Neurology Reviews

An epilepsy drug sold in Europe as Ospolot and also known as sulthiame showed promise in reducing sleep disordered breathing and other symptoms of obstructive sleep apnea (OSA), based on data from nearly 300 individuals presented in a late-breaking study at the annual congress of the European Respiratory Society.

“Current therapies are mechanical and based on the notion of an airway splint,” presenting author Jan Hedner, MD, professor of respiratory medicine at Sahlgrenska University Hospital and the University of Gothenburg, both in Sweden, said in an interview. “In other words, applying an airflow at elevated pressure [continuous positive airway pressure] or advancing the jaw with a dental device. Adherence to this type of therapy is limited. In the case of continuous positive airway pressure [CPAP], it is < 50% after 3-4 years of therapy.” Therefore, there is a need for a better-tolerated therapy, such as a drug, and possibly a combination of mechanical and pharmaceutical therapies.

The use of medication has emerged as a viable option for OSA, with a high rate of compliance and acceptable safety profile, Dr. Hedner said in his presentation.

“Modified carbonic anhydrase activity may be a pathophysiological mechanism in OSA,” said Dr. Hedner. Sulthiame, a carbonic anhydrase inhibitor, showed safety and effectiveness for improving OSA in a previous phase 2b trial.

In the current study, the researchers sought to determine the most effective dose of sulthiame for patients with OSA. They randomized 298 adults with OSA who could not accept or tolerate oral splints or CPAP to 100 mg, 200 mg, or 300 mg of sulthiame daily (74, 74, and 75 patients, respectively) or placebo (75 patients).

The mean age of the patients was 56 years, 26.2% were women, and the average apnea-hypopnea index (AHI3a) at baseline was 29 n/h. Patients were treated at centers in Spain, France, Belgium, Germany, and the Czech Republic. Baseline demographics and clinical characteristics were similar among the treatment groups.

The primary endpoint was the change in AHI3a from baseline to 15 weeks, and significant changes occurred in patients who received the 100-mg, 200-mg, and 300-mg doses, with decreases of 17.8%, 34.8%, and 39.9%, respectively.

Peak efficacy occurred in the range of 200-300 mg and was similar for patients with moderate or severe OSA, Dr. Hedner said in his presentation.

Notably, in a post hoc analysis, apnea improved by 47.1% at a 300-mg dose when the AHI4 measure (apnea/hypopnea with ≥ 4% O₂ desaturation) was used in a placebo-adjusted dose-dependent reduction, the researchers wrote. The changes in AHI4 from baseline in this analysis also were significant for 200 mg and 100 mg doses (36.8% and 26.2%, respectively).

Patients underwent polysomnography at baseline and at weeks 4 and 12.

Mean overnight oxygen saturation also improved significantly from baseline with doses of 200 mg and 300 mg, compared with placebo (P < .0001 for both).

In addition, scores on the Epworth Sleepiness Scale (ESS) improved from baseline to week 15 in all dosage groups, and the subgroup of patients with ESS scores of ≥ 11 at baseline showed even greater improvement in ESS, Dr. Hedner said in his presentation.

Total arousal index and sleep quality also improved from baseline compared with placebo, and no clinically relevant reduction in REM sleep was noted, Dr. Hedner added.

Treatment-emergent adverse events were in line with the known safety profile of sulthiame and included paresthesia, headache, fatigue, and nausea; these were mainly moderate and dose-dependent, with no evidence of cardiovascular safety issues, he said.

Although the study results were not surprising given previous research, the investigators were pleased with the potency of the therapy. “We are also happy about potential added values such as a blood pressure lowering effect, which is beneficial in this group of patients; however, we need to further study these mechanisms in detail,” Dr. Hedner noted.

The study findings were limited by the relatively small scale, and larger studies on long-term efficacy and tolerability are also needed, he said.

“The current study was a dose-finding study, and we now have useful information on most suitable dose,” he said.

However, the results support sulthiame as an effective, well-tolerated, and promising novel candidate for drug therapy in patients with OSA, worthy of phase 3 studies, Dr. Hedner said.
 

Oral Option Could Be Game-Changer, But Not Yet

The gold standard of treatment for OSA is a CPAP machine, but the effectiveness is limited by patient tolerance, Q. Afifa Shamim-Uzzaman, MD, an associate professor and a sleep medicine specialist at the University of Michigan, Ann Arbor, said in an interview.

“Presently, there are no effective pharmacological treatments for OSA — having a pill that treats OSA would be a total game changer and huge advance for the treatment of OSA and the field of sleep medicine,” said Dr. Shamim-Uzzaman, who was not involved in the study. “More patients may be able to obtain treatment for OSA and thereby reduce the potential complications of untreated OSA.

“Carbonic anhydrase inhibitors such as acetazolamide and sulthiame have been studied with limited success for the treatment of other forms of sleep disordered breathing such as central sleep apnea [CSA] but have shown less efficacy for OSA and are presently not recommended in the treatment of OSA by the American Academy of Sleep Medicine,” Dr. Shamim-Uzzaman said.

Recently, emerging evidence about different phenotypes of OSA suggests that nonanatomic features (such as high loop gain) may play a role in patients with OSA, not only in those with CSA, she said. Whether carbonic anhydrase inhibitors could play a greater role in treating sleep apnea in patients with predominantly nonanatomic pathophysiologic traits remains to be seen.

The sulthiame data are promising, but more research is needed, Dr. Shamim-Uzzaman said. Although patients in the highest dose group showed a reduction in AHI of nearly 40%, they still would have moderate OSA, and the OSA did not appear to decrease to a normal range in any of the treatment groups.

“More research is needed to identify which types of patients would be responders to this form of therapy, to understand if these effects are maintained long term (beyond 15 weeks), to evaluate patient-centered outcomes, especially in different sleep apnea subgroups (such as phenotypes with high loop gain vs those without), and to assess interactions with other therapies,” she said.

The study was supported by manufacturer Desitin. Dr. Hedner disclosed serving as a consultant to AstraZeneca, Bayer, CereusScience, Jazz Pharmaceuticals, MSD, Weinmann, Desitin, SomnoMed, and Itamar Medical; serving on the speakers’ bureau for Almirall, AstraZeneca, Jazz Pharmaceuticals, ResMed, Philips Respironics, and Weinmann; and receiving grants or research support from Bayer, ResMed, Philips Respironics, and SomnoMed. He also disclosed shared ownership of intellectual property related to sleep apnea therapy. Dr. Shamim-Uzzaman had no financial conflicts to disclose.

A version of this article appeared on Medscape.com.

An epilepsy drug sold in Europe as Ospolot and also known as sulthiame showed promise in reducing sleep disordered breathing and other symptoms of obstructive sleep apnea (OSA), based on data from nearly 300 individuals presented in a late-breaking study at the annual congress of the European Respiratory Society.

“Current therapies are mechanical and based on the notion of an airway splint,” presenting author Jan Hedner, MD, professor of respiratory medicine at Sahlgrenska University Hospital and the University of Gothenburg, both in Sweden, said in an interview. “In other words, applying an airflow at elevated pressure [continuous positive airway pressure] or advancing the jaw with a dental device. Adherence to this type of therapy is limited. In the case of continuous positive airway pressure [CPAP], it is < 50% after 3-4 years of therapy.” Therefore, there is a need for a better-tolerated therapy, such as a drug, and possibly a combination of mechanical and pharmaceutical therapies.

The use of medication has emerged as a viable option for OSA, with a high rate of compliance and acceptable safety profile, Dr. Hedner said in his presentation.

“Modified carbonic anhydrase activity may be a pathophysiological mechanism in OSA,” said Dr. Hedner. Sulthiame, a carbonic anhydrase inhibitor, showed safety and effectiveness for improving OSA in a previous phase 2b trial.

In the current study, the researchers sought to determine the most effective dose of sulthiame for patients with OSA. They randomized 298 adults with OSA who could not accept or tolerate oral splints or CPAP to 100 mg, 200 mg, or 300 mg of sulthiame daily (74, 74, and 75 patients, respectively) or placebo (75 patients).

The mean age of the patients was 56 years, 26.2% were women, and the average apnea-hypopnea index (AHI3a) at baseline was 29 n/h. Patients were treated at centers in Spain, France, Belgium, Germany, and the Czech Republic. Baseline demographics and clinical characteristics were similar among the treatment groups.

The primary endpoint was the change in AHI3a from baseline to 15 weeks, and significant changes occurred in patients who received the 100-mg, 200-mg, and 300-mg doses, with decreases of 17.8%, 34.8%, and 39.9%, respectively.

Peak efficacy occurred in the range of 200-300 mg and was similar for patients with moderate or severe OSA, Dr. Hedner said in his presentation.

Notably, in a post hoc analysis, apnea improved by 47.1% at a 300-mg dose when the AHI4 measure (apnea/hypopnea with ≥ 4% O₂ desaturation) was used in a placebo-adjusted dose-dependent reduction, the researchers wrote. The changes in AHI4 from baseline in this analysis also were significant for 200 mg and 100 mg doses (36.8% and 26.2%, respectively).

Patients underwent polysomnography at baseline and at weeks 4 and 12.

Mean overnight oxygen saturation also improved significantly from baseline with doses of 200 mg and 300 mg, compared with placebo (P < .0001 for both).

In addition, scores on the Epworth Sleepiness Scale (ESS) improved from baseline to week 15 in all dosage groups, and the subgroup of patients with ESS scores of ≥ 11 at baseline showed even greater improvement in ESS, Dr. Hedner said in his presentation.

Total arousal index and sleep quality also improved from baseline compared with placebo, and no clinically relevant reduction in REM sleep was noted, Dr. Hedner added.

Treatment-emergent adverse events were in line with the known safety profile of sulthiame and included paresthesia, headache, fatigue, and nausea; these were mainly moderate and dose-dependent, with no evidence of cardiovascular safety issues, he said.

Although the study results were not surprising given previous research, the investigators were pleased with the potency of the therapy. “We are also happy about potential added values such as a blood pressure lowering effect, which is beneficial in this group of patients; however, we need to further study these mechanisms in detail,” Dr. Hedner noted.

The study findings were limited by the relatively small scale, and larger studies on long-term efficacy and tolerability are also needed, he said.

“The current study was a dose-finding study, and we now have useful information on most suitable dose,” he said.

However, the results support sulthiame as an effective, well-tolerated, and promising novel candidate for drug therapy in patients with OSA, worthy of phase 3 studies, Dr. Hedner said.
 

Oral Option Could Be Game-Changer, But Not Yet

The gold standard of treatment for OSA is a CPAP machine, but the effectiveness is limited by patient tolerance, Q. Afifa Shamim-Uzzaman, MD, an associate professor and a sleep medicine specialist at the University of Michigan, Ann Arbor, said in an interview.

“Presently, there are no effective pharmacological treatments for OSA — having a pill that treats OSA would be a total game changer and huge advance for the treatment of OSA and the field of sleep medicine,” said Dr. Shamim-Uzzaman, who was not involved in the study. “More patients may be able to obtain treatment for OSA and thereby reduce the potential complications of untreated OSA.

“Carbonic anhydrase inhibitors such as acetazolamide and sulthiame have been studied with limited success for the treatment of other forms of sleep disordered breathing such as central sleep apnea [CSA] but have shown less efficacy for OSA and are presently not recommended in the treatment of OSA by the American Academy of Sleep Medicine,” Dr. Shamim-Uzzaman said.

Recently, emerging evidence about different phenotypes of OSA suggests that nonanatomic features (such as high loop gain) may play a role in patients with OSA, not only in those with CSA, she said. Whether carbonic anhydrase inhibitors could play a greater role in treating sleep apnea in patients with predominantly nonanatomic pathophysiologic traits remains to be seen.

The sulthiame data are promising, but more research is needed, Dr. Shamim-Uzzaman said. Although patients in the highest dose group showed a reduction in AHI of nearly 40%, they still would have moderate OSA, and the OSA did not appear to decrease to a normal range in any of the treatment groups.

“More research is needed to identify which types of patients would be responders to this form of therapy, to understand if these effects are maintained long term (beyond 15 weeks), to evaluate patient-centered outcomes, especially in different sleep apnea subgroups (such as phenotypes with high loop gain vs those without), and to assess interactions with other therapies,” she said.

The study was supported by manufacturer Desitin. Dr. Hedner disclosed serving as a consultant to AstraZeneca, Bayer, CereusScience, Jazz Pharmaceuticals, MSD, Weinmann, Desitin, SomnoMed, and Itamar Medical; serving on the speakers’ bureau for Almirall, AstraZeneca, Jazz Pharmaceuticals, ResMed, Philips Respironics, and Weinmann; and receiving grants or research support from Bayer, ResMed, Philips Respironics, and SomnoMed. He also disclosed shared ownership of intellectual property related to sleep apnea therapy. Dr. Shamim-Uzzaman had no financial conflicts to disclose.

A version of this article appeared on Medscape.com.

An epilepsy drug sold in Europe as Ospolot and also known as sulthiame showed promise in reducing sleep disordered breathing and other symptoms of obstructive sleep apnea (OSA), based on data from nearly 300 individuals presented in a late-breaking study at the annual congress of the European Respiratory Society.

“Current therapies are mechanical and based on the notion of an airway splint,” presenting author Jan Hedner, MD, professor of respiratory medicine at Sahlgrenska University Hospital and the University of Gothenburg, both in Sweden, said in an interview. “In other words, applying an airflow at elevated pressure [continuous positive airway pressure] or advancing the jaw with a dental device. Adherence to this type of therapy is limited. In the case of continuous positive airway pressure [CPAP], it is < 50% after 3-4 years of therapy.” Therefore, there is a need for a better-tolerated therapy, such as a drug, and possibly a combination of mechanical and pharmaceutical therapies.

The use of medication has emerged as a viable option for OSA, with a high rate of compliance and acceptable safety profile, Dr. Hedner said in his presentation.

“Modified carbonic anhydrase activity may be a pathophysiological mechanism in OSA,” said Dr. Hedner. Sulthiame, a carbonic anhydrase inhibitor, showed safety and effectiveness for improving OSA in a previous phase 2b trial.

In the current study, the researchers sought to determine the most effective dose of sulthiame for patients with OSA. They randomized 298 adults with OSA who could not accept or tolerate oral splints or CPAP to 100 mg, 200 mg, or 300 mg of sulthiame daily (74, 74, and 75 patients, respectively) or placebo (75 patients).

The mean age of the patients was 56 years, 26.2% were women, and the average apnea-hypopnea index (AHI3a) at baseline was 29 n/h. Patients were treated at centers in Spain, France, Belgium, Germany, and the Czech Republic. Baseline demographics and clinical characteristics were similar among the treatment groups.

The primary endpoint was the change in AHI3a from baseline to 15 weeks, and significant changes occurred in patients who received the 100-mg, 200-mg, and 300-mg doses, with decreases of 17.8%, 34.8%, and 39.9%, respectively.

Peak efficacy occurred in the range of 200-300 mg and was similar for patients with moderate or severe OSA, Dr. Hedner said in his presentation.

Notably, in a post hoc analysis, apnea improved by 47.1% at a 300-mg dose when the AHI4 measure (apnea/hypopnea with ≥ 4% O₂ desaturation) was used in a placebo-adjusted dose-dependent reduction, the researchers wrote. The changes in AHI4 from baseline in this analysis also were significant for 200 mg and 100 mg doses (36.8% and 26.2%, respectively).

Patients underwent polysomnography at baseline and at weeks 4 and 12.

Mean overnight oxygen saturation also improved significantly from baseline with doses of 200 mg and 300 mg, compared with placebo (P < .0001 for both).

In addition, scores on the Epworth Sleepiness Scale (ESS) improved from baseline to week 15 in all dosage groups, and the subgroup of patients with ESS scores of ≥ 11 at baseline showed even greater improvement in ESS, Dr. Hedner said in his presentation.

Total arousal index and sleep quality also improved from baseline compared with placebo, and no clinically relevant reduction in REM sleep was noted, Dr. Hedner added.

Treatment-emergent adverse events were in line with the known safety profile of sulthiame and included paresthesia, headache, fatigue, and nausea; these were mainly moderate and dose-dependent, with no evidence of cardiovascular safety issues, he said.

Although the study results were not surprising given previous research, the investigators were pleased with the potency of the therapy. “We are also happy about potential added values such as a blood pressure lowering effect, which is beneficial in this group of patients; however, we need to further study these mechanisms in detail,” Dr. Hedner noted.

The study findings were limited by the relatively small scale, and larger studies on long-term efficacy and tolerability are also needed, he said.

“The current study was a dose-finding study, and we now have useful information on most suitable dose,” he said.

However, the results support sulthiame as an effective, well-tolerated, and promising novel candidate for drug therapy in patients with OSA, worthy of phase 3 studies, Dr. Hedner said.
 

Oral Option Could Be Game-Changer, But Not Yet

The gold standard of treatment for OSA is a CPAP machine, but the effectiveness is limited by patient tolerance, Q. Afifa Shamim-Uzzaman, MD, an associate professor and a sleep medicine specialist at the University of Michigan, Ann Arbor, said in an interview.

“Presently, there are no effective pharmacological treatments for OSA — having a pill that treats OSA would be a total game changer and huge advance for the treatment of OSA and the field of sleep medicine,” said Dr. Shamim-Uzzaman, who was not involved in the study. “More patients may be able to obtain treatment for OSA and thereby reduce the potential complications of untreated OSA.

“Carbonic anhydrase inhibitors such as acetazolamide and sulthiame have been studied with limited success for the treatment of other forms of sleep disordered breathing such as central sleep apnea [CSA] but have shown less efficacy for OSA and are presently not recommended in the treatment of OSA by the American Academy of Sleep Medicine,” Dr. Shamim-Uzzaman said.

Recently, emerging evidence about different phenotypes of OSA suggests that nonanatomic features (such as high loop gain) may play a role in patients with OSA, not only in those with CSA, she said. Whether carbonic anhydrase inhibitors could play a greater role in treating sleep apnea in patients with predominantly nonanatomic pathophysiologic traits remains to be seen.

The sulthiame data are promising, but more research is needed, Dr. Shamim-Uzzaman said. Although patients in the highest dose group showed a reduction in AHI of nearly 40%, they still would have moderate OSA, and the OSA did not appear to decrease to a normal range in any of the treatment groups.

“More research is needed to identify which types of patients would be responders to this form of therapy, to understand if these effects are maintained long term (beyond 15 weeks), to evaluate patient-centered outcomes, especially in different sleep apnea subgroups (such as phenotypes with high loop gain vs those without), and to assess interactions with other therapies,” she said.

The study was supported by manufacturer Desitin. Dr. Hedner disclosed serving as a consultant to AstraZeneca, Bayer, CereusScience, Jazz Pharmaceuticals, MSD, Weinmann, Desitin, SomnoMed, and Itamar Medical; serving on the speakers’ bureau for Almirall, AstraZeneca, Jazz Pharmaceuticals, ResMed, Philips Respironics, and Weinmann; and receiving grants or research support from Bayer, ResMed, Philips Respironics, and SomnoMed. He also disclosed shared ownership of intellectual property related to sleep apnea therapy. Dr. Shamim-Uzzaman had no financial conflicts to disclose.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity. 

There’s a very interesting story in the medical press. A few years ago, a plastic surgeon named Edmond Cabbabe was preparing to do a follow-up cosmetic procedure on his wife at Mercy Hospital South, which is a big hospital in the St. Louis, Missouri, area.

He put her on the operating schedule, and he had done that when he had performed the original operation on her. On the day of the surgery, he got a call from the hospital saying the procedure was canceled. They said that the hospital’s policy, maybe a new one, would not allow doctors to operate on family members.

This physician was a past president of the Missouri State Medical Association. I think he was also on the board or president of the American Medical Association (AMA) Foundation. This was a physician not only in a skilled area where he felt confident he could take care of his wife, but also someone who was prominent in medical politics and medical policy.

The AMA forever has had a policy that says don’t treat relatives. This physician basically said, I think that policy is too restrictive, too cautious, and it doesn’t make much sense to continue to say that you can’t treat family and friends.

By implication, he was saying, I know exactly what I’m doing in my field and I know exactly what I’m doing with her procedure. I should have a right to perform it. I think I do a great job and I’d be best for her.

If you look at medical boards, every once in a while in some state, someone is brought up on a charge of doing different things with family members and saying that they’re going to get censured. They don’t usually lose their license, but they get a reprimand or get told that is just not ethical to do.

I think, in the long run, the policy about not treating your family and friends makes sense. The problem is, as is well known from the social sciences and psychology, people get biased when they deal with those they care about, love, and hold close to them.

It’s hard for the doctor to be objective when dealing with people that they really like or love. It’s also difficult for patients because they may not want to bring up something or they are uncomfortable talking with a doctor who’s a family member or close friend. They may not want to complain. They may be a little bit embarrassed about things. It just adds an emotional edge, I think, that’s difficult.

All that said, do I know doctors who regularly prescribe, say, an ointment for something that’s itchy or some kind of a pill when allergy season breaks out? I do. Do I think they’re acting in a horribly unethical manner? I don’t.

You need some judgment here. There are absolutely minor things where objectivity, fear, and anxiety are not in play. You’re going to be able to prescribe the routine thing for the routine itch without worrying too much about whether it’s a stranger, a friend, or your daughter.

What sorts of things am I really talking about when I say that minor variability ought to be allowed? It’s one thing when someone has poison ivy and they’re going to need some kind of standard medicine to treat it. A very different area that’s much more dangerous, and one I would avoid, is in the mental health field, and for that matter, the pain field.

It’s tempting to say: “Oh, my relative is just having a bad time. I’ll give her a little bit of antidepressant medicine,” or “They seem to be having pain after an operation or something, and I’m going to give them a little bit of pain meds just to get them through.”

Those areas are flying red flags. It’s easy to abuse and easy for someone to become a user and manipulate a friend or a doctor who’s a relative into getting things that another doctor wouldn’t be giving. I think that’s the space where you’ve got to exercise extreme caution.

Time and again, when those people get called up in front of the boards for treating relatives, it’s in those spaces of mental health, anxiety, and pain control. Again, when you know that there’s a likelihood of abuse, I think that’s the place where the line has to hold. Don’t treat the relative. Don’t treat the friend.

At the end of the day, I wouldn’t change the AMA policy. I think we should keep it in place and morally try to discourage doctors from caring for those they’re close to or they have emotional ties to.

At the same time, as with all ethical situations, there has to be a little bit of wiggle room for those super-minor cases where it just makes sense to say: “You don’t have to go find somebody else to do this. I can prescribe this ointment or this minor thing for you. No one’s objectivity is going to be soured, and you’re not going to feel in any way at risk because I’m going to prescribe this for you.”

Common sense ought to prevail. The default position is don’t do it; however, maybe with a tiny bit of space for what’s minor, what’s routine, and what really does just save people some inconvenience, there I might just give a little.

Dr. Caplan, Director, Division of Medical Ethics, New York University Langone Medical Center, New York City, has disclosed relationships with Johnson & Johnson’s Panel for Compassionate Drug Use and Medscape.

A version of this article first appeared on Medscape.com.

This transcript has been edited for clarity. 

There’s a very interesting story in the medical press. A few years ago, a plastic surgeon named Edmond Cabbabe was preparing to do a follow-up cosmetic procedure on his wife at Mercy Hospital South, which is a big hospital in the St. Louis, Missouri, area.

He put her on the operating schedule, and he had done that when he had performed the original operation on her. On the day of the surgery, he got a call from the hospital saying the procedure was canceled. They said that the hospital’s policy, maybe a new one, would not allow doctors to operate on family members.

This physician was a past president of the Missouri State Medical Association. I think he was also on the board or president of the American Medical Association (AMA) Foundation. This was a physician not only in a skilled area where he felt confident he could take care of his wife, but also someone who was prominent in medical politics and medical policy.

The AMA forever has had a policy that says don’t treat relatives. This physician basically said, I think that policy is too restrictive, too cautious, and it doesn’t make much sense to continue to say that you can’t treat family and friends.

By implication, he was saying, I know exactly what I’m doing in my field and I know exactly what I’m doing with her procedure. I should have a right to perform it. I think I do a great job and I’d be best for her.

If you look at medical boards, every once in a while in some state, someone is brought up on a charge of doing different things with family members and saying that they’re going to get censured. They don’t usually lose their license, but they get a reprimand or get told that is just not ethical to do.

I think, in the long run, the policy about not treating your family and friends makes sense. The problem is, as is well known from the social sciences and psychology, people get biased when they deal with those they care about, love, and hold close to them.

It’s hard for the doctor to be objective when dealing with people that they really like or love. It’s also difficult for patients because they may not want to bring up something or they are uncomfortable talking with a doctor who’s a family member or close friend. They may not want to complain. They may be a little bit embarrassed about things. It just adds an emotional edge, I think, that’s difficult.

All that said, do I know doctors who regularly prescribe, say, an ointment for something that’s itchy or some kind of a pill when allergy season breaks out? I do. Do I think they’re acting in a horribly unethical manner? I don’t.

You need some judgment here. There are absolutely minor things where objectivity, fear, and anxiety are not in play. You’re going to be able to prescribe the routine thing for the routine itch without worrying too much about whether it’s a stranger, a friend, or your daughter.

What sorts of things am I really talking about when I say that minor variability ought to be allowed? It’s one thing when someone has poison ivy and they’re going to need some kind of standard medicine to treat it. A very different area that’s much more dangerous, and one I would avoid, is in the mental health field, and for that matter, the pain field.

It’s tempting to say: “Oh, my relative is just having a bad time. I’ll give her a little bit of antidepressant medicine,” or “They seem to be having pain after an operation or something, and I’m going to give them a little bit of pain meds just to get them through.”

Those areas are flying red flags. It’s easy to abuse and easy for someone to become a user and manipulate a friend or a doctor who’s a relative into getting things that another doctor wouldn’t be giving. I think that’s the space where you’ve got to exercise extreme caution.

Time and again, when those people get called up in front of the boards for treating relatives, it’s in those spaces of mental health, anxiety, and pain control. Again, when you know that there’s a likelihood of abuse, I think that’s the place where the line has to hold. Don’t treat the relative. Don’t treat the friend.

At the end of the day, I wouldn’t change the AMA policy. I think we should keep it in place and morally try to discourage doctors from caring for those they’re close to or they have emotional ties to.

At the same time, as with all ethical situations, there has to be a little bit of wiggle room for those super-minor cases where it just makes sense to say: “You don’t have to go find somebody else to do this. I can prescribe this ointment or this minor thing for you. No one’s objectivity is going to be soured, and you’re not going to feel in any way at risk because I’m going to prescribe this for you.”

Common sense ought to prevail. The default position is don’t do it; however, maybe with a tiny bit of space for what’s minor, what’s routine, and what really does just save people some inconvenience, there I might just give a little.

Dr. Caplan, Director, Division of Medical Ethics, New York University Langone Medical Center, New York City, has disclosed relationships with Johnson & Johnson’s Panel for Compassionate Drug Use and Medscape.

A version of this article first appeared on Medscape.com.

This transcript has been edited for clarity. 

There’s a very interesting story in the medical press. A few years ago, a plastic surgeon named Edmond Cabbabe was preparing to do a follow-up cosmetic procedure on his wife at Mercy Hospital South, which is a big hospital in the St. Louis, Missouri, area.

He put her on the operating schedule, and he had done that when he had performed the original operation on her. On the day of the surgery, he got a call from the hospital saying the procedure was canceled. They said that the hospital’s policy, maybe a new one, would not allow doctors to operate on family members.

This physician was a past president of the Missouri State Medical Association. I think he was also on the board or president of the American Medical Association (AMA) Foundation. This was a physician not only in a skilled area where he felt confident he could take care of his wife, but also someone who was prominent in medical politics and medical policy.

The AMA forever has had a policy that says don’t treat relatives. This physician basically said, I think that policy is too restrictive, too cautious, and it doesn’t make much sense to continue to say that you can’t treat family and friends.

By implication, he was saying, I know exactly what I’m doing in my field and I know exactly what I’m doing with her procedure. I should have a right to perform it. I think I do a great job and I’d be best for her.

If you look at medical boards, every once in a while in some state, someone is brought up on a charge of doing different things with family members and saying that they’re going to get censured. They don’t usually lose their license, but they get a reprimand or get told that is just not ethical to do.

I think, in the long run, the policy about not treating your family and friends makes sense. The problem is, as is well known from the social sciences and psychology, people get biased when they deal with those they care about, love, and hold close to them.

It’s hard for the doctor to be objective when dealing with people that they really like or love. It’s also difficult for patients because they may not want to bring up something or they are uncomfortable talking with a doctor who’s a family member or close friend. They may not want to complain. They may be a little bit embarrassed about things. It just adds an emotional edge, I think, that’s difficult.

All that said, do I know doctors who regularly prescribe, say, an ointment for something that’s itchy or some kind of a pill when allergy season breaks out? I do. Do I think they’re acting in a horribly unethical manner? I don’t.

You need some judgment here. There are absolutely minor things where objectivity, fear, and anxiety are not in play. You’re going to be able to prescribe the routine thing for the routine itch without worrying too much about whether it’s a stranger, a friend, or your daughter.

What sorts of things am I really talking about when I say that minor variability ought to be allowed? It’s one thing when someone has poison ivy and they’re going to need some kind of standard medicine to treat it. A very different area that’s much more dangerous, and one I would avoid, is in the mental health field, and for that matter, the pain field.

It’s tempting to say: “Oh, my relative is just having a bad time. I’ll give her a little bit of antidepressant medicine,” or “They seem to be having pain after an operation or something, and I’m going to give them a little bit of pain meds just to get them through.”

Those areas are flying red flags. It’s easy to abuse and easy for someone to become a user and manipulate a friend or a doctor who’s a relative into getting things that another doctor wouldn’t be giving. I think that’s the space where you’ve got to exercise extreme caution.

Time and again, when those people get called up in front of the boards for treating relatives, it’s in those spaces of mental health, anxiety, and pain control. Again, when you know that there’s a likelihood of abuse, I think that’s the place where the line has to hold. Don’t treat the relative. Don’t treat the friend.

At the end of the day, I wouldn’t change the AMA policy. I think we should keep it in place and morally try to discourage doctors from caring for those they’re close to or they have emotional ties to.

At the same time, as with all ethical situations, there has to be a little bit of wiggle room for those super-minor cases where it just makes sense to say: “You don’t have to go find somebody else to do this. I can prescribe this ointment or this minor thing for you. No one’s objectivity is going to be soured, and you’re not going to feel in any way at risk because I’m going to prescribe this for you.”

Common sense ought to prevail. The default position is don’t do it; however, maybe with a tiny bit of space for what’s minor, what’s routine, and what really does just save people some inconvenience, there I might just give a little.

Dr. Caplan, Director, Division of Medical Ethics, New York University Langone Medical Center, New York City, has disclosed relationships with Johnson & Johnson’s Panel for Compassionate Drug Use and Medscape.

A version of this article first appeared on Medscape.com.

COPENHAGEN — In two phase 3 head-to-head comparing the Bruton tyrosine kinase inhibitor (BTKi) tolebrutinib to the immunomodulatory teriflunomide for relapsing-remitting multiple sclerosis (RRMS), there was no advantage on the primary endpoint of relapse, but the greater protection against disability, a secondary endpoint, might change thinking about BTKis as a potential MS therapy.

For annualized relapse rate (ARR), which is the basis on which these two drugs were compared, “there was no difference between tolebrutinib and teriflunomide,” reported Jiwon Oh, MD, Medical Director, Barlo Multiple Sclerosis Program, St. Michael’s Hospital, University of Toronto, Canada.

In the similar GEMINI 1 and 2 trials, the ARRs were nearly identical in the first, (0.13 and 0.12), and completely identical in the second (0.11) for tolebrutinib and teriflunomide, respectively.
 

Although Negative, GEMINI Trials Offer Intriguing Data

These data rule out the study hypothesis that a BTKi offers greater protection against relapse than a commonly used immunomodulator, but Dr. Oh suggested the study is still potentially relevant to MS research. Although data on the primary endpoint were disappointing, Dr. Oh suggested that the secondary outcomes support an anti-MS mechanism for the BTKi that is different from that of teriflunomide.

“There is hope,” Dr. Oh said, when reporting the findings of the GEMINI I and II trials during the latebreaker session at the 2024 ECTRIMS annual meeting. Ultimately, a substantial part of this hope was derived from the consistency of the GEMINI data with the placebo-controlled HERCULES trial of tolebrutinib presented immediately afterwards, but the disparity between the primary and secondary outcomes of GEMINI are, by themselves, relevant, suggesting that targets of treatment change as MS progresses from an acute to a chronic inflammatory process.
 

BTKi Associated With Reduced Disability

At 3 months, the rate of confirmed disability worsening (CDW) in the pooled GEMINI trials was 18.5% and 14.7% for tolebrutinib and teriflunomide, respectively, producing at 27% reduction in hazard ratio (HR) for this outcome (HR 0.73; P = .0018). At 6 months, the protection against disability (13.2% vs. 9.9%) persisted for tolebrutinib relative to teriflunomide (HR 0.71; P = .023).*

For the outcome of a confirmed disability improvement at 6 months, the higher rate in the tolebrutinib arm did not reach statistical significance (12.8% vs. 12.0%), but it did suggest a favorable trend (HR 1.22; P = .17).

While Dr. Oh acknowledged that secondary outcomes can only be considered hypothesis generating when the primary outcome is negative, she said these outcomes provide intriguing support for the potential of this BTKi drug to inhibit “smoldering inflammation.” Even if tolebrutinib was no more effective than teriflunomide against the acute inflammation that drives relapse, the GEMINI trials data support greater inhibition of the chronic inflammation implicated in progression in the absence of flares.

On MRI, the annualized rate of new and enlarging T2 lesions, although numerically higher in the tolebrutinib group, did not differ significantly in either GEMINI 1 (5.6 vs. 5.2; P = .46) or GEMINI 2 (5.1 vs. 4.4; P = .24). The least mean square difference in brain volume at end of study relative to 6 months into the study was 0.2% less in the tolebrutinib arm than the teriflunomide arm (P = .0002) in GEMINI 1, but the 0.04 numerical advantage for tolebrutinib did not reach statistical significance in GEMINI 2 (P = .43).

Of the 974 patients randomized in GEMINI 1 and 899 randomized in GEMINI 2, about 85% completed the 3-year trial. Almost all had RRMS (99%) rather than progressing MS. The median age was approximately 36 years, the baseline EDSS score was approximately 1.2, and the median time since diagnosis was about 6.5 years. The mean number of relapses in the prior year was approximately 0.6.

In GEMINI, the secondary outcomes foreshadowed the positive findings in the phase 3 HERCULES trial that came immediately after Dr. Oh’s GEMINI trials presentation. The HERCULES trial associated tolebrutinib with a 31% reduction in the risk of confirmed disability progression (CDW) relative to placebo in patients with non-relapsing secondary progressive MS (nrSPMS).

In HERCULES, 1172 patients with nrSPMS were randomized in a 2:1 fashion to tolebrutinib or placebo. For the primary endpoint of CDW at 6 months, tolebrutinib demonstrated a major and highly significant reduction in this primary endpoint (HR 0.69; P = .00026).
 

BTKi Disability Protection Supported By Progressive MS Trial

“This is the first trial to show significant slowing of disability in people with nrSPMS,” reported the principal investigator Robert J. Fox, MD, Vice Chair of the Neurological Institute at Cleveland Clinic, Cleveland, Ohio.

For disability improvement at 6 months, tolebrutinib was associated with a nearly 2-fold improvement (HR 1.88; P = .021). According to both Dr. Oh and Dr. Fox the results of these two major phase 3 tolebrutinib studies support the principle that the BTKi, which was shown to offer inhibition of relapse comparable to teriflunomide in the GEMINI trials, offers a greater inhibition of chronic inflammation.

“These results are consistent with the hypothesis that acute focal inflammation and smoldering neuroinflammation are two distinct biological processes,” Dr. Oh said.

Dr. Fox said that the HERCULES results will be submitted to regulatory authorities with the goal of securing an indication for tolebrutinib for nrSPMS.

Both Dr. Oh and Dr. Fox suggested these results are likely to reorient thinking about the pathophysiology of MS progression and how different processes can be targeted in the future. Other experts agreed.

“I think we are starting to look at different endpoints than ARR, particularly at those that might better reflect progression in later stages of MS and that are independent of ARR,” said Dalia Rotstein, MD, MS researcher and an assistant professor of neurology, University of Toronto, Canada.

A moderator of the ECTRIMS latebreaker session, she suggested that the differences between outcomes of the GEMINI trials and HERCULES trials might have relevance to each other even if the GEMINI trials did not meet their primary endpoint.

Dr. Oh reported financial relationships with Amgen, Biogen, Eli Lilly, EMD Serono, Novartis, Roche, and Sanofi, which provided funding for the GEMINI trials. Dr. Fox reported financial relationships with more than 15 pharmaceutical companies, including Sanofi, which also provided funding for the HERCULES trial. Dr. Rotstein reported financial relationships with Alexion, Biogen, EMD Serono, Horizon, Novartis, Roche, Sanofi, and Touch IME.

*Correction, 9/26/24: A previous version of this article contained an incorrect P value.

COPENHAGEN — In two phase 3 head-to-head comparing the Bruton tyrosine kinase inhibitor (BTKi) tolebrutinib to the immunomodulatory teriflunomide for relapsing-remitting multiple sclerosis (RRMS), there was no advantage on the primary endpoint of relapse, but the greater protection against disability, a secondary endpoint, might change thinking about BTKis as a potential MS therapy.

For annualized relapse rate (ARR), which is the basis on which these two drugs were compared, “there was no difference between tolebrutinib and teriflunomide,” reported Jiwon Oh, MD, Medical Director, Barlo Multiple Sclerosis Program, St. Michael’s Hospital, University of Toronto, Canada.

In the similar GEMINI 1 and 2 trials, the ARRs were nearly identical in the first, (0.13 and 0.12), and completely identical in the second (0.11) for tolebrutinib and teriflunomide, respectively.
 

Although Negative, GEMINI Trials Offer Intriguing Data

These data rule out the study hypothesis that a BTKi offers greater protection against relapse than a commonly used immunomodulator, but Dr. Oh suggested the study is still potentially relevant to MS research. Although data on the primary endpoint were disappointing, Dr. Oh suggested that the secondary outcomes support an anti-MS mechanism for the BTKi that is different from that of teriflunomide.

“There is hope,” Dr. Oh said, when reporting the findings of the GEMINI I and II trials during the latebreaker session at the 2024 ECTRIMS annual meeting. Ultimately, a substantial part of this hope was derived from the consistency of the GEMINI data with the placebo-controlled HERCULES trial of tolebrutinib presented immediately afterwards, but the disparity between the primary and secondary outcomes of GEMINI are, by themselves, relevant, suggesting that targets of treatment change as MS progresses from an acute to a chronic inflammatory process.
 

BTKi Associated With Reduced Disability

At 3 months, the rate of confirmed disability worsening (CDW) in the pooled GEMINI trials was 18.5% and 14.7% for tolebrutinib and teriflunomide, respectively, producing at 27% reduction in hazard ratio (HR) for this outcome (HR 0.73; P = .0018). At 6 months, the protection against disability (13.2% vs. 9.9%) persisted for tolebrutinib relative to teriflunomide (HR 0.71; P = .023).*

For the outcome of a confirmed disability improvement at 6 months, the higher rate in the tolebrutinib arm did not reach statistical significance (12.8% vs. 12.0%), but it did suggest a favorable trend (HR 1.22; P = .17).

While Dr. Oh acknowledged that secondary outcomes can only be considered hypothesis generating when the primary outcome is negative, she said these outcomes provide intriguing support for the potential of this BTKi drug to inhibit “smoldering inflammation.” Even if tolebrutinib was no more effective than teriflunomide against the acute inflammation that drives relapse, the GEMINI trials data support greater inhibition of the chronic inflammation implicated in progression in the absence of flares.

On MRI, the annualized rate of new and enlarging T2 lesions, although numerically higher in the tolebrutinib group, did not differ significantly in either GEMINI 1 (5.6 vs. 5.2; P = .46) or GEMINI 2 (5.1 vs. 4.4; P = .24). The least mean square difference in brain volume at end of study relative to 6 months into the study was 0.2% less in the tolebrutinib arm than the teriflunomide arm (P = .0002) in GEMINI 1, but the 0.04 numerical advantage for tolebrutinib did not reach statistical significance in GEMINI 2 (P = .43).

Of the 974 patients randomized in GEMINI 1 and 899 randomized in GEMINI 2, about 85% completed the 3-year trial. Almost all had RRMS (99%) rather than progressing MS. The median age was approximately 36 years, the baseline EDSS score was approximately 1.2, and the median time since diagnosis was about 6.5 years. The mean number of relapses in the prior year was approximately 0.6.

In GEMINI, the secondary outcomes foreshadowed the positive findings in the phase 3 HERCULES trial that came immediately after Dr. Oh’s GEMINI trials presentation. The HERCULES trial associated tolebrutinib with a 31% reduction in the risk of confirmed disability progression (CDW) relative to placebo in patients with non-relapsing secondary progressive MS (nrSPMS).

In HERCULES, 1172 patients with nrSPMS were randomized in a 2:1 fashion to tolebrutinib or placebo. For the primary endpoint of CDW at 6 months, tolebrutinib demonstrated a major and highly significant reduction in this primary endpoint (HR 0.69; P = .00026).
 

BTKi Disability Protection Supported By Progressive MS Trial

“This is the first trial to show significant slowing of disability in people with nrSPMS,” reported the principal investigator Robert J. Fox, MD, Vice Chair of the Neurological Institute at Cleveland Clinic, Cleveland, Ohio.

For disability improvement at 6 months, tolebrutinib was associated with a nearly 2-fold improvement (HR 1.88; P = .021). According to both Dr. Oh and Dr. Fox the results of these two major phase 3 tolebrutinib studies support the principle that the BTKi, which was shown to offer inhibition of relapse comparable to teriflunomide in the GEMINI trials, offers a greater inhibition of chronic inflammation.

“These results are consistent with the hypothesis that acute focal inflammation and smoldering neuroinflammation are two distinct biological processes,” Dr. Oh said.

Dr. Fox said that the HERCULES results will be submitted to regulatory authorities with the goal of securing an indication for tolebrutinib for nrSPMS.

Both Dr. Oh and Dr. Fox suggested these results are likely to reorient thinking about the pathophysiology of MS progression and how different processes can be targeted in the future. Other experts agreed.

“I think we are starting to look at different endpoints than ARR, particularly at those that might better reflect progression in later stages of MS and that are independent of ARR,” said Dalia Rotstein, MD, MS researcher and an assistant professor of neurology, University of Toronto, Canada.

A moderator of the ECTRIMS latebreaker session, she suggested that the differences between outcomes of the GEMINI trials and HERCULES trials might have relevance to each other even if the GEMINI trials did not meet their primary endpoint.

Dr. Oh reported financial relationships with Amgen, Biogen, Eli Lilly, EMD Serono, Novartis, Roche, and Sanofi, which provided funding for the GEMINI trials. Dr. Fox reported financial relationships with more than 15 pharmaceutical companies, including Sanofi, which also provided funding for the HERCULES trial. Dr. Rotstein reported financial relationships with Alexion, Biogen, EMD Serono, Horizon, Novartis, Roche, Sanofi, and Touch IME.

*Correction, 9/26/24: A previous version of this article contained an incorrect P value.

COPENHAGEN — In two phase 3 head-to-head comparing the Bruton tyrosine kinase inhibitor (BTKi) tolebrutinib to the immunomodulatory teriflunomide for relapsing-remitting multiple sclerosis (RRMS), there was no advantage on the primary endpoint of relapse, but the greater protection against disability, a secondary endpoint, might change thinking about BTKis as a potential MS therapy.

For annualized relapse rate (ARR), which is the basis on which these two drugs were compared, “there was no difference between tolebrutinib and teriflunomide,” reported Jiwon Oh, MD, Medical Director, Barlo Multiple Sclerosis Program, St. Michael’s Hospital, University of Toronto, Canada.

In the similar GEMINI 1 and 2 trials, the ARRs were nearly identical in the first, (0.13 and 0.12), and completely identical in the second (0.11) for tolebrutinib and teriflunomide, respectively.
 

Although Negative, GEMINI Trials Offer Intriguing Data

These data rule out the study hypothesis that a BTKi offers greater protection against relapse than a commonly used immunomodulator, but Dr. Oh suggested the study is still potentially relevant to MS research. Although data on the primary endpoint were disappointing, Dr. Oh suggested that the secondary outcomes support an anti-MS mechanism for the BTKi that is different from that of teriflunomide.

“There is hope,” Dr. Oh said, when reporting the findings of the GEMINI I and II trials during the latebreaker session at the 2024 ECTRIMS annual meeting. Ultimately, a substantial part of this hope was derived from the consistency of the GEMINI data with the placebo-controlled HERCULES trial of tolebrutinib presented immediately afterwards, but the disparity between the primary and secondary outcomes of GEMINI are, by themselves, relevant, suggesting that targets of treatment change as MS progresses from an acute to a chronic inflammatory process.
 

BTKi Associated With Reduced Disability

At 3 months, the rate of confirmed disability worsening (CDW) in the pooled GEMINI trials was 18.5% and 14.7% for tolebrutinib and teriflunomide, respectively, producing at 27% reduction in hazard ratio (HR) for this outcome (HR 0.73; P = .0018). At 6 months, the protection against disability (13.2% vs. 9.9%) persisted for tolebrutinib relative to teriflunomide (HR 0.71; P = .023).*

For the outcome of a confirmed disability improvement at 6 months, the higher rate in the tolebrutinib arm did not reach statistical significance (12.8% vs. 12.0%), but it did suggest a favorable trend (HR 1.22; P = .17).

While Dr. Oh acknowledged that secondary outcomes can only be considered hypothesis generating when the primary outcome is negative, she said these outcomes provide intriguing support for the potential of this BTKi drug to inhibit “smoldering inflammation.” Even if tolebrutinib was no more effective than teriflunomide against the acute inflammation that drives relapse, the GEMINI trials data support greater inhibition of the chronic inflammation implicated in progression in the absence of flares.

On MRI, the annualized rate of new and enlarging T2 lesions, although numerically higher in the tolebrutinib group, did not differ significantly in either GEMINI 1 (5.6 vs. 5.2; P = .46) or GEMINI 2 (5.1 vs. 4.4; P = .24). The least mean square difference in brain volume at end of study relative to 6 months into the study was 0.2% less in the tolebrutinib arm than the teriflunomide arm (P = .0002) in GEMINI 1, but the 0.04 numerical advantage for tolebrutinib did not reach statistical significance in GEMINI 2 (P = .43).

Of the 974 patients randomized in GEMINI 1 and 899 randomized in GEMINI 2, about 85% completed the 3-year trial. Almost all had RRMS (99%) rather than progressing MS. The median age was approximately 36 years, the baseline EDSS score was approximately 1.2, and the median time since diagnosis was about 6.5 years. The mean number of relapses in the prior year was approximately 0.6.

In GEMINI, the secondary outcomes foreshadowed the positive findings in the phase 3 HERCULES trial that came immediately after Dr. Oh’s GEMINI trials presentation. The HERCULES trial associated tolebrutinib with a 31% reduction in the risk of confirmed disability progression (CDW) relative to placebo in patients with non-relapsing secondary progressive MS (nrSPMS).

In HERCULES, 1172 patients with nrSPMS were randomized in a 2:1 fashion to tolebrutinib or placebo. For the primary endpoint of CDW at 6 months, tolebrutinib demonstrated a major and highly significant reduction in this primary endpoint (HR 0.69; P = .00026).
 

BTKi Disability Protection Supported By Progressive MS Trial

“This is the first trial to show significant slowing of disability in people with nrSPMS,” reported the principal investigator Robert J. Fox, MD, Vice Chair of the Neurological Institute at Cleveland Clinic, Cleveland, Ohio.

For disability improvement at 6 months, tolebrutinib was associated with a nearly 2-fold improvement (HR 1.88; P = .021). According to both Dr. Oh and Dr. Fox the results of these two major phase 3 tolebrutinib studies support the principle that the BTKi, which was shown to offer inhibition of relapse comparable to teriflunomide in the GEMINI trials, offers a greater inhibition of chronic inflammation.

“These results are consistent with the hypothesis that acute focal inflammation and smoldering neuroinflammation are two distinct biological processes,” Dr. Oh said.

Dr. Fox said that the HERCULES results will be submitted to regulatory authorities with the goal of securing an indication for tolebrutinib for nrSPMS.

Both Dr. Oh and Dr. Fox suggested these results are likely to reorient thinking about the pathophysiology of MS progression and how different processes can be targeted in the future. Other experts agreed.

“I think we are starting to look at different endpoints than ARR, particularly at those that might better reflect progression in later stages of MS and that are independent of ARR,” said Dalia Rotstein, MD, MS researcher and an assistant professor of neurology, University of Toronto, Canada.

A moderator of the ECTRIMS latebreaker session, she suggested that the differences between outcomes of the GEMINI trials and HERCULES trials might have relevance to each other even if the GEMINI trials did not meet their primary endpoint.

Dr. Oh reported financial relationships with Amgen, Biogen, Eli Lilly, EMD Serono, Novartis, Roche, and Sanofi, which provided funding for the GEMINI trials. Dr. Fox reported financial relationships with more than 15 pharmaceutical companies, including Sanofi, which also provided funding for the HERCULES trial. Dr. Rotstein reported financial relationships with Alexion, Biogen, EMD Serono, Horizon, Novartis, Roche, Sanofi, and Touch IME.

*Correction, 9/26/24: A previous version of this article contained an incorrect P value.

NEW YORK — Underrepresentation by gender and race in major clinical trials has been a cause for complaint for decades, but the Food and Drug Administration (FDA) has drafted a regulatory solution to this issue expected to be implemented sometime in 2025.

This initiative, known as the FDA’s Diversity Action Plan (DAP), will require plans for all pivotal and phase 3 trials to provide details in their design of how diversity will be achieved or, if there are no plans for diversity, the reason why, according to Valerie M. Harvey, MD, MPH, associate clinical professor, Edward Via College of Osteopathic Medicine, Blacksburg, Virginia. These rules will be codified, she said at the 2024 Skin of Color Update.

Once the DAP is enacted, “the sponsor must specify the rationale and goals for study enrollment by age, ethnicity, sex, and race,” she said. Furthermore, the submission to the FDA must “describe the methods to meet the diversity benchmarks.”
 

Lack of Trial Diversity Is Common Across Medicine

Although she focused on the relevance of this initiative to dermatology, Dr. Harvey said the lack of diversity in clinical trials is pervasive throughout medicine. In one survey of randomized controlled trials, less than 60% of trials even specified the race and ethnicity of the participants. In recent psoriasis trials, only 30% met a diversity definition of ≥ 20% of patients identifying as minority (Black, Hispanic, Asian, or other non-White group), said Dr. Harvey, who practices dermatology in Newport News, Virginia.

The FDA draft guidance for the DAP was released in June 2024 and is now available for submitting comments (until September 26). The plan is expected to be published in June 2025, according to Dr. Harvey. It will pertain to all pivotal and phase 3 trials enrolling 180 days after the publication date and will be relevant to all drugs and biologics as well as certain devices.

This initiative could be a critical step toward ensuring diversity in major clinical trials after years of stagnation, Dr. Harvey said, noting that despite repeated calls for more diversity in clinical trials, the literature suggests “little progress.”

However, she said that increasing diversity in clinical trials is just one step toward gathering data about the generalizability of efficacy and safety across racial and ethnic groups. A much more complex issue involves how race and ethnicity are defined in order to understand differences, if any, for efficacy and risk.

“Race is a dynamic social construct and a poor measure for biologic variation and skin color,” Dr. Harvey said. This means that work is needed to address the more complex issue of race and ethnicity stratification that will help clinicians understand the relative benefits and risks for the drugs in these trials.

Rather than differences based on genetic or other sources of biologic differences, she said, outcomes by race alone are often suspected of reflecting disparities in access to healthcare rather than a difference in therapeutic response.
 

Skin Color Is Inadequate to Define Race

When stratifying patients by race or ethnicity, Dr. Harvey said that “we have to be very, very careful in considering the study purpose and what the study question is.” A study attempting to compare benefits and risks among subgroups by race or ethnicity will require descriptors beyond skin color.

The recognized limitations of measuring skin tone as a surrogate of race are one reason for widespread interest in moving away from the Fitzpatrick skin type (FST) rating that has been widely considered a standard, according to Dr. Harvey. Several alternatives have been proposed, including the Monk Skin Tone Scale, the Individual Typology Angle, and the Eumelanin Human Skin Color Scale, but she cautioned that these are less well validated and generally have the limitations of the FST.

If skin color was ever useful for grouping individuals on the basis of shared physiology, growing rates of intermarriage and immigration have made skin color increasingly irrelevant to racial identity. If the goal is to evaluate the safety and efficacy of drugs across racial groups and ethnicities, the characterization of populations will almost certainly require multiple descriptors and biomarkers, she said.

“It is very important to have many tools for characterizing patients by skin type,” Susan Taylor, MD, professor of dermatology and vice chair for diversity, equity, and inclusion for the Department of Dermatology, University of Pennsylvania, Philadelphia, said in an interview at the meeting.

The reason is “there are limitations to all of them,” she said, noting also that the questions being asked about how and if skin color and race are relevant to therapeutic options differ by the question, such as innate response or access to care.

Dr. Taylor is part of a workshop that she said is evaluating a combination of instruments for characterizing skin color and race in ways relevant to the specific question being asked.

The solutions might differ. While simple clinical assessments involving skin color might be made with methods captured on a smartphone app, Dr. Taylor acknowledged that far more complex tools might be required to document the effect of racial or ethnic differences in drug efficacy and safety in a research setting.

Outside of a research setting, any tools that might be useful for assessing race as a variable must be practical, according to Dr. Harvey. She suggested that these must be time efficient, of reasonable cost, and most importantly, reliable.

Tools meeting these criteria do not currently exist, but Dr. Harvey said the work is underway. She expects a “top-down” collaborative approach to validate alternatives to the FST. If such tools can be developed with buy-in from the FDA, they might be particularly useful for translating trial data to patient care, she added.

Dr. Harvey reported financial relationships with AbbVie, Bristol-Myers Squibb, Janssen, Johnson & Johnson, L’Oréal, and SkinCeuticals. Dr. Taylor, president-elect of the American Academy of Dermatology, reported financial relationships with more than 25 pharmaceutical and cosmetic companies.

A version of this article appeared on Medscape.com.

NEW YORK — Underrepresentation by gender and race in major clinical trials has been a cause for complaint for decades, but the Food and Drug Administration (FDA) has drafted a regulatory solution to this issue expected to be implemented sometime in 2025.

This initiative, known as the FDA’s Diversity Action Plan (DAP), will require plans for all pivotal and phase 3 trials to provide details in their design of how diversity will be achieved or, if there are no plans for diversity, the reason why, according to Valerie M. Harvey, MD, MPH, associate clinical professor, Edward Via College of Osteopathic Medicine, Blacksburg, Virginia. These rules will be codified, she said at the 2024 Skin of Color Update.

Once the DAP is enacted, “the sponsor must specify the rationale and goals for study enrollment by age, ethnicity, sex, and race,” she said. Furthermore, the submission to the FDA must “describe the methods to meet the diversity benchmarks.”
 

Lack of Trial Diversity Is Common Across Medicine

Although she focused on the relevance of this initiative to dermatology, Dr. Harvey said the lack of diversity in clinical trials is pervasive throughout medicine. In one survey of randomized controlled trials, less than 60% of trials even specified the race and ethnicity of the participants. In recent psoriasis trials, only 30% met a diversity definition of ≥ 20% of patients identifying as minority (Black, Hispanic, Asian, or other non-White group), said Dr. Harvey, who practices dermatology in Newport News, Virginia.

The FDA draft guidance for the DAP was released in June 2024 and is now available for submitting comments (until September 26). The plan is expected to be published in June 2025, according to Dr. Harvey. It will pertain to all pivotal and phase 3 trials enrolling 180 days after the publication date and will be relevant to all drugs and biologics as well as certain devices.

This initiative could be a critical step toward ensuring diversity in major clinical trials after years of stagnation, Dr. Harvey said, noting that despite repeated calls for more diversity in clinical trials, the literature suggests “little progress.”

However, she said that increasing diversity in clinical trials is just one step toward gathering data about the generalizability of efficacy and safety across racial and ethnic groups. A much more complex issue involves how race and ethnicity are defined in order to understand differences, if any, for efficacy and risk.

“Race is a dynamic social construct and a poor measure for biologic variation and skin color,” Dr. Harvey said. This means that work is needed to address the more complex issue of race and ethnicity stratification that will help clinicians understand the relative benefits and risks for the drugs in these trials.

Rather than differences based on genetic or other sources of biologic differences, she said, outcomes by race alone are often suspected of reflecting disparities in access to healthcare rather than a difference in therapeutic response.
 

Skin Color Is Inadequate to Define Race

When stratifying patients by race or ethnicity, Dr. Harvey said that “we have to be very, very careful in considering the study purpose and what the study question is.” A study attempting to compare benefits and risks among subgroups by race or ethnicity will require descriptors beyond skin color.

The recognized limitations of measuring skin tone as a surrogate of race are one reason for widespread interest in moving away from the Fitzpatrick skin type (FST) rating that has been widely considered a standard, according to Dr. Harvey. Several alternatives have been proposed, including the Monk Skin Tone Scale, the Individual Typology Angle, and the Eumelanin Human Skin Color Scale, but she cautioned that these are less well validated and generally have the limitations of the FST.

If skin color was ever useful for grouping individuals on the basis of shared physiology, growing rates of intermarriage and immigration have made skin color increasingly irrelevant to racial identity. If the goal is to evaluate the safety and efficacy of drugs across racial groups and ethnicities, the characterization of populations will almost certainly require multiple descriptors and biomarkers, she said.

“It is very important to have many tools for characterizing patients by skin type,” Susan Taylor, MD, professor of dermatology and vice chair for diversity, equity, and inclusion for the Department of Dermatology, University of Pennsylvania, Philadelphia, said in an interview at the meeting.

The reason is “there are limitations to all of them,” she said, noting also that the questions being asked about how and if skin color and race are relevant to therapeutic options differ by the question, such as innate response or access to care.

Dr. Taylor is part of a workshop that she said is evaluating a combination of instruments for characterizing skin color and race in ways relevant to the specific question being asked.

The solutions might differ. While simple clinical assessments involving skin color might be made with methods captured on a smartphone app, Dr. Taylor acknowledged that far more complex tools might be required to document the effect of racial or ethnic differences in drug efficacy and safety in a research setting.

Outside of a research setting, any tools that might be useful for assessing race as a variable must be practical, according to Dr. Harvey. She suggested that these must be time efficient, of reasonable cost, and most importantly, reliable.

Tools meeting these criteria do not currently exist, but Dr. Harvey said the work is underway. She expects a “top-down” collaborative approach to validate alternatives to the FST. If such tools can be developed with buy-in from the FDA, they might be particularly useful for translating trial data to patient care, she added.

Dr. Harvey reported financial relationships with AbbVie, Bristol-Myers Squibb, Janssen, Johnson & Johnson, L’Oréal, and SkinCeuticals. Dr. Taylor, president-elect of the American Academy of Dermatology, reported financial relationships with more than 25 pharmaceutical and cosmetic companies.

A version of this article appeared on Medscape.com.

NEW YORK — Underrepresentation by gender and race in major clinical trials has been a cause for complaint for decades, but the Food and Drug Administration (FDA) has drafted a regulatory solution to this issue expected to be implemented sometime in 2025.

This initiative, known as the FDA’s Diversity Action Plan (DAP), will require plans for all pivotal and phase 3 trials to provide details in their design of how diversity will be achieved or, if there are no plans for diversity, the reason why, according to Valerie M. Harvey, MD, MPH, associate clinical professor, Edward Via College of Osteopathic Medicine, Blacksburg, Virginia. These rules will be codified, she said at the 2024 Skin of Color Update.

Once the DAP is enacted, “the sponsor must specify the rationale and goals for study enrollment by age, ethnicity, sex, and race,” she said. Furthermore, the submission to the FDA must “describe the methods to meet the diversity benchmarks.”
 

Lack of Trial Diversity Is Common Across Medicine

Although she focused on the relevance of this initiative to dermatology, Dr. Harvey said the lack of diversity in clinical trials is pervasive throughout medicine. In one survey of randomized controlled trials, less than 60% of trials even specified the race and ethnicity of the participants. In recent psoriasis trials, only 30% met a diversity definition of ≥ 20% of patients identifying as minority (Black, Hispanic, Asian, or other non-White group), said Dr. Harvey, who practices dermatology in Newport News, Virginia.

The FDA draft guidance for the DAP was released in June 2024 and is now available for submitting comments (until September 26). The plan is expected to be published in June 2025, according to Dr. Harvey. It will pertain to all pivotal and phase 3 trials enrolling 180 days after the publication date and will be relevant to all drugs and biologics as well as certain devices.

This initiative could be a critical step toward ensuring diversity in major clinical trials after years of stagnation, Dr. Harvey said, noting that despite repeated calls for more diversity in clinical trials, the literature suggests “little progress.”

However, she said that increasing diversity in clinical trials is just one step toward gathering data about the generalizability of efficacy and safety across racial and ethnic groups. A much more complex issue involves how race and ethnicity are defined in order to understand differences, if any, for efficacy and risk.

“Race is a dynamic social construct and a poor measure for biologic variation and skin color,” Dr. Harvey said. This means that work is needed to address the more complex issue of race and ethnicity stratification that will help clinicians understand the relative benefits and risks for the drugs in these trials.

Rather than differences based on genetic or other sources of biologic differences, she said, outcomes by race alone are often suspected of reflecting disparities in access to healthcare rather than a difference in therapeutic response.
 

Skin Color Is Inadequate to Define Race

When stratifying patients by race or ethnicity, Dr. Harvey said that “we have to be very, very careful in considering the study purpose and what the study question is.” A study attempting to compare benefits and risks among subgroups by race or ethnicity will require descriptors beyond skin color.

The recognized limitations of measuring skin tone as a surrogate of race are one reason for widespread interest in moving away from the Fitzpatrick skin type (FST) rating that has been widely considered a standard, according to Dr. Harvey. Several alternatives have been proposed, including the Monk Skin Tone Scale, the Individual Typology Angle, and the Eumelanin Human Skin Color Scale, but she cautioned that these are less well validated and generally have the limitations of the FST.

If skin color was ever useful for grouping individuals on the basis of shared physiology, growing rates of intermarriage and immigration have made skin color increasingly irrelevant to racial identity. If the goal is to evaluate the safety and efficacy of drugs across racial groups and ethnicities, the characterization of populations will almost certainly require multiple descriptors and biomarkers, she said.

“It is very important to have many tools for characterizing patients by skin type,” Susan Taylor, MD, professor of dermatology and vice chair for diversity, equity, and inclusion for the Department of Dermatology, University of Pennsylvania, Philadelphia, said in an interview at the meeting.

The reason is “there are limitations to all of them,” she said, noting also that the questions being asked about how and if skin color and race are relevant to therapeutic options differ by the question, such as innate response or access to care.

Dr. Taylor is part of a workshop that she said is evaluating a combination of instruments for characterizing skin color and race in ways relevant to the specific question being asked.

The solutions might differ. While simple clinical assessments involving skin color might be made with methods captured on a smartphone app, Dr. Taylor acknowledged that far more complex tools might be required to document the effect of racial or ethnic differences in drug efficacy and safety in a research setting.

Outside of a research setting, any tools that might be useful for assessing race as a variable must be practical, according to Dr. Harvey. She suggested that these must be time efficient, of reasonable cost, and most importantly, reliable.

Tools meeting these criteria do not currently exist, but Dr. Harvey said the work is underway. She expects a “top-down” collaborative approach to validate alternatives to the FST. If such tools can be developed with buy-in from the FDA, they might be particularly useful for translating trial data to patient care, she added.

Dr. Harvey reported financial relationships with AbbVie, Bristol-Myers Squibb, Janssen, Johnson & Johnson, L’Oréal, and SkinCeuticals. Dr. Taylor, president-elect of the American Academy of Dermatology, reported financial relationships with more than 25 pharmaceutical and cosmetic companies.

A version of this article appeared on Medscape.com.

Five years have passed since the member states of the World Health Organization (WHO) gathered at the 72nd World Health Assembly and decided that September 17 should be recognized as World Patient Safety Day, acknowledging it as a global health priority.

WHO data indicate the following findings related to medical safety:

• One in 10 patients is harmed while receiving healthcare, and 3 million die as a result.
• More than half of these incidents could be prevented.
• Indirect costs could amount to several billion US dollars annually.

Given the magnitude of preventable harm related to medication use, in 2017, the WHO launched the third Global Patient Safety Challenge: Medication Without Harm with the goal of reducing serious and preventable harm related to medication by 50%. In addition, considering the volume of medication packages prescribed in 2023 by physicians in Spain’s National Health System, it is necessary to understand the most common types of medication errors to provide an effective and efficient response.

According to Spain’s Institute for Safe Medication Practices (ISMP), the 10 types of medication errors detected in 2020 with the most serious consequences were the following:

• Errors due to omission or delay in medication.
• Administration of medication to the wrong patient.
• Errors related to allergies or known adverse effects of medications.
• Dosing errors in pediatric patients.
• Errors due to similarities in the labeling or packaging of marketed medications.
• Errors associated with the lack of use of smart infusion pumps.
• Errors due to accidental administration of neuromuscular blocking agents.
• Incorrect intravenous administration of oral liquid medications.
• Errors in medication reconciliation upon hospital admission and discharge.
• Errors due to patient misunderstandings regarding medication use.

I would like to focus on the fifth item, errors due to similarities in the labeling or packaging of marketed medications.

Medications with similar names or with similar labeling or packaging are known as “look alike–sound alike” medications. They are estimated to account for between 6.2% and 14.7% of all medication errors. Confusion can arise due to spelling and phonetic similarities.

As shown in bulletin no. 50 of the ISMP, difficulties in distinguishing different medications or different presentations of the same medication due to similar packaging and labeling have frequently been associated with reported incidents.

Most cases involve either medications marketed by the same laboratory with a design based on brand image or different medications marketed by different laboratories in screen-printed ampoules used in the same settings.

In 2020, the ISMP published 11 new cases of labeling or packaging that may promote errors on its website. It reported 49 incidents to the Spanish Agency for Medicines and Medical Devices.

Shortages caused by the COVID-19 pandemic have further contributed to these incidents, as healthcare facilities sometimes had to change the medications they usually acquired and purchase whatever was available, without being able to select products that would not be confused with existing medications in the facility.

The ISMP recommends the following general practices for healthcare institutions, professionals, and patients to prevent these errors:

• Develop short lists of easily confused medication names and distribute them among all healthcare professionals.
• Prioritize medication names by active ingredient instead of brand name.
• For similar names, highlight the differences in capital letters, eg, DOBUTamine, DOPamine.
• For similar active ingredients, use brand names.
• Avoid placing similar medications near each other.
• Prescribe all medications electronically to minimize the risk of selecting the wrong medication.
• Make manual prescriptions legible, with clearly written dosages and pharmaceutical forms.
• Encourage patients to actively participate in their treatment and consult a clinician if they have any questions about the medications they are receiving.
• Raise awareness among patients, family members, and caregivers about the issues caused by medication name confusion and inform them about how to avoid these errors.
• Instruct patients to focus on and always use the active ingredient name as an identifying element for the medications they are taking.
• Review treatments with patients to ensure they know the medications they are taking.
•  

Julia María Ruiz Redondo is the regional nursing advisor inspector of Spanish Society of General and Family Physicians of Castilla-La Mancha (SEMG-CLM), coordinator of the National Working Group on Public Health in the SEMG, and director of the international public health master’s degree at TECH Technological University. This article is the result of an editorial collaboration between the SEMG and Univadis, which you can access here. 

This story was translated from Univadis Spain, which is part of the Medscape professional network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Five years have passed since the member states of the World Health Organization (WHO) gathered at the 72nd World Health Assembly and decided that September 17 should be recognized as World Patient Safety Day, acknowledging it as a global health priority.

WHO data indicate the following findings related to medical safety:

• One in 10 patients is harmed while receiving healthcare, and 3 million die as a result.
• More than half of these incidents could be prevented.
• Indirect costs could amount to several billion US dollars annually.

Given the magnitude of preventable harm related to medication use, in 2017, the WHO launched the third Global Patient Safety Challenge: Medication Without Harm with the goal of reducing serious and preventable harm related to medication by 50%. In addition, considering the volume of medication packages prescribed in 2023 by physicians in Spain’s National Health System, it is necessary to understand the most common types of medication errors to provide an effective and efficient response.

According to Spain’s Institute for Safe Medication Practices (ISMP), the 10 types of medication errors detected in 2020 with the most serious consequences were the following:

• Errors due to omission or delay in medication.
• Administration of medication to the wrong patient.
• Errors related to allergies or known adverse effects of medications.
• Dosing errors in pediatric patients.
• Errors due to similarities in the labeling or packaging of marketed medications.
• Errors associated with the lack of use of smart infusion pumps.
• Errors due to accidental administration of neuromuscular blocking agents.
• Incorrect intravenous administration of oral liquid medications.
• Errors in medication reconciliation upon hospital admission and discharge.
• Errors due to patient misunderstandings regarding medication use.

I would like to focus on the fifth item, errors due to similarities in the labeling or packaging of marketed medications.

Medications with similar names or with similar labeling or packaging are known as “look alike–sound alike” medications. They are estimated to account for between 6.2% and 14.7% of all medication errors. Confusion can arise due to spelling and phonetic similarities.

As shown in bulletin no. 50 of the ISMP, difficulties in distinguishing different medications or different presentations of the same medication due to similar packaging and labeling have frequently been associated with reported incidents.

Most cases involve either medications marketed by the same laboratory with a design based on brand image or different medications marketed by different laboratories in screen-printed ampoules used in the same settings.

In 2020, the ISMP published 11 new cases of labeling or packaging that may promote errors on its website. It reported 49 incidents to the Spanish Agency for Medicines and Medical Devices.

Shortages caused by the COVID-19 pandemic have further contributed to these incidents, as healthcare facilities sometimes had to change the medications they usually acquired and purchase whatever was available, without being able to select products that would not be confused with existing medications in the facility.

The ISMP recommends the following general practices for healthcare institutions, professionals, and patients to prevent these errors:

• Develop short lists of easily confused medication names and distribute them among all healthcare professionals.
• Prioritize medication names by active ingredient instead of brand name.
• For similar names, highlight the differences in capital letters, eg, DOBUTamine, DOPamine.
• For similar active ingredients, use brand names.
• Avoid placing similar medications near each other.
• Prescribe all medications electronically to minimize the risk of selecting the wrong medication.
• Make manual prescriptions legible, with clearly written dosages and pharmaceutical forms.
• Encourage patients to actively participate in their treatment and consult a clinician if they have any questions about the medications they are receiving.
• Raise awareness among patients, family members, and caregivers about the issues caused by medication name confusion and inform them about how to avoid these errors.
• Instruct patients to focus on and always use the active ingredient name as an identifying element for the medications they are taking.
• Review treatments with patients to ensure they know the medications they are taking.
•  

Julia María Ruiz Redondo is the regional nursing advisor inspector of Spanish Society of General and Family Physicians of Castilla-La Mancha (SEMG-CLM), coordinator of the National Working Group on Public Health in the SEMG, and director of the international public health master’s degree at TECH Technological University. This article is the result of an editorial collaboration between the SEMG and Univadis, which you can access here. 

This story was translated from Univadis Spain, which is part of the Medscape professional network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Five years have passed since the member states of the World Health Organization (WHO) gathered at the 72nd World Health Assembly and decided that September 17 should be recognized as World Patient Safety Day, acknowledging it as a global health priority.

WHO data indicate the following findings related to medical safety:

• One in 10 patients is harmed while receiving healthcare, and 3 million die as a result.
• More than half of these incidents could be prevented.
• Indirect costs could amount to several billion US dollars annually.

Given the magnitude of preventable harm related to medication use, in 2017, the WHO launched the third Global Patient Safety Challenge: Medication Without Harm with the goal of reducing serious and preventable harm related to medication by 50%. In addition, considering the volume of medication packages prescribed in 2023 by physicians in Spain’s National Health System, it is necessary to understand the most common types of medication errors to provide an effective and efficient response.

According to Spain’s Institute for Safe Medication Practices (ISMP), the 10 types of medication errors detected in 2020 with the most serious consequences were the following:

• Errors due to omission or delay in medication.
• Administration of medication to the wrong patient.
• Errors related to allergies or known adverse effects of medications.
• Dosing errors in pediatric patients.
• Errors due to similarities in the labeling or packaging of marketed medications.
• Errors associated with the lack of use of smart infusion pumps.
• Errors due to accidental administration of neuromuscular blocking agents.
• Incorrect intravenous administration of oral liquid medications.
• Errors in medication reconciliation upon hospital admission and discharge.
• Errors due to patient misunderstandings regarding medication use.

I would like to focus on the fifth item, errors due to similarities in the labeling or packaging of marketed medications.

Medications with similar names or with similar labeling or packaging are known as “look alike–sound alike” medications. They are estimated to account for between 6.2% and 14.7% of all medication errors. Confusion can arise due to spelling and phonetic similarities.

As shown in bulletin no. 50 of the ISMP, difficulties in distinguishing different medications or different presentations of the same medication due to similar packaging and labeling have frequently been associated with reported incidents.

Most cases involve either medications marketed by the same laboratory with a design based on brand image or different medications marketed by different laboratories in screen-printed ampoules used in the same settings.

In 2020, the ISMP published 11 new cases of labeling or packaging that may promote errors on its website. It reported 49 incidents to the Spanish Agency for Medicines and Medical Devices.

Shortages caused by the COVID-19 pandemic have further contributed to these incidents, as healthcare facilities sometimes had to change the medications they usually acquired and purchase whatever was available, without being able to select products that would not be confused with existing medications in the facility.

The ISMP recommends the following general practices for healthcare institutions, professionals, and patients to prevent these errors:

• Develop short lists of easily confused medication names and distribute them among all healthcare professionals.
• Prioritize medication names by active ingredient instead of brand name.
• For similar names, highlight the differences in capital letters, eg, DOBUTamine, DOPamine.
• For similar active ingredients, use brand names.
• Avoid placing similar medications near each other.
• Prescribe all medications electronically to minimize the risk of selecting the wrong medication.
• Make manual prescriptions legible, with clearly written dosages and pharmaceutical forms.
• Encourage patients to actively participate in their treatment and consult a clinician if they have any questions about the medications they are receiving.
• Raise awareness among patients, family members, and caregivers about the issues caused by medication name confusion and inform them about how to avoid these errors.
• Instruct patients to focus on and always use the active ingredient name as an identifying element for the medications they are taking.
• Review treatments with patients to ensure they know the medications they are taking.
•  

Julia María Ruiz Redondo is the regional nursing advisor inspector of Spanish Society of General and Family Physicians of Castilla-La Mancha (SEMG-CLM), coordinator of the National Working Group on Public Health in the SEMG, and director of the international public health master’s degree at TECH Technological University. This article is the result of an editorial collaboration between the SEMG and Univadis, which you can access here. 

This story was translated from Univadis Spain, which is part of the Medscape professional network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Pesticides have transformed modern agriculture by boosting production yields and helping alleviate food insecurity amid rapid global population growth. However, from a public health perspective, exposure to pesticides has been linked to numerous harmful effects, including neurologic disorders like Parkinson’s disease, weakened immune function, and an increased risk for cancer.

Pesticide exposure has been associated with cancers such as colorectal cancer, lung cancer, leukemia (in children and adults), lymphoma, and pancreatic cancer. But these studies primarily have focused on specific groups of individuals with known exposure to certain pesticides or cancer types, thus offering a limited perspective.

A comprehensive assessment of how pesticide use affects cancer risk across a broader population has yet to be conducted.

A recent population-level study aimed to address this gap by evaluating cancer risks in the US population using a model that accounts for pesticide use and adjusts for various factors. The goal was to identify regional disparities in exposure and contribute to the development of public health policies that protect populations from potential harm.
 

Calculating Cancer Risk

Researchers developed a model using several data sources to estimate the additional cancer risk from agricultural pesticide use. Key data included:

• Pesticide use data from the US Geological Survey in 2019, which covered 69 agricultural pesticides across 3143 counties
• Cancer incidence rates per 100,000 people, which were collected between 2015 and 2019 by the National Institutes of Health and the Centers for Disease Control and Prevention; these data covered various cancers, including bladder, colorectal, leukemia, lung, non-Hodgkin lymphoma, and pancreatic cancers
• Covariates, including smoking prevalence, the Social Vulnerability Index, agricultural land use, and total US population in 2019

Pesticide use profile patterns were developed using latent class analysis, a statistical method used to identify homogeneous subgroups within a heterogeneous population. A generalized linear model then estimated how these pesticide use patterns and the covariates affected cancer incidence.

The model highlighted regions with the highest and lowest “additional” cancer risks linked to pesticide exposure, calculating the estimated increase in cancer cases per year that resulted from variations in agricultural pesticide use.
 

Midwest Most Affected

While this model doesn’t establish causality or assess individual risk, it reveals regional trends in the association between pesticide use patterns and cancer incidence from a population-based perspective.

The Midwest, known for its high corn production, emerged as the region most affected by pesticide use. Compared with regions with the lowest risk, the Midwest faced an additional 154,541 cancer cases annually across all types. For colorectal and pancreatic cancers, the yearly increases were 20,927 and 3835 cases, respectively. Similar trends were observed for leukemia and non-Hodgkin lymphoma.
 

Pesticides vs Smoking

The researchers also estimated the additional cancer risk related to smoking, using the same model. They found that pesticides contributed to a higher risk for cancer than smoking in several cases.

The most significant difference was observed with non-Hodgkin lymphoma, where pesticides were linked to 154.1% more cases than smoking. For all cancers combined, as well as bladder cancer and leukemia, the increases were moderate: 18.7%, 19.3%, and 21.0%, respectively.

This result highlights the importance of considering pesticide exposure alongside smoking when studying cancer risks.
 

Expanding Scope of Research

Some limitations of this study should be noted. Certain counties lacked complete data, and there was heterogeneity in the size and population of the counties studied. The research also did not account for seasonal and migrant workers, who are likely to be heavily exposed. In addition, the data used in the study were not independently validated, and they could not be used to assess individual risk.

The effect of pesticides on human health is a vast and critical field of research, often focusing on a limited range of pesticides or specific cancers. This study stands out by taking a broader, more holistic approach, aiming to highlight regional inequalities and identify less-studied pesticides that could be future research priorities.

Given the significant public health impact, the authors encouraged the authorities to share these findings with the most vulnerable communities to raise awareness.
 

This story was translated from JIM using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Pesticides have transformed modern agriculture by boosting production yields and helping alleviate food insecurity amid rapid global population growth. However, from a public health perspective, exposure to pesticides has been linked to numerous harmful effects, including neurologic disorders like Parkinson’s disease, weakened immune function, and an increased risk for cancer.

Pesticide exposure has been associated with cancers such as colorectal cancer, lung cancer, leukemia (in children and adults), lymphoma, and pancreatic cancer. But these studies primarily have focused on specific groups of individuals with known exposure to certain pesticides or cancer types, thus offering a limited perspective.

A comprehensive assessment of how pesticide use affects cancer risk across a broader population has yet to be conducted.

A recent population-level study aimed to address this gap by evaluating cancer risks in the US population using a model that accounts for pesticide use and adjusts for various factors. The goal was to identify regional disparities in exposure and contribute to the development of public health policies that protect populations from potential harm.
 

Calculating Cancer Risk

Researchers developed a model using several data sources to estimate the additional cancer risk from agricultural pesticide use. Key data included:

• Pesticide use data from the US Geological Survey in 2019, which covered 69 agricultural pesticides across 3143 counties
• Cancer incidence rates per 100,000 people, which were collected between 2015 and 2019 by the National Institutes of Health and the Centers for Disease Control and Prevention; these data covered various cancers, including bladder, colorectal, leukemia, lung, non-Hodgkin lymphoma, and pancreatic cancers
• Covariates, including smoking prevalence, the Social Vulnerability Index, agricultural land use, and total US population in 2019

Pesticide use profile patterns were developed using latent class analysis, a statistical method used to identify homogeneous subgroups within a heterogeneous population. A generalized linear model then estimated how these pesticide use patterns and the covariates affected cancer incidence.

The model highlighted regions with the highest and lowest “additional” cancer risks linked to pesticide exposure, calculating the estimated increase in cancer cases per year that resulted from variations in agricultural pesticide use.
 

Midwest Most Affected

While this model doesn’t establish causality or assess individual risk, it reveals regional trends in the association between pesticide use patterns and cancer incidence from a population-based perspective.

The Midwest, known for its high corn production, emerged as the region most affected by pesticide use. Compared with regions with the lowest risk, the Midwest faced an additional 154,541 cancer cases annually across all types. For colorectal and pancreatic cancers, the yearly increases were 20,927 and 3835 cases, respectively. Similar trends were observed for leukemia and non-Hodgkin lymphoma.
 

Pesticides vs Smoking

The researchers also estimated the additional cancer risk related to smoking, using the same model. They found that pesticides contributed to a higher risk for cancer than smoking in several cases.

The most significant difference was observed with non-Hodgkin lymphoma, where pesticides were linked to 154.1% more cases than smoking. For all cancers combined, as well as bladder cancer and leukemia, the increases were moderate: 18.7%, 19.3%, and 21.0%, respectively.

This result highlights the importance of considering pesticide exposure alongside smoking when studying cancer risks.
 

Expanding Scope of Research

Some limitations of this study should be noted. Certain counties lacked complete data, and there was heterogeneity in the size and population of the counties studied. The research also did not account for seasonal and migrant workers, who are likely to be heavily exposed. In addition, the data used in the study were not independently validated, and they could not be used to assess individual risk.

The effect of pesticides on human health is a vast and critical field of research, often focusing on a limited range of pesticides or specific cancers. This study stands out by taking a broader, more holistic approach, aiming to highlight regional inequalities and identify less-studied pesticides that could be future research priorities.

Given the significant public health impact, the authors encouraged the authorities to share these findings with the most vulnerable communities to raise awareness.
 

This story was translated from JIM using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Pesticides have transformed modern agriculture by boosting production yields and helping alleviate food insecurity amid rapid global population growth. However, from a public health perspective, exposure to pesticides has been linked to numerous harmful effects, including neurologic disorders like Parkinson’s disease, weakened immune function, and an increased risk for cancer.

Pesticide exposure has been associated with cancers such as colorectal cancer, lung cancer, leukemia (in children and adults), lymphoma, and pancreatic cancer. But these studies primarily have focused on specific groups of individuals with known exposure to certain pesticides or cancer types, thus offering a limited perspective.

A comprehensive assessment of how pesticide use affects cancer risk across a broader population has yet to be conducted.

A recent population-level study aimed to address this gap by evaluating cancer risks in the US population using a model that accounts for pesticide use and adjusts for various factors. The goal was to identify regional disparities in exposure and contribute to the development of public health policies that protect populations from potential harm.
 

Calculating Cancer Risk

Researchers developed a model using several data sources to estimate the additional cancer risk from agricultural pesticide use. Key data included:

• Pesticide use data from the US Geological Survey in 2019, which covered 69 agricultural pesticides across 3143 counties
• Cancer incidence rates per 100,000 people, which were collected between 2015 and 2019 by the National Institutes of Health and the Centers for Disease Control and Prevention; these data covered various cancers, including bladder, colorectal, leukemia, lung, non-Hodgkin lymphoma, and pancreatic cancers
• Covariates, including smoking prevalence, the Social Vulnerability Index, agricultural land use, and total US population in 2019

Pesticide use profile patterns were developed using latent class analysis, a statistical method used to identify homogeneous subgroups within a heterogeneous population. A generalized linear model then estimated how these pesticide use patterns and the covariates affected cancer incidence.

The model highlighted regions with the highest and lowest “additional” cancer risks linked to pesticide exposure, calculating the estimated increase in cancer cases per year that resulted from variations in agricultural pesticide use.
 

Midwest Most Affected

While this model doesn’t establish causality or assess individual risk, it reveals regional trends in the association between pesticide use patterns and cancer incidence from a population-based perspective.

The Midwest, known for its high corn production, emerged as the region most affected by pesticide use. Compared with regions with the lowest risk, the Midwest faced an additional 154,541 cancer cases annually across all types. For colorectal and pancreatic cancers, the yearly increases were 20,927 and 3835 cases, respectively. Similar trends were observed for leukemia and non-Hodgkin lymphoma.
 

Pesticides vs Smoking

The researchers also estimated the additional cancer risk related to smoking, using the same model. They found that pesticides contributed to a higher risk for cancer than smoking in several cases.

The most significant difference was observed with non-Hodgkin lymphoma, where pesticides were linked to 154.1% more cases than smoking. For all cancers combined, as well as bladder cancer and leukemia, the increases were moderate: 18.7%, 19.3%, and 21.0%, respectively.

This result highlights the importance of considering pesticide exposure alongside smoking when studying cancer risks.
 

Expanding Scope of Research

Some limitations of this study should be noted. Certain counties lacked complete data, and there was heterogeneity in the size and population of the counties studied. The research also did not account for seasonal and migrant workers, who are likely to be heavily exposed. In addition, the data used in the study were not independently validated, and they could not be used to assess individual risk.

The effect of pesticides on human health is a vast and critical field of research, often focusing on a limited range of pesticides or specific cancers. This study stands out by taking a broader, more holistic approach, aiming to highlight regional inequalities and identify less-studied pesticides that could be future research priorities.

Given the significant public health impact, the authors encouraged the authorities to share these findings with the most vulnerable communities to raise awareness.
 

This story was translated from JIM using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

COPENHAGEN — High-dose oral cholecalciferol (vitamin D3) supplementation significantly reduces evidence of disease activity in patients with clinically isolated syndrome (CIS), results of a randomized, controlled trial suggest. In addition, cholecalciferol had a favorable safety profile and was well tolerated.

“These data support high-dose vitamin D supplementation in early MS and make vitamin D the best candidate for add-on therapy evaluation in the therapeutic strategy for multiple sclerosis [MS],” said study author Eric Thouvenot, MD, PhD, University Hospital of Nimes, Neurology Department, Nimes, France.

The study was presented at the 2024 ECTRIMS annual meeting.
 

Vitamin D Supplementation Versus Placebo

Research shows vitamin D deficiency is a risk factor for MS. However, results of previous research investigating vitamin D supplementation in MS, with different regimens and durations, have been contradictory.

The current double-blind study included 303 adults newly diagnosed with CIS (within 90 days) and a serum 25-hydroxy vitamin D concentration of less than 100 nmol/L at baseline. Participants had a median age of 34 years, and 70% were women.

About one third of participants had optic neuritis, two thirds had oligoclonal bands from cerebrospinal fluid analysis, and the median Expanded Disability Status Scale (EDSS) score was 1.0. Of the total, 89% fulfilled 2017 McDonald criteria for the diagnosis of relapsing-remitting MS (RRMS).

Participants were randomly assigned to receive high-dose (100,000 international units) oral cholecalciferol or placebo every 2 weeks for 24 months. Participants had a clinical visit at 3, 6, 12, 18, and 24 months, and brain and spinal cord MRI with and without gadolinium at 3, 12, and 24 months.

The primary outcome was occurrence of disease activity — relapse, new or enlarging T2 lesions, and presence of contrast-enhancing lesions.
 

Significant Difference

During follow-up, 60.3% in the vitamin group showed evidence of disease activity versus 74.1% in the placebo group (hazard ratio [HR], 0.66; 95% CI, 0.50-0.87; P = .004). In addition, the median time to evidence of disease activity was 432 days in the vitamin D group versus 224 days in the placebo group (P = .003).

“As you can see, the difference is really, really significant,” said Dr. Thouvenot, referring to a Kaplan-Meier curve. He said he was somewhat surprised by the “very rapid” effect of vitamin D.

He noted that the 34% reduction in relative risk for disease activity is “similar to that of some published platform therapies for CIS patients.”

An analysis of the 247 patients who met 2017 McDonald criteria for RRMS at baseline showed the same results.

Secondary analyses showed no significant reduction in relapses and no significant differences for annual change in EDSS, quality of life, fatigue, anxiety, or depression.

Additional analyses showed the HR was unchanged after adjusting for known prognostic factors including age, sex, number of lesions (< 9 vs ≥ 9), EDSS score at baseline, and delay between CIS and treatment onset.

Results showed vitamin D3 supplementation was safe and well tolerated. Dr. Thouvenot noted that 95% of participants completed the trial, and none of the 33 severe adverse events in 30 patients suggested hypercalcemia or were related to the study drug.

These encouraging new data support further studies of high-dose vitamin D supplementation as an add-on therapy in early MS, said Dr. Thouvenot. He noted that animal models suggest vitamin D added to interferon beta has a synergistic effect on the immune system.
 

‘Fabulous’ Research

During a question-and-answer session, delegates praised the study, with some describing it as “fantastic” or “fabulous.”

Addressing a query about why this study succeeded in showing the benefits of vitamin D while numerous previous studies did not, Dr. Thouvenot said it may be due to the longer duration or a design that was better powered to show differences.

Asked if researchers examined vitamin D blood levels during the study, Dr. Thouvenot said these measures are “ongoing.”

Responding to a question of whether high-dose vitamin D could be a lifelong treatment, he referred again to the “excellent” safety of the intervention. Not only is it well tolerated, but vitamin D benefits bones and the risk for hypercalcemia is low except perhaps for patients with tuberculosis or sarcoidosis, he said.

“When you exclude those patients, the safety is huge, so I don’t know why we should stop it once it’s started.”

This study was funded in part by the French Ministry of Health. Dr. Thouvenot reported no relevant disclosures.

A version of this article first appeared on Medscape.com.

COPENHAGEN — High-dose oral cholecalciferol (vitamin D3) supplementation significantly reduces evidence of disease activity in patients with clinically isolated syndrome (CIS), results of a randomized, controlled trial suggest. In addition, cholecalciferol had a favorable safety profile and was well tolerated.

“These data support high-dose vitamin D supplementation in early MS and make vitamin D the best candidate for add-on therapy evaluation in the therapeutic strategy for multiple sclerosis [MS],” said study author Eric Thouvenot, MD, PhD, University Hospital of Nimes, Neurology Department, Nimes, France.

The study was presented at the 2024 ECTRIMS annual meeting.
 

Vitamin D Supplementation Versus Placebo

Research shows vitamin D deficiency is a risk factor for MS. However, results of previous research investigating vitamin D supplementation in MS, with different regimens and durations, have been contradictory.

The current double-blind study included 303 adults newly diagnosed with CIS (within 90 days) and a serum 25-hydroxy vitamin D concentration of less than 100 nmol/L at baseline. Participants had a median age of 34 years, and 70% were women.

About one third of participants had optic neuritis, two thirds had oligoclonal bands from cerebrospinal fluid analysis, and the median Expanded Disability Status Scale (EDSS) score was 1.0. Of the total, 89% fulfilled 2017 McDonald criteria for the diagnosis of relapsing-remitting MS (RRMS).

Participants were randomly assigned to receive high-dose (100,000 international units) oral cholecalciferol or placebo every 2 weeks for 24 months. Participants had a clinical visit at 3, 6, 12, 18, and 24 months, and brain and spinal cord MRI with and without gadolinium at 3, 12, and 24 months.

The primary outcome was occurrence of disease activity — relapse, new or enlarging T2 lesions, and presence of contrast-enhancing lesions.
 

Significant Difference

During follow-up, 60.3% in the vitamin group showed evidence of disease activity versus 74.1% in the placebo group (hazard ratio [HR], 0.66; 95% CI, 0.50-0.87; P = .004). In addition, the median time to evidence of disease activity was 432 days in the vitamin D group versus 224 days in the placebo group (P = .003).

“As you can see, the difference is really, really significant,” said Dr. Thouvenot, referring to a Kaplan-Meier curve. He said he was somewhat surprised by the “very rapid” effect of vitamin D.

He noted that the 34% reduction in relative risk for disease activity is “similar to that of some published platform therapies for CIS patients.”

An analysis of the 247 patients who met 2017 McDonald criteria for RRMS at baseline showed the same results.

Secondary analyses showed no significant reduction in relapses and no significant differences for annual change in EDSS, quality of life, fatigue, anxiety, or depression.

Additional analyses showed the HR was unchanged after adjusting for known prognostic factors including age, sex, number of lesions (< 9 vs ≥ 9), EDSS score at baseline, and delay between CIS and treatment onset.

Results showed vitamin D3 supplementation was safe and well tolerated. Dr. Thouvenot noted that 95% of participants completed the trial, and none of the 33 severe adverse events in 30 patients suggested hypercalcemia or were related to the study drug.

These encouraging new data support further studies of high-dose vitamin D supplementation as an add-on therapy in early MS, said Dr. Thouvenot. He noted that animal models suggest vitamin D added to interferon beta has a synergistic effect on the immune system.
 

‘Fabulous’ Research

During a question-and-answer session, delegates praised the study, with some describing it as “fantastic” or “fabulous.”

Addressing a query about why this study succeeded in showing the benefits of vitamin D while numerous previous studies did not, Dr. Thouvenot said it may be due to the longer duration or a design that was better powered to show differences.

Asked if researchers examined vitamin D blood levels during the study, Dr. Thouvenot said these measures are “ongoing.”

Responding to a question of whether high-dose vitamin D could be a lifelong treatment, he referred again to the “excellent” safety of the intervention. Not only is it well tolerated, but vitamin D benefits bones and the risk for hypercalcemia is low except perhaps for patients with tuberculosis or sarcoidosis, he said.

“When you exclude those patients, the safety is huge, so I don’t know why we should stop it once it’s started.”

This study was funded in part by the French Ministry of Health. Dr. Thouvenot reported no relevant disclosures.

A version of this article first appeared on Medscape.com.

COPENHAGEN — High-dose oral cholecalciferol (vitamin D3) supplementation significantly reduces evidence of disease activity in patients with clinically isolated syndrome (CIS), results of a randomized, controlled trial suggest. In addition, cholecalciferol had a favorable safety profile and was well tolerated.

“These data support high-dose vitamin D supplementation in early MS and make vitamin D the best candidate for add-on therapy evaluation in the therapeutic strategy for multiple sclerosis [MS],” said study author Eric Thouvenot, MD, PhD, University Hospital of Nimes, Neurology Department, Nimes, France.

The study was presented at the 2024 ECTRIMS annual meeting.
 

Vitamin D Supplementation Versus Placebo

Research shows vitamin D deficiency is a risk factor for MS. However, results of previous research investigating vitamin D supplementation in MS, with different regimens and durations, have been contradictory.

The current double-blind study included 303 adults newly diagnosed with CIS (within 90 days) and a serum 25-hydroxy vitamin D concentration of less than 100 nmol/L at baseline. Participants had a median age of 34 years, and 70% were women.

About one third of participants had optic neuritis, two thirds had oligoclonal bands from cerebrospinal fluid analysis, and the median Expanded Disability Status Scale (EDSS) score was 1.0. Of the total, 89% fulfilled 2017 McDonald criteria for the diagnosis of relapsing-remitting MS (RRMS).

Participants were randomly assigned to receive high-dose (100,000 international units) oral cholecalciferol or placebo every 2 weeks for 24 months. Participants had a clinical visit at 3, 6, 12, 18, and 24 months, and brain and spinal cord MRI with and without gadolinium at 3, 12, and 24 months.

The primary outcome was occurrence of disease activity — relapse, new or enlarging T2 lesions, and presence of contrast-enhancing lesions.
 

Significant Difference

During follow-up, 60.3% in the vitamin group showed evidence of disease activity versus 74.1% in the placebo group (hazard ratio [HR], 0.66; 95% CI, 0.50-0.87; P = .004). In addition, the median time to evidence of disease activity was 432 days in the vitamin D group versus 224 days in the placebo group (P = .003).

“As you can see, the difference is really, really significant,” said Dr. Thouvenot, referring to a Kaplan-Meier curve. He said he was somewhat surprised by the “very rapid” effect of vitamin D.

He noted that the 34% reduction in relative risk for disease activity is “similar to that of some published platform therapies for CIS patients.”

An analysis of the 247 patients who met 2017 McDonald criteria for RRMS at baseline showed the same results.

Secondary analyses showed no significant reduction in relapses and no significant differences for annual change in EDSS, quality of life, fatigue, anxiety, or depression.

Additional analyses showed the HR was unchanged after adjusting for known prognostic factors including age, sex, number of lesions (< 9 vs ≥ 9), EDSS score at baseline, and delay between CIS and treatment onset.

Results showed vitamin D3 supplementation was safe and well tolerated. Dr. Thouvenot noted that 95% of participants completed the trial, and none of the 33 severe adverse events in 30 patients suggested hypercalcemia or were related to the study drug.

These encouraging new data support further studies of high-dose vitamin D supplementation as an add-on therapy in early MS, said Dr. Thouvenot. He noted that animal models suggest vitamin D added to interferon beta has a synergistic effect on the immune system.
 

‘Fabulous’ Research

During a question-and-answer session, delegates praised the study, with some describing it as “fantastic” or “fabulous.”

Addressing a query about why this study succeeded in showing the benefits of vitamin D while numerous previous studies did not, Dr. Thouvenot said it may be due to the longer duration or a design that was better powered to show differences.

Asked if researchers examined vitamin D blood levels during the study, Dr. Thouvenot said these measures are “ongoing.”

Responding to a question of whether high-dose vitamin D could be a lifelong treatment, he referred again to the “excellent” safety of the intervention. Not only is it well tolerated, but vitamin D benefits bones and the risk for hypercalcemia is low except perhaps for patients with tuberculosis or sarcoidosis, he said.

“When you exclude those patients, the safety is huge, so I don’t know why we should stop it once it’s started.”

This study was funded in part by the French Ministry of Health. Dr. Thouvenot reported no relevant disclosures.

A version of this article first appeared on Medscape.com.

This transcript has been edited for clarity. 

I’d like to pose a question: When should doctors retire? When, as practicing physicians or surgeons, do we become too old to deliver competent service? 

You will be amazed to hear, those of you who have listened to my videos before — and although it is a matter of public knowledge — that I’m 68. I know it’s impossible to imagine, due to this youthful appearance, visage, and so on, but I am. I’ve been a cancer doctor for 40 years; therefore, I need to think a little about retirement. 

There are two elements of this for me. I’m a university professor, and in Oxford we did vote, as a democracy of scholars, to have a mandatory retirement age around 68. This is so that we can bring new blood forward so that we can create the space to promote new professors, to bring youngsters in to make new ideas, and to get rid of us fusty old lot. 

The other argument would be, of course, that we are wise, we’re experienced, we are world-weary, and we’re successful — otherwise, we wouldn’t have lasted as academics as long. Nevertheless, we voted to do that. 

It’s possible to have a discussion with the university to extend this, and for those of us who are clinical academics, I have an honorary appointment as a consultant cancer physician in the hospital and my university professorial appointment, too.

I can extend it probably until I’m about 70. It feels like a nice, round number at which to retire — somewhat arbitrarily, one would admit. But does that feel right? 

In the United States, more than 25% of the physician workforce is over the age of 65. There are many studies showing that there is a 20% cognitive decline for most individuals between the ages of 45 and 65.

Are we as capable as an elderly workforce as once we were? Clearly, it’s hardly individualistic. It depends on each of our own health status, where we started from, and so on, but are there any general rules that we can apply? I think these are starting to creep in around the sense of revalidation.

In the United Kingdom, we have a General Medical Council (GMC). I need to have a license to practice from the GMC and a sense of fitness to practice. I have annual appraisals within the hospital system, in which I explore delivery of care, how I’m doing as a mentor, am I reaching the milestones I’ve set in terms of academic achievements, and so on.

This is a peer-to-peer process. We have senior physicians — people like myself — who act as appraisers to support our colleagues and to maintain that sense of fitness to practice. Every 5 years, I’m revalidated by the GMC. They take account of the annual appraisals and a report made by the senior physician within my hospital network who’s a so-called designated person.

These two elements come together with patient feedback, with 360-degree feedback from colleagues, and so on. This is quite a firmly regulated system that I think works. Our mandatory retirement age of 65 has gone. That was phased out by the government. In fact, our NHS is making an effort to retain older elders in the workforce.

They see the benefits of mentorship, experience, leadership, and networks. At a time when the majority of NHS are actively seeking to retire when 65, the NHS is trying to retain and pull back those of us who have been around for that wee bit longer and who still feel committed to doing it. 

I’d be really interested to see what you think. There’s variation from country to country. I know that, in Australia, they’re talking about annual appraisals of doctors over the age of 70. I’d be very interested to hear what you think is likely to happen in the United States. 

I think our system works pretty well, as long as you’re within the NHS and hospital system. If you wanted to still practice, but practice privately, you would still have to find somebody who’d be prepared to conduct appraisals and so on outside of the NHS. It’s an interesting area. 

For myself, I still feel competent. Patients seem to like me. That’s an objective assessment by this 360-degree thing in which patients reflected very positively, indeed, in my approach to the delivery of the care and so on, as did colleagues. I’m still publishing, I go to meetings, I cheer things, bits and bobs. I’d say I’m a wee bit unusual in terms of still having a strong academic profile in doing stuff.

It’s an interesting question. Richard Doll, one of the world’s great epidemiologists who, of course, was the dominant discoverer of the link between smoking and lung cancer, was attending seminars, sitting in the front row, and coming into university 3 days a week at age 90, continuing to be contributory with his extraordinarily sharp intellect and vast, vast experience.

When I think of experience, all young cancer doctors are now immunologists. When I was a young doctor, I was a clinical pharmacologist. There are many lessons and tricks that I learned which I do need to pass on to the younger generation of today. What do you think? Should there be a mandatory retirement age? How do we best measure, assess, and revalidate elderly physicians and surgeons? How can we continue to contribute to those who choose to do so? For the time being, as always, thanks for listening.
 

Dr. Kerr is professor, Nuffield Department of Clinical Laboratory Science, University of Oxford, and professor of cancer medicine, Oxford Cancer Centre, Oxford, United Kingdom. He has disclosed ties with Celleron Therapeutics, Oxford Cancer Biomarkers (Board of Directors); Afrox (charity; Trustee); GlaxoSmithKline and Bayer HealthCare Pharmaceuticals (Consultant), Genomic Health; Merck Serono, and Roche.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity. 

I’d like to pose a question: When should doctors retire? When, as practicing physicians or surgeons, do we become too old to deliver competent service? 

You will be amazed to hear, those of you who have listened to my videos before — and although it is a matter of public knowledge — that I’m 68. I know it’s impossible to imagine, due to this youthful appearance, visage, and so on, but I am. I’ve been a cancer doctor for 40 years; therefore, I need to think a little about retirement. 

There are two elements of this for me. I’m a university professor, and in Oxford we did vote, as a democracy of scholars, to have a mandatory retirement age around 68. This is so that we can bring new blood forward so that we can create the space to promote new professors, to bring youngsters in to make new ideas, and to get rid of us fusty old lot. 

The other argument would be, of course, that we are wise, we’re experienced, we are world-weary, and we’re successful — otherwise, we wouldn’t have lasted as academics as long. Nevertheless, we voted to do that. 

It’s possible to have a discussion with the university to extend this, and for those of us who are clinical academics, I have an honorary appointment as a consultant cancer physician in the hospital and my university professorial appointment, too.

I can extend it probably until I’m about 70. It feels like a nice, round number at which to retire — somewhat arbitrarily, one would admit. But does that feel right? 

In the United States, more than 25% of the physician workforce is over the age of 65. There are many studies showing that there is a 20% cognitive decline for most individuals between the ages of 45 and 65.

Are we as capable as an elderly workforce as once we were? Clearly, it’s hardly individualistic. It depends on each of our own health status, where we started from, and so on, but are there any general rules that we can apply? I think these are starting to creep in around the sense of revalidation.

In the United Kingdom, we have a General Medical Council (GMC). I need to have a license to practice from the GMC and a sense of fitness to practice. I have annual appraisals within the hospital system, in which I explore delivery of care, how I’m doing as a mentor, am I reaching the milestones I’ve set in terms of academic achievements, and so on.

This is a peer-to-peer process. We have senior physicians — people like myself — who act as appraisers to support our colleagues and to maintain that sense of fitness to practice. Every 5 years, I’m revalidated by the GMC. They take account of the annual appraisals and a report made by the senior physician within my hospital network who’s a so-called designated person.

These two elements come together with patient feedback, with 360-degree feedback from colleagues, and so on. This is quite a firmly regulated system that I think works. Our mandatory retirement age of 65 has gone. That was phased out by the government. In fact, our NHS is making an effort to retain older elders in the workforce.

They see the benefits of mentorship, experience, leadership, and networks. At a time when the majority of NHS are actively seeking to retire when 65, the NHS is trying to retain and pull back those of us who have been around for that wee bit longer and who still feel committed to doing it. 

I’d be really interested to see what you think. There’s variation from country to country. I know that, in Australia, they’re talking about annual appraisals of doctors over the age of 70. I’d be very interested to hear what you think is likely to happen in the United States. 

I think our system works pretty well, as long as you’re within the NHS and hospital system. If you wanted to still practice, but practice privately, you would still have to find somebody who’d be prepared to conduct appraisals and so on outside of the NHS. It’s an interesting area. 

For myself, I still feel competent. Patients seem to like me. That’s an objective assessment by this 360-degree thing in which patients reflected very positively, indeed, in my approach to the delivery of the care and so on, as did colleagues. I’m still publishing, I go to meetings, I cheer things, bits and bobs. I’d say I’m a wee bit unusual in terms of still having a strong academic profile in doing stuff.

It’s an interesting question. Richard Doll, one of the world’s great epidemiologists who, of course, was the dominant discoverer of the link between smoking and lung cancer, was attending seminars, sitting in the front row, and coming into university 3 days a week at age 90, continuing to be contributory with his extraordinarily sharp intellect and vast, vast experience.

When I think of experience, all young cancer doctors are now immunologists. When I was a young doctor, I was a clinical pharmacologist. There are many lessons and tricks that I learned which I do need to pass on to the younger generation of today. What do you think? Should there be a mandatory retirement age? How do we best measure, assess, and revalidate elderly physicians and surgeons? How can we continue to contribute to those who choose to do so? For the time being, as always, thanks for listening.
 

Dr. Kerr is professor, Nuffield Department of Clinical Laboratory Science, University of Oxford, and professor of cancer medicine, Oxford Cancer Centre, Oxford, United Kingdom. He has disclosed ties with Celleron Therapeutics, Oxford Cancer Biomarkers (Board of Directors); Afrox (charity; Trustee); GlaxoSmithKline and Bayer HealthCare Pharmaceuticals (Consultant), Genomic Health; Merck Serono, and Roche.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity. 

I’d like to pose a question: When should doctors retire? When, as practicing physicians or surgeons, do we become too old to deliver competent service? 

You will be amazed to hear, those of you who have listened to my videos before — and although it is a matter of public knowledge — that I’m 68. I know it’s impossible to imagine, due to this youthful appearance, visage, and so on, but I am. I’ve been a cancer doctor for 40 years; therefore, I need to think a little about retirement. 

There are two elements of this for me. I’m a university professor, and in Oxford we did vote, as a democracy of scholars, to have a mandatory retirement age around 68. This is so that we can bring new blood forward so that we can create the space to promote new professors, to bring youngsters in to make new ideas, and to get rid of us fusty old lot. 

The other argument would be, of course, that we are wise, we’re experienced, we are world-weary, and we’re successful — otherwise, we wouldn’t have lasted as academics as long. Nevertheless, we voted to do that. 

It’s possible to have a discussion with the university to extend this, and for those of us who are clinical academics, I have an honorary appointment as a consultant cancer physician in the hospital and my university professorial appointment, too.

I can extend it probably until I’m about 70. It feels like a nice, round number at which to retire — somewhat arbitrarily, one would admit. But does that feel right? 

In the United States, more than 25% of the physician workforce is over the age of 65. There are many studies showing that there is a 20% cognitive decline for most individuals between the ages of 45 and 65.

Are we as capable as an elderly workforce as once we were? Clearly, it’s hardly individualistic. It depends on each of our own health status, where we started from, and so on, but are there any general rules that we can apply? I think these are starting to creep in around the sense of revalidation.

In the United Kingdom, we have a General Medical Council (GMC). I need to have a license to practice from the GMC and a sense of fitness to practice. I have annual appraisals within the hospital system, in which I explore delivery of care, how I’m doing as a mentor, am I reaching the milestones I’ve set in terms of academic achievements, and so on.

This is a peer-to-peer process. We have senior physicians — people like myself — who act as appraisers to support our colleagues and to maintain that sense of fitness to practice. Every 5 years, I’m revalidated by the GMC. They take account of the annual appraisals and a report made by the senior physician within my hospital network who’s a so-called designated person.

These two elements come together with patient feedback, with 360-degree feedback from colleagues, and so on. This is quite a firmly regulated system that I think works. Our mandatory retirement age of 65 has gone. That was phased out by the government. In fact, our NHS is making an effort to retain older elders in the workforce.

They see the benefits of mentorship, experience, leadership, and networks. At a time when the majority of NHS are actively seeking to retire when 65, the NHS is trying to retain and pull back those of us who have been around for that wee bit longer and who still feel committed to doing it. 

I’d be really interested to see what you think. There’s variation from country to country. I know that, in Australia, they’re talking about annual appraisals of doctors over the age of 70. I’d be very interested to hear what you think is likely to happen in the United States. 

I think our system works pretty well, as long as you’re within the NHS and hospital system. If you wanted to still practice, but practice privately, you would still have to find somebody who’d be prepared to conduct appraisals and so on outside of the NHS. It’s an interesting area. 

For myself, I still feel competent. Patients seem to like me. That’s an objective assessment by this 360-degree thing in which patients reflected very positively, indeed, in my approach to the delivery of the care and so on, as did colleagues. I’m still publishing, I go to meetings, I cheer things, bits and bobs. I’d say I’m a wee bit unusual in terms of still having a strong academic profile in doing stuff.

It’s an interesting question. Richard Doll, one of the world’s great epidemiologists who, of course, was the dominant discoverer of the link between smoking and lung cancer, was attending seminars, sitting in the front row, and coming into university 3 days a week at age 90, continuing to be contributory with his extraordinarily sharp intellect and vast, vast experience.

When I think of experience, all young cancer doctors are now immunologists. When I was a young doctor, I was a clinical pharmacologist. There are many lessons and tricks that I learned which I do need to pass on to the younger generation of today. What do you think? Should there be a mandatory retirement age? How do we best measure, assess, and revalidate elderly physicians and surgeons? How can we continue to contribute to those who choose to do so? For the time being, as always, thanks for listening.
 

Dr. Kerr is professor, Nuffield Department of Clinical Laboratory Science, University of Oxford, and professor of cancer medicine, Oxford Cancer Centre, Oxford, United Kingdom. He has disclosed ties with Celleron Therapeutics, Oxford Cancer Biomarkers (Board of Directors); Afrox (charity; Trustee); GlaxoSmithKline and Bayer HealthCare Pharmaceuticals (Consultant), Genomic Health; Merck Serono, and Roche.

A version of this article appeared on Medscape.com.

Four triptans are more effective for acute migraine than newer, more expensive medications for this headache type, new research suggested.

Results of a large systematic review and meta-analysis showed that eletriptan, rizatriptan, sumatriptan, and zolmitriptan were more effective than lasmiditan, rimegepant, and ubrogepant, which investigators found were as effective as nonsteroidal anti-inflammatory drugs (NSAIDs).

International guidelines generally endorse NSAIDs as the first-line treatment for migraine and recommend triptans for moderate to severe episodes or when the response to NSAIDs is insufficient.

However, based on the study’s findings, these four triptans should be considered the treatment of choice for migraine, study investigator Andrea Cipriani, MD, PhD, professor of psychiatry at the University of Oxford in England and director of the Oxford Health Clinical Research Facility, told a press briefing.

The investigators added that these particular triptans should be “included in the WHO [World Health Organization] List of Essential Medicines to promote global accessibility and uniform standards of care.”

The study was published online in The BMJ.
 

Filling the Knowledge Gap

To date, almost all migraine studies have compared migraine drugs with placebo, so there’s a knowledge gap, said Dr. Cipriani. As a result, “there’s no clear consensus among experts and guidelines about which specific drug classes should be prescribed initially, and this is a clinical problem.”

The researchers pointed out that, in recent years, lasmiditan and gepants have been introduced as further treatment options, especially for patients in whom triptans are contraindicated because of their potential vasoconstrictive effects and higher risk for ischemic events.

The analysis included 137 double-blind, randomized, controlled trials that were primarily sponsored by the pharmaceutical industry. It included 89,445 adult outpatients with migraine (mean age, 40.3 years; 85.6% women).

Only drugs licensed for migraine or headache that are recommended in at least one country were included. Researchers divided these 17 drugs into five categories: Antipyretics (paracetamol), ditans (lasmiditan), gepants (rimegepant and ubrogepant), NSAIDs (acetylsalicylic acid, celecoxib, diclofenac potassium, ibuprofen, naproxen sodium, and phenazone), and triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan).

The study’s primary outcomes were freedom from pain at 2 hours and at 2-24 hours, without the use of rescue drugs.

Investigators used sumatriptan as the reference intervention because it is the most commonly prescribed migraine drug and is included in the WHO Model Lists of Essential Medicines.

The study showed all active interventions were better than placebo for pain freedom at 2 hours; with the exception of paracetamol and naratriptan, all were better for sustained pain freedom from 2 to 24 hours.

When the active interventions were compared with each other, eletriptan outperformed other drugs for achieving pain freedom at 2 hours. It was followed by rizatriptan, sumatriptan, and zolmitriptan (odds ratio [OR], 1.35-3.01). For sustained pain freedom up to 24 hours, the most efficacious interventions were eletriptan (OR, 1.41-2.73) and ibuprofen (OR, 3.16-4.82).

As for secondary efficacy outcomes, in head-to-head comparisons, eletriptan was superior to nearly all other active interventions for pain relief at 2 hours and for the use of rescue drugs.

As for adverse events, dizziness was more commonly associated with lasmiditan, eletriptan, sumatriptan, and zolmitriptan, while fatigue and sedation occurred more frequently with eletriptan and lasmiditan. Nausea was more often associated with lasmiditan, sumatriptan, zolmitriptan, and ubrogepant. Eletriptan was the only intervention most frequently associated with chest pain or discomfort.
 

Need to Update Guidelines?

Considering the new results, Dr. Cipriani and study coauthor Messoud Ashina, MD, PhD, professor of neurology, University of Copenhagen in Denmark, said clinical guidelines for acute migraine management should be updated.

While triptans are contraindicated in patients with vascular disease, the researchers noted that “cerebrovascular events may present primarily as migraine-like headaches, and misdiagnosis of transient ischemic attack and minor stroke as migraine is not rare.”

Recently, lasmiditan, rimegepant, and ubrogepant — which are not associated with vasoconstrictive effects — have been promoted as alternatives in patients for whom triptans are contraindicated or not tolerated. But the high costs of these drugs put them out of reach for some patients, the investigators noted.

Triptans are widely underutilized, Dr. Ashina noted during the press briefing. Current use ranges from 17% to 22% in the United States and from 3% to 22.5% in Europe.

The investigators said that triptans have been shown to be superior and should be promoted globally, adding that the limited access and substantial underutilization of these medications are “missed opportunities to offer more effective treatments.”

The new results underscore the importance of head-to-head trials, which is the gold standard, said Dr. Cipriani.

The investigators noted that the study’s main limitation was the quality of the data, which was deemed to be low, or very low, for most comparisons. Other potential limitations included lack of individual patient data; exclusion of combination drugs; inclusion of only oral treatments; and not considering type of oral formulation, consistency in response across migraine episodes, or cost-effectiveness.

The study also did not cover important clinical issues that might inform treatment decision-making, including drug overuse headache or potential withdrawal symptoms. And the authors were unable to quantify some outcomes, such as global functioning.
 

‘Best Profile’?

Reached for comment, Neurologist Nina Riggins, MD, PhD, Headache Center of Excellence, Palo Alto VA Medical Center in California, praised the authors for a “great job” of bringing attention to the topic.

However, she noted that the investigators’ characterization of the four triptans as having the “best profile” for acute migraine gave her pause.

“Calling triptans the medication with the ‘best profile’ might be not applicable in many cases,” she said. For example, those who need acute medication more than two to three times a week in addition to those with cardiovascular contraindications to triptans may fall outside of that category.

Dr. Riggins said that “it makes sense” that longer-acting triptans like frovatriptan and naratriptan may not rank highly for efficacy within the first 2 hours. However, these agents likely offer a superior therapeutic profile in specific contexts, such as menstrual-related migraine.

In addition, while triptans are known to cause medication overuse headache, this may not be the case with gepants, she noted.

In a release from the Science Media Center, a nonprofit organization promoting voices and views of the scientific community, Eloísa Rubio-Beltrán, PhD, research associate with The Migraine Trust at the Wolfson Sensory, Pain and Regeneration Centre, King’s College London in England, said the findings should affect migraine treatment guidelines.

“As the study highlights, due to their high efficacy and low cost, triptans should be the first-line treatment option for the acute treatment of migraine. These results should inform treatment guidelines and support the inclusion of the best performing triptans into the List of Essential Medicines, to optimize treatment, allowing patients to access more efficacious options,” said Dr. Rubio-Beltrán.

It is also important to note that gepants and ditans were developed to offer alternatives for patients who show no improvement from triptans, she added.

She pointed out that these medications were not developed as a substitute for triptans, but rather to expand the number of treatment options for migraine.

“Nonetheless,” she added, “this study highlights the need for further research on the pathophysiology of migraine, which will allow the discovery of novel targets, and thus, novel treatments options that will benefit all patient populations.”

The study was funded by the NIHR Oxford Health Biomedical Research Centre and the Lundbeck Foundation. Dr. Cipriani reported receiving research, educational, and consultancy fees from Italian Network for Pediatric Clinical Trials, Fondazione Cariplo, Lundbeck, and Angelini Pharma. Dr. Ashina is a consultant, speaker, or scientific adviser for AbbVie, Amgen, AstraZeneca, Eli Lilly, GSK, Lundbeck, Novartis, Pfizer, and Teva; is the past president of the International Headache Society; and an associate editor of The Journal of Headache and Pain and Brain. Dr. Riggins has consulted for Gerson Lehrman Group; participated in compensated work with AcademicCME and Association of Migraine Disorders; was a principal investigator on research with electroCore, Theranica, and Eli Lilly; serves on advisory boards for Theranica, Teva, Lundbeck, Amneal Pharmaceuticals, NeurologyLive, and Miles for Migraine; and is a project advisor for Clinical Awareness Initiative with Clinical Neurological Society of America. Dr. Rubio-Beltrán reported serving as a junior editorial board member of The Journal of Headache and Pain and a junior representative of the International Headache Society; receiving research support from The Migraine Trust, Eli Lilly, CoLucid Pharmaceuticals, Amgen, Novartis, and Kallyope; and receiving travel support from CoLucid Pharmaceuticals, Allergan, and Novartis.

A version of this article first appeared on Medscape.com.

Four triptans are more effective for acute migraine than newer, more expensive medications for this headache type, new research suggested.

Results of a large systematic review and meta-analysis showed that eletriptan, rizatriptan, sumatriptan, and zolmitriptan were more effective than lasmiditan, rimegepant, and ubrogepant, which investigators found were as effective as nonsteroidal anti-inflammatory drugs (NSAIDs).

International guidelines generally endorse NSAIDs as the first-line treatment for migraine and recommend triptans for moderate to severe episodes or when the response to NSAIDs is insufficient.

However, based on the study’s findings, these four triptans should be considered the treatment of choice for migraine, study investigator Andrea Cipriani, MD, PhD, professor of psychiatry at the University of Oxford in England and director of the Oxford Health Clinical Research Facility, told a press briefing.

The investigators added that these particular triptans should be “included in the WHO [World Health Organization] List of Essential Medicines to promote global accessibility and uniform standards of care.”

The study was published online in The BMJ.
 

Filling the Knowledge Gap

To date, almost all migraine studies have compared migraine drugs with placebo, so there’s a knowledge gap, said Dr. Cipriani. As a result, “there’s no clear consensus among experts and guidelines about which specific drug classes should be prescribed initially, and this is a clinical problem.”

The researchers pointed out that, in recent years, lasmiditan and gepants have been introduced as further treatment options, especially for patients in whom triptans are contraindicated because of their potential vasoconstrictive effects and higher risk for ischemic events.

The analysis included 137 double-blind, randomized, controlled trials that were primarily sponsored by the pharmaceutical industry. It included 89,445 adult outpatients with migraine (mean age, 40.3 years; 85.6% women).

Only drugs licensed for migraine or headache that are recommended in at least one country were included. Researchers divided these 17 drugs into five categories: Antipyretics (paracetamol), ditans (lasmiditan), gepants (rimegepant and ubrogepant), NSAIDs (acetylsalicylic acid, celecoxib, diclofenac potassium, ibuprofen, naproxen sodium, and phenazone), and triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan).

The study’s primary outcomes were freedom from pain at 2 hours and at 2-24 hours, without the use of rescue drugs.

Investigators used sumatriptan as the reference intervention because it is the most commonly prescribed migraine drug and is included in the WHO Model Lists of Essential Medicines.

The study showed all active interventions were better than placebo for pain freedom at 2 hours; with the exception of paracetamol and naratriptan, all were better for sustained pain freedom from 2 to 24 hours.

When the active interventions were compared with each other, eletriptan outperformed other drugs for achieving pain freedom at 2 hours. It was followed by rizatriptan, sumatriptan, and zolmitriptan (odds ratio [OR], 1.35-3.01). For sustained pain freedom up to 24 hours, the most efficacious interventions were eletriptan (OR, 1.41-2.73) and ibuprofen (OR, 3.16-4.82).

As for secondary efficacy outcomes, in head-to-head comparisons, eletriptan was superior to nearly all other active interventions for pain relief at 2 hours and for the use of rescue drugs.

As for adverse events, dizziness was more commonly associated with lasmiditan, eletriptan, sumatriptan, and zolmitriptan, while fatigue and sedation occurred more frequently with eletriptan and lasmiditan. Nausea was more often associated with lasmiditan, sumatriptan, zolmitriptan, and ubrogepant. Eletriptan was the only intervention most frequently associated with chest pain or discomfort.
 

Need to Update Guidelines?

Considering the new results, Dr. Cipriani and study coauthor Messoud Ashina, MD, PhD, professor of neurology, University of Copenhagen in Denmark, said clinical guidelines for acute migraine management should be updated.

While triptans are contraindicated in patients with vascular disease, the researchers noted that “cerebrovascular events may present primarily as migraine-like headaches, and misdiagnosis of transient ischemic attack and minor stroke as migraine is not rare.”

Recently, lasmiditan, rimegepant, and ubrogepant — which are not associated with vasoconstrictive effects — have been promoted as alternatives in patients for whom triptans are contraindicated or not tolerated. But the high costs of these drugs put them out of reach for some patients, the investigators noted.

Triptans are widely underutilized, Dr. Ashina noted during the press briefing. Current use ranges from 17% to 22% in the United States and from 3% to 22.5% in Europe.

The investigators said that triptans have been shown to be superior and should be promoted globally, adding that the limited access and substantial underutilization of these medications are “missed opportunities to offer more effective treatments.”

The new results underscore the importance of head-to-head trials, which is the gold standard, said Dr. Cipriani.

The investigators noted that the study’s main limitation was the quality of the data, which was deemed to be low, or very low, for most comparisons. Other potential limitations included lack of individual patient data; exclusion of combination drugs; inclusion of only oral treatments; and not considering type of oral formulation, consistency in response across migraine episodes, or cost-effectiveness.

The study also did not cover important clinical issues that might inform treatment decision-making, including drug overuse headache or potential withdrawal symptoms. And the authors were unable to quantify some outcomes, such as global functioning.
 

‘Best Profile’?

Reached for comment, Neurologist Nina Riggins, MD, PhD, Headache Center of Excellence, Palo Alto VA Medical Center in California, praised the authors for a “great job” of bringing attention to the topic.

However, she noted that the investigators’ characterization of the four triptans as having the “best profile” for acute migraine gave her pause.

“Calling triptans the medication with the ‘best profile’ might be not applicable in many cases,” she said. For example, those who need acute medication more than two to three times a week in addition to those with cardiovascular contraindications to triptans may fall outside of that category.

Dr. Riggins said that “it makes sense” that longer-acting triptans like frovatriptan and naratriptan may not rank highly for efficacy within the first 2 hours. However, these agents likely offer a superior therapeutic profile in specific contexts, such as menstrual-related migraine.

In addition, while triptans are known to cause medication overuse headache, this may not be the case with gepants, she noted.

In a release from the Science Media Center, a nonprofit organization promoting voices and views of the scientific community, Eloísa Rubio-Beltrán, PhD, research associate with The Migraine Trust at the Wolfson Sensory, Pain and Regeneration Centre, King’s College London in England, said the findings should affect migraine treatment guidelines.

“As the study highlights, due to their high efficacy and low cost, triptans should be the first-line treatment option for the acute treatment of migraine. These results should inform treatment guidelines and support the inclusion of the best performing triptans into the List of Essential Medicines, to optimize treatment, allowing patients to access more efficacious options,” said Dr. Rubio-Beltrán.

It is also important to note that gepants and ditans were developed to offer alternatives for patients who show no improvement from triptans, she added.

She pointed out that these medications were not developed as a substitute for triptans, but rather to expand the number of treatment options for migraine.

“Nonetheless,” she added, “this study highlights the need for further research on the pathophysiology of migraine, which will allow the discovery of novel targets, and thus, novel treatments options that will benefit all patient populations.”

The study was funded by the NIHR Oxford Health Biomedical Research Centre and the Lundbeck Foundation. Dr. Cipriani reported receiving research, educational, and consultancy fees from Italian Network for Pediatric Clinical Trials, Fondazione Cariplo, Lundbeck, and Angelini Pharma. Dr. Ashina is a consultant, speaker, or scientific adviser for AbbVie, Amgen, AstraZeneca, Eli Lilly, GSK, Lundbeck, Novartis, Pfizer, and Teva; is the past president of the International Headache Society; and an associate editor of The Journal of Headache and Pain and Brain. Dr. Riggins has consulted for Gerson Lehrman Group; participated in compensated work with AcademicCME and Association of Migraine Disorders; was a principal investigator on research with electroCore, Theranica, and Eli Lilly; serves on advisory boards for Theranica, Teva, Lundbeck, Amneal Pharmaceuticals, NeurologyLive, and Miles for Migraine; and is a project advisor for Clinical Awareness Initiative with Clinical Neurological Society of America. Dr. Rubio-Beltrán reported serving as a junior editorial board member of The Journal of Headache and Pain and a junior representative of the International Headache Society; receiving research support from The Migraine Trust, Eli Lilly, CoLucid Pharmaceuticals, Amgen, Novartis, and Kallyope; and receiving travel support from CoLucid Pharmaceuticals, Allergan, and Novartis.

A version of this article first appeared on Medscape.com.

Four triptans are more effective for acute migraine than newer, more expensive medications for this headache type, new research suggested.

Results of a large systematic review and meta-analysis showed that eletriptan, rizatriptan, sumatriptan, and zolmitriptan were more effective than lasmiditan, rimegepant, and ubrogepant, which investigators found were as effective as nonsteroidal anti-inflammatory drugs (NSAIDs).

International guidelines generally endorse NSAIDs as the first-line treatment for migraine and recommend triptans for moderate to severe episodes or when the response to NSAIDs is insufficient.

However, based on the study’s findings, these four triptans should be considered the treatment of choice for migraine, study investigator Andrea Cipriani, MD, PhD, professor of psychiatry at the University of Oxford in England and director of the Oxford Health Clinical Research Facility, told a press briefing.

The investigators added that these particular triptans should be “included in the WHO [World Health Organization] List of Essential Medicines to promote global accessibility and uniform standards of care.”

The study was published online in The BMJ.
 

Filling the Knowledge Gap

To date, almost all migraine studies have compared migraine drugs with placebo, so there’s a knowledge gap, said Dr. Cipriani. As a result, “there’s no clear consensus among experts and guidelines about which specific drug classes should be prescribed initially, and this is a clinical problem.”

The researchers pointed out that, in recent years, lasmiditan and gepants have been introduced as further treatment options, especially for patients in whom triptans are contraindicated because of their potential vasoconstrictive effects and higher risk for ischemic events.

The analysis included 137 double-blind, randomized, controlled trials that were primarily sponsored by the pharmaceutical industry. It included 89,445 adult outpatients with migraine (mean age, 40.3 years; 85.6% women).

Only drugs licensed for migraine or headache that are recommended in at least one country were included. Researchers divided these 17 drugs into five categories: Antipyretics (paracetamol), ditans (lasmiditan), gepants (rimegepant and ubrogepant), NSAIDs (acetylsalicylic acid, celecoxib, diclofenac potassium, ibuprofen, naproxen sodium, and phenazone), and triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan).

The study’s primary outcomes were freedom from pain at 2 hours and at 2-24 hours, without the use of rescue drugs.

Investigators used sumatriptan as the reference intervention because it is the most commonly prescribed migraine drug and is included in the WHO Model Lists of Essential Medicines.

The study showed all active interventions were better than placebo for pain freedom at 2 hours; with the exception of paracetamol and naratriptan, all were better for sustained pain freedom from 2 to 24 hours.

When the active interventions were compared with each other, eletriptan outperformed other drugs for achieving pain freedom at 2 hours. It was followed by rizatriptan, sumatriptan, and zolmitriptan (odds ratio [OR], 1.35-3.01). For sustained pain freedom up to 24 hours, the most efficacious interventions were eletriptan (OR, 1.41-2.73) and ibuprofen (OR, 3.16-4.82).

As for secondary efficacy outcomes, in head-to-head comparisons, eletriptan was superior to nearly all other active interventions for pain relief at 2 hours and for the use of rescue drugs.

As for adverse events, dizziness was more commonly associated with lasmiditan, eletriptan, sumatriptan, and zolmitriptan, while fatigue and sedation occurred more frequently with eletriptan and lasmiditan. Nausea was more often associated with lasmiditan, sumatriptan, zolmitriptan, and ubrogepant. Eletriptan was the only intervention most frequently associated with chest pain or discomfort.
 

Need to Update Guidelines?

Considering the new results, Dr. Cipriani and study coauthor Messoud Ashina, MD, PhD, professor of neurology, University of Copenhagen in Denmark, said clinical guidelines for acute migraine management should be updated.

While triptans are contraindicated in patients with vascular disease, the researchers noted that “cerebrovascular events may present primarily as migraine-like headaches, and misdiagnosis of transient ischemic attack and minor stroke as migraine is not rare.”

Recently, lasmiditan, rimegepant, and ubrogepant — which are not associated with vasoconstrictive effects — have been promoted as alternatives in patients for whom triptans are contraindicated or not tolerated. But the high costs of these drugs put them out of reach for some patients, the investigators noted.

Triptans are widely underutilized, Dr. Ashina noted during the press briefing. Current use ranges from 17% to 22% in the United States and from 3% to 22.5% in Europe.

The investigators said that triptans have been shown to be superior and should be promoted globally, adding that the limited access and substantial underutilization of these medications are “missed opportunities to offer more effective treatments.”

The new results underscore the importance of head-to-head trials, which is the gold standard, said Dr. Cipriani.

The investigators noted that the study’s main limitation was the quality of the data, which was deemed to be low, or very low, for most comparisons. Other potential limitations included lack of individual patient data; exclusion of combination drugs; inclusion of only oral treatments; and not considering type of oral formulation, consistency in response across migraine episodes, or cost-effectiveness.

The study also did not cover important clinical issues that might inform treatment decision-making, including drug overuse headache or potential withdrawal symptoms. And the authors were unable to quantify some outcomes, such as global functioning.
 

‘Best Profile’?

Reached for comment, Neurologist Nina Riggins, MD, PhD, Headache Center of Excellence, Palo Alto VA Medical Center in California, praised the authors for a “great job” of bringing attention to the topic.

However, she noted that the investigators’ characterization of the four triptans as having the “best profile” for acute migraine gave her pause.

“Calling triptans the medication with the ‘best profile’ might be not applicable in many cases,” she said. For example, those who need acute medication more than two to three times a week in addition to those with cardiovascular contraindications to triptans may fall outside of that category.

Dr. Riggins said that “it makes sense” that longer-acting triptans like frovatriptan and naratriptan may not rank highly for efficacy within the first 2 hours. However, these agents likely offer a superior therapeutic profile in specific contexts, such as menstrual-related migraine.

In addition, while triptans are known to cause medication overuse headache, this may not be the case with gepants, she noted.

In a release from the Science Media Center, a nonprofit organization promoting voices and views of the scientific community, Eloísa Rubio-Beltrán, PhD, research associate with The Migraine Trust at the Wolfson Sensory, Pain and Regeneration Centre, King’s College London in England, said the findings should affect migraine treatment guidelines.

“As the study highlights, due to their high efficacy and low cost, triptans should be the first-line treatment option for the acute treatment of migraine. These results should inform treatment guidelines and support the inclusion of the best performing triptans into the List of Essential Medicines, to optimize treatment, allowing patients to access more efficacious options,” said Dr. Rubio-Beltrán.

It is also important to note that gepants and ditans were developed to offer alternatives for patients who show no improvement from triptans, she added.

She pointed out that these medications were not developed as a substitute for triptans, but rather to expand the number of treatment options for migraine.

“Nonetheless,” she added, “this study highlights the need for further research on the pathophysiology of migraine, which will allow the discovery of novel targets, and thus, novel treatments options that will benefit all patient populations.”

The study was funded by the NIHR Oxford Health Biomedical Research Centre and the Lundbeck Foundation. Dr. Cipriani reported receiving research, educational, and consultancy fees from Italian Network for Pediatric Clinical Trials, Fondazione Cariplo, Lundbeck, and Angelini Pharma. Dr. Ashina is a consultant, speaker, or scientific adviser for AbbVie, Amgen, AstraZeneca, Eli Lilly, GSK, Lundbeck, Novartis, Pfizer, and Teva; is the past president of the International Headache Society; and an associate editor of The Journal of Headache and Pain and Brain. Dr. Riggins has consulted for Gerson Lehrman Group; participated in compensated work with AcademicCME and Association of Migraine Disorders; was a principal investigator on research with electroCore, Theranica, and Eli Lilly; serves on advisory boards for Theranica, Teva, Lundbeck, Amneal Pharmaceuticals, NeurologyLive, and Miles for Migraine; and is a project advisor for Clinical Awareness Initiative with Clinical Neurological Society of America. Dr. Rubio-Beltrán reported serving as a junior editorial board member of The Journal of Headache and Pain and a junior representative of the International Headache Society; receiving research support from The Migraine Trust, Eli Lilly, CoLucid Pharmaceuticals, Amgen, Novartis, and Kallyope; and receiving travel support from CoLucid Pharmaceuticals, Allergan, and Novartis.

A version of this article first appeared on Medscape.com.

COPENHAGEN — As a rescue intervention for multiple sclerosis (MS), hematopoietic stem cell transplant (HSCT) is being offered with greater frequency at centers experienced with this approach.

With only one completed randomized trial available, HSCT remains experimental but the number of patients treated with this approach has now reached substantial numbers over 20 years of experience at multiple centers, according to two representative real-world studies presented at the 2024 ECTRIMS annual meeting.

The latest data are wholly consistent with a 2019 multinational randomized trial that found HSCT, which is a one-time intervention, to be relatively well tolerated and more effective than disease-modifying therapy (DMT) for median time to progression in patients refractory to DMT.

Relative to 24 months in the DMT group, median time to relapse was not reached among those randomized to HSCT because there were too few events. The hazard ratio (HR) reduction for progression was greater than 90% (HR, 0.07; P < 0.001). Other endpoints, such as EDSS, which improved in the group receiving HSCT but declined on DMT, also favored the single-treatment therapy.
 

Two Real-World Experiences With HSCT Reported

Of the two multicenter real world studies presented at ECTRIMS, one included 363 patients treated at one of 14 participating public hospitals in the United Kingdom since 2002. This analysis was uncontrolled. The other, with 97 patients treated at one of 20 participating centers in Italy since 1999, compared HSCT to alemtuzumab retrospectively.

In the UK data, presented by Paolo Muraro, MD, PhD, Senior Consultant, Division of Brain Sciences, Imperial College, London, England, 94.6% were in relapse-free survival (RFS) at 2 years and 88.6% at 5 years after undergoing HSCT. He called these numbers “impressive.”

In addition, MRI-free activity survival (MFS) was 88.2% and 78.8% at 2 and 5 years, respectively, Dr. Muraro said.

On the Expanded Disability Status Scale (EDSS), the cumulative incidence of improvement was 24.6% at 2 years and 28.6% at 5 years. There was no evidence of disease activity on the endpoints of symptoms, relapse, and MRI (NEDA-3) in 72% of patients at 2 years and 48.5% at 5 years.

Relative to historical response rates in a refractory population, Dr. Muraro considered these results favorable. Although there were four deaths, producing a treatment-related mortality of 1.1%, all occurred at an early stage of the HSCT program when there was limited experience in the management of cytopenias and other acute complications of HSCT.

“In this real-world cohort, stem cell transplant led to a durable remission of inflammatory activity and to clinical stability even though this included patients with a high EDSS at baseline [median 6.0] and a substantial proportion [39%) with progressive disease,” Dr. Muraro said.

In the Italian data, presented by Alessio Signori, MD, PhD, associate professor, Department of Health Sciences, University of Genoa, Italy, the 97 HSCT patients were matched with 314 treated with alemtuzumab over the same period and compared with propensity score overlap weighting. Baseline features were comparable.
 

HSCT Outperforms Alemtuzumab on All Measures

After a median follow-up of 62 months in the HSCT group and 30 months in the alemtuzumab group, HSCT outperformed drug therapy on all efficacy measures. When translated into HR, HSCT relative to alemtuzumab was associated with a 50% reduction in the probability of disability progression (HR, 0.50; P = 0.025), a 66% reduction in probability of relapse (HR, 0.34; P < 0.001), and a 62% reduction in the probability of MRI activity (HR, 0.38; P < 0.001).

“At 5 years, 58.3% of patients in the HSCT group versus 22.3% of the patients in the alemtuzumab group maintained NEDA-3,” said Dr. Signori, who reported that this difference represented a greater than 50% reduction (HR, 0.48; P < 0.001).

In this study there were two treatment-related deaths. Both occurred within 30 days of HSCT and, again, were confined to the early experience with HSCT.

There are questions that remain unanswered, such as whether there are predictors of response to HSCT. Although sustained responses have been greater on HSCT than drug therapy on average, poor responses appeared to be more common among those with a progressive phenotype in the UK experience.

Although patients with progressive disease were excluded from the Italian study, a real-world experience published 2 years ago also indicated that patients with progressive forms of MS respond less well to HSCT. Conducted in the United States at a single center (Northwestern University, Chicago) with 414 patients of whom 93 had progressive disease, EDSS progressively declined over the 5 years of follow-up among those with secondary progressive MS even as it improved in those with relapsing-remitting multiple sclerosis.
 

HSCT Considered on Compassionate Basis

Overall, the HSCT experience as a rescue therapy for MS patients with an inadequate response to DMT has led a growing number of centers active in this area to offer this option on a compassionate basis, according to Dr. Muraro and Dr. Signori. Joachim Burman, MD, PhD, who was the moderator of the scientific session at ECTRIMS and the leader of a research program into HSCT for MS at Uppsala University, Uppsala, Sweden, agreed.

The increasing number of centers offering HSCT to MS patients does not preclude the need or the value of the ongoing phase 3 trials, according to Dr. Burman, but he suggested that there is a growing focus of how it should be used, not whether it will be used.

Ultimately, he speculated that HSCT, once accepted as a mainstream option for MS, will probably be confined to the 5%-10% of patients with very aggressive disease. This is not for lack of safety or efficacy, but he sees several barriers to using this approach first-line, outside of special situations.

“You need a team of several different specialists to offer HSCT,” he said, suggesting that this approach to MS is much more complicated than a visit to a neurologist’s office for a DMT prescription. However, he thinks other barriers, such as concern about safety, are dissipating.

HSCT “is still being characterized as a high-risk procedure, but I would object to that,” he said. “The deaths associated with HSCT largely occurred 20 years ago when the field was new.”

Dr. Muraro reported a financial relationship with Cellerys AG that is unrelated to this study. Dr. Signori reported financial relationships with Chiesi, Horizon, and Novartis. Dr. Burman reports no potential conflicts of interest.

COPENHAGEN — As a rescue intervention for multiple sclerosis (MS), hematopoietic stem cell transplant (HSCT) is being offered with greater frequency at centers experienced with this approach.

With only one completed randomized trial available, HSCT remains experimental but the number of patients treated with this approach has now reached substantial numbers over 20 years of experience at multiple centers, according to two representative real-world studies presented at the 2024 ECTRIMS annual meeting.

The latest data are wholly consistent with a 2019 multinational randomized trial that found HSCT, which is a one-time intervention, to be relatively well tolerated and more effective than disease-modifying therapy (DMT) for median time to progression in patients refractory to DMT.

Relative to 24 months in the DMT group, median time to relapse was not reached among those randomized to HSCT because there were too few events. The hazard ratio (HR) reduction for progression was greater than 90% (HR, 0.07; P < 0.001). Other endpoints, such as EDSS, which improved in the group receiving HSCT but declined on DMT, also favored the single-treatment therapy.
 

Two Real-World Experiences With HSCT Reported

Of the two multicenter real world studies presented at ECTRIMS, one included 363 patients treated at one of 14 participating public hospitals in the United Kingdom since 2002. This analysis was uncontrolled. The other, with 97 patients treated at one of 20 participating centers in Italy since 1999, compared HSCT to alemtuzumab retrospectively.

In the UK data, presented by Paolo Muraro, MD, PhD, Senior Consultant, Division of Brain Sciences, Imperial College, London, England, 94.6% were in relapse-free survival (RFS) at 2 years and 88.6% at 5 years after undergoing HSCT. He called these numbers “impressive.”

In addition, MRI-free activity survival (MFS) was 88.2% and 78.8% at 2 and 5 years, respectively, Dr. Muraro said.

On the Expanded Disability Status Scale (EDSS), the cumulative incidence of improvement was 24.6% at 2 years and 28.6% at 5 years. There was no evidence of disease activity on the endpoints of symptoms, relapse, and MRI (NEDA-3) in 72% of patients at 2 years and 48.5% at 5 years.

Relative to historical response rates in a refractory population, Dr. Muraro considered these results favorable. Although there were four deaths, producing a treatment-related mortality of 1.1%, all occurred at an early stage of the HSCT program when there was limited experience in the management of cytopenias and other acute complications of HSCT.

“In this real-world cohort, stem cell transplant led to a durable remission of inflammatory activity and to clinical stability even though this included patients with a high EDSS at baseline [median 6.0] and a substantial proportion [39%) with progressive disease,” Dr. Muraro said.

In the Italian data, presented by Alessio Signori, MD, PhD, associate professor, Department of Health Sciences, University of Genoa, Italy, the 97 HSCT patients were matched with 314 treated with alemtuzumab over the same period and compared with propensity score overlap weighting. Baseline features were comparable.
 

HSCT Outperforms Alemtuzumab on All Measures

After a median follow-up of 62 months in the HSCT group and 30 months in the alemtuzumab group, HSCT outperformed drug therapy on all efficacy measures. When translated into HR, HSCT relative to alemtuzumab was associated with a 50% reduction in the probability of disability progression (HR, 0.50; P = 0.025), a 66% reduction in probability of relapse (HR, 0.34; P < 0.001), and a 62% reduction in the probability of MRI activity (HR, 0.38; P < 0.001).

“At 5 years, 58.3% of patients in the HSCT group versus 22.3% of the patients in the alemtuzumab group maintained NEDA-3,” said Dr. Signori, who reported that this difference represented a greater than 50% reduction (HR, 0.48; P < 0.001).

In this study there were two treatment-related deaths. Both occurred within 30 days of HSCT and, again, were confined to the early experience with HSCT.

There are questions that remain unanswered, such as whether there are predictors of response to HSCT. Although sustained responses have been greater on HSCT than drug therapy on average, poor responses appeared to be more common among those with a progressive phenotype in the UK experience.

Although patients with progressive disease were excluded from the Italian study, a real-world experience published 2 years ago also indicated that patients with progressive forms of MS respond less well to HSCT. Conducted in the United States at a single center (Northwestern University, Chicago) with 414 patients of whom 93 had progressive disease, EDSS progressively declined over the 5 years of follow-up among those with secondary progressive MS even as it improved in those with relapsing-remitting multiple sclerosis.
 

HSCT Considered on Compassionate Basis

Overall, the HSCT experience as a rescue therapy for MS patients with an inadequate response to DMT has led a growing number of centers active in this area to offer this option on a compassionate basis, according to Dr. Muraro and Dr. Signori. Joachim Burman, MD, PhD, who was the moderator of the scientific session at ECTRIMS and the leader of a research program into HSCT for MS at Uppsala University, Uppsala, Sweden, agreed.

The increasing number of centers offering HSCT to MS patients does not preclude the need or the value of the ongoing phase 3 trials, according to Dr. Burman, but he suggested that there is a growing focus of how it should be used, not whether it will be used.

Ultimately, he speculated that HSCT, once accepted as a mainstream option for MS, will probably be confined to the 5%-10% of patients with very aggressive disease. This is not for lack of safety or efficacy, but he sees several barriers to using this approach first-line, outside of special situations.

“You need a team of several different specialists to offer HSCT,” he said, suggesting that this approach to MS is much more complicated than a visit to a neurologist’s office for a DMT prescription. However, he thinks other barriers, such as concern about safety, are dissipating.

HSCT “is still being characterized as a high-risk procedure, but I would object to that,” he said. “The deaths associated with HSCT largely occurred 20 years ago when the field was new.”

Dr. Muraro reported a financial relationship with Cellerys AG that is unrelated to this study. Dr. Signori reported financial relationships with Chiesi, Horizon, and Novartis. Dr. Burman reports no potential conflicts of interest.

COPENHAGEN — As a rescue intervention for multiple sclerosis (MS), hematopoietic stem cell transplant (HSCT) is being offered with greater frequency at centers experienced with this approach.

With only one completed randomized trial available, HSCT remains experimental but the number of patients treated with this approach has now reached substantial numbers over 20 years of experience at multiple centers, according to two representative real-world studies presented at the 2024 ECTRIMS annual meeting.

The latest data are wholly consistent with a 2019 multinational randomized trial that found HSCT, which is a one-time intervention, to be relatively well tolerated and more effective than disease-modifying therapy (DMT) for median time to progression in patients refractory to DMT.

Relative to 24 months in the DMT group, median time to relapse was not reached among those randomized to HSCT because there were too few events. The hazard ratio (HR) reduction for progression was greater than 90% (HR, 0.07; P < 0.001). Other endpoints, such as EDSS, which improved in the group receiving HSCT but declined on DMT, also favored the single-treatment therapy.
 

Two Real-World Experiences With HSCT Reported

Of the two multicenter real world studies presented at ECTRIMS, one included 363 patients treated at one of 14 participating public hospitals in the United Kingdom since 2002. This analysis was uncontrolled. The other, with 97 patients treated at one of 20 participating centers in Italy since 1999, compared HSCT to alemtuzumab retrospectively.

In the UK data, presented by Paolo Muraro, MD, PhD, Senior Consultant, Division of Brain Sciences, Imperial College, London, England, 94.6% were in relapse-free survival (RFS) at 2 years and 88.6% at 5 years after undergoing HSCT. He called these numbers “impressive.”

In addition, MRI-free activity survival (MFS) was 88.2% and 78.8% at 2 and 5 years, respectively, Dr. Muraro said.

On the Expanded Disability Status Scale (EDSS), the cumulative incidence of improvement was 24.6% at 2 years and 28.6% at 5 years. There was no evidence of disease activity on the endpoints of symptoms, relapse, and MRI (NEDA-3) in 72% of patients at 2 years and 48.5% at 5 years.

Relative to historical response rates in a refractory population, Dr. Muraro considered these results favorable. Although there were four deaths, producing a treatment-related mortality of 1.1%, all occurred at an early stage of the HSCT program when there was limited experience in the management of cytopenias and other acute complications of HSCT.

“In this real-world cohort, stem cell transplant led to a durable remission of inflammatory activity and to clinical stability even though this included patients with a high EDSS at baseline [median 6.0] and a substantial proportion [39%) with progressive disease,” Dr. Muraro said.

In the Italian data, presented by Alessio Signori, MD, PhD, associate professor, Department of Health Sciences, University of Genoa, Italy, the 97 HSCT patients were matched with 314 treated with alemtuzumab over the same period and compared with propensity score overlap weighting. Baseline features were comparable.
 

HSCT Outperforms Alemtuzumab on All Measures

After a median follow-up of 62 months in the HSCT group and 30 months in the alemtuzumab group, HSCT outperformed drug therapy on all efficacy measures. When translated into HR, HSCT relative to alemtuzumab was associated with a 50% reduction in the probability of disability progression (HR, 0.50; P = 0.025), a 66% reduction in probability of relapse (HR, 0.34; P < 0.001), and a 62% reduction in the probability of MRI activity (HR, 0.38; P < 0.001).

“At 5 years, 58.3% of patients in the HSCT group versus 22.3% of the patients in the alemtuzumab group maintained NEDA-3,” said Dr. Signori, who reported that this difference represented a greater than 50% reduction (HR, 0.48; P < 0.001).

In this study there were two treatment-related deaths. Both occurred within 30 days of HSCT and, again, were confined to the early experience with HSCT.

There are questions that remain unanswered, such as whether there are predictors of response to HSCT. Although sustained responses have been greater on HSCT than drug therapy on average, poor responses appeared to be more common among those with a progressive phenotype in the UK experience.

Although patients with progressive disease were excluded from the Italian study, a real-world experience published 2 years ago also indicated that patients with progressive forms of MS respond less well to HSCT. Conducted in the United States at a single center (Northwestern University, Chicago) with 414 patients of whom 93 had progressive disease, EDSS progressively declined over the 5 years of follow-up among those with secondary progressive MS even as it improved in those with relapsing-remitting multiple sclerosis.
 

HSCT Considered on Compassionate Basis

Overall, the HSCT experience as a rescue therapy for MS patients with an inadequate response to DMT has led a growing number of centers active in this area to offer this option on a compassionate basis, according to Dr. Muraro and Dr. Signori. Joachim Burman, MD, PhD, who was the moderator of the scientific session at ECTRIMS and the leader of a research program into HSCT for MS at Uppsala University, Uppsala, Sweden, agreed.

The increasing number of centers offering HSCT to MS patients does not preclude the need or the value of the ongoing phase 3 trials, according to Dr. Burman, but he suggested that there is a growing focus of how it should be used, not whether it will be used.

Ultimately, he speculated that HSCT, once accepted as a mainstream option for MS, will probably be confined to the 5%-10% of patients with very aggressive disease. This is not for lack of safety or efficacy, but he sees several barriers to using this approach first-line, outside of special situations.

“You need a team of several different specialists to offer HSCT,” he said, suggesting that this approach to MS is much more complicated than a visit to a neurologist’s office for a DMT prescription. However, he thinks other barriers, such as concern about safety, are dissipating.

HSCT “is still being characterized as a high-risk procedure, but I would object to that,” he said. “The deaths associated with HSCT largely occurred 20 years ago when the field was new.”

Dr. Muraro reported a financial relationship with Cellerys AG that is unrelated to this study. Dr. Signori reported financial relationships with Chiesi, Horizon, and Novartis. Dr. Burman reports no potential conflicts of interest.