Randy Dotinga

LAS VEGAS – Pay close attention to the urinary system with an eye toward spotting injuries and repairing them – but when the time is appropriate, John B. Gebhart, MD, MS, urged.

You don’t need to stop a procedure to fix a bladder injury. Rather, mark the spot with a suture, finish what you are doing, then come back and fix the bladder injury, he advised.

“We need to be thinking [of the]urinary tract all the time in the procedures that we’re doing,” Dr. Gebhart, a urogynecologist and reconstructive pelvic surgeon from the Mayo Clinic, Rochester, Minn, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.

“Can you look at the bladder and see that it’s intact, that ureters are functioning like they should? You don’t need to have the skill set to place stents, but you should be able to look in and know you’re okay leaving the operating room,” he said.

According to Dr. Gebhart, urethral injuries can occur in these procedures: anterior repair, cystoscopy, midurethral sling, and treatment of diverticulitis or Skene’s duct abscess.

He offered these tips about urethral injuries:

• Use catheters, dyes, and urethroscopy to reveal injuries. “Putting in a catheter is great because it helps you identify injury because you can visually see it,” he said. “We can squirt some dye in the urethra and see if it’s leaking out. We can put in a zero-degree scope and do urethroscopy.”
• Consider linking multiple holes in the urethra. “Don’t make individual repairs,” he said. “Connect the holes, making them into one hole that you can fix in one setting.”
• Check your repairs for leakage. “I might take a little indigo carmine or methylene blue in a little [angiocatheter], squirt it down the urethra, and see if I’ve got anything leaking out from my repair site,” he said. “If I do, then I want to go back and repair that so that I’ve got a watertight closure.”
• Consider a catheter after repair. “If you do a repair, you want to place a catheter at the end of the splint in the urethra for 7 to 10 to 14 days to help prevent stricture afterwards.”

Dr. Gebhart also discussed bladder injuries, which he said can occur in anterior repair, cystoscopy, hysterectomy, midurethral slings, sacrocolpopexy, and other procedures.

He offered these tips:

• Use bladder backfilling to detect injury. “We can backfill the bladder with the little methylene blue stain–normal saline to help identify whether you’ve got a leak or an injury,” he said. “[Cystogram] can also be very helpful as well.”
• Don’t stop a hysterectomy to fix a bladder injury. “Mark the hole with a suture, finish the hysterectomy and get it out of the way, then come back and fix the hole in the bladder,” Dr. Gebhart said.
• After repair, drain the bladder with a catheter for 10-14 days. “You’re always better draining through a catheter a little longer than pulling the catheter too soon, putting a stretch on the bladder, and maybe compromising your repair,” he said.

He recommended performing a quick cystogram before pulling the catheter to make sure there’s no leak.

Dr. Gebhart disclosed consultant (Hologic) and advisory board (UroCure) relationships and royalties (UpToDate, Elsevier).

This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – Pay close attention to the urinary system with an eye toward spotting injuries and repairing them – but when the time is appropriate, John B. Gebhart, MD, MS, urged.

You don’t need to stop a procedure to fix a bladder injury. Rather, mark the spot with a suture, finish what you are doing, then come back and fix the bladder injury, he advised.

“We need to be thinking [of the]urinary tract all the time in the procedures that we’re doing,” Dr. Gebhart, a urogynecologist and reconstructive pelvic surgeon from the Mayo Clinic, Rochester, Minn, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.

“Can you look at the bladder and see that it’s intact, that ureters are functioning like they should? You don’t need to have the skill set to place stents, but you should be able to look in and know you’re okay leaving the operating room,” he said.

According to Dr. Gebhart, urethral injuries can occur in these procedures: anterior repair, cystoscopy, midurethral sling, and treatment of diverticulitis or Skene’s duct abscess.

He offered these tips about urethral injuries:

• Use catheters, dyes, and urethroscopy to reveal injuries. “Putting in a catheter is great because it helps you identify injury because you can visually see it,” he said. “We can squirt some dye in the urethra and see if it’s leaking out. We can put in a zero-degree scope and do urethroscopy.”
• Consider linking multiple holes in the urethra. “Don’t make individual repairs,” he said. “Connect the holes, making them into one hole that you can fix in one setting.”
• Check your repairs for leakage. “I might take a little indigo carmine or methylene blue in a little [angiocatheter], squirt it down the urethra, and see if I’ve got anything leaking out from my repair site,” he said. “If I do, then I want to go back and repair that so that I’ve got a watertight closure.”
• Consider a catheter after repair. “If you do a repair, you want to place a catheter at the end of the splint in the urethra for 7 to 10 to 14 days to help prevent stricture afterwards.”

Dr. Gebhart also discussed bladder injuries, which he said can occur in anterior repair, cystoscopy, hysterectomy, midurethral slings, sacrocolpopexy, and other procedures.

He offered these tips:

• Use bladder backfilling to detect injury. “We can backfill the bladder with the little methylene blue stain–normal saline to help identify whether you’ve got a leak or an injury,” he said. “[Cystogram] can also be very helpful as well.”
• Don’t stop a hysterectomy to fix a bladder injury. “Mark the hole with a suture, finish the hysterectomy and get it out of the way, then come back and fix the hole in the bladder,” Dr. Gebhart said.
• After repair, drain the bladder with a catheter for 10-14 days. “You’re always better draining through a catheter a little longer than pulling the catheter too soon, putting a stretch on the bladder, and maybe compromising your repair,” he said.

He recommended performing a quick cystogram before pulling the catheter to make sure there’s no leak.

Dr. Gebhart disclosed consultant (Hologic) and advisory board (UroCure) relationships and royalties (UpToDate, Elsevier).

This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – Pay close attention to the urinary system with an eye toward spotting injuries and repairing them – but when the time is appropriate, John B. Gebhart, MD, MS, urged.

You don’t need to stop a procedure to fix a bladder injury. Rather, mark the spot with a suture, finish what you are doing, then come back and fix the bladder injury, he advised.

“We need to be thinking [of the]urinary tract all the time in the procedures that we’re doing,” Dr. Gebhart, a urogynecologist and reconstructive pelvic surgeon from the Mayo Clinic, Rochester, Minn, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.

“Can you look at the bladder and see that it’s intact, that ureters are functioning like they should? You don’t need to have the skill set to place stents, but you should be able to look in and know you’re okay leaving the operating room,” he said.

According to Dr. Gebhart, urethral injuries can occur in these procedures: anterior repair, cystoscopy, midurethral sling, and treatment of diverticulitis or Skene’s duct abscess.

He offered these tips about urethral injuries:

• Use catheters, dyes, and urethroscopy to reveal injuries. “Putting in a catheter is great because it helps you identify injury because you can visually see it,” he said. “We can squirt some dye in the urethra and see if it’s leaking out. We can put in a zero-degree scope and do urethroscopy.”
• Consider linking multiple holes in the urethra. “Don’t make individual repairs,” he said. “Connect the holes, making them into one hole that you can fix in one setting.”
• Check your repairs for leakage. “I might take a little indigo carmine or methylene blue in a little [angiocatheter], squirt it down the urethra, and see if I’ve got anything leaking out from my repair site,” he said. “If I do, then I want to go back and repair that so that I’ve got a watertight closure.”
• Consider a catheter after repair. “If you do a repair, you want to place a catheter at the end of the splint in the urethra for 7 to 10 to 14 days to help prevent stricture afterwards.”

Dr. Gebhart also discussed bladder injuries, which he said can occur in anterior repair, cystoscopy, hysterectomy, midurethral slings, sacrocolpopexy, and other procedures.

He offered these tips:

• Use bladder backfilling to detect injury. “We can backfill the bladder with the little methylene blue stain–normal saline to help identify whether you’ve got a leak or an injury,” he said. “[Cystogram] can also be very helpful as well.”
• Don’t stop a hysterectomy to fix a bladder injury. “Mark the hole with a suture, finish the hysterectomy and get it out of the way, then come back and fix the hole in the bladder,” Dr. Gebhart said.
• After repair, drain the bladder with a catheter for 10-14 days. “You’re always better draining through a catheter a little longer than pulling the catheter too soon, putting a stretch on the bladder, and maybe compromising your repair,” he said.

He recommended performing a quick cystogram before pulling the catheter to make sure there’s no leak.

Dr. Gebhart disclosed consultant (Hologic) and advisory board (UroCure) relationships and royalties (UpToDate, Elsevier).

This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – Use caution when positioning patients during vaginal surgery to prevent potentially severe nerve injuries, a pelvic surgeon urged colleagues.

“It’s a very high medical and legal risk. You have to think about the various nerves that can be influenced,” urogynecologist Mickey M. Karram, MD, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.

Dr. Karram, director of urogynecology and reconstructive surgery at the Christ Hospital in Cincinnati and clinical professor of obstetrics and gynecology at the University of Cincinnati, offered these pearls:

• Understand the anatomy of nerves at risk. These include the ilioinguinal nerve, obturator neurovascular bundle, and pudendal nerve.
• Position the patient correctly. The buttocks should be at edge of table, Dr. Karram said, and there should be slight extension and lateral rotation of the thigh. Beware of compression of the lateral knee.
• Avoid compression from stirrups. If you still use candy-cane stirrups, he said, you can get compression along the lateral aspect of the knee. “You can [get] common perineal nerve injuries. You can also get femoral nerve injuries that are stretch injuries and over-extension injuries as well. Just be careful about this.” Dr. Karram said he prefers fin-type stirrups such as the Allen Yellofin brand. Also, he said, avoid compression injuries that result when there are too many people between the patient’s legs and someone leans on the thighs, he said.
• Free the retractor in abdominal procedures. “If you’re operating abdominally and use retractors, free the retractor at times,” he said. Otherwise, “you can get injuries to the genitofemoral nerve and the femoral nerve itself.”
• Beware buttock pain after sacrospinous fixation. “About 15%-20% of the time, you’ll get extreme buttock pain,” Dr. Karram said. “Assuming the buttock pain doesn’t radiate anywhere and doesn’t go down the leg, it’s definitely not a problem. If it goes down the leg, then you have to think about things like deligating pretty quickly.”

Dr. Karram disclosed consulting (Coloplast and Cynosure/Hologic) and speaker (Allergan, Astellas, Coloplast, and Cynosure/Hologic) relationships. He has royalties from Fidelis Medical and LumeNXT.

This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – Use caution when positioning patients during vaginal surgery to prevent potentially severe nerve injuries, a pelvic surgeon urged colleagues.

“It’s a very high medical and legal risk. You have to think about the various nerves that can be influenced,” urogynecologist Mickey M. Karram, MD, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.

Dr. Karram, director of urogynecology and reconstructive surgery at the Christ Hospital in Cincinnati and clinical professor of obstetrics and gynecology at the University of Cincinnati, offered these pearls:

• Understand the anatomy of nerves at risk. These include the ilioinguinal nerve, obturator neurovascular bundle, and pudendal nerve.
• Position the patient correctly. The buttocks should be at edge of table, Dr. Karram said, and there should be slight extension and lateral rotation of the thigh. Beware of compression of the lateral knee.
• Avoid compression from stirrups. If you still use candy-cane stirrups, he said, you can get compression along the lateral aspect of the knee. “You can [get] common perineal nerve injuries. You can also get femoral nerve injuries that are stretch injuries and over-extension injuries as well. Just be careful about this.” Dr. Karram said he prefers fin-type stirrups such as the Allen Yellofin brand. Also, he said, avoid compression injuries that result when there are too many people between the patient’s legs and someone leans on the thighs, he said.
• Free the retractor in abdominal procedures. “If you’re operating abdominally and use retractors, free the retractor at times,” he said. Otherwise, “you can get injuries to the genitofemoral nerve and the femoral nerve itself.”
• Beware buttock pain after sacrospinous fixation. “About 15%-20% of the time, you’ll get extreme buttock pain,” Dr. Karram said. “Assuming the buttock pain doesn’t radiate anywhere and doesn’t go down the leg, it’s definitely not a problem. If it goes down the leg, then you have to think about things like deligating pretty quickly.”

Dr. Karram disclosed consulting (Coloplast and Cynosure/Hologic) and speaker (Allergan, Astellas, Coloplast, and Cynosure/Hologic) relationships. He has royalties from Fidelis Medical and LumeNXT.

This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – Use caution when positioning patients during vaginal surgery to prevent potentially severe nerve injuries, a pelvic surgeon urged colleagues.

“It’s a very high medical and legal risk. You have to think about the various nerves that can be influenced,” urogynecologist Mickey M. Karram, MD, said at the Pelvic Anatomy and Gynecologic Surgery Symposium.

Dr. Karram, director of urogynecology and reconstructive surgery at the Christ Hospital in Cincinnati and clinical professor of obstetrics and gynecology at the University of Cincinnati, offered these pearls:

• Understand the anatomy of nerves at risk. These include the ilioinguinal nerve, obturator neurovascular bundle, and pudendal nerve.
• Position the patient correctly. The buttocks should be at edge of table, Dr. Karram said, and there should be slight extension and lateral rotation of the thigh. Beware of compression of the lateral knee.
• Avoid compression from stirrups. If you still use candy-cane stirrups, he said, you can get compression along the lateral aspect of the knee. “You can [get] common perineal nerve injuries. You can also get femoral nerve injuries that are stretch injuries and over-extension injuries as well. Just be careful about this.” Dr. Karram said he prefers fin-type stirrups such as the Allen Yellofin brand. Also, he said, avoid compression injuries that result when there are too many people between the patient’s legs and someone leans on the thighs, he said.
• Free the retractor in abdominal procedures. “If you’re operating abdominally and use retractors, free the retractor at times,” he said. Otherwise, “you can get injuries to the genitofemoral nerve and the femoral nerve itself.”
• Beware buttock pain after sacrospinous fixation. “About 15%-20% of the time, you’ll get extreme buttock pain,” Dr. Karram said. “Assuming the buttock pain doesn’t radiate anywhere and doesn’t go down the leg, it’s definitely not a problem. If it goes down the leg, then you have to think about things like deligating pretty quickly.”

Dr. Karram disclosed consulting (Coloplast and Cynosure/Hologic) and speaker (Allergan, Astellas, Coloplast, and Cynosure/Hologic) relationships. He has royalties from Fidelis Medical and LumeNXT.

This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – Surgical repair of pelvic organ prolapse often may seem like an uncomplicated procedure. But many factors play roles into decisions, and surgeons around the world vary widely in how they handle the operations, Mark D. Walters, MD, told colleagues at the Pelvic Anatomy and Gynecologic Surgery Symposium.

“These prolapse repairs seem relatively simple at first, but they’re not simple at all,” he said. “Experts can have completely different and sometimes almost opposite opinions” on how to perform pelvic organ prolapse repairs.
 

Questions to ask prior to surgery

It’s important to first answer a number of questions, said Dr. Walters, professor and vice-chair of gynecology at the Cleveland Clinic. “When you see a patient like this, you may not realize how many decisions you’re making.”

These questions include:

• Is the patient sexually active or planning to be?
• Has she had a hysterectomy, and or is one necessary? If so, how should it be done? What does the patient think about a hysterectomy?
• Should the prolapse procedure be performed vaginally, open, laparoscopically, or robotically?
• Is adding a graft advisable? What kind?
• Should there be a sling to prevent stress urinary incontinence?”

Dr. Walters talked to colleagues from several nations and learned about these variations in surgical techniques.

Chinese surgeons use a variety of techniques with transvaginal mesh (TVM). Their use is more common in more populated cities because of the effect of medical education; native tissue procedures are more common in less-populated regions that are considered “backward.”

TVM with hysteropexy (“apical sling”) also is common in Latin America, while Middle Eastern surgeons have little training in female pelvic medicine and reconstructive surgery.

In Europe, France embraces mesh surgery and laparoscopy, while the United Kingdom has “completely abandoned” mesh surgery, and the Netherlands rarely uses it in favor of vaginal procedures.

In the United States, he said, TVM is “discouraged” while a variety of other procedures are used.

What procedures should surgeons embrace? There are many topics of debate, Dr. Walters said, including type of transvaginal repair (native tissue or mesh-augmented or sacrocolpopexy?), repair of “defects” in the vagina (even if they’re nonsymptomatic?) and the removal of the uterus (yes or no?).

Dr. Walters pointed to several explanations for this variation, including lack of high-quality research, confirmation bias, economic conflicts – surgeons are in the business of surgery, after all – and lack of insight into what women prefer.
 

Consider patient choice

In a survey, Dr. Walters polled women in their 50s with this question: “How much do you value your uterus?” Three women, he said, had widely varied opinions on a scale of 1-10, with one at 10 and another at 0.

“A doctor doesn’t know this and doesn’t have a way to ask, and the doctor has [his/her] own opinion about the value of the uterus,” he said. “Shouldn’t we know what patients think?”
 

How to measure success

He offered these tips about measuring success:

• Focus on symptomatic cure more than clinical cure.
• Remember that perfect anatomic support isn’t linked to health-related quality of life, and some loss of anatomic support is normal.
• Understand that commonly used definitions of anatomic success often aren’t clinically relevant.

Dr. Walters’ disclosures: royalties (Elsevier, UpToDate), website/lecturer (International Academy of Pelvic Surgery), and website editor (Foundation for Female Health Awareness).

This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – Surgical repair of pelvic organ prolapse often may seem like an uncomplicated procedure. But many factors play roles into decisions, and surgeons around the world vary widely in how they handle the operations, Mark D. Walters, MD, told colleagues at the Pelvic Anatomy and Gynecologic Surgery Symposium.

“These prolapse repairs seem relatively simple at first, but they’re not simple at all,” he said. “Experts can have completely different and sometimes almost opposite opinions” on how to perform pelvic organ prolapse repairs.
 

Questions to ask prior to surgery

It’s important to first answer a number of questions, said Dr. Walters, professor and vice-chair of gynecology at the Cleveland Clinic. “When you see a patient like this, you may not realize how many decisions you’re making.”

These questions include:

• Is the patient sexually active or planning to be?
• Has she had a hysterectomy, and or is one necessary? If so, how should it be done? What does the patient think about a hysterectomy?
• Should the prolapse procedure be performed vaginally, open, laparoscopically, or robotically?
• Is adding a graft advisable? What kind?
• Should there be a sling to prevent stress urinary incontinence?”

Dr. Walters talked to colleagues from several nations and learned about these variations in surgical techniques.

Chinese surgeons use a variety of techniques with transvaginal mesh (TVM). Their use is more common in more populated cities because of the effect of medical education; native tissue procedures are more common in less-populated regions that are considered “backward.”

TVM with hysteropexy (“apical sling”) also is common in Latin America, while Middle Eastern surgeons have little training in female pelvic medicine and reconstructive surgery.

In Europe, France embraces mesh surgery and laparoscopy, while the United Kingdom has “completely abandoned” mesh surgery, and the Netherlands rarely uses it in favor of vaginal procedures.

In the United States, he said, TVM is “discouraged” while a variety of other procedures are used.

What procedures should surgeons embrace? There are many topics of debate, Dr. Walters said, including type of transvaginal repair (native tissue or mesh-augmented or sacrocolpopexy?), repair of “defects” in the vagina (even if they’re nonsymptomatic?) and the removal of the uterus (yes or no?).

Dr. Walters pointed to several explanations for this variation, including lack of high-quality research, confirmation bias, economic conflicts – surgeons are in the business of surgery, after all – and lack of insight into what women prefer.
 

Consider patient choice

In a survey, Dr. Walters polled women in their 50s with this question: “How much do you value your uterus?” Three women, he said, had widely varied opinions on a scale of 1-10, with one at 10 and another at 0.

“A doctor doesn’t know this and doesn’t have a way to ask, and the doctor has [his/her] own opinion about the value of the uterus,” he said. “Shouldn’t we know what patients think?”
 

How to measure success

He offered these tips about measuring success:

• Focus on symptomatic cure more than clinical cure.
• Remember that perfect anatomic support isn’t linked to health-related quality of life, and some loss of anatomic support is normal.
• Understand that commonly used definitions of anatomic success often aren’t clinically relevant.

Dr. Walters’ disclosures: royalties (Elsevier, UpToDate), website/lecturer (International Academy of Pelvic Surgery), and website editor (Foundation for Female Health Awareness).

This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

LAS VEGAS – Surgical repair of pelvic organ prolapse often may seem like an uncomplicated procedure. But many factors play roles into decisions, and surgeons around the world vary widely in how they handle the operations, Mark D. Walters, MD, told colleagues at the Pelvic Anatomy and Gynecologic Surgery Symposium.

“These prolapse repairs seem relatively simple at first, but they’re not simple at all,” he said. “Experts can have completely different and sometimes almost opposite opinions” on how to perform pelvic organ prolapse repairs.
 

Questions to ask prior to surgery

It’s important to first answer a number of questions, said Dr. Walters, professor and vice-chair of gynecology at the Cleveland Clinic. “When you see a patient like this, you may not realize how many decisions you’re making.”

These questions include:

• Is the patient sexually active or planning to be?
• Has she had a hysterectomy, and or is one necessary? If so, how should it be done? What does the patient think about a hysterectomy?
• Should the prolapse procedure be performed vaginally, open, laparoscopically, or robotically?
• Is adding a graft advisable? What kind?
• Should there be a sling to prevent stress urinary incontinence?”

Dr. Walters talked to colleagues from several nations and learned about these variations in surgical techniques.

Chinese surgeons use a variety of techniques with transvaginal mesh (TVM). Their use is more common in more populated cities because of the effect of medical education; native tissue procedures are more common in less-populated regions that are considered “backward.”

TVM with hysteropexy (“apical sling”) also is common in Latin America, while Middle Eastern surgeons have little training in female pelvic medicine and reconstructive surgery.

In Europe, France embraces mesh surgery and laparoscopy, while the United Kingdom has “completely abandoned” mesh surgery, and the Netherlands rarely uses it in favor of vaginal procedures.

In the United States, he said, TVM is “discouraged” while a variety of other procedures are used.

What procedures should surgeons embrace? There are many topics of debate, Dr. Walters said, including type of transvaginal repair (native tissue or mesh-augmented or sacrocolpopexy?), repair of “defects” in the vagina (even if they’re nonsymptomatic?) and the removal of the uterus (yes or no?).

Dr. Walters pointed to several explanations for this variation, including lack of high-quality research, confirmation bias, economic conflicts – surgeons are in the business of surgery, after all – and lack of insight into what women prefer.
 

Consider patient choice

In a survey, Dr. Walters polled women in their 50s with this question: “How much do you value your uterus?” Three women, he said, had widely varied opinions on a scale of 1-10, with one at 10 and another at 0.

“A doctor doesn’t know this and doesn’t have a way to ask, and the doctor has [his/her] own opinion about the value of the uterus,” he said. “Shouldn’t we know what patients think?”
 

How to measure success

He offered these tips about measuring success:

• Focus on symptomatic cure more than clinical cure.
• Remember that perfect anatomic support isn’t linked to health-related quality of life, and some loss of anatomic support is normal.
• Understand that commonly used definitions of anatomic success often aren’t clinically relevant.

Dr. Walters’ disclosures: royalties (Elsevier, UpToDate), website/lecturer (International Academy of Pelvic Surgery), and website editor (Foundation for Female Health Awareness).

This meeting was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.

SAN DIEGO – Emergency physicians can be persuaded to follow a recommended strategy to prescribe buprenorphine to patients with opioid addictions and to refer them to follow-up care, Kathryn F. Hawk, MD, said at the annual meeting of the American Academy of Addiction Psychiatry.

“People are willing to change their practices and evolve as long as they have the support to do so,” Dr. Hawk, assistant professor of emergency medicine at Yale University, New Haven, Conn., said at the meeting.

Dr. Hawk highlighted a landmark 2015 study led by Yale colleagues that compared three strategies to treating patients with opioid use disorder in the emergency department. Researchers randomly assigned 329 patients to 1) referral to treatment; 2) brief intervention and facilitated referral to community-based treatment services; and 3) emergency department-initiated treatment with buprenorphine/naloxone (Suboxone) plus referral to primary care for 10-week follow-up.

At 30 days, 78% of patients in the third group were in addiction treatment vs. 37% in the first group and 45% in the second group. (P less than .001). However, the percentage of patients in the groups who had negative urine screens for opioids were not statistically different (JAMA. 2015. Apr 28;313[16]:1636-44).

Both the American College of Emergency Physicians (ACEP) and the American College of Medical Toxicology have endorsed the use of buprenorphine in the ED “as a bridge to long-term addiction treatment,” said Dr. Hawk, who also is affiliated with Yale New Haven Hospital.

Emergency department physicians, however, have been reluctant to start prescribing buprenorphine and get more deeply involved in referrals to care, said E. Jennifer Edelman, MD, associate professor of general internal medicine at Yale. She described the results of a 2017-2019 survey of 268 medical professionals at urban emergency departments in Seattle, Cincinnati, New York City, and Baltimore. Only 20% of the survey respondents said they were “ready” to initiate the buprenorphine treatment protocol.

Researchers also held focus groups with 74 clinicians who offered insight into their hesitation. “That’s not something that we’re even really taught in medical school and certainly not in our training as emergency physicians,” one faculty member said. “It is this detox black box across the street, and that’s how it is in many places.”

Another faculty member expressed regret about the current system: “I feel like this is particularly vulnerable patient population [and] we’re just saying, ‘Here’s a sheet. Call some numbers. Good luck.’ That’s the way it feels when I discharge these folks.” And a resident said: “We can’t provide all of that care up front. It’s just too time-consuming, and there are other patients to see.”

But not all of the findings were grim.

“There was broad recognition that the status quo was unacceptable, and emergency medicine physicians were excited about an opportunity to do more,” Dr. Edelman said.

According to her, strategies aimed at boosting the Suboxone approach include establishing protocols, and providing leadership support and resources. Addiction psychiatrists also can be helpful, she said.

“Let’s think about partnering together to bridge that gap,” she said. One idea: Invite emergency physicians to observe a treatment initiation.

“Showing how you counsel patients to start medication at home would be really a wonderful way to facilitate practices in the emergency department,” she said.

Another idea, she said, is to “give them feedback on their patients.” If an emergency physician refers a patient and they walk in the door, “let them know how they did. That’s going to be really, really powerful.”

ACEP and the American Society of Addiction Medicine have created a tool aimed at helping facilitate the use of buprenorphine and naloxone in the emergency department.

Dr. Hawk and Dr. Edelman reported no relevant disclosures.

SAN DIEGO – Emergency physicians can be persuaded to follow a recommended strategy to prescribe buprenorphine to patients with opioid addictions and to refer them to follow-up care, Kathryn F. Hawk, MD, said at the annual meeting of the American Academy of Addiction Psychiatry.

“People are willing to change their practices and evolve as long as they have the support to do so,” Dr. Hawk, assistant professor of emergency medicine at Yale University, New Haven, Conn., said at the meeting.

Dr. Hawk highlighted a landmark 2015 study led by Yale colleagues that compared three strategies to treating patients with opioid use disorder in the emergency department. Researchers randomly assigned 329 patients to 1) referral to treatment; 2) brief intervention and facilitated referral to community-based treatment services; and 3) emergency department-initiated treatment with buprenorphine/naloxone (Suboxone) plus referral to primary care for 10-week follow-up.

At 30 days, 78% of patients in the third group were in addiction treatment vs. 37% in the first group and 45% in the second group. (P less than .001). However, the percentage of patients in the groups who had negative urine screens for opioids were not statistically different (JAMA. 2015. Apr 28;313[16]:1636-44).

Both the American College of Emergency Physicians (ACEP) and the American College of Medical Toxicology have endorsed the use of buprenorphine in the ED “as a bridge to long-term addiction treatment,” said Dr. Hawk, who also is affiliated with Yale New Haven Hospital.

Emergency department physicians, however, have been reluctant to start prescribing buprenorphine and get more deeply involved in referrals to care, said E. Jennifer Edelman, MD, associate professor of general internal medicine at Yale. She described the results of a 2017-2019 survey of 268 medical professionals at urban emergency departments in Seattle, Cincinnati, New York City, and Baltimore. Only 20% of the survey respondents said they were “ready” to initiate the buprenorphine treatment protocol.

Researchers also held focus groups with 74 clinicians who offered insight into their hesitation. “That’s not something that we’re even really taught in medical school and certainly not in our training as emergency physicians,” one faculty member said. “It is this detox black box across the street, and that’s how it is in many places.”

Another faculty member expressed regret about the current system: “I feel like this is particularly vulnerable patient population [and] we’re just saying, ‘Here’s a sheet. Call some numbers. Good luck.’ That’s the way it feels when I discharge these folks.” And a resident said: “We can’t provide all of that care up front. It’s just too time-consuming, and there are other patients to see.”

But not all of the findings were grim.

“There was broad recognition that the status quo was unacceptable, and emergency medicine physicians were excited about an opportunity to do more,” Dr. Edelman said.

According to her, strategies aimed at boosting the Suboxone approach include establishing protocols, and providing leadership support and resources. Addiction psychiatrists also can be helpful, she said.

“Let’s think about partnering together to bridge that gap,” she said. One idea: Invite emergency physicians to observe a treatment initiation.

“Showing how you counsel patients to start medication at home would be really a wonderful way to facilitate practices in the emergency department,” she said.

Another idea, she said, is to “give them feedback on their patients.” If an emergency physician refers a patient and they walk in the door, “let them know how they did. That’s going to be really, really powerful.”

ACEP and the American Society of Addiction Medicine have created a tool aimed at helping facilitate the use of buprenorphine and naloxone in the emergency department.

Dr. Hawk and Dr. Edelman reported no relevant disclosures.

SAN DIEGO – Emergency physicians can be persuaded to follow a recommended strategy to prescribe buprenorphine to patients with opioid addictions and to refer them to follow-up care, Kathryn F. Hawk, MD, said at the annual meeting of the American Academy of Addiction Psychiatry.

“People are willing to change their practices and evolve as long as they have the support to do so,” Dr. Hawk, assistant professor of emergency medicine at Yale University, New Haven, Conn., said at the meeting.

Dr. Hawk highlighted a landmark 2015 study led by Yale colleagues that compared three strategies to treating patients with opioid use disorder in the emergency department. Researchers randomly assigned 329 patients to 1) referral to treatment; 2) brief intervention and facilitated referral to community-based treatment services; and 3) emergency department-initiated treatment with buprenorphine/naloxone (Suboxone) plus referral to primary care for 10-week follow-up.

At 30 days, 78% of patients in the third group were in addiction treatment vs. 37% in the first group and 45% in the second group. (P less than .001). However, the percentage of patients in the groups who had negative urine screens for opioids were not statistically different (JAMA. 2015. Apr 28;313[16]:1636-44).

Both the American College of Emergency Physicians (ACEP) and the American College of Medical Toxicology have endorsed the use of buprenorphine in the ED “as a bridge to long-term addiction treatment,” said Dr. Hawk, who also is affiliated with Yale New Haven Hospital.

Emergency department physicians, however, have been reluctant to start prescribing buprenorphine and get more deeply involved in referrals to care, said E. Jennifer Edelman, MD, associate professor of general internal medicine at Yale. She described the results of a 2017-2019 survey of 268 medical professionals at urban emergency departments in Seattle, Cincinnati, New York City, and Baltimore. Only 20% of the survey respondents said they were “ready” to initiate the buprenorphine treatment protocol.

Researchers also held focus groups with 74 clinicians who offered insight into their hesitation. “That’s not something that we’re even really taught in medical school and certainly not in our training as emergency physicians,” one faculty member said. “It is this detox black box across the street, and that’s how it is in many places.”

Another faculty member expressed regret about the current system: “I feel like this is particularly vulnerable patient population [and] we’re just saying, ‘Here’s a sheet. Call some numbers. Good luck.’ That’s the way it feels when I discharge these folks.” And a resident said: “We can’t provide all of that care up front. It’s just too time-consuming, and there are other patients to see.”

But not all of the findings were grim.

“There was broad recognition that the status quo was unacceptable, and emergency medicine physicians were excited about an opportunity to do more,” Dr. Edelman said.

According to her, strategies aimed at boosting the Suboxone approach include establishing protocols, and providing leadership support and resources. Addiction psychiatrists also can be helpful, she said.

“Let’s think about partnering together to bridge that gap,” she said. One idea: Invite emergency physicians to observe a treatment initiation.

“Showing how you counsel patients to start medication at home would be really a wonderful way to facilitate practices in the emergency department,” she said.

Another idea, she said, is to “give them feedback on their patients.” If an emergency physician refers a patient and they walk in the door, “let them know how they did. That’s going to be really, really powerful.”

ACEP and the American Society of Addiction Medicine have created a tool aimed at helping facilitate the use of buprenorphine and naloxone in the emergency department.

Dr. Hawk and Dr. Edelman reported no relevant disclosures.

SAN DIEGO – Many factors drive addiction. But clinicians often fail to address the important role played by abusive intimate partners, a psychiatrist told colleagues at the annual meeting of the American Academy of Addiction Psychiatry.

Photodisc/Thinkstock

Violence is not the only source of harm, said Carole Warshaw, MD, as abusers also turn to sabotage, gaslighting, and manipulation – especially when substance users seek help.

“Abusive partners deliberately engage in behaviors designed to undermine their partner’s sanity or sobriety,” said Dr. Warshaw, director of the National Center on Domestic Violence, Trauma & Mental Health in Chicago, in a presentation at the meeting. “We’ve talked a lot about drivers of the opioid epidemic, including pharmaceutical industry greed and disorders of despair. But nobody’s been really talking about gender-based violence as a potential driver of the opioid epidemic, including intimate-partner violence, trafficking, and commercial sex exploitation.”

Dr. Warshaw highlighted the findings of a 2014 study that examined the survey responses of 2,546 adult women (54% white, 19% black, 19% Hispanic) who called the National Domestic Violence Hotline. The study, led by Dr. Warshaw, only included women who had experienced domestic violence and were not in immediate crisis.

The women answered questions about abusive partners, and their responses were often emotional, Dr. Warshaw said. “People would say: ‘No one asked me this before,’ and they’d be in tears. It was just very moving for people to start thinking about this.”

Gaslighting, sabotage, and accusations of mental illness were common. More than 85% of respondents said their current or ex-partner had called them “crazy,” and 74% agreed that “your partner or ex-partner has ... deliberately done things to make you feel like you are going crazy or losing your mind.”

Strategies of abusive partners include sabotaging and discrediting their partners’ attempts at recovery, Dr. Warshaw said. Half of callers agreed that a partner or ex-partner “tried to prevent or discourage you from getting ... help or taking medication you were prescribed for your feelings.”

About 92% of callers who said they’d tried to get help in recent years “reported that their partner or ex-partner had threatened to report their alcohol or other drug use to authorities to keep them from getting something they wanted or needed,” the study found.

All of the abuse can create a kind of addiction feedback loop, she said. “Research has consistently documented that abuse by an intimate partner increases a person’s risk for developing a range of health and mental health conditions – including depression, PTSD, anxiety – that are risk factors for opioid and substance use.”

One resource that clinicians can use to protect patients from abusive and manipulative partners is her center’s toolkit on “Coercion Related to Mental Health and Substance Use in the Context of Intimate Partner Violence.”

The toolkit, she said, provides insight into how to integrate questions about abusive partners into your practice and how to partner with domestic violence programs.

Dr. Warshaw reported no relevant disclosures.

SAN DIEGO – Many factors drive addiction. But clinicians often fail to address the important role played by abusive intimate partners, a psychiatrist told colleagues at the annual meeting of the American Academy of Addiction Psychiatry.

Photodisc/Thinkstock

Violence is not the only source of harm, said Carole Warshaw, MD, as abusers also turn to sabotage, gaslighting, and manipulation – especially when substance users seek help.

“Abusive partners deliberately engage in behaviors designed to undermine their partner’s sanity or sobriety,” said Dr. Warshaw, director of the National Center on Domestic Violence, Trauma & Mental Health in Chicago, in a presentation at the meeting. “We’ve talked a lot about drivers of the opioid epidemic, including pharmaceutical industry greed and disorders of despair. But nobody’s been really talking about gender-based violence as a potential driver of the opioid epidemic, including intimate-partner violence, trafficking, and commercial sex exploitation.”

Dr. Warshaw highlighted the findings of a 2014 study that examined the survey responses of 2,546 adult women (54% white, 19% black, 19% Hispanic) who called the National Domestic Violence Hotline. The study, led by Dr. Warshaw, only included women who had experienced domestic violence and were not in immediate crisis.

The women answered questions about abusive partners, and their responses were often emotional, Dr. Warshaw said. “People would say: ‘No one asked me this before,’ and they’d be in tears. It was just very moving for people to start thinking about this.”

Gaslighting, sabotage, and accusations of mental illness were common. More than 85% of respondents said their current or ex-partner had called them “crazy,” and 74% agreed that “your partner or ex-partner has ... deliberately done things to make you feel like you are going crazy or losing your mind.”

Strategies of abusive partners include sabotaging and discrediting their partners’ attempts at recovery, Dr. Warshaw said. Half of callers agreed that a partner or ex-partner “tried to prevent or discourage you from getting ... help or taking medication you were prescribed for your feelings.”

About 92% of callers who said they’d tried to get help in recent years “reported that their partner or ex-partner had threatened to report their alcohol or other drug use to authorities to keep them from getting something they wanted or needed,” the study found.

All of the abuse can create a kind of addiction feedback loop, she said. “Research has consistently documented that abuse by an intimate partner increases a person’s risk for developing a range of health and mental health conditions – including depression, PTSD, anxiety – that are risk factors for opioid and substance use.”

One resource that clinicians can use to protect patients from abusive and manipulative partners is her center’s toolkit on “Coercion Related to Mental Health and Substance Use in the Context of Intimate Partner Violence.”

The toolkit, she said, provides insight into how to integrate questions about abusive partners into your practice and how to partner with domestic violence programs.

Dr. Warshaw reported no relevant disclosures.

SAN DIEGO – Many factors drive addiction. But clinicians often fail to address the important role played by abusive intimate partners, a psychiatrist told colleagues at the annual meeting of the American Academy of Addiction Psychiatry.

Photodisc/Thinkstock

Violence is not the only source of harm, said Carole Warshaw, MD, as abusers also turn to sabotage, gaslighting, and manipulation – especially when substance users seek help.

“Abusive partners deliberately engage in behaviors designed to undermine their partner’s sanity or sobriety,” said Dr. Warshaw, director of the National Center on Domestic Violence, Trauma & Mental Health in Chicago, in a presentation at the meeting. “We’ve talked a lot about drivers of the opioid epidemic, including pharmaceutical industry greed and disorders of despair. But nobody’s been really talking about gender-based violence as a potential driver of the opioid epidemic, including intimate-partner violence, trafficking, and commercial sex exploitation.”

Dr. Warshaw highlighted the findings of a 2014 study that examined the survey responses of 2,546 adult women (54% white, 19% black, 19% Hispanic) who called the National Domestic Violence Hotline. The study, led by Dr. Warshaw, only included women who had experienced domestic violence and were not in immediate crisis.

The women answered questions about abusive partners, and their responses were often emotional, Dr. Warshaw said. “People would say: ‘No one asked me this before,’ and they’d be in tears. It was just very moving for people to start thinking about this.”

Gaslighting, sabotage, and accusations of mental illness were common. More than 85% of respondents said their current or ex-partner had called them “crazy,” and 74% agreed that “your partner or ex-partner has ... deliberately done things to make you feel like you are going crazy or losing your mind.”

Strategies of abusive partners include sabotaging and discrediting their partners’ attempts at recovery, Dr. Warshaw said. Half of callers agreed that a partner or ex-partner “tried to prevent or discourage you from getting ... help or taking medication you were prescribed for your feelings.”

About 92% of callers who said they’d tried to get help in recent years “reported that their partner or ex-partner had threatened to report their alcohol or other drug use to authorities to keep them from getting something they wanted or needed,” the study found.

All of the abuse can create a kind of addiction feedback loop, she said. “Research has consistently documented that abuse by an intimate partner increases a person’s risk for developing a range of health and mental health conditions – including depression, PTSD, anxiety – that are risk factors for opioid and substance use.”

One resource that clinicians can use to protect patients from abusive and manipulative partners is her center’s toolkit on “Coercion Related to Mental Health and Substance Use in the Context of Intimate Partner Violence.”

The toolkit, she said, provides insight into how to integrate questions about abusive partners into your practice and how to partner with domestic violence programs.

Dr. Warshaw reported no relevant disclosures.

SAN DIEGO – Addiction specialists have a message for American policymakers who are rushing to create laws to allow the use of medical and recreational marijuana: You’re doing it wrong, but we know how you can do it right.

Smithore

“We can have spirited debates on these policies, recreational, medical decriminalization, etc. But we can’t argue how we’ve done a poor job implementing these policies in the United States,” psychiatrist Kevin P. Hill, MD, of Harvard Medical School, Boston, said in a symposium about cannabis policy at the annual meeting of the American Academy of Addiction Psychiatry.

The AAAP is proposing a “model state law” regarding cannabis. Among other things, the proposal urges states to:

• Ban recreational use of cannabis until the age of 21, and perhaps even until 25.
• Not denote psychiatric indications such as posttraumatic stress disorder, anxiety, and depression as qualifying conditions for the use of medical marijuana.
• Educate the public about potential harms of cannabis.
• Provide state-level regulation that includes funding of high-grade analytic equipment to test cannabis.
• Maintain a public registry that reports annually on adverse outcomes.

Research suggests that marijuana use has spiked in recent years, Dr. Hill said. Meanwhile, states have dramatically broadened the legality of marijuana. According to the National Conference of State Legislatures, 33 states and the District of Columbia allow the medical use of marijuana. Of those, 11 states and the District of Columbia also allow the adult use of recreational marijuana. Several other states allow access to cannabidiol (CBD)/low-THC products in some cases (www.ncsl.org/research/health/state-medical-marijuana-laws.aspx).

The problem, Dr. Hill said, is that there’s “a big gap between what the science says and what the laws are saying, unfortunately. So we’re in this precarious spot.”

He pointed to his own 2015 review of cannabinoid studies that found high-quality evidence for an effect for just three conditions – chronic pain, neuropathic pain, and spasticity associated with multiple sclerosis. The study notes that Food and Drug Administration–approved cannabinoids are also available to treat nausea and vomiting linked to chemotherapy and to boost appetite in patients with wasting disease. (JAMA. 2015 Jun 23-30;313(24):2474-83).

However, states have listed dozens of conditions – 53 overall – as qualifying conditions for the use of medical marijuana, Dr. Hill said. And, he said, “the reality is that a lot of people who are using medical cannabis don’t have any of these conditions,” he said.

Researchers at the symposium focused on the use of cannabis as a treatment for addiction and other psychiatric illnesses.

Four states have legalized the use of cannabis in patients with opioid use disorder, said cannabis researcher Ziva D. Cooper, PhD, of the University of California, Los Angeles, who spoke at the symposium. But can cannabis actually reduce opioid use? Preliminary clinical data suggest THC could reduce opioid use, Dr. Cooper said, while population and state-level research is mixed.

What about other mental health disorders? Posttraumatic stress disorder is commonly listed as a qualifying condition for medical marijuana use in state laws. And some states, like California, give physicians wide leeway in recommending marijuana use for patients with conditions that aren’t listed in the law.

However, symposium speaker and psychiatrist Frances R. Levin, MD, of New York State Psychiatric Institute, pointed to a 2019 review that suggests “there is scarce evidence to suggest that cannabinoids improve depressive disorders and symptoms, anxiety disorders, attention-deficit hyperactivity disorder, Tourette syndrome, posttraumatic stress disorder, or psychosis” (Lancet Psychiatry. 2019 Dec;6[12]:995-1010). 

What now? The AAAP hopes lawmakers will pay attention to its proposed model state law, which will be published soon in the association’s journal, the American Journal on Addictions.

SAN DIEGO – Addiction specialists have a message for American policymakers who are rushing to create laws to allow the use of medical and recreational marijuana: You’re doing it wrong, but we know how you can do it right.

Smithore

“We can have spirited debates on these policies, recreational, medical decriminalization, etc. But we can’t argue how we’ve done a poor job implementing these policies in the United States,” psychiatrist Kevin P. Hill, MD, of Harvard Medical School, Boston, said in a symposium about cannabis policy at the annual meeting of the American Academy of Addiction Psychiatry.

The AAAP is proposing a “model state law” regarding cannabis. Among other things, the proposal urges states to:

• Ban recreational use of cannabis until the age of 21, and perhaps even until 25.
• Not denote psychiatric indications such as posttraumatic stress disorder, anxiety, and depression as qualifying conditions for the use of medical marijuana.
• Educate the public about potential harms of cannabis.
• Provide state-level regulation that includes funding of high-grade analytic equipment to test cannabis.
• Maintain a public registry that reports annually on adverse outcomes.

Research suggests that marijuana use has spiked in recent years, Dr. Hill said. Meanwhile, states have dramatically broadened the legality of marijuana. According to the National Conference of State Legislatures, 33 states and the District of Columbia allow the medical use of marijuana. Of those, 11 states and the District of Columbia also allow the adult use of recreational marijuana. Several other states allow access to cannabidiol (CBD)/low-THC products in some cases (www.ncsl.org/research/health/state-medical-marijuana-laws.aspx).

The problem, Dr. Hill said, is that there’s “a big gap between what the science says and what the laws are saying, unfortunately. So we’re in this precarious spot.”

He pointed to his own 2015 review of cannabinoid studies that found high-quality evidence for an effect for just three conditions – chronic pain, neuropathic pain, and spasticity associated with multiple sclerosis. The study notes that Food and Drug Administration–approved cannabinoids are also available to treat nausea and vomiting linked to chemotherapy and to boost appetite in patients with wasting disease. (JAMA. 2015 Jun 23-30;313(24):2474-83).

However, states have listed dozens of conditions – 53 overall – as qualifying conditions for the use of medical marijuana, Dr. Hill said. And, he said, “the reality is that a lot of people who are using medical cannabis don’t have any of these conditions,” he said.

Researchers at the symposium focused on the use of cannabis as a treatment for addiction and other psychiatric illnesses.

Four states have legalized the use of cannabis in patients with opioid use disorder, said cannabis researcher Ziva D. Cooper, PhD, of the University of California, Los Angeles, who spoke at the symposium. But can cannabis actually reduce opioid use? Preliminary clinical data suggest THC could reduce opioid use, Dr. Cooper said, while population and state-level research is mixed.

What about other mental health disorders? Posttraumatic stress disorder is commonly listed as a qualifying condition for medical marijuana use in state laws. And some states, like California, give physicians wide leeway in recommending marijuana use for patients with conditions that aren’t listed in the law.

However, symposium speaker and psychiatrist Frances R. Levin, MD, of New York State Psychiatric Institute, pointed to a 2019 review that suggests “there is scarce evidence to suggest that cannabinoids improve depressive disorders and symptoms, anxiety disorders, attention-deficit hyperactivity disorder, Tourette syndrome, posttraumatic stress disorder, or psychosis” (Lancet Psychiatry. 2019 Dec;6[12]:995-1010). 

What now? The AAAP hopes lawmakers will pay attention to its proposed model state law, which will be published soon in the association’s journal, the American Journal on Addictions.

SAN DIEGO – Addiction specialists have a message for American policymakers who are rushing to create laws to allow the use of medical and recreational marijuana: You’re doing it wrong, but we know how you can do it right.

Smithore

“We can have spirited debates on these policies, recreational, medical decriminalization, etc. But we can’t argue how we’ve done a poor job implementing these policies in the United States,” psychiatrist Kevin P. Hill, MD, of Harvard Medical School, Boston, said in a symposium about cannabis policy at the annual meeting of the American Academy of Addiction Psychiatry.

The AAAP is proposing a “model state law” regarding cannabis. Among other things, the proposal urges states to:

• Ban recreational use of cannabis until the age of 21, and perhaps even until 25.
• Not denote psychiatric indications such as posttraumatic stress disorder, anxiety, and depression as qualifying conditions for the use of medical marijuana.
• Educate the public about potential harms of cannabis.
• Provide state-level regulation that includes funding of high-grade analytic equipment to test cannabis.
• Maintain a public registry that reports annually on adverse outcomes.

Research suggests that marijuana use has spiked in recent years, Dr. Hill said. Meanwhile, states have dramatically broadened the legality of marijuana. According to the National Conference of State Legislatures, 33 states and the District of Columbia allow the medical use of marijuana. Of those, 11 states and the District of Columbia also allow the adult use of recreational marijuana. Several other states allow access to cannabidiol (CBD)/low-THC products in some cases (www.ncsl.org/research/health/state-medical-marijuana-laws.aspx).

The problem, Dr. Hill said, is that there’s “a big gap between what the science says and what the laws are saying, unfortunately. So we’re in this precarious spot.”

He pointed to his own 2015 review of cannabinoid studies that found high-quality evidence for an effect for just three conditions – chronic pain, neuropathic pain, and spasticity associated with multiple sclerosis. The study notes that Food and Drug Administration–approved cannabinoids are also available to treat nausea and vomiting linked to chemotherapy and to boost appetite in patients with wasting disease. (JAMA. 2015 Jun 23-30;313(24):2474-83).

However, states have listed dozens of conditions – 53 overall – as qualifying conditions for the use of medical marijuana, Dr. Hill said. And, he said, “the reality is that a lot of people who are using medical cannabis don’t have any of these conditions,” he said.

Researchers at the symposium focused on the use of cannabis as a treatment for addiction and other psychiatric illnesses.

Four states have legalized the use of cannabis in patients with opioid use disorder, said cannabis researcher Ziva D. Cooper, PhD, of the University of California, Los Angeles, who spoke at the symposium. But can cannabis actually reduce opioid use? Preliminary clinical data suggest THC could reduce opioid use, Dr. Cooper said, while population and state-level research is mixed.

What about other mental health disorders? Posttraumatic stress disorder is commonly listed as a qualifying condition for medical marijuana use in state laws. And some states, like California, give physicians wide leeway in recommending marijuana use for patients with conditions that aren’t listed in the law.

However, symposium speaker and psychiatrist Frances R. Levin, MD, of New York State Psychiatric Institute, pointed to a 2019 review that suggests “there is scarce evidence to suggest that cannabinoids improve depressive disorders and symptoms, anxiety disorders, attention-deficit hyperactivity disorder, Tourette syndrome, posttraumatic stress disorder, or psychosis” (Lancet Psychiatry. 2019 Dec;6[12]:995-1010). 

What now? The AAAP hopes lawmakers will pay attention to its proposed model state law, which will be published soon in the association’s journal, the American Journal on Addictions.

LAS VEGAS – Recent research is offering new insights into psoriasis and alopecia in the pediatric population, a dermatologist told colleagues, and it’s time to be on the lookout for psoriasis linked to treatment with tumor necrosis factor (TNF) inhibitors.

Lawrence F. Eichenfield, MD, professor of dermatology and pediatrics, at the University of California, San Diego, offered these tips and comments in a presentation at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar:

Psoriasis

It’s a brand new day for adult psoriasis sufferers, but it seems to be only a brand new morning for their pediatric counterparts. “Kids and teenagers were left behind in the biologic revolution,” Dr. Eichenfield said. “Only two systemic biologics have been approved for psoriasis in children.” They are ustekinumab (Stelara), approved by the Food and Drug Administration for treating psoriasis in children aged 12 years and older, and etanercept, approved for aged 4 years and older.

The good news, he said, is that “our new biologic agents are now being studied in children.”

Research is also providing new insight into pediatric psoriasis, said Dr. Eichenfield, who is also chief of pediatric and adolescent dermatology at Rady Children’s Hospital in San Diego. It’s now clear that “there’s a lot more facial involvement, and a high involvement of scalp and nail,” he noted.

It’s also clear, he said, that inflammation begins early in pediatric psoriasis. That raises the question of whether it’s a good idea to launch aggressive treatment to stop the “psoriatic march” toward cardiovascular and other medical problems down the line, he commented.

“Keep an open mind to getting aggressive in therapy,” he advised, although he acknowledged that “it’s hard to get beyond the two biologics, and only one is approved for children under 12.”

Dr. Eichenfield advised colleagues to keep an eye out for TNF inhibitor–induced psoriasis. “We’re seeing it pretty regularly,” he said, commonly in children who are treated with TNF inhibitors for rheumatoid arthritis or Crohn’s disease.

The lesions “look like dermatitis but are very psoriasiform,” he said, and research suggests this can appear after a single dose or after as many as 63 months of treatment. Topical and light therapy can be helpful. But if those treatments do not help, he said, it’s time to consider changing the biologic that the patient is taking. “Is the biologic adequately controlling their underlying disease? If not, you can help find one that would be great for their underlying disease and clear up their psoriasis.”

Alopecia

Pediatric alopecia “is a problem I see pretty regularly in practice,” Dr. Eichenfield said. When he sees patients with alopecia, he says that, “‘if your child doesn’t have 50% hair loss, you’re in the good group. It will generally heal up and never come back again.’ ”

He referred to a recent study, where investigators at the Children’s Hospital of Philadelphia retrospectively studied 125 children under age 4 years who were diagnosed with alopecia areata and followed for 2 years. Over time, those children with over 50% of hair loss initially were more likely to have worsening Severity of Alopecia Tool (SALT) scores over the follow-up period. But a high proportion of those with mild alopecia initially continued to have mild alopecia at follow-up (Pediatr Dermatol. 2019 Aug 29. doi: 10.1111/pde.13990).

Dr. Eichenfield noted that the study found that 41% of the patients also had atopic dermatitis.

He also highlighted two other recent studies on pediatric alopecia: One found that while vitamin D levels were low in a majority of children with alopecia in the study, the proportion who had a deficiency was similar to the proportion in a larger pediatric population, at about 22% in both groups (J Am Acad Dermatol. 2018 Sep;79(3):e43-e44). Supplementation doesn’t seem to help. “It’s not important to test levels,” he said.

Another study examined whether it’s a good idea to test patients for celiac disease in children with alopecia (Pediatr Dermatol. 2018 Jul;35[4]:535-8). Some parents may ask this question, but the answer, he said, is generally no.

What’s next? “We were hoping oral and topical JAK inhibitors would work well” in this population, Dr. Eichenfield said, but study findings haven’t been promising.

Still, oral tofacitinib (Xeljanz) showed some “pretty impressive” success in a recent study in four children, he noted. Based on the results, the authors wrote that “we suggest that, after proper counseling regarding the risks, including severe infection and malignancy, the use of tofacitinib may be considered for preadolescent children with AA [alopecia areata] who are experiencing psychosocial impairment” (J Am Acad Dermatol. 2019 Feb;80[2]:568-70).

In general, Dr. Eichenfield said, research on pediatric alopecia “will be secondary, especially with JAK inhibitors because of the risk of side effects. But [children will] probably tolerate them better than adults do because they have fewer medical problems.”

Meanwhile, he added, controversy continues to swirl around how to treat children over age 10 years who have lost 50% or more of their hair. “I’ve seen hundreds of kids with alopecia areata,” he said, “and I can’t predict what the course may be.”

Dr. Eichenfield reports multiple relationships (consultant or investigator) with various pharmaceutical companies, including Abbvie, Allergan, Lilly, Novartis, and others. SDEF and this news organization are owned by the same parent company.

LAS VEGAS – Recent research is offering new insights into psoriasis and alopecia in the pediatric population, a dermatologist told colleagues, and it’s time to be on the lookout for psoriasis linked to treatment with tumor necrosis factor (TNF) inhibitors.

Lawrence F. Eichenfield, MD, professor of dermatology and pediatrics, at the University of California, San Diego, offered these tips and comments in a presentation at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar:

Psoriasis

It’s a brand new day for adult psoriasis sufferers, but it seems to be only a brand new morning for their pediatric counterparts. “Kids and teenagers were left behind in the biologic revolution,” Dr. Eichenfield said. “Only two systemic biologics have been approved for psoriasis in children.” They are ustekinumab (Stelara), approved by the Food and Drug Administration for treating psoriasis in children aged 12 years and older, and etanercept, approved for aged 4 years and older.

The good news, he said, is that “our new biologic agents are now being studied in children.”

Research is also providing new insight into pediatric psoriasis, said Dr. Eichenfield, who is also chief of pediatric and adolescent dermatology at Rady Children’s Hospital in San Diego. It’s now clear that “there’s a lot more facial involvement, and a high involvement of scalp and nail,” he noted.

It’s also clear, he said, that inflammation begins early in pediatric psoriasis. That raises the question of whether it’s a good idea to launch aggressive treatment to stop the “psoriatic march” toward cardiovascular and other medical problems down the line, he commented.

“Keep an open mind to getting aggressive in therapy,” he advised, although he acknowledged that “it’s hard to get beyond the two biologics, and only one is approved for children under 12.”

Dr. Eichenfield advised colleagues to keep an eye out for TNF inhibitor–induced psoriasis. “We’re seeing it pretty regularly,” he said, commonly in children who are treated with TNF inhibitors for rheumatoid arthritis or Crohn’s disease.

The lesions “look like dermatitis but are very psoriasiform,” he said, and research suggests this can appear after a single dose or after as many as 63 months of treatment. Topical and light therapy can be helpful. But if those treatments do not help, he said, it’s time to consider changing the biologic that the patient is taking. “Is the biologic adequately controlling their underlying disease? If not, you can help find one that would be great for their underlying disease and clear up their psoriasis.”

Alopecia

Pediatric alopecia “is a problem I see pretty regularly in practice,” Dr. Eichenfield said. When he sees patients with alopecia, he says that, “‘if your child doesn’t have 50% hair loss, you’re in the good group. It will generally heal up and never come back again.’ ”

He referred to a recent study, where investigators at the Children’s Hospital of Philadelphia retrospectively studied 125 children under age 4 years who were diagnosed with alopecia areata and followed for 2 years. Over time, those children with over 50% of hair loss initially were more likely to have worsening Severity of Alopecia Tool (SALT) scores over the follow-up period. But a high proportion of those with mild alopecia initially continued to have mild alopecia at follow-up (Pediatr Dermatol. 2019 Aug 29. doi: 10.1111/pde.13990).

Dr. Eichenfield noted that the study found that 41% of the patients also had atopic dermatitis.

He also highlighted two other recent studies on pediatric alopecia: One found that while vitamin D levels were low in a majority of children with alopecia in the study, the proportion who had a deficiency was similar to the proportion in a larger pediatric population, at about 22% in both groups (J Am Acad Dermatol. 2018 Sep;79(3):e43-e44). Supplementation doesn’t seem to help. “It’s not important to test levels,” he said.

Another study examined whether it’s a good idea to test patients for celiac disease in children with alopecia (Pediatr Dermatol. 2018 Jul;35[4]:535-8). Some parents may ask this question, but the answer, he said, is generally no.

What’s next? “We were hoping oral and topical JAK inhibitors would work well” in this population, Dr. Eichenfield said, but study findings haven’t been promising.

Still, oral tofacitinib (Xeljanz) showed some “pretty impressive” success in a recent study in four children, he noted. Based on the results, the authors wrote that “we suggest that, after proper counseling regarding the risks, including severe infection and malignancy, the use of tofacitinib may be considered for preadolescent children with AA [alopecia areata] who are experiencing psychosocial impairment” (J Am Acad Dermatol. 2019 Feb;80[2]:568-70).

In general, Dr. Eichenfield said, research on pediatric alopecia “will be secondary, especially with JAK inhibitors because of the risk of side effects. But [children will] probably tolerate them better than adults do because they have fewer medical problems.”

Meanwhile, he added, controversy continues to swirl around how to treat children over age 10 years who have lost 50% or more of their hair. “I’ve seen hundreds of kids with alopecia areata,” he said, “and I can’t predict what the course may be.”

Dr. Eichenfield reports multiple relationships (consultant or investigator) with various pharmaceutical companies, including Abbvie, Allergan, Lilly, Novartis, and others. SDEF and this news organization are owned by the same parent company.

LAS VEGAS – Recent research is offering new insights into psoriasis and alopecia in the pediatric population, a dermatologist told colleagues, and it’s time to be on the lookout for psoriasis linked to treatment with tumor necrosis factor (TNF) inhibitors.

Lawrence F. Eichenfield, MD, professor of dermatology and pediatrics, at the University of California, San Diego, offered these tips and comments in a presentation at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar:

Psoriasis

It’s a brand new day for adult psoriasis sufferers, but it seems to be only a brand new morning for their pediatric counterparts. “Kids and teenagers were left behind in the biologic revolution,” Dr. Eichenfield said. “Only two systemic biologics have been approved for psoriasis in children.” They are ustekinumab (Stelara), approved by the Food and Drug Administration for treating psoriasis in children aged 12 years and older, and etanercept, approved for aged 4 years and older.

The good news, he said, is that “our new biologic agents are now being studied in children.”

Research is also providing new insight into pediatric psoriasis, said Dr. Eichenfield, who is also chief of pediatric and adolescent dermatology at Rady Children’s Hospital in San Diego. It’s now clear that “there’s a lot more facial involvement, and a high involvement of scalp and nail,” he noted.

It’s also clear, he said, that inflammation begins early in pediatric psoriasis. That raises the question of whether it’s a good idea to launch aggressive treatment to stop the “psoriatic march” toward cardiovascular and other medical problems down the line, he commented.

“Keep an open mind to getting aggressive in therapy,” he advised, although he acknowledged that “it’s hard to get beyond the two biologics, and only one is approved for children under 12.”

Dr. Eichenfield advised colleagues to keep an eye out for TNF inhibitor–induced psoriasis. “We’re seeing it pretty regularly,” he said, commonly in children who are treated with TNF inhibitors for rheumatoid arthritis or Crohn’s disease.

The lesions “look like dermatitis but are very psoriasiform,” he said, and research suggests this can appear after a single dose or after as many as 63 months of treatment. Topical and light therapy can be helpful. But if those treatments do not help, he said, it’s time to consider changing the biologic that the patient is taking. “Is the biologic adequately controlling their underlying disease? If not, you can help find one that would be great for their underlying disease and clear up their psoriasis.”

Alopecia

Pediatric alopecia “is a problem I see pretty regularly in practice,” Dr. Eichenfield said. When he sees patients with alopecia, he says that, “‘if your child doesn’t have 50% hair loss, you’re in the good group. It will generally heal up and never come back again.’ ”

He referred to a recent study, where investigators at the Children’s Hospital of Philadelphia retrospectively studied 125 children under age 4 years who were diagnosed with alopecia areata and followed for 2 years. Over time, those children with over 50% of hair loss initially were more likely to have worsening Severity of Alopecia Tool (SALT) scores over the follow-up period. But a high proportion of those with mild alopecia initially continued to have mild alopecia at follow-up (Pediatr Dermatol. 2019 Aug 29. doi: 10.1111/pde.13990).

Dr. Eichenfield noted that the study found that 41% of the patients also had atopic dermatitis.

He also highlighted two other recent studies on pediatric alopecia: One found that while vitamin D levels were low in a majority of children with alopecia in the study, the proportion who had a deficiency was similar to the proportion in a larger pediatric population, at about 22% in both groups (J Am Acad Dermatol. 2018 Sep;79(3):e43-e44). Supplementation doesn’t seem to help. “It’s not important to test levels,” he said.

Another study examined whether it’s a good idea to test patients for celiac disease in children with alopecia (Pediatr Dermatol. 2018 Jul;35[4]:535-8). Some parents may ask this question, but the answer, he said, is generally no.

What’s next? “We were hoping oral and topical JAK inhibitors would work well” in this population, Dr. Eichenfield said, but study findings haven’t been promising.

Still, oral tofacitinib (Xeljanz) showed some “pretty impressive” success in a recent study in four children, he noted. Based on the results, the authors wrote that “we suggest that, after proper counseling regarding the risks, including severe infection and malignancy, the use of tofacitinib may be considered for preadolescent children with AA [alopecia areata] who are experiencing psychosocial impairment” (J Am Acad Dermatol. 2019 Feb;80[2]:568-70).

In general, Dr. Eichenfield said, research on pediatric alopecia “will be secondary, especially with JAK inhibitors because of the risk of side effects. But [children will] probably tolerate them better than adults do because they have fewer medical problems.”

Meanwhile, he added, controversy continues to swirl around how to treat children over age 10 years who have lost 50% or more of their hair. “I’ve seen hundreds of kids with alopecia areata,” he said, “and I can’t predict what the course may be.”

Dr. Eichenfield reports multiple relationships (consultant or investigator) with various pharmaceutical companies, including Abbvie, Allergan, Lilly, Novartis, and others. SDEF and this news organization are owned by the same parent company.

LAS VEGAS – While biologics have dramatically changed the picture, drugs like methotrexate, acitretin, cyclosporine, and apremilast still have roles to play in the treatment of psoriasis, a dermatologist told colleagues.

However, caution is necessary, especially when the drugs are used in combination with biologics, Bruce E. Strober, MD, PhD, of Yale University, New Haven, Conn., and Central Connecticut Dermatology, Cromwell, Conn., said at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.

Dr. Strober offered these tips about the proper use of these four drugs in psoriasis patients:

Acitretin (Soriatane). “This was used as monotherapy initially, but at this point in history, fewer and fewer patients are getting it as monotherapy,” he said. A dose of 25 mg/day appears to provide the best mix of efficacy and side-effect control, “although it’s not a high-efficacy drug, especially at 25 mg a day. It’s a slow-acting drug, and you may need 4 if not 6 months to see the maximum effect before you give up on it.”

What about using acitretin in combination with other therapies? Studies examining its use with phototherapy haven’t been promising, Dr. Strober said. The drug can be used with methotrexate, he said, even though the combination will worry pharmacists. “Follow the liver, and you’ll be fine” he noted. “That combination can be successful. Laboratory monitoring is not onerous: Discontinue after a few months if you’ve not seen any movement.” The drug can also be used with biologics, he said.

Apremilast (Otezla). This drug will bring about a third of patients to a Psoriasis Area and Severity Index (PASI) 75. “That’s not the most impressive efficacy. Rarely do we clear patients with this drug, and it has tolerability issues in some patients,” Dr. Strober said. Side effects can include diarrhea, nausea, headache, and depression. “Warn patients of these possibilities,” he added.

Methotrexate. “It’s very helpful and not a drug to be feared if it’s monitored correctly,” Dr. Strober said. “It’s certainly not a biologic, but it’s not a bad drug from an efficacy standpoint, and it does have efficacy in psoriatic arthritis.”

The drug’s low cost can make it a good alternative to biologics in patients with limited insurance options – such as those on Medicare – or those who don’t have insurance, he said.

“Psoriasis is often controlled at a mean dose of 15 mg/week [orally], with no test dose; start at 15-mg weekly,” he said. “It’s an interesting drug that allows you to dose weekly and still get efficacy,” especially when dosed subcutaneously.

Beware the many contraindications such as pregnancy, possible pregnancy, and high alcohol intake, he added. Dr. Strober doesn’t recommend liver biopsies to monitor hepatic effects. “It’s a poor test with risk and sampling error,” he said.

Cyclosporine. This drug is best “in severe patients in need of a quick response,” said Dr. Strober, who added that biologics are often a better option even in patients who are sensitive to price since samples and free-drug programs are available. “It’s in and out of the body quickly, and most people skip doses and get recurrence of their disease quickly,” he said.

Blood tests are a hassle for patients, he said, and “people often don’t feel great on the drug,” said Dr. Strober, who added, however, that he still does occasionally use it.

Dr. Strober reported multiple disclosures including consultant/advisory board (AbbVie, Amgen, Lilly, Pfizer, among others) and investigator relationships. SDEF and this news organization are owned by the same parent company.

LAS VEGAS – While biologics have dramatically changed the picture, drugs like methotrexate, acitretin, cyclosporine, and apremilast still have roles to play in the treatment of psoriasis, a dermatologist told colleagues.

However, caution is necessary, especially when the drugs are used in combination with biologics, Bruce E. Strober, MD, PhD, of Yale University, New Haven, Conn., and Central Connecticut Dermatology, Cromwell, Conn., said at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.

Dr. Strober offered these tips about the proper use of these four drugs in psoriasis patients:

Acitretin (Soriatane). “This was used as monotherapy initially, but at this point in history, fewer and fewer patients are getting it as monotherapy,” he said. A dose of 25 mg/day appears to provide the best mix of efficacy and side-effect control, “although it’s not a high-efficacy drug, especially at 25 mg a day. It’s a slow-acting drug, and you may need 4 if not 6 months to see the maximum effect before you give up on it.”

What about using acitretin in combination with other therapies? Studies examining its use with phototherapy haven’t been promising, Dr. Strober said. The drug can be used with methotrexate, he said, even though the combination will worry pharmacists. “Follow the liver, and you’ll be fine” he noted. “That combination can be successful. Laboratory monitoring is not onerous: Discontinue after a few months if you’ve not seen any movement.” The drug can also be used with biologics, he said.

Apremilast (Otezla). This drug will bring about a third of patients to a Psoriasis Area and Severity Index (PASI) 75. “That’s not the most impressive efficacy. Rarely do we clear patients with this drug, and it has tolerability issues in some patients,” Dr. Strober said. Side effects can include diarrhea, nausea, headache, and depression. “Warn patients of these possibilities,” he added.

Methotrexate. “It’s very helpful and not a drug to be feared if it’s monitored correctly,” Dr. Strober said. “It’s certainly not a biologic, but it’s not a bad drug from an efficacy standpoint, and it does have efficacy in psoriatic arthritis.”

The drug’s low cost can make it a good alternative to biologics in patients with limited insurance options – such as those on Medicare – or those who don’t have insurance, he said.

“Psoriasis is often controlled at a mean dose of 15 mg/week [orally], with no test dose; start at 15-mg weekly,” he said. “It’s an interesting drug that allows you to dose weekly and still get efficacy,” especially when dosed subcutaneously.

Beware the many contraindications such as pregnancy, possible pregnancy, and high alcohol intake, he added. Dr. Strober doesn’t recommend liver biopsies to monitor hepatic effects. “It’s a poor test with risk and sampling error,” he said.

Cyclosporine. This drug is best “in severe patients in need of a quick response,” said Dr. Strober, who added that biologics are often a better option even in patients who are sensitive to price since samples and free-drug programs are available. “It’s in and out of the body quickly, and most people skip doses and get recurrence of their disease quickly,” he said.

Blood tests are a hassle for patients, he said, and “people often don’t feel great on the drug,” said Dr. Strober, who added, however, that he still does occasionally use it.

Dr. Strober reported multiple disclosures including consultant/advisory board (AbbVie, Amgen, Lilly, Pfizer, among others) and investigator relationships. SDEF and this news organization are owned by the same parent company.

LAS VEGAS – While biologics have dramatically changed the picture, drugs like methotrexate, acitretin, cyclosporine, and apremilast still have roles to play in the treatment of psoriasis, a dermatologist told colleagues.

However, caution is necessary, especially when the drugs are used in combination with biologics, Bruce E. Strober, MD, PhD, of Yale University, New Haven, Conn., and Central Connecticut Dermatology, Cromwell, Conn., said at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.

Dr. Strober offered these tips about the proper use of these four drugs in psoriasis patients:

Acitretin (Soriatane). “This was used as monotherapy initially, but at this point in history, fewer and fewer patients are getting it as monotherapy,” he said. A dose of 25 mg/day appears to provide the best mix of efficacy and side-effect control, “although it’s not a high-efficacy drug, especially at 25 mg a day. It’s a slow-acting drug, and you may need 4 if not 6 months to see the maximum effect before you give up on it.”

What about using acitretin in combination with other therapies? Studies examining its use with phototherapy haven’t been promising, Dr. Strober said. The drug can be used with methotrexate, he said, even though the combination will worry pharmacists. “Follow the liver, and you’ll be fine” he noted. “That combination can be successful. Laboratory monitoring is not onerous: Discontinue after a few months if you’ve not seen any movement.” The drug can also be used with biologics, he said.

Apremilast (Otezla). This drug will bring about a third of patients to a Psoriasis Area and Severity Index (PASI) 75. “That’s not the most impressive efficacy. Rarely do we clear patients with this drug, and it has tolerability issues in some patients,” Dr. Strober said. Side effects can include diarrhea, nausea, headache, and depression. “Warn patients of these possibilities,” he added.

Methotrexate. “It’s very helpful and not a drug to be feared if it’s monitored correctly,” Dr. Strober said. “It’s certainly not a biologic, but it’s not a bad drug from an efficacy standpoint, and it does have efficacy in psoriatic arthritis.”

The drug’s low cost can make it a good alternative to biologics in patients with limited insurance options – such as those on Medicare – or those who don’t have insurance, he said.

“Psoriasis is often controlled at a mean dose of 15 mg/week [orally], with no test dose; start at 15-mg weekly,” he said. “It’s an interesting drug that allows you to dose weekly and still get efficacy,” especially when dosed subcutaneously.

Beware the many contraindications such as pregnancy, possible pregnancy, and high alcohol intake, he added. Dr. Strober doesn’t recommend liver biopsies to monitor hepatic effects. “It’s a poor test with risk and sampling error,” he said.

Cyclosporine. This drug is best “in severe patients in need of a quick response,” said Dr. Strober, who added that biologics are often a better option even in patients who are sensitive to price since samples and free-drug programs are available. “It’s in and out of the body quickly, and most people skip doses and get recurrence of their disease quickly,” he said.

Blood tests are a hassle for patients, he said, and “people often don’t feel great on the drug,” said Dr. Strober, who added, however, that he still does occasionally use it.

Dr. Strober reported multiple disclosures including consultant/advisory board (AbbVie, Amgen, Lilly, Pfizer, among others) and investigator relationships. SDEF and this news organization are owned by the same parent company.

LAS VEGAS – Eczema is eczema is eczema, right? Maybe not. “Atopic dermatitis might not be one disease,” a dermatologist told colleagues, and treatments may need to be adjusted to reflect the age and ethnicity of patients.

More research is needed, Kenneth B. Gordon, MD, chair and professor of dermatology at the Medical College of Wisconsin, Milwaukee, said during a presentation at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar. “We’re probably just on the tip of the iceberg of understanding the physiology of atopic dermatitis. Hopefully, it will lead to the therapeutic advances we’ve seen in psoriasis.”

As Dr. Gordon explained, there’s a wide gap between our understanding of psoriasis and atopic dermatitis (AD). Currently, there’s only one biologic treatment for AD, he said, “and our medicines aren’t well understood.”

As for the disease itself, he said, “you might hear a renowned [expert] say, ‘This is how it works,’ and another say, ‘This is absolutely not how it works.’ ” One camp focused on the skin barrier, he said, while another camp highlighted inflammation in AD.

“Both the barrier and inflammation are important,” he said. “There are multiple cell types and cytokines that are important, but we don’t know yet the relative importance of them all. You have this cytokine soup, and we’re still trying to figure out the driving forces.”

What is clear, Dr. Gordon said, is that AD acts differently in certain patient populations. It’s not the same in pediatric versus adult patients, he said, and it’s not the same in white versus black versus Asian patients. Research, for example, suggests that Th2, Th22, and Th17 pathways appear to be important in pediatric AD, but not Th1, he said. In contrast, the Th1 pathway plays a role in white adults – but not in black adults

Different cytokines appear to play different roles in these populations, he said. “One of the key things moving forward is going to be figuring out which patients you apply these medications to,” he noted.

Dr. Gordon has multiple disclosures including honoraria or research support from Abbvie, Lilly, Novartis, Pfizer, UCB, and others. SDEF and this news organization are owned by the same parent company.

LAS VEGAS – Eczema is eczema is eczema, right? Maybe not. “Atopic dermatitis might not be one disease,” a dermatologist told colleagues, and treatments may need to be adjusted to reflect the age and ethnicity of patients.

More research is needed, Kenneth B. Gordon, MD, chair and professor of dermatology at the Medical College of Wisconsin, Milwaukee, said during a presentation at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar. “We’re probably just on the tip of the iceberg of understanding the physiology of atopic dermatitis. Hopefully, it will lead to the therapeutic advances we’ve seen in psoriasis.”

As Dr. Gordon explained, there’s a wide gap between our understanding of psoriasis and atopic dermatitis (AD). Currently, there’s only one biologic treatment for AD, he said, “and our medicines aren’t well understood.”

As for the disease itself, he said, “you might hear a renowned [expert] say, ‘This is how it works,’ and another say, ‘This is absolutely not how it works.’ ” One camp focused on the skin barrier, he said, while another camp highlighted inflammation in AD.

“Both the barrier and inflammation are important,” he said. “There are multiple cell types and cytokines that are important, but we don’t know yet the relative importance of them all. You have this cytokine soup, and we’re still trying to figure out the driving forces.”

What is clear, Dr. Gordon said, is that AD acts differently in certain patient populations. It’s not the same in pediatric versus adult patients, he said, and it’s not the same in white versus black versus Asian patients. Research, for example, suggests that Th2, Th22, and Th17 pathways appear to be important in pediatric AD, but not Th1, he said. In contrast, the Th1 pathway plays a role in white adults – but not in black adults

Different cytokines appear to play different roles in these populations, he said. “One of the key things moving forward is going to be figuring out which patients you apply these medications to,” he noted.

Dr. Gordon has multiple disclosures including honoraria or research support from Abbvie, Lilly, Novartis, Pfizer, UCB, and others. SDEF and this news organization are owned by the same parent company.

LAS VEGAS – Eczema is eczema is eczema, right? Maybe not. “Atopic dermatitis might not be one disease,” a dermatologist told colleagues, and treatments may need to be adjusted to reflect the age and ethnicity of patients.

More research is needed, Kenneth B. Gordon, MD, chair and professor of dermatology at the Medical College of Wisconsin, Milwaukee, said during a presentation at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar. “We’re probably just on the tip of the iceberg of understanding the physiology of atopic dermatitis. Hopefully, it will lead to the therapeutic advances we’ve seen in psoriasis.”

As Dr. Gordon explained, there’s a wide gap between our understanding of psoriasis and atopic dermatitis (AD). Currently, there’s only one biologic treatment for AD, he said, “and our medicines aren’t well understood.”

As for the disease itself, he said, “you might hear a renowned [expert] say, ‘This is how it works,’ and another say, ‘This is absolutely not how it works.’ ” One camp focused on the skin barrier, he said, while another camp highlighted inflammation in AD.

“Both the barrier and inflammation are important,” he said. “There are multiple cell types and cytokines that are important, but we don’t know yet the relative importance of them all. You have this cytokine soup, and we’re still trying to figure out the driving forces.”

What is clear, Dr. Gordon said, is that AD acts differently in certain patient populations. It’s not the same in pediatric versus adult patients, he said, and it’s not the same in white versus black versus Asian patients. Research, for example, suggests that Th2, Th22, and Th17 pathways appear to be important in pediatric AD, but not Th1, he said. In contrast, the Th1 pathway plays a role in white adults – but not in black adults

Different cytokines appear to play different roles in these populations, he said. “One of the key things moving forward is going to be figuring out which patients you apply these medications to,” he noted.

Dr. Gordon has multiple disclosures including honoraria or research support from Abbvie, Lilly, Novartis, Pfizer, UCB, and others. SDEF and this news organization are owned by the same parent company.

LAS VEGAS – Biologics are revolutionizing the treatment of atopic dermatitis (AD), but a dermatologist urged colleagues to keep in mind the value of traditional topical and systemic treatments.

Joseph F. Fowler Jr., MD, of the University of Louisville, Ky., offered these tips about AD treatment in a presentation at the Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar:

• Keep the epidermal skin barrier in mind.

The epidermal skin barrier is abnormal in patients with AD, Dr. Fowler said, because of several possible factors: altered levels of natural moisturizing factor (which can be caused by a genetic mutation), imbalances between ceramides and lipids, and reduced aquaporin levels.

Enhancing the skin barrier is crucial in treating AD, he said, and products with these ingredients may help: ceramides, glycerin/glycerol (glucoside), colloidal oatmeal, and components of natural moisturizing factor.

• Expensive products are probably better.

“These products are available over the counter and via prescription,” he said. “Do they make the skin barrier stronger? The answer is they probably they do. But most do tend to be expensive, especially Rx products.”

Not all patients, of course, can afford the most expensive options. “You and your patients have to decide whether it’s better to get something like plain old Vaseline or a very inexpensive cream at Walmart that may be more accessible,” he said. “I tell patients that if the cost is not a big issue, these other products are probably better, and they will make your skin heal better and feel better. But if cost is a problem, use what you can afford.”

• Don’t forget about hypochlorous acid.

While it’s chemically similar to bleach, this product “doesn’t bleach your clothes or smell bleachy,” Dr. Fowler said. “It does have antibiotic and antipruritic effects.”

• For predictability, try methotrexate.

Methotrexate, an old workhorse in dermatology, remains an option, especially for patients who need alternatives to biologics, Dr. Fowler said. “I’ve used it much more in the last 10 years for eczema than for psoriasis and anything else. We’re used to using it, and I find it predictably effective at a dosage that’s similar to that for psoriasis.”

• Mycophenolate mofetil (CellCept) may be helpful.

Dr. Fowler’s research has shown that mycophenolate mofetil is useful in about 50% of chronic AD cases. “The problem with the drug is that you couldn’t tell which ones would get better and which ones wouldn’t.” Still, it can be an alternative to methotrexate and cyclosporine, he said.

• Cyclosporine is a short-term treatment.

“It’s like steroids on steroids,” Dr. Fowler said. “I’ve had to use it sometimes even in the age of biologics, which may not work as fast as we’d like in someone who’s really miserable.” The drug is linked to liver and kidney risks, he cautioned, and “you don’t want to be on it very long.”

• Ultraviolet light therapy can help.

This strategy works well “if they come in and get to the office and do it,” Dr. Fowler said. “We should remember it as an option.”

A patient who’s over 80 years old with bad AD has been getting narrow-band UVB treatments for at least 5 years, he said. “I just look at him every 3-4 months. Every time he says, ‘Can I keep coming and get my light treatments?’ and I say sure. At 80-plus, I’m not too worried about cutaneous malignancy or any other side effects.”

Dr. Fowler reported relationships with the speaker’s bureau of SmartPractice and ties with Asana, Johnson & Johnson, Lilly, Novartis and Pfizer. SDEF and this news organization are owned by the same parent company.

LAS VEGAS – Biologics are revolutionizing the treatment of atopic dermatitis (AD), but a dermatologist urged colleagues to keep in mind the value of traditional topical and systemic treatments.

Joseph F. Fowler Jr., MD, of the University of Louisville, Ky., offered these tips about AD treatment in a presentation at the Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar:

• Keep the epidermal skin barrier in mind.

The epidermal skin barrier is abnormal in patients with AD, Dr. Fowler said, because of several possible factors: altered levels of natural moisturizing factor (which can be caused by a genetic mutation), imbalances between ceramides and lipids, and reduced aquaporin levels.

Enhancing the skin barrier is crucial in treating AD, he said, and products with these ingredients may help: ceramides, glycerin/glycerol (glucoside), colloidal oatmeal, and components of natural moisturizing factor.

• Expensive products are probably better.

“These products are available over the counter and via prescription,” he said. “Do they make the skin barrier stronger? The answer is they probably they do. But most do tend to be expensive, especially Rx products.”

Not all patients, of course, can afford the most expensive options. “You and your patients have to decide whether it’s better to get something like plain old Vaseline or a very inexpensive cream at Walmart that may be more accessible,” he said. “I tell patients that if the cost is not a big issue, these other products are probably better, and they will make your skin heal better and feel better. But if cost is a problem, use what you can afford.”

• Don’t forget about hypochlorous acid.

While it’s chemically similar to bleach, this product “doesn’t bleach your clothes or smell bleachy,” Dr. Fowler said. “It does have antibiotic and antipruritic effects.”

• For predictability, try methotrexate.

Methotrexate, an old workhorse in dermatology, remains an option, especially for patients who need alternatives to biologics, Dr. Fowler said. “I’ve used it much more in the last 10 years for eczema than for psoriasis and anything else. We’re used to using it, and I find it predictably effective at a dosage that’s similar to that for psoriasis.”

• Mycophenolate mofetil (CellCept) may be helpful.

Dr. Fowler’s research has shown that mycophenolate mofetil is useful in about 50% of chronic AD cases. “The problem with the drug is that you couldn’t tell which ones would get better and which ones wouldn’t.” Still, it can be an alternative to methotrexate and cyclosporine, he said.

• Cyclosporine is a short-term treatment.

“It’s like steroids on steroids,” Dr. Fowler said. “I’ve had to use it sometimes even in the age of biologics, which may not work as fast as we’d like in someone who’s really miserable.” The drug is linked to liver and kidney risks, he cautioned, and “you don’t want to be on it very long.”

• Ultraviolet light therapy can help.

This strategy works well “if they come in and get to the office and do it,” Dr. Fowler said. “We should remember it as an option.”

A patient who’s over 80 years old with bad AD has been getting narrow-band UVB treatments for at least 5 years, he said. “I just look at him every 3-4 months. Every time he says, ‘Can I keep coming and get my light treatments?’ and I say sure. At 80-plus, I’m not too worried about cutaneous malignancy or any other side effects.”

Dr. Fowler reported relationships with the speaker’s bureau of SmartPractice and ties with Asana, Johnson & Johnson, Lilly, Novartis and Pfizer. SDEF and this news organization are owned by the same parent company.

LAS VEGAS – Biologics are revolutionizing the treatment of atopic dermatitis (AD), but a dermatologist urged colleagues to keep in mind the value of traditional topical and systemic treatments.

Joseph F. Fowler Jr., MD, of the University of Louisville, Ky., offered these tips about AD treatment in a presentation at the Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar:

• Keep the epidermal skin barrier in mind.

The epidermal skin barrier is abnormal in patients with AD, Dr. Fowler said, because of several possible factors: altered levels of natural moisturizing factor (which can be caused by a genetic mutation), imbalances between ceramides and lipids, and reduced aquaporin levels.

Enhancing the skin barrier is crucial in treating AD, he said, and products with these ingredients may help: ceramides, glycerin/glycerol (glucoside), colloidal oatmeal, and components of natural moisturizing factor.

• Expensive products are probably better.

“These products are available over the counter and via prescription,” he said. “Do they make the skin barrier stronger? The answer is they probably they do. But most do tend to be expensive, especially Rx products.”

Not all patients, of course, can afford the most expensive options. “You and your patients have to decide whether it’s better to get something like plain old Vaseline or a very inexpensive cream at Walmart that may be more accessible,” he said. “I tell patients that if the cost is not a big issue, these other products are probably better, and they will make your skin heal better and feel better. But if cost is a problem, use what you can afford.”

• Don’t forget about hypochlorous acid.

While it’s chemically similar to bleach, this product “doesn’t bleach your clothes or smell bleachy,” Dr. Fowler said. “It does have antibiotic and antipruritic effects.”

• For predictability, try methotrexate.

Methotrexate, an old workhorse in dermatology, remains an option, especially for patients who need alternatives to biologics, Dr. Fowler said. “I’ve used it much more in the last 10 years for eczema than for psoriasis and anything else. We’re used to using it, and I find it predictably effective at a dosage that’s similar to that for psoriasis.”

• Mycophenolate mofetil (CellCept) may be helpful.

Dr. Fowler’s research has shown that mycophenolate mofetil is useful in about 50% of chronic AD cases. “The problem with the drug is that you couldn’t tell which ones would get better and which ones wouldn’t.” Still, it can be an alternative to methotrexate and cyclosporine, he said.

• Cyclosporine is a short-term treatment.

“It’s like steroids on steroids,” Dr. Fowler said. “I’ve had to use it sometimes even in the age of biologics, which may not work as fast as we’d like in someone who’s really miserable.” The drug is linked to liver and kidney risks, he cautioned, and “you don’t want to be on it very long.”

• Ultraviolet light therapy can help.

This strategy works well “if they come in and get to the office and do it,” Dr. Fowler said. “We should remember it as an option.”

A patient who’s over 80 years old with bad AD has been getting narrow-band UVB treatments for at least 5 years, he said. “I just look at him every 3-4 months. Every time he says, ‘Can I keep coming and get my light treatments?’ and I say sure. At 80-plus, I’m not too worried about cutaneous malignancy or any other side effects.”

Dr. Fowler reported relationships with the speaker’s bureau of SmartPractice and ties with Asana, Johnson & Johnson, Lilly, Novartis and Pfizer. SDEF and this news organization are owned by the same parent company.