision medicine to identify those who are most likely to have that progressive phenotype is very important, not only for risk stratification but also treatment considerations.”
Some retrospective studies suggest certain subgroups of patients with IPF are genetically predisposed to respond to certain types of therapy, he said in a video interview. Now, researchers are in the process of submitting grants to better study that in a prospective fashion.
Dr. Oldham reported receiving funding from the National Institutes of Health, the American Lung Association, and the ACCP, as well as consulting and speaker fees from Genentech and Boehringer Ingelheim.
SAN ANTONIO – Although the research is in early phases, (IPF), Justin Oldham, MD, said in a plenary presentation at the annual meeting of the American College of Chest Physicians.
“IPF is a highly variable disease,” said Dr. Oldham, director of the Interstitial Lung Disease Program at the University of California, Davis. “Some patients have more rapidly progressive disease than others, and so using precision medicine to identify those who are most likely to have that progressive phenotype is very important, not only for risk stratification but also treatment considerations.”
Some retrospective studies suggest certain subgroups of patients with IPF are genetically predisposed to respond to certain types of therapy, he said in a video interview. Now, researchers are in the process of submitting grants to better study that in a prospective fashion.
Dr. Oldham reported receiving funding from the National Institutes of Health, the American Lung Association, and the ACCP, as well as consulting and speaker fees from Genentech and Boehringer Ingelheim.
SAN ANTONIO – Although the research is in early phases, (IPF), Justin Oldham, MD, said in a plenary presentation at the annual meeting of the American College of Chest Physicians.
“IPF is a highly variable disease,” said Dr. Oldham, director of the Interstitial Lung Disease Program at the University of California, Davis. “Some patients have more rapidly progressive disease than others, and so using precision medicine to identify those who are most likely to have that progressive phenotype is very important, not only for risk stratification but also treatment considerations.”
Some retrospective studies suggest certain subgroups of patients with IPF are genetically predisposed to respond to certain types of therapy, he said in a video interview. Now, researchers are in the process of submitting grants to better study that in a prospective fashion.
Dr. Oldham reported receiving funding from the National Institutes of Health, the American Lung Association, and the ACCP, as well as consulting and speaker fees from Genentech and Boehringer Ingelheim.
EXPERT ANALYSIS FROM CHEST 2018
ADVENT-HF early results: High ASV compliance, no safety concerns
SAN ANTONIO – The in heart failure patients with sleep apnea, so far has better compliance than previous trials, with no safety concerns to date, according to investigator T. Douglas Bradley, MD.
On average, patients with obstructive sleep apnea were using the device 4.6 hours per night at 1 month and 4.1 hours at 12 months, while patients with central sleep apnea were using the device 5.2 hours per night both at 1 month and 12 months, Dr. Bradley said.
“This represents much better compliance than the other trials that have looked into this area, so we are quite happy about that,” Dr. Bradley said at the annual meeting of the American College of Chest Physicians.
The study has been reviewed five times by the data safety monitoring board since the announcement of SERVE-HF trial results, with no safety concerns in either obstructive sleep apnea or central sleep apnea patients, Dr. Bradley noted in a podium presentation.
The compliance results have been submitted for publication, though efficacy results of the study will have to wait. The estimated study completion date is June 2020, according to the latest study information on ClinicalTrials.gov.
More than 600 patients have been enrolled in ADVENT-HF to date, and the investigators hope to enroll more than 800: “We should be there by the end of next year,” Dr. Bradley said.
He provided disclosures related to Philips Respironics (funding and devices) and the Canadian Institutes of Health Research.
SAN ANTONIO – The in heart failure patients with sleep apnea, so far has better compliance than previous trials, with no safety concerns to date, according to investigator T. Douglas Bradley, MD.
On average, patients with obstructive sleep apnea were using the device 4.6 hours per night at 1 month and 4.1 hours at 12 months, while patients with central sleep apnea were using the device 5.2 hours per night both at 1 month and 12 months, Dr. Bradley said.
“This represents much better compliance than the other trials that have looked into this area, so we are quite happy about that,” Dr. Bradley said at the annual meeting of the American College of Chest Physicians.
The study has been reviewed five times by the data safety monitoring board since the announcement of SERVE-HF trial results, with no safety concerns in either obstructive sleep apnea or central sleep apnea patients, Dr. Bradley noted in a podium presentation.
The compliance results have been submitted for publication, though efficacy results of the study will have to wait. The estimated study completion date is June 2020, according to the latest study information on ClinicalTrials.gov.
More than 600 patients have been enrolled in ADVENT-HF to date, and the investigators hope to enroll more than 800: “We should be there by the end of next year,” Dr. Bradley said.
He provided disclosures related to Philips Respironics (funding and devices) and the Canadian Institutes of Health Research.
SAN ANTONIO – The in heart failure patients with sleep apnea, so far has better compliance than previous trials, with no safety concerns to date, according to investigator T. Douglas Bradley, MD.
On average, patients with obstructive sleep apnea were using the device 4.6 hours per night at 1 month and 4.1 hours at 12 months, while patients with central sleep apnea were using the device 5.2 hours per night both at 1 month and 12 months, Dr. Bradley said.
“This represents much better compliance than the other trials that have looked into this area, so we are quite happy about that,” Dr. Bradley said at the annual meeting of the American College of Chest Physicians.
The study has been reviewed five times by the data safety monitoring board since the announcement of SERVE-HF trial results, with no safety concerns in either obstructive sleep apnea or central sleep apnea patients, Dr. Bradley noted in a podium presentation.
The compliance results have been submitted for publication, though efficacy results of the study will have to wait. The estimated study completion date is June 2020, according to the latest study information on ClinicalTrials.gov.
More than 600 patients have been enrolled in ADVENT-HF to date, and the investigators hope to enroll more than 800: “We should be there by the end of next year,” Dr. Bradley said.
He provided disclosures related to Philips Respironics (funding and devices) and the Canadian Institutes of Health Research.
REPORTING FROM CHEST 2018
Modeling favors immediate AED after unprovoked first seizure
including those who are at low risk of recurrent seizures, results of a decision analysis suggest.
Taking into account quality of life, seizure risk, and antiepileptic drug (AED) side effects, the model favored treatment of a patient with a single unprovoked seizure who did not meet the International League Against Epilepsy (ILAE) definition of epilepsy, investigators reported.
The model also favored treatment of patients who did meet ILAE criteria, namely, a 10-year recurrence risk greater than 60% in a patients with a single unprovoked seizure, according to their report in Neurology.
Together, these findings suggest that the current ILAE epilepsy definition is “too simplistic” for deciding whether to start or withhold AED treatment after a first unprovoked seizure, said M. Brandon Westover, MD, PhD, of the department of neurology, Massachusetts General Hospital, Boston, and his coauthors in their report.
“A more precise and patient-personalized definition of epilepsy should encompass not only seizure recurrence probability but also a multitude of other risks and benefits associated with AED treatment,” they said in a discussion of their study results.
To determine which patients with a first unprovoked seizure might benefit from immediate AED treatment, Dr. Westover and his colleagues used a decision model with measures constructed from retrospective clinical trial data.
The goal of the simulation was to determine which treatment strategy – immediate or delayed AED – would maximize the patient’s expected quality-adjusted life years (QALYs). Toward that end, Dr. Westover and his coinvestigators considered three base cases, which represented various degrees of seizure-recurrence risk.
The first base case was a 30-year-old man with no other risk factors for recurrent seizure, other than having had a first seizure. In that case, immediate and deferred AED treatment resulted in 19.04 and 18.65 QALYs, respectively.
“In dollar values, using the conservative approximation of $50,000/QALY gained, this difference in treatment outcomes would amount to $19,500 gained per individual,” Dr. Westover and his coauthors wrote in their report.
The second case was a 30-year-old woman who presented with a first unprovoked seizure and had positive MRI results that establish a high risk of recurrence. As expected, because of the high recurrence risk, this scenario also favored immediate treatment, with 15.23 and 14.75 QALYs, respectively, for the immediate and deferred strategies.
The final case was a wheelchair-bound 60-year-old woman with a first unprovoked seizure and high risk of recurrence, but also a high risk of AED adverse effects and a smaller expected quality of life reduction from further seizures. In this scenario, in which treatment might be “intuitively discouraged” because of the AED side-effect risk, the cohort simulation indeed favored deferred AED treatment by a small margin, the investigators said.
“A high baseline risk for recurrent seizures does not by itself always favor immediate AED treatment,” they wrote.
The study was supported by the National Institutes of Health-National Institute of Neurological Disorders and Stroke. Dr. Westover and his coauthors had no relevant disclosures to report.
SOURCE: Bao EL et al. Neurology. 2018 Sep 12. pii: 10.1212/WNL.0000000000006319.
The conclusion of this decision analysis by Bao and colleagues is “likely correct” that early treatment of a first unprovoked seizure could be favorable in a wide range of clinical scenarios, according to authors of an accompanying editorial.
The decision analysis is based on a reasonable though not comprehensive set of parameters to simulate base cases representative of common first-ever seizure clinical scenarios, Claire S. Jacobs, MD, PhD, and Jong Woo Lee, MD, PhD, said in the editorial.
Potentially the most controversial scenario addressed in the decision model, they noted, is the patient with low seizure recurrence risk but substantial quality of life decline upon recurrence. While that patient would not meet the commonly accepted 60% recurrence risk threshold that would indicate treatment is warranted, this model favors immediate treatment because of the potentially disruptive effect of recurrence.
This study does not address important issues such as the cost of medication and patient preferences, they pointed out, and furthermore, quality-adjusted life years (QALYs) can be difficult to integrate into clinical decision making.
Nonetheless, the findings are worth considering in clinical practice, authors suggested. “At the very least, this study should, however subtly, shift the starting point of discussion with the patient toward a default of immediate, rather than deferred, treatment after a first unprovoked seizure and apparent absence of disease,” they wrote.
Claire S. Jacobs, MD, PhD, and Jong Woo Lee, MD, PhD , are with department of neurology, Brigham and Women’s Hospital, Boston. Their editorial appeared in Neurology . Dr. Jacobs reported being partially supported by NIH/National Institute of Neurological Disorders and Stroke and is an inventor on patents related to synthesis and use of DNA-binding small molecules targeted to transcription factor–binding sites. Dr. Lee reported that he has received prior NIH funding, has served on the scientific advisory board of Lundbeck, has done contract work for SleepMed/DigiTrace and Advance Medical.
The conclusion of this decision analysis by Bao and colleagues is “likely correct” that early treatment of a first unprovoked seizure could be favorable in a wide range of clinical scenarios, according to authors of an accompanying editorial.
The decision analysis is based on a reasonable though not comprehensive set of parameters to simulate base cases representative of common first-ever seizure clinical scenarios, Claire S. Jacobs, MD, PhD, and Jong Woo Lee, MD, PhD, said in the editorial.
Potentially the most controversial scenario addressed in the decision model, they noted, is the patient with low seizure recurrence risk but substantial quality of life decline upon recurrence. While that patient would not meet the commonly accepted 60% recurrence risk threshold that would indicate treatment is warranted, this model favors immediate treatment because of the potentially disruptive effect of recurrence.
This study does not address important issues such as the cost of medication and patient preferences, they pointed out, and furthermore, quality-adjusted life years (QALYs) can be difficult to integrate into clinical decision making.
Nonetheless, the findings are worth considering in clinical practice, authors suggested. “At the very least, this study should, however subtly, shift the starting point of discussion with the patient toward a default of immediate, rather than deferred, treatment after a first unprovoked seizure and apparent absence of disease,” they wrote.
Claire S. Jacobs, MD, PhD, and Jong Woo Lee, MD, PhD , are with department of neurology, Brigham and Women’s Hospital, Boston. Their editorial appeared in Neurology . Dr. Jacobs reported being partially supported by NIH/National Institute of Neurological Disorders and Stroke and is an inventor on patents related to synthesis and use of DNA-binding small molecules targeted to transcription factor–binding sites. Dr. Lee reported that he has received prior NIH funding, has served on the scientific advisory board of Lundbeck, has done contract work for SleepMed/DigiTrace and Advance Medical.
The conclusion of this decision analysis by Bao and colleagues is “likely correct” that early treatment of a first unprovoked seizure could be favorable in a wide range of clinical scenarios, according to authors of an accompanying editorial.
The decision analysis is based on a reasonable though not comprehensive set of parameters to simulate base cases representative of common first-ever seizure clinical scenarios, Claire S. Jacobs, MD, PhD, and Jong Woo Lee, MD, PhD, said in the editorial.
Potentially the most controversial scenario addressed in the decision model, they noted, is the patient with low seizure recurrence risk but substantial quality of life decline upon recurrence. While that patient would not meet the commonly accepted 60% recurrence risk threshold that would indicate treatment is warranted, this model favors immediate treatment because of the potentially disruptive effect of recurrence.
This study does not address important issues such as the cost of medication and patient preferences, they pointed out, and furthermore, quality-adjusted life years (QALYs) can be difficult to integrate into clinical decision making.
Nonetheless, the findings are worth considering in clinical practice, authors suggested. “At the very least, this study should, however subtly, shift the starting point of discussion with the patient toward a default of immediate, rather than deferred, treatment after a first unprovoked seizure and apparent absence of disease,” they wrote.
Claire S. Jacobs, MD, PhD, and Jong Woo Lee, MD, PhD , are with department of neurology, Brigham and Women’s Hospital, Boston. Their editorial appeared in Neurology . Dr. Jacobs reported being partially supported by NIH/National Institute of Neurological Disorders and Stroke and is an inventor on patents related to synthesis and use of DNA-binding small molecules targeted to transcription factor–binding sites. Dr. Lee reported that he has received prior NIH funding, has served on the scientific advisory board of Lundbeck, has done contract work for SleepMed/DigiTrace and Advance Medical.
including those who are at low risk of recurrent seizures, results of a decision analysis suggest.
Taking into account quality of life, seizure risk, and antiepileptic drug (AED) side effects, the model favored treatment of a patient with a single unprovoked seizure who did not meet the International League Against Epilepsy (ILAE) definition of epilepsy, investigators reported.
The model also favored treatment of patients who did meet ILAE criteria, namely, a 10-year recurrence risk greater than 60% in a patients with a single unprovoked seizure, according to their report in Neurology.
Together, these findings suggest that the current ILAE epilepsy definition is “too simplistic” for deciding whether to start or withhold AED treatment after a first unprovoked seizure, said M. Brandon Westover, MD, PhD, of the department of neurology, Massachusetts General Hospital, Boston, and his coauthors in their report.
“A more precise and patient-personalized definition of epilepsy should encompass not only seizure recurrence probability but also a multitude of other risks and benefits associated with AED treatment,” they said in a discussion of their study results.
To determine which patients with a first unprovoked seizure might benefit from immediate AED treatment, Dr. Westover and his colleagues used a decision model with measures constructed from retrospective clinical trial data.
The goal of the simulation was to determine which treatment strategy – immediate or delayed AED – would maximize the patient’s expected quality-adjusted life years (QALYs). Toward that end, Dr. Westover and his coinvestigators considered three base cases, which represented various degrees of seizure-recurrence risk.
The first base case was a 30-year-old man with no other risk factors for recurrent seizure, other than having had a first seizure. In that case, immediate and deferred AED treatment resulted in 19.04 and 18.65 QALYs, respectively.
“In dollar values, using the conservative approximation of $50,000/QALY gained, this difference in treatment outcomes would amount to $19,500 gained per individual,” Dr. Westover and his coauthors wrote in their report.
The second case was a 30-year-old woman who presented with a first unprovoked seizure and had positive MRI results that establish a high risk of recurrence. As expected, because of the high recurrence risk, this scenario also favored immediate treatment, with 15.23 and 14.75 QALYs, respectively, for the immediate and deferred strategies.
The final case was a wheelchair-bound 60-year-old woman with a first unprovoked seizure and high risk of recurrence, but also a high risk of AED adverse effects and a smaller expected quality of life reduction from further seizures. In this scenario, in which treatment might be “intuitively discouraged” because of the AED side-effect risk, the cohort simulation indeed favored deferred AED treatment by a small margin, the investigators said.
“A high baseline risk for recurrent seizures does not by itself always favor immediate AED treatment,” they wrote.
The study was supported by the National Institutes of Health-National Institute of Neurological Disorders and Stroke. Dr. Westover and his coauthors had no relevant disclosures to report.
SOURCE: Bao EL et al. Neurology. 2018 Sep 12. pii: 10.1212/WNL.0000000000006319.
including those who are at low risk of recurrent seizures, results of a decision analysis suggest.
Taking into account quality of life, seizure risk, and antiepileptic drug (AED) side effects, the model favored treatment of a patient with a single unprovoked seizure who did not meet the International League Against Epilepsy (ILAE) definition of epilepsy, investigators reported.
The model also favored treatment of patients who did meet ILAE criteria, namely, a 10-year recurrence risk greater than 60% in a patients with a single unprovoked seizure, according to their report in Neurology.
Together, these findings suggest that the current ILAE epilepsy definition is “too simplistic” for deciding whether to start or withhold AED treatment after a first unprovoked seizure, said M. Brandon Westover, MD, PhD, of the department of neurology, Massachusetts General Hospital, Boston, and his coauthors in their report.
“A more precise and patient-personalized definition of epilepsy should encompass not only seizure recurrence probability but also a multitude of other risks and benefits associated with AED treatment,” they said in a discussion of their study results.
To determine which patients with a first unprovoked seizure might benefit from immediate AED treatment, Dr. Westover and his colleagues used a decision model with measures constructed from retrospective clinical trial data.
The goal of the simulation was to determine which treatment strategy – immediate or delayed AED – would maximize the patient’s expected quality-adjusted life years (QALYs). Toward that end, Dr. Westover and his coinvestigators considered three base cases, which represented various degrees of seizure-recurrence risk.
The first base case was a 30-year-old man with no other risk factors for recurrent seizure, other than having had a first seizure. In that case, immediate and deferred AED treatment resulted in 19.04 and 18.65 QALYs, respectively.
“In dollar values, using the conservative approximation of $50,000/QALY gained, this difference in treatment outcomes would amount to $19,500 gained per individual,” Dr. Westover and his coauthors wrote in their report.
The second case was a 30-year-old woman who presented with a first unprovoked seizure and had positive MRI results that establish a high risk of recurrence. As expected, because of the high recurrence risk, this scenario also favored immediate treatment, with 15.23 and 14.75 QALYs, respectively, for the immediate and deferred strategies.
The final case was a wheelchair-bound 60-year-old woman with a first unprovoked seizure and high risk of recurrence, but also a high risk of AED adverse effects and a smaller expected quality of life reduction from further seizures. In this scenario, in which treatment might be “intuitively discouraged” because of the AED side-effect risk, the cohort simulation indeed favored deferred AED treatment by a small margin, the investigators said.
“A high baseline risk for recurrent seizures does not by itself always favor immediate AED treatment,” they wrote.
The study was supported by the National Institutes of Health-National Institute of Neurological Disorders and Stroke. Dr. Westover and his coauthors had no relevant disclosures to report.
SOURCE: Bao EL et al. Neurology. 2018 Sep 12. pii: 10.1212/WNL.0000000000006319.
FROM NEUROLOGY
Key clinical point: Based on quality-adjusted life years (QALYs), immediate treatment of a first unprovoked seizure may be preferable to delayed treatment over a wide range of patients, including those who are at low risk of recurrent seizures.
Major finding: In a base case of a first unprovoked seizure and no other risk factors for recurrent seizure, immediate, and deferred antiepileptic drug treatment resulted in 19.04 and 18.65 QALYs, respectively.
Study details: A simulated clinical trial using decision analysis modeling, which included three base cases representing various degrees of seizure recurrence risk.
Disclosures: The study was supported by the National Institute of Neurological Disorders and Stroke. Study authors had no relevant disclosures to report.
Source: Bao EL et al. Neurology. 2018 Sep 12. pii: 10.1212/WNL.0000000000006319.
SSRIs linked to reduced height in risperidone-treated boys
according to results of an analysis reported in The Journal of Pediatrics.
The inverse association between SSRI use and height was particularly notable in boys undergoing puberty, according to the authors of the retrospective study. Follow-up into adulthood will be needed to see if the effects are reversible or have a negative impact on adult height.
“In the meantime, clinicians should continue to closely monitor children and adolescents starting antidepressant treatment to minimize side effects,” said Chadi A. Calarge, MD, of Baylor College of Medicine, Houston, and his coauthors.
These observations by Dr. Calarge and his colleagues were based on an analysis of 267 boys, of whom 190 had been treated with SSRIs. The boys had been in one of four previous studies, three of which included risperidone treatment for at least 6 or 12 months, and one small longitudinal observational study including children who had initiated risperidone in the month prior to enrollment. All four studies excluded subjects with chronic medical or neurologic conditions and those taking more than one antipsychotic medication.
Use of an SSRI was associated with reduced growth in height, particularly among boys in Tanner stages 3 and 4. “This effect is of a moderate magnitude of about 1 cm for every 1 year of treatment with SSRIs during adolescence,” Dr. Calarge and his coauthors said.
Among boys who took SSRIs continuously, the strongest inverse association with height z scores was in boys in Tanner stages 3 and 4 (r = –0.69; P less than .009). By contrast, this correlation was “negligible” in boys in Tanner stage 1 and stage 5, and there were only 5 boys of Tanner stage 2 in this analysis, the investigators said.
The mechanism by which SSRIs may have an effect on longitudinal growth has not been well investigated, according to Dr. Calarge and his coauthors. “Impaired growth hormone secretion or activity has been implicated, given that SSRIs alter serotonin signaling, which is known to control GH secretion.”
Funding for the study came from the National Institutes of Health, and other grants. One study coauthor reported funding support from Pfizer and Aeterna Zentaris.
SOURCE: Calarge CA et al. J Pediatr. 2018 Oct;201:245-51.
Although results of this secondary analysis require confirmation, they do underscore the need to consider how “complex combinations” of psychotropic agents may affect growth and development, according to Philip S. Zeitler, MD, PhD.
Such combinations are increasingly seen in the management of behavioral disorders in children and adolescents, Dr. Zeitler noted in a commentary on the findings by Calarge et al.
While side effects are well described for individual drugs used to treat youths with complex mental and behavioral disorders, the potential for side effects particular to combinations of these drugs are less well understood, he said.
The present study shows that in risperidone-treated youth, SSRI use was associated with decreased longitudinal growth. The estimated decrease of 1 cm per year of exposure to SSRIs suggests “a potentially significant decrease in adult height for peripubertal youth who are treated for many years,” according to the author.
“Unlike with stimulants, the decreased longitudinal growth was not associated with suppression of weight gain, suggesting an independent effect of SSRIs on growth during puberty,” he added.
Dr. Zeitler, of Aurora, Colo., is on the editorial board of The Journal of Pediatrics. His commentary on this study appeared in the October 2018 issue (J Pediatr. 2018;201:3). Dr. Zeitler also serves on the editorial board of the Journal of Clinical Endocrinology & Metabolism and Current Diabetes Reports, and is the editor-in-chief of Pediatric Diabetes. He reported serving on the data and safety monitoring board for Tolmar Pharmaceuticals, and serving as a consultant for Daiichi Sankyo, Merck, Boehringer-Ingelheim, and Janssen Pharmaceuticals.
Although results of this secondary analysis require confirmation, they do underscore the need to consider how “complex combinations” of psychotropic agents may affect growth and development, according to Philip S. Zeitler, MD, PhD.
Such combinations are increasingly seen in the management of behavioral disorders in children and adolescents, Dr. Zeitler noted in a commentary on the findings by Calarge et al.
While side effects are well described for individual drugs used to treat youths with complex mental and behavioral disorders, the potential for side effects particular to combinations of these drugs are less well understood, he said.
The present study shows that in risperidone-treated youth, SSRI use was associated with decreased longitudinal growth. The estimated decrease of 1 cm per year of exposure to SSRIs suggests “a potentially significant decrease in adult height for peripubertal youth who are treated for many years,” according to the author.
“Unlike with stimulants, the decreased longitudinal growth was not associated with suppression of weight gain, suggesting an independent effect of SSRIs on growth during puberty,” he added.
Dr. Zeitler, of Aurora, Colo., is on the editorial board of The Journal of Pediatrics. His commentary on this study appeared in the October 2018 issue (J Pediatr. 2018;201:3). Dr. Zeitler also serves on the editorial board of the Journal of Clinical Endocrinology & Metabolism and Current Diabetes Reports, and is the editor-in-chief of Pediatric Diabetes. He reported serving on the data and safety monitoring board for Tolmar Pharmaceuticals, and serving as a consultant for Daiichi Sankyo, Merck, Boehringer-Ingelheim, and Janssen Pharmaceuticals.
Although results of this secondary analysis require confirmation, they do underscore the need to consider how “complex combinations” of psychotropic agents may affect growth and development, according to Philip S. Zeitler, MD, PhD.
Such combinations are increasingly seen in the management of behavioral disorders in children and adolescents, Dr. Zeitler noted in a commentary on the findings by Calarge et al.
While side effects are well described for individual drugs used to treat youths with complex mental and behavioral disorders, the potential for side effects particular to combinations of these drugs are less well understood, he said.
The present study shows that in risperidone-treated youth, SSRI use was associated with decreased longitudinal growth. The estimated decrease of 1 cm per year of exposure to SSRIs suggests “a potentially significant decrease in adult height for peripubertal youth who are treated for many years,” according to the author.
“Unlike with stimulants, the decreased longitudinal growth was not associated with suppression of weight gain, suggesting an independent effect of SSRIs on growth during puberty,” he added.
Dr. Zeitler, of Aurora, Colo., is on the editorial board of The Journal of Pediatrics. His commentary on this study appeared in the October 2018 issue (J Pediatr. 2018;201:3). Dr. Zeitler also serves on the editorial board of the Journal of Clinical Endocrinology & Metabolism and Current Diabetes Reports, and is the editor-in-chief of Pediatric Diabetes. He reported serving on the data and safety monitoring board for Tolmar Pharmaceuticals, and serving as a consultant for Daiichi Sankyo, Merck, Boehringer-Ingelheim, and Janssen Pharmaceuticals.
according to results of an analysis reported in The Journal of Pediatrics.
The inverse association between SSRI use and height was particularly notable in boys undergoing puberty, according to the authors of the retrospective study. Follow-up into adulthood will be needed to see if the effects are reversible or have a negative impact on adult height.
“In the meantime, clinicians should continue to closely monitor children and adolescents starting antidepressant treatment to minimize side effects,” said Chadi A. Calarge, MD, of Baylor College of Medicine, Houston, and his coauthors.
These observations by Dr. Calarge and his colleagues were based on an analysis of 267 boys, of whom 190 had been treated with SSRIs. The boys had been in one of four previous studies, three of which included risperidone treatment for at least 6 or 12 months, and one small longitudinal observational study including children who had initiated risperidone in the month prior to enrollment. All four studies excluded subjects with chronic medical or neurologic conditions and those taking more than one antipsychotic medication.
Use of an SSRI was associated with reduced growth in height, particularly among boys in Tanner stages 3 and 4. “This effect is of a moderate magnitude of about 1 cm for every 1 year of treatment with SSRIs during adolescence,” Dr. Calarge and his coauthors said.
Among boys who took SSRIs continuously, the strongest inverse association with height z scores was in boys in Tanner stages 3 and 4 (r = –0.69; P less than .009). By contrast, this correlation was “negligible” in boys in Tanner stage 1 and stage 5, and there were only 5 boys of Tanner stage 2 in this analysis, the investigators said.
The mechanism by which SSRIs may have an effect on longitudinal growth has not been well investigated, according to Dr. Calarge and his coauthors. “Impaired growth hormone secretion or activity has been implicated, given that SSRIs alter serotonin signaling, which is known to control GH secretion.”
Funding for the study came from the National Institutes of Health, and other grants. One study coauthor reported funding support from Pfizer and Aeterna Zentaris.
SOURCE: Calarge CA et al. J Pediatr. 2018 Oct;201:245-51.
according to results of an analysis reported in The Journal of Pediatrics.
The inverse association between SSRI use and height was particularly notable in boys undergoing puberty, according to the authors of the retrospective study. Follow-up into adulthood will be needed to see if the effects are reversible or have a negative impact on adult height.
“In the meantime, clinicians should continue to closely monitor children and adolescents starting antidepressant treatment to minimize side effects,” said Chadi A. Calarge, MD, of Baylor College of Medicine, Houston, and his coauthors.
These observations by Dr. Calarge and his colleagues were based on an analysis of 267 boys, of whom 190 had been treated with SSRIs. The boys had been in one of four previous studies, three of which included risperidone treatment for at least 6 or 12 months, and one small longitudinal observational study including children who had initiated risperidone in the month prior to enrollment. All four studies excluded subjects with chronic medical or neurologic conditions and those taking more than one antipsychotic medication.
Use of an SSRI was associated with reduced growth in height, particularly among boys in Tanner stages 3 and 4. “This effect is of a moderate magnitude of about 1 cm for every 1 year of treatment with SSRIs during adolescence,” Dr. Calarge and his coauthors said.
Among boys who took SSRIs continuously, the strongest inverse association with height z scores was in boys in Tanner stages 3 and 4 (r = –0.69; P less than .009). By contrast, this correlation was “negligible” in boys in Tanner stage 1 and stage 5, and there were only 5 boys of Tanner stage 2 in this analysis, the investigators said.
The mechanism by which SSRIs may have an effect on longitudinal growth has not been well investigated, according to Dr. Calarge and his coauthors. “Impaired growth hormone secretion or activity has been implicated, given that SSRIs alter serotonin signaling, which is known to control GH secretion.”
Funding for the study came from the National Institutes of Health, and other grants. One study coauthor reported funding support from Pfizer and Aeterna Zentaris.
SOURCE: Calarge CA et al. J Pediatr. 2018 Oct;201:245-51.
FROM THE JOURNAL OF PEDIATRICS
Key clinical point: Among risperidone-treated boys, use of SSRIs was linked to reduced longitudinal growth, according to results of an analysis.
Major finding: The strongest inverse association between continuous SSRI use and height z scores was in boys in Tanner stages 3 and 4 (r = −0.69; P less than .009).
Study details: Retrospective analysis of 267 boys enrolled in four previous studies evaluating risperidone use.
Disclosures: Funding for the study came from the National Institutes of Health and other grants. One study coauthor reported funding support from Pfizer and Aeterna Zentaris.
Source: Calarge CA et al. J Pediatr. 2018;201:245-51.
Rosacea likely underdiagnosed, suboptimally treated in skin of color
in this population, according to the authors of a clinical review article on the topic.
“Current reports of rosacea in patients with skin of color may point to a large pool of undiagnosed patients,” said Andrew F. Alexis, MD, chairman of the department of dermatology, Mount Sinai St. Luke’s and Mount Sinai West, New York, and his coauthors.
Increased awareness of rosacea in these patients may reduce disparities in disease management, they wrote in the review, published in the Journal of the American Academy of Dermatology, which outlines strategies for timely diagnosis and effective treatment of rosacea in skin of color.
The erroneous perception that rosacea does not occur in skin of color may arise from epidemiologic reports, which frequently position it as a disease that occurs in fair-skinned individuals of Northern European or Celtic background, they said.
The reported prevalence of rosacea in skin of color varies worldwide and is as high as 10%, according to the authors. Moreover, a recent U.S. medical care survey found that 3.9% of rosacea patients were Hispanic or Latino, 2.3% were Asian or Pacific Islander, and 2% were black.
A low index of suspicion for rosacea in skin of color may lead to delayed diagnosis, and consequently, advanced disease that could include disfigurement with disease progression (such as rhinophyma and otophyma) and, in the case of ocular disease, loss of sight, Dr. Alexis and his coauthors pointed out.
One clinical aspect of rosacea in skin of color is that persistent facial erythema is less frequently reported than are papules and pustules. That may be due to the difficulty of visualizing erythema in darker skin, they suggested, noting that the postinflammatory hyperpigmentation that is more common in skin of color could also mask erythema.
A rosacea variant seen more often in these patients is the granulomatous subtype, which may not present with flushing, persistent erythema, or other typical rosacea signs, they pointed out.
One key to accurately diagnosing rosacea in skin of color is the patient’s own observations, such as whether they experience flushing or a warm sensation in the face, according to the authors, who said patients may report stinging or burning with certain skin care products.
Dr. Alexis and his coauthors said they have tried various strategies to assess dark skin for erythema and telangiectasia. Photographing subjects on a dark-blue background may better highlight any redness, they said, while using a dermatoscope may help differentiate skin pigment from blood vessels.
A magnifying glass or microscope slide can be used to test skin for blanching: “If the skin pales when pressed under the glass or slide, erythema is present,” they wrote.
Although data on treatment of rosacea in skin of color is limited, the general treatment approach is similar to that of lighter skin and may include topical and oral therapies, laser or light-based treatment, or surgery. “Patients with skin of color may have unique clinical features that need to be addressed during the treatment of rosacea, such as postinflammatory pigment alteration or risk of developing this complication with laser/light-based therapies,” they noted.
In the review, they referred to a few studies of oral or topical treatments that suggest similar benefits in Fitzpatrick skin phototypes I-III (lighter) and IV-VI (darker) that the authors describe in their review.
Allergan sponsored development of the paper, which was developed with editorial assistance from Peloton Advantage. Dr. Alexis and his coauthors provided disclosures related to Allergan, BioPharmx, Galderma, Bayer, Beiersdorf, Croma-Pharma, Aclaris, and Unilever.
SOURCE: Alexis AF et al. J Am Acad Dermatol. 2018 Sep 18. pii: S0190-9622(18)32576-3. doi: 10.1016/j.jaad.2018.08.049.
in this population, according to the authors of a clinical review article on the topic.
“Current reports of rosacea in patients with skin of color may point to a large pool of undiagnosed patients,” said Andrew F. Alexis, MD, chairman of the department of dermatology, Mount Sinai St. Luke’s and Mount Sinai West, New York, and his coauthors.
Increased awareness of rosacea in these patients may reduce disparities in disease management, they wrote in the review, published in the Journal of the American Academy of Dermatology, which outlines strategies for timely diagnosis and effective treatment of rosacea in skin of color.
The erroneous perception that rosacea does not occur in skin of color may arise from epidemiologic reports, which frequently position it as a disease that occurs in fair-skinned individuals of Northern European or Celtic background, they said.
The reported prevalence of rosacea in skin of color varies worldwide and is as high as 10%, according to the authors. Moreover, a recent U.S. medical care survey found that 3.9% of rosacea patients were Hispanic or Latino, 2.3% were Asian or Pacific Islander, and 2% were black.
A low index of suspicion for rosacea in skin of color may lead to delayed diagnosis, and consequently, advanced disease that could include disfigurement with disease progression (such as rhinophyma and otophyma) and, in the case of ocular disease, loss of sight, Dr. Alexis and his coauthors pointed out.
One clinical aspect of rosacea in skin of color is that persistent facial erythema is less frequently reported than are papules and pustules. That may be due to the difficulty of visualizing erythema in darker skin, they suggested, noting that the postinflammatory hyperpigmentation that is more common in skin of color could also mask erythema.
A rosacea variant seen more often in these patients is the granulomatous subtype, which may not present with flushing, persistent erythema, or other typical rosacea signs, they pointed out.
One key to accurately diagnosing rosacea in skin of color is the patient’s own observations, such as whether they experience flushing or a warm sensation in the face, according to the authors, who said patients may report stinging or burning with certain skin care products.
Dr. Alexis and his coauthors said they have tried various strategies to assess dark skin for erythema and telangiectasia. Photographing subjects on a dark-blue background may better highlight any redness, they said, while using a dermatoscope may help differentiate skin pigment from blood vessels.
A magnifying glass or microscope slide can be used to test skin for blanching: “If the skin pales when pressed under the glass or slide, erythema is present,” they wrote.
Although data on treatment of rosacea in skin of color is limited, the general treatment approach is similar to that of lighter skin and may include topical and oral therapies, laser or light-based treatment, or surgery. “Patients with skin of color may have unique clinical features that need to be addressed during the treatment of rosacea, such as postinflammatory pigment alteration or risk of developing this complication with laser/light-based therapies,” they noted.
In the review, they referred to a few studies of oral or topical treatments that suggest similar benefits in Fitzpatrick skin phototypes I-III (lighter) and IV-VI (darker) that the authors describe in their review.
Allergan sponsored development of the paper, which was developed with editorial assistance from Peloton Advantage. Dr. Alexis and his coauthors provided disclosures related to Allergan, BioPharmx, Galderma, Bayer, Beiersdorf, Croma-Pharma, Aclaris, and Unilever.
SOURCE: Alexis AF et al. J Am Acad Dermatol. 2018 Sep 18. pii: S0190-9622(18)32576-3. doi: 10.1016/j.jaad.2018.08.049.
in this population, according to the authors of a clinical review article on the topic.
“Current reports of rosacea in patients with skin of color may point to a large pool of undiagnosed patients,” said Andrew F. Alexis, MD, chairman of the department of dermatology, Mount Sinai St. Luke’s and Mount Sinai West, New York, and his coauthors.
Increased awareness of rosacea in these patients may reduce disparities in disease management, they wrote in the review, published in the Journal of the American Academy of Dermatology, which outlines strategies for timely diagnosis and effective treatment of rosacea in skin of color.
The erroneous perception that rosacea does not occur in skin of color may arise from epidemiologic reports, which frequently position it as a disease that occurs in fair-skinned individuals of Northern European or Celtic background, they said.
The reported prevalence of rosacea in skin of color varies worldwide and is as high as 10%, according to the authors. Moreover, a recent U.S. medical care survey found that 3.9% of rosacea patients were Hispanic or Latino, 2.3% were Asian or Pacific Islander, and 2% were black.
A low index of suspicion for rosacea in skin of color may lead to delayed diagnosis, and consequently, advanced disease that could include disfigurement with disease progression (such as rhinophyma and otophyma) and, in the case of ocular disease, loss of sight, Dr. Alexis and his coauthors pointed out.
One clinical aspect of rosacea in skin of color is that persistent facial erythema is less frequently reported than are papules and pustules. That may be due to the difficulty of visualizing erythema in darker skin, they suggested, noting that the postinflammatory hyperpigmentation that is more common in skin of color could also mask erythema.
A rosacea variant seen more often in these patients is the granulomatous subtype, which may not present with flushing, persistent erythema, or other typical rosacea signs, they pointed out.
One key to accurately diagnosing rosacea in skin of color is the patient’s own observations, such as whether they experience flushing or a warm sensation in the face, according to the authors, who said patients may report stinging or burning with certain skin care products.
Dr. Alexis and his coauthors said they have tried various strategies to assess dark skin for erythema and telangiectasia. Photographing subjects on a dark-blue background may better highlight any redness, they said, while using a dermatoscope may help differentiate skin pigment from blood vessels.
A magnifying glass or microscope slide can be used to test skin for blanching: “If the skin pales when pressed under the glass or slide, erythema is present,” they wrote.
Although data on treatment of rosacea in skin of color is limited, the general treatment approach is similar to that of lighter skin and may include topical and oral therapies, laser or light-based treatment, or surgery. “Patients with skin of color may have unique clinical features that need to be addressed during the treatment of rosacea, such as postinflammatory pigment alteration or risk of developing this complication with laser/light-based therapies,” they noted.
In the review, they referred to a few studies of oral or topical treatments that suggest similar benefits in Fitzpatrick skin phototypes I-III (lighter) and IV-VI (darker) that the authors describe in their review.
Allergan sponsored development of the paper, which was developed with editorial assistance from Peloton Advantage. Dr. Alexis and his coauthors provided disclosures related to Allergan, BioPharmx, Galderma, Bayer, Beiersdorf, Croma-Pharma, Aclaris, and Unilever.
SOURCE: Alexis AF et al. J Am Acad Dermatol. 2018 Sep 18. pii: S0190-9622(18)32576-3. doi: 10.1016/j.jaad.2018.08.049.
FROM THE JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY