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NEW YORK – according to Galen T. Foulke, MD, who discussed avoidable clinical disasters in practice at the American Academy of Dermatology summer meeting.
Of a list of known and predictable risks that “fall under the purview of ‘You Should Have Known Better,’ ” Dr. Foulke focused on glucocorticoid-associated osteoporosis and infections associated with biologics.
Prior to delivering advice about preventing osteoporosis in patients taking glucocorticoids, he polled the audience about what they considered appropriate prophylaxis in this setting. The vast majority opted for vitamin D and calcium supplementation.
“This is a common answer, but it is the wrong answer,” said Dr. Foulke, a dermatologist affiliated with Penn State Milton S. Hershey Medical Center in Hershey, Pennsylvania.
The available data show that patients on vitamin D and calcium supplementation will continue to lose bone density on therapeutic doses of steroids, according to Dr. Foulke. This is true even when the daily doses for these supplements exceed 800 units and 900 mg, respectively. Moreover, calcium supplementation is associated with an increased risk of heart disease in patients without a calcium deficiency, he noted.
The correct answer is a bisphosphonate, said Dr. Foulke. Of the bisphosphonates, he recommended alendronate as one that is particularly well tolerated and readily reimbursed.
He believes that dermatologists prescribing glucocorticoids should not overlook the substantial risk of osteoporosis or their responsibility to discuss strategies for risk mitigation. Moreover, he believes dermatologists should consider prescribing alendronate in the appropriate candidates, not just refer to another specialist.
“In the first year of steroid use, substantial bone loss is a risk even at doses below 5 mg,” Dr. Foulke warned. At higher doses, patients can lose up to 25% of their bone density, he added.
Of preventable risks of biologics, Dr. Foulke focused on infection. In particular, he urged dermatologists who prescribe these drugs to routinely inform patients about the role and safety of vaccines in infection prevention.
“An immunosuppressant suppresses the immune system, increasing the risk of infection. It is our responsibility to protect patients from the known risks of the therapies we offer them,” he said.
Several organizations recommend the pneumococcal vaccine series and the annual influenza vaccine for patients taking biologics. Although Dr. Foulke was unable to find reliable data on vaccination rates among patients prescribed a biologic for a dermatologic indication, he cited rheumatology practice data to suggest that less than half of patients receive this protection.
A major reason for the low rate of vaccination was failure of the biologic prescriber to assume responsibility for this recommended step, according to Dr. Foulke. Although he does not believe that biologic prescribers need to administer the vaccine, and he acknowledged that he does not stock vaccines in his clinic, he does believe they should inform patients when vaccination is safe and appropriate.
Live attenuated vaccines, in his opinion, are not safe. Although he reported that this is an area of controversy, he takes a conservative approach, advising candidates for a live attenuated vaccine to undergo vaccination prior to starting the biologic or during a break from biologic therapy.
When he polled the audience about which vaccines are live attenuated vaccines, several failed to recognize that the MMR vaccine falls into this category. However, he also noted that the majority of vaccines are not live attenuated and should be considered. He specifically singled out the recombinant herpes zoster as a vaccine recommended by the American College of Rheumatology in patients on biologics.
“We do not have to give the shots, but we should be the ones who start the discussion,” said Dr. Foulke, referring to vaccines in patients on a biologic. He called these important steps “to protect patients from preventable disasters.”
Dr. Foulke reported no potential conflicts of interest.
SOURCE: Summer AAD 2019, Session F02.
NEW YORK – according to Galen T. Foulke, MD, who discussed avoidable clinical disasters in practice at the American Academy of Dermatology summer meeting.
Of a list of known and predictable risks that “fall under the purview of ‘You Should Have Known Better,’ ” Dr. Foulke focused on glucocorticoid-associated osteoporosis and infections associated with biologics.
Prior to delivering advice about preventing osteoporosis in patients taking glucocorticoids, he polled the audience about what they considered appropriate prophylaxis in this setting. The vast majority opted for vitamin D and calcium supplementation.
“This is a common answer, but it is the wrong answer,” said Dr. Foulke, a dermatologist affiliated with Penn State Milton S. Hershey Medical Center in Hershey, Pennsylvania.
The available data show that patients on vitamin D and calcium supplementation will continue to lose bone density on therapeutic doses of steroids, according to Dr. Foulke. This is true even when the daily doses for these supplements exceed 800 units and 900 mg, respectively. Moreover, calcium supplementation is associated with an increased risk of heart disease in patients without a calcium deficiency, he noted.
The correct answer is a bisphosphonate, said Dr. Foulke. Of the bisphosphonates, he recommended alendronate as one that is particularly well tolerated and readily reimbursed.
He believes that dermatologists prescribing glucocorticoids should not overlook the substantial risk of osteoporosis or their responsibility to discuss strategies for risk mitigation. Moreover, he believes dermatologists should consider prescribing alendronate in the appropriate candidates, not just refer to another specialist.
“In the first year of steroid use, substantial bone loss is a risk even at doses below 5 mg,” Dr. Foulke warned. At higher doses, patients can lose up to 25% of their bone density, he added.
Of preventable risks of biologics, Dr. Foulke focused on infection. In particular, he urged dermatologists who prescribe these drugs to routinely inform patients about the role and safety of vaccines in infection prevention.
“An immunosuppressant suppresses the immune system, increasing the risk of infection. It is our responsibility to protect patients from the known risks of the therapies we offer them,” he said.
Several organizations recommend the pneumococcal vaccine series and the annual influenza vaccine for patients taking biologics. Although Dr. Foulke was unable to find reliable data on vaccination rates among patients prescribed a biologic for a dermatologic indication, he cited rheumatology practice data to suggest that less than half of patients receive this protection.
A major reason for the low rate of vaccination was failure of the biologic prescriber to assume responsibility for this recommended step, according to Dr. Foulke. Although he does not believe that biologic prescribers need to administer the vaccine, and he acknowledged that he does not stock vaccines in his clinic, he does believe they should inform patients when vaccination is safe and appropriate.
Live attenuated vaccines, in his opinion, are not safe. Although he reported that this is an area of controversy, he takes a conservative approach, advising candidates for a live attenuated vaccine to undergo vaccination prior to starting the biologic or during a break from biologic therapy.
When he polled the audience about which vaccines are live attenuated vaccines, several failed to recognize that the MMR vaccine falls into this category. However, he also noted that the majority of vaccines are not live attenuated and should be considered. He specifically singled out the recombinant herpes zoster as a vaccine recommended by the American College of Rheumatology in patients on biologics.
“We do not have to give the shots, but we should be the ones who start the discussion,” said Dr. Foulke, referring to vaccines in patients on a biologic. He called these important steps “to protect patients from preventable disasters.”
Dr. Foulke reported no potential conflicts of interest.
SOURCE: Summer AAD 2019, Session F02.
NEW YORK – according to Galen T. Foulke, MD, who discussed avoidable clinical disasters in practice at the American Academy of Dermatology summer meeting.
Of a list of known and predictable risks that “fall under the purview of ‘You Should Have Known Better,’ ” Dr. Foulke focused on glucocorticoid-associated osteoporosis and infections associated with biologics.
Prior to delivering advice about preventing osteoporosis in patients taking glucocorticoids, he polled the audience about what they considered appropriate prophylaxis in this setting. The vast majority opted for vitamin D and calcium supplementation.
“This is a common answer, but it is the wrong answer,” said Dr. Foulke, a dermatologist affiliated with Penn State Milton S. Hershey Medical Center in Hershey, Pennsylvania.
The available data show that patients on vitamin D and calcium supplementation will continue to lose bone density on therapeutic doses of steroids, according to Dr. Foulke. This is true even when the daily doses for these supplements exceed 800 units and 900 mg, respectively. Moreover, calcium supplementation is associated with an increased risk of heart disease in patients without a calcium deficiency, he noted.
The correct answer is a bisphosphonate, said Dr. Foulke. Of the bisphosphonates, he recommended alendronate as one that is particularly well tolerated and readily reimbursed.
He believes that dermatologists prescribing glucocorticoids should not overlook the substantial risk of osteoporosis or their responsibility to discuss strategies for risk mitigation. Moreover, he believes dermatologists should consider prescribing alendronate in the appropriate candidates, not just refer to another specialist.
“In the first year of steroid use, substantial bone loss is a risk even at doses below 5 mg,” Dr. Foulke warned. At higher doses, patients can lose up to 25% of their bone density, he added.
Of preventable risks of biologics, Dr. Foulke focused on infection. In particular, he urged dermatologists who prescribe these drugs to routinely inform patients about the role and safety of vaccines in infection prevention.
“An immunosuppressant suppresses the immune system, increasing the risk of infection. It is our responsibility to protect patients from the known risks of the therapies we offer them,” he said.
Several organizations recommend the pneumococcal vaccine series and the annual influenza vaccine for patients taking biologics. Although Dr. Foulke was unable to find reliable data on vaccination rates among patients prescribed a biologic for a dermatologic indication, he cited rheumatology practice data to suggest that less than half of patients receive this protection.
A major reason for the low rate of vaccination was failure of the biologic prescriber to assume responsibility for this recommended step, according to Dr. Foulke. Although he does not believe that biologic prescribers need to administer the vaccine, and he acknowledged that he does not stock vaccines in his clinic, he does believe they should inform patients when vaccination is safe and appropriate.
Live attenuated vaccines, in his opinion, are not safe. Although he reported that this is an area of controversy, he takes a conservative approach, advising candidates for a live attenuated vaccine to undergo vaccination prior to starting the biologic or during a break from biologic therapy.
When he polled the audience about which vaccines are live attenuated vaccines, several failed to recognize that the MMR vaccine falls into this category. However, he also noted that the majority of vaccines are not live attenuated and should be considered. He specifically singled out the recombinant herpes zoster as a vaccine recommended by the American College of Rheumatology in patients on biologics.
“We do not have to give the shots, but we should be the ones who start the discussion,” said Dr. Foulke, referring to vaccines in patients on a biologic. He called these important steps “to protect patients from preventable disasters.”
Dr. Foulke reported no potential conflicts of interest.
SOURCE: Summer AAD 2019, Session F02.
EXPERT ANALYSIS FROM SUMMER AAD 2019