ORLANDO – Most adolescents expressed interest in and support for access to over-the-counter oral contraceptives, a survey found.

Data from a separate cross-sectional study showed that adolescents are skilled at self-screening for contraindications to combined OCs, demonstrating preliminary support for the safety of over-the-counter access.

Fuse/ThinkStockPhotos.com

Of 348 girls aged 14-17 years who completed the survey in the first study, 73% reported supporting over-the-counter (OTC) OC access for teens, and 61% reported being likely to use OCs if they were available OTC. Significant associations were found between support for OTC access and having used birth control and having had sex. An association was also found between the likelihood of OTC use and having used birth control, having had sex, and being white, Ruth Manski of the Jane Fonda Center for Adolescent Reproductive Health, Atlanta, reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Those who had never been tested for sexually transmitted infections were more likely to support OTC access (91% vs. 76%).

Support for, and the likelihood of, using OTC OCs were not influenced by age, geographic region, rural/urban location, health insurance status, or pregnancy history. Race played a factor in that white participants were more likely than nonwhite participants to be interested in OTC access. The study also showed that participants understood an average of 7.1 of 8 key product-labeling concepts, and that most would be willing to pay up to $20 per month for OTC OCs, with the largest percentage (42%) willing to pay between $11 and $20. About a third said they would pay $21 or more.

Survey respondents were girls recruited via Facebook advertisements in 2014. Nearly a third (32%) were aged 17 years, 31% were aged 16 years, 24% were aged 15, and 13% were aged 14. Most (79%) were white, Ms. Manski said, adding that the respondents represented 44 states, 53% lived in a suburban area, 41% had private health insurance, and 33% had public health insurance.

About 90% reported having used contraception, and 44% reported having had sex. Of those who had sex, 60% reported having had unprotected sex, 58% used OCs, and 12% reported having been pregnant.

“So results from this study show that participants are supportive of over-the-counter access and that they’re interested in obtaining oral contraceptives over the counter. The findings also suggest that teenagers understand how to use oral contraceptives based on independent label review, which offers some evidence in response to concerns raised in other studies about teenagers’ ability to understand how to use over-the-counter products,” Ms. Manski said.

The findings suggest that while cost is a concern for teens and could impact their contraceptive choices, making OCs available OTC without age restrictions may help increase adolescents’ contraceptive access and use, she said, noting that this is important given the unique barriers that adolescents face with respect to accessing contraception.

The high levels of interest, and the perception of benefit, highlight the potential of this strategy to increase contraceptive access and reduce unintended pregnancy, she added.

Although some respondents expressed concerns about safety and the potential impact on sexual behavior, the evidence with respect to currently available OTC emergency contraception demonstrates that easier access does not increase sexual risk taking, and that teens can safely use OTC emergency contraception, she said.

However, the behavioral effects of OTC OC availability are not known and should be evaluated in actual use studies, Ms. Manski added.

Concerns about the safety of OTC OC access were specifically addressed in the second study, which sought to determine whether adolescents are capable of self-screening for contraindications to OC use.

Prior studies have shown that adults are able to self-screen adequately, but little is known about adolescents’ ability to do so, Dr. Rebekah L. Williams of Riley Hospital for Children, Indianapolis, said at the meeting.

Findings in the first 61 teens aged 14-21 years enrolled in the study showed that the teens were actually more likely than their providers to report potential contraindications.

The teens completed screening questionnaires prior to their office visit, and the provider completed the medical history questionnaire after the visit.

Perfectly concordant responses between providers and patients were seen for six potential contraindications: diabetes (which was present in two cases) and heavy smoking, breastfeeding, wheelchair use, surgery within 4 weeks, and current HIV medication use (which were not present in any cases). Discordant responses were seen for the remaining potential contraindications, including breast cancer, liver disease, medication interactions, smoking, migraine, hypertension, gallbladder disease, thromboembolism/heart disease, having a first-degree relative with thromboembolism, weight over 200 pounds, and having been told/having the perception that OCs should not be used.

Potential contraindications reported only by the participant were breast cancer, liver disease, medication interaction, any smoking, hypertension, personal history of thromboembolism or heart disease, and having a first-degree relative with thromboembolism.

Participants were adolescents with a mean age of 17 years from a primary care medicine clinic in a Midwest urban setting. Of the 61 subjects, 62% were black, 62% reported having ever used contraceptives, 44% were currently using contraceptives, and 62% said they would be interested in OTC OC access. Among the 38 who reported having penile/vaginal sex, 87% had ever used OCs, and 60% were currently using them.

“In summary, adolescent women are interested in over-the-counter access to combined oral contraceptive pills, they’re skilled at self-screening, and they’re mostly more likely than providers to report potential contraindications. So these data really provide some preliminary support for the over-the-counter provision of oral contraceptive pills to adolescents,” Dr. Williams said, noting that additional research is needed to assess adolescents’ ability to use combined oral contraceptive pills correctly.

In addition, larger studies in groups with a higher prevalence of contraindications are needed, as are studies with recruitment from nonclinical settings and more diverse populations, she said.

Ms. Manski and Dr. Williams both reported having no relevant financial disclosures.

sworcester@frontlinemedcom.com

ORLANDO – Most adolescents expressed interest in and support for access to over-the-counter oral contraceptives, a survey found.

Data from a separate cross-sectional study showed that adolescents are skilled at self-screening for contraindications to combined OCs, demonstrating preliminary support for the safety of over-the-counter access.

Fuse/ThinkStockPhotos.com

Of 348 girls aged 14-17 years who completed the survey in the first study, 73% reported supporting over-the-counter (OTC) OC access for teens, and 61% reported being likely to use OCs if they were available OTC. Significant associations were found between support for OTC access and having used birth control and having had sex. An association was also found between the likelihood of OTC use and having used birth control, having had sex, and being white, Ruth Manski of the Jane Fonda Center for Adolescent Reproductive Health, Atlanta, reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Those who had never been tested for sexually transmitted infections were more likely to support OTC access (91% vs. 76%).

Support for, and the likelihood of, using OTC OCs were not influenced by age, geographic region, rural/urban location, health insurance status, or pregnancy history. Race played a factor in that white participants were more likely than nonwhite participants to be interested in OTC access. The study also showed that participants understood an average of 7.1 of 8 key product-labeling concepts, and that most would be willing to pay up to $20 per month for OTC OCs, with the largest percentage (42%) willing to pay between $11 and $20. About a third said they would pay $21 or more.

Survey respondents were girls recruited via Facebook advertisements in 2014. Nearly a third (32%) were aged 17 years, 31% were aged 16 years, 24% were aged 15, and 13% were aged 14. Most (79%) were white, Ms. Manski said, adding that the respondents represented 44 states, 53% lived in a suburban area, 41% had private health insurance, and 33% had public health insurance.

About 90% reported having used contraception, and 44% reported having had sex. Of those who had sex, 60% reported having had unprotected sex, 58% used OCs, and 12% reported having been pregnant.

“So results from this study show that participants are supportive of over-the-counter access and that they’re interested in obtaining oral contraceptives over the counter. The findings also suggest that teenagers understand how to use oral contraceptives based on independent label review, which offers some evidence in response to concerns raised in other studies about teenagers’ ability to understand how to use over-the-counter products,” Ms. Manski said.

The findings suggest that while cost is a concern for teens and could impact their contraceptive choices, making OCs available OTC without age restrictions may help increase adolescents’ contraceptive access and use, she said, noting that this is important given the unique barriers that adolescents face with respect to accessing contraception.

The high levels of interest, and the perception of benefit, highlight the potential of this strategy to increase contraceptive access and reduce unintended pregnancy, she added.

Although some respondents expressed concerns about safety and the potential impact on sexual behavior, the evidence with respect to currently available OTC emergency contraception demonstrates that easier access does not increase sexual risk taking, and that teens can safely use OTC emergency contraception, she said.

However, the behavioral effects of OTC OC availability are not known and should be evaluated in actual use studies, Ms. Manski added.

Concerns about the safety of OTC OC access were specifically addressed in the second study, which sought to determine whether adolescents are capable of self-screening for contraindications to OC use.

Prior studies have shown that adults are able to self-screen adequately, but little is known about adolescents’ ability to do so, Dr. Rebekah L. Williams of Riley Hospital for Children, Indianapolis, said at the meeting.

Findings in the first 61 teens aged 14-21 years enrolled in the study showed that the teens were actually more likely than their providers to report potential contraindications.

The teens completed screening questionnaires prior to their office visit, and the provider completed the medical history questionnaire after the visit.

Perfectly concordant responses between providers and patients were seen for six potential contraindications: diabetes (which was present in two cases) and heavy smoking, breastfeeding, wheelchair use, surgery within 4 weeks, and current HIV medication use (which were not present in any cases). Discordant responses were seen for the remaining potential contraindications, including breast cancer, liver disease, medication interactions, smoking, migraine, hypertension, gallbladder disease, thromboembolism/heart disease, having a first-degree relative with thromboembolism, weight over 200 pounds, and having been told/having the perception that OCs should not be used.

Potential contraindications reported only by the participant were breast cancer, liver disease, medication interaction, any smoking, hypertension, personal history of thromboembolism or heart disease, and having a first-degree relative with thromboembolism.

Participants were adolescents with a mean age of 17 years from a primary care medicine clinic in a Midwest urban setting. Of the 61 subjects, 62% were black, 62% reported having ever used contraceptives, 44% were currently using contraceptives, and 62% said they would be interested in OTC OC access. Among the 38 who reported having penile/vaginal sex, 87% had ever used OCs, and 60% were currently using them.

“In summary, adolescent women are interested in over-the-counter access to combined oral contraceptive pills, they’re skilled at self-screening, and they’re mostly more likely than providers to report potential contraindications. So these data really provide some preliminary support for the over-the-counter provision of oral contraceptive pills to adolescents,” Dr. Williams said, noting that additional research is needed to assess adolescents’ ability to use combined oral contraceptive pills correctly.

In addition, larger studies in groups with a higher prevalence of contraindications are needed, as are studies with recruitment from nonclinical settings and more diverse populations, she said.

Ms. Manski and Dr. Williams both reported having no relevant financial disclosures.

sworcester@frontlinemedcom.com

ORLANDO – Most adolescents expressed interest in and support for access to over-the-counter oral contraceptives, a survey found.

Data from a separate cross-sectional study showed that adolescents are skilled at self-screening for contraindications to combined OCs, demonstrating preliminary support for the safety of over-the-counter access.

Fuse/ThinkStockPhotos.com

Of 348 girls aged 14-17 years who completed the survey in the first study, 73% reported supporting over-the-counter (OTC) OC access for teens, and 61% reported being likely to use OCs if they were available OTC. Significant associations were found between support for OTC access and having used birth control and having had sex. An association was also found between the likelihood of OTC use and having used birth control, having had sex, and being white, Ruth Manski of the Jane Fonda Center for Adolescent Reproductive Health, Atlanta, reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Those who had never been tested for sexually transmitted infections were more likely to support OTC access (91% vs. 76%).

Support for, and the likelihood of, using OTC OCs were not influenced by age, geographic region, rural/urban location, health insurance status, or pregnancy history. Race played a factor in that white participants were more likely than nonwhite participants to be interested in OTC access. The study also showed that participants understood an average of 7.1 of 8 key product-labeling concepts, and that most would be willing to pay up to $20 per month for OTC OCs, with the largest percentage (42%) willing to pay between $11 and $20. About a third said they would pay $21 or more.

Survey respondents were girls recruited via Facebook advertisements in 2014. Nearly a third (32%) were aged 17 years, 31% were aged 16 years, 24% were aged 15, and 13% were aged 14. Most (79%) were white, Ms. Manski said, adding that the respondents represented 44 states, 53% lived in a suburban area, 41% had private health insurance, and 33% had public health insurance.

About 90% reported having used contraception, and 44% reported having had sex. Of those who had sex, 60% reported having had unprotected sex, 58% used OCs, and 12% reported having been pregnant.

“So results from this study show that participants are supportive of over-the-counter access and that they’re interested in obtaining oral contraceptives over the counter. The findings also suggest that teenagers understand how to use oral contraceptives based on independent label review, which offers some evidence in response to concerns raised in other studies about teenagers’ ability to understand how to use over-the-counter products,” Ms. Manski said.

The findings suggest that while cost is a concern for teens and could impact their contraceptive choices, making OCs available OTC without age restrictions may help increase adolescents’ contraceptive access and use, she said, noting that this is important given the unique barriers that adolescents face with respect to accessing contraception.

The high levels of interest, and the perception of benefit, highlight the potential of this strategy to increase contraceptive access and reduce unintended pregnancy, she added.

Although some respondents expressed concerns about safety and the potential impact on sexual behavior, the evidence with respect to currently available OTC emergency contraception demonstrates that easier access does not increase sexual risk taking, and that teens can safely use OTC emergency contraception, she said.

However, the behavioral effects of OTC OC availability are not known and should be evaluated in actual use studies, Ms. Manski added.

Concerns about the safety of OTC OC access were specifically addressed in the second study, which sought to determine whether adolescents are capable of self-screening for contraindications to OC use.

Prior studies have shown that adults are able to self-screen adequately, but little is known about adolescents’ ability to do so, Dr. Rebekah L. Williams of Riley Hospital for Children, Indianapolis, said at the meeting.

Findings in the first 61 teens aged 14-21 years enrolled in the study showed that the teens were actually more likely than their providers to report potential contraindications.

The teens completed screening questionnaires prior to their office visit, and the provider completed the medical history questionnaire after the visit.

Perfectly concordant responses between providers and patients were seen for six potential contraindications: diabetes (which was present in two cases) and heavy smoking, breastfeeding, wheelchair use, surgery within 4 weeks, and current HIV medication use (which were not present in any cases). Discordant responses were seen for the remaining potential contraindications, including breast cancer, liver disease, medication interactions, smoking, migraine, hypertension, gallbladder disease, thromboembolism/heart disease, having a first-degree relative with thromboembolism, weight over 200 pounds, and having been told/having the perception that OCs should not be used.

Potential contraindications reported only by the participant were breast cancer, liver disease, medication interaction, any smoking, hypertension, personal history of thromboembolism or heart disease, and having a first-degree relative with thromboembolism.

Participants were adolescents with a mean age of 17 years from a primary care medicine clinic in a Midwest urban setting. Of the 61 subjects, 62% were black, 62% reported having ever used contraceptives, 44% were currently using contraceptives, and 62% said they would be interested in OTC OC access. Among the 38 who reported having penile/vaginal sex, 87% had ever used OCs, and 60% were currently using them.

“In summary, adolescent women are interested in over-the-counter access to combined oral contraceptive pills, they’re skilled at self-screening, and they’re mostly more likely than providers to report potential contraindications. So these data really provide some preliminary support for the over-the-counter provision of oral contraceptive pills to adolescents,” Dr. Williams said, noting that additional research is needed to assess adolescents’ ability to use combined oral contraceptive pills correctly.

In addition, larger studies in groups with a higher prevalence of contraindications are needed, as are studies with recruitment from nonclinical settings and more diverse populations, she said.

Ms. Manski and Dr. Williams both reported having no relevant financial disclosures.

sworcester@frontlinemedcom.com

Photomicrograph of liver

tissue with active HCV

Photo: Sutter Health

VIENNA, AUSTRIA—A 5-year retrospective study has shown that the cancer rate in patients with hepatitis C virus (HCV) is about double that for people without HCV, even when liver cancer is excluded.

And when liver cancer is included, the rate increases to 2.5 times higher in people with HCV.

Researchers presented these findings at the International Liver Congress 2015 as abstract 0058.

The team reviewed patient records from 2008 to 2012 at Kaiser Permanente Southern California, recording all cancer diagnoses in patients 18 years or older with or without HCV.

During the 5-year time period, there were 145,210 patient years in the HCV cohort and 13,948,826 patient years in the non-HCV cohort.

The mean age at cancer diagnosis was 61.8 in the HCV cohort and 63.5 in the non-HCV cohort.

Researchers recorded 2213 cancer diagnoses in the HCV cohort (1524/100,000). This number decreased to 1654 when they excluded liver cancer (1139/100,000).

In the non-HCV cohort, they recorded 84,419 cancer diagnoses (605/100,000), which decreased to 83,795 when liver cancer was excluded (601/100,000).

Cancer types known to be associated with HCV include non-Hodgkin lymphoma (NHL), renal and prostate cancers, and liver cancer.

NHL occurred 3.63 times more frequently in patients with HCV than in those without HCV, and myeloma occurred 2.93 times more frequently.

Renal cancer occurred 3.27 times and prostate cancer 1.98 times more frequently in patients with HCV than in those without.

“The results suggest that cancer rates are increased in the cohort of hepatitis C patients versus the non-hepatitis C patients, both including and excluding liver cancers,” said senior study author Lisa Nyberg, MD, MPH, of Kaiser Permanente.

“These findings certainly point to the suggestion that hepatitis C may be associated with an increased risk of cancer.”

However, she added that the findings “must be interpreted with caution, as the study also showed that confounding factors such as alcohol abuse, tobacco, obesity, and diabetes modified the results.”

Photomicrograph of liver

tissue with active HCV

Photo: Sutter Health

VIENNA, AUSTRIA—A 5-year retrospective study has shown that the cancer rate in patients with hepatitis C virus (HCV) is about double that for people without HCV, even when liver cancer is excluded.

And when liver cancer is included, the rate increases to 2.5 times higher in people with HCV.

Researchers presented these findings at the International Liver Congress 2015 as abstract 0058.

The team reviewed patient records from 2008 to 2012 at Kaiser Permanente Southern California, recording all cancer diagnoses in patients 18 years or older with or without HCV.

During the 5-year time period, there were 145,210 patient years in the HCV cohort and 13,948,826 patient years in the non-HCV cohort.

The mean age at cancer diagnosis was 61.8 in the HCV cohort and 63.5 in the non-HCV cohort.

Researchers recorded 2213 cancer diagnoses in the HCV cohort (1524/100,000). This number decreased to 1654 when they excluded liver cancer (1139/100,000).

In the non-HCV cohort, they recorded 84,419 cancer diagnoses (605/100,000), which decreased to 83,795 when liver cancer was excluded (601/100,000).

Cancer types known to be associated with HCV include non-Hodgkin lymphoma (NHL), renal and prostate cancers, and liver cancer.

NHL occurred 3.63 times more frequently in patients with HCV than in those without HCV, and myeloma occurred 2.93 times more frequently.

Renal cancer occurred 3.27 times and prostate cancer 1.98 times more frequently in patients with HCV than in those without.

“The results suggest that cancer rates are increased in the cohort of hepatitis C patients versus the non-hepatitis C patients, both including and excluding liver cancers,” said senior study author Lisa Nyberg, MD, MPH, of Kaiser Permanente.

“These findings certainly point to the suggestion that hepatitis C may be associated with an increased risk of cancer.”

However, she added that the findings “must be interpreted with caution, as the study also showed that confounding factors such as alcohol abuse, tobacco, obesity, and diabetes modified the results.”

Photomicrograph of liver

tissue with active HCV

Photo: Sutter Health

VIENNA, AUSTRIA—A 5-year retrospective study has shown that the cancer rate in patients with hepatitis C virus (HCV) is about double that for people without HCV, even when liver cancer is excluded.

And when liver cancer is included, the rate increases to 2.5 times higher in people with HCV.

Researchers presented these findings at the International Liver Congress 2015 as abstract 0058.

The team reviewed patient records from 2008 to 2012 at Kaiser Permanente Southern California, recording all cancer diagnoses in patients 18 years or older with or without HCV.

During the 5-year time period, there were 145,210 patient years in the HCV cohort and 13,948,826 patient years in the non-HCV cohort.

The mean age at cancer diagnosis was 61.8 in the HCV cohort and 63.5 in the non-HCV cohort.

Researchers recorded 2213 cancer diagnoses in the HCV cohort (1524/100,000). This number decreased to 1654 when they excluded liver cancer (1139/100,000).

In the non-HCV cohort, they recorded 84,419 cancer diagnoses (605/100,000), which decreased to 83,795 when liver cancer was excluded (601/100,000).

Cancer types known to be associated with HCV include non-Hodgkin lymphoma (NHL), renal and prostate cancers, and liver cancer.

NHL occurred 3.63 times more frequently in patients with HCV than in those without HCV, and myeloma occurred 2.93 times more frequently.

Renal cancer occurred 3.27 times and prostate cancer 1.98 times more frequently in patients with HCV than in those without.

“The results suggest that cancer rates are increased in the cohort of hepatitis C patients versus the non-hepatitis C patients, both including and excluding liver cancers,” said senior study author Lisa Nyberg, MD, MPH, of Kaiser Permanente.

“These findings certainly point to the suggestion that hepatitis C may be associated with an increased risk of cancer.”

However, she added that the findings “must be interpreted with caution, as the study also showed that confounding factors such as alcohol abuse, tobacco, obesity, and diabetes modified the results.”

SAN DIEGO– A fuller picture of the benefits of vorapaxar for secondary cardiovascular prevention emerged from three separate secondary analyses of the pivotal Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischemic Events (TRA 2°P TIMI-50) trial presented at the annual meeting of the American College of Cardiology.

These new reports provided evidence that vorapaxar (Zontivity), a first-in-class, once-daily thrombin inhibitor with rapid onset and a half-life in excess of 7 days, reduces acute limb ischemia and the need for peripheral revascularization in patients with peripheral arterial disease (PAD), and also that the antiplatelet agent is particularly beneficial in patients with a history of coronary artery bypass graft surgery.

That being said, the three secondary analyses were post hoc and as such are inherently exploratory and hypothesis-generating rather than definitive, the investigators noted.

The Food and Drug Administration approved vorapaxar in May 2014 for the reduction of thrombotic cardiovascular events in patients with a history of MI or in patients with PAD in the absence of a previous stroke or TIA. Marketing approval was based chiefly on the results of the landmark 26,449-patient, double-blind, prospective, multinational TIMI 50 trial. In an analysis of the 20,170 randomized patients without a prior stroke or TIA, vorapaxar at 2.5 mg once daily, when added to standard therapy with aspirin and/or clopidogrel, reduced the 3-year rate of a composite outcome – comprised of cardiovascular death, MI, or stroke – by 20% compared with placebo, with a number-needed-to-treat of 63 (J. Am. Heart Assoc. 2015 [doi: 10.1161/JAHA.114.001505]).

At ACC 15, Dr. Ethan C. Kosova presented a subanalysis involving the 2,942 TIMI 50 participants who had undergone CABG surgery prior to the study. The rationale for taking a closer look at this group is that rates of venous graft occlusion and recurrent ischemic events remain high after CABG surgery, so the efficacy and safety of vorapaxar in this population are of particular interest.

Underscoring the high-risk nature of this population, at baseline the patients with a history of CABG were significantly older and had higher rates of hypertension, dyslipidemia, diabetes, PAD, heart failure, and chronic kidney disease than participants without prior CABG who had no history of stroke or TIA, observed Dr. Kosova of Brigham and Women’s Hospital, Boston.

The 3-year composite event rate of cardiovascular death, MI, or stroke occurred in 11.9% of the 1,471 patients with prior CABG who were randomized to vorapaxar compared with 15.6% of those on placebo. That translates into a 29% relative risk reduction and a number-needed-to-treat of 27, an even stronger result than in the general study population.

Moreover, the clinically relevant composite outcome consisting of cardiovascular death or MI occurred in 10.9% of those on vorapaxar compared with 14.3% of controls, for a 29% relative risk reduction and a number-needed-to-treat of 29, he continued.

The 3-year all-cause mortality was 5.8% in patients with prior CABG who received vorapaxar compared to 8% in those on placebo.

Vorapaxar, which inhibits protease-activated receptor-1 on platelets and vascular endothelium, increased the rate of GUSTO moderate-to-severe bleeding: 6.8% compared with 3.7% in controls.

“Putting together the efficacy and safety data to derive the net clinical outcome – the combined endpoint of all-cause mortality, MI, cerebrovascular accident, and GUSTO severe bleeding – the result was a 28% improvement with vorapaxar compared with placebo,” Dr. Kosova said.

In a separate presentation focused on the 3,787 patients who gained entry into the TIMI 50 trial on the basis of symptomatic PAD, Dr. Antonio Gutierrez reported that acute limb ischemia occurred in 109 of them during the trial. Fifty-four percent of these events were due to acute surgical graft thrombosis, 27% to in situ thrombosis of a native vessel, and lesser numbers were due to thromboembolissm or stent thrombosis.

The 3-year acute limb ischemia rate in patients with baseline PAD was 3.9% with placebo compared to 2.3% with vorapaxar, for a 42% relative risk reduction, according to Dr. Gutierrez of Brigham and Women’s Hospital.

Dr. Ian Gilchrist, also from Brigham and Women’s Hospital, reported that in TIMI 50 participants with a history of PAD, vorapaxar resulted in a 16% reduction in the need for peripheral revascularization procedures for claudication, with rates of 9.4% for vorapaxar and 11.6% for placebo. There was also a statistically significant 41% reduction in the rate of surgical peripheral revascularization procedures, with rates of 4.5% for vorapaxar and 7.7% for placebo.

The TIMI 50 trial was funded by Merck. Drs. Kosova, Gutierrez, and Gilchrist reported having no financial conflicts of interest.

bjancin@frontlinemedcom.com

SAN DIEGO– A fuller picture of the benefits of vorapaxar for secondary cardiovascular prevention emerged from three separate secondary analyses of the pivotal Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischemic Events (TRA 2°P TIMI-50) trial presented at the annual meeting of the American College of Cardiology.

These new reports provided evidence that vorapaxar (Zontivity), a first-in-class, once-daily thrombin inhibitor with rapid onset and a half-life in excess of 7 days, reduces acute limb ischemia and the need for peripheral revascularization in patients with peripheral arterial disease (PAD), and also that the antiplatelet agent is particularly beneficial in patients with a history of coronary artery bypass graft surgery.

That being said, the three secondary analyses were post hoc and as such are inherently exploratory and hypothesis-generating rather than definitive, the investigators noted.

The Food and Drug Administration approved vorapaxar in May 2014 for the reduction of thrombotic cardiovascular events in patients with a history of MI or in patients with PAD in the absence of a previous stroke or TIA. Marketing approval was based chiefly on the results of the landmark 26,449-patient, double-blind, prospective, multinational TIMI 50 trial. In an analysis of the 20,170 randomized patients without a prior stroke or TIA, vorapaxar at 2.5 mg once daily, when added to standard therapy with aspirin and/or clopidogrel, reduced the 3-year rate of a composite outcome – comprised of cardiovascular death, MI, or stroke – by 20% compared with placebo, with a number-needed-to-treat of 63 (J. Am. Heart Assoc. 2015 [doi: 10.1161/JAHA.114.001505]).

At ACC 15, Dr. Ethan C. Kosova presented a subanalysis involving the 2,942 TIMI 50 participants who had undergone CABG surgery prior to the study. The rationale for taking a closer look at this group is that rates of venous graft occlusion and recurrent ischemic events remain high after CABG surgery, so the efficacy and safety of vorapaxar in this population are of particular interest.

Underscoring the high-risk nature of this population, at baseline the patients with a history of CABG were significantly older and had higher rates of hypertension, dyslipidemia, diabetes, PAD, heart failure, and chronic kidney disease than participants without prior CABG who had no history of stroke or TIA, observed Dr. Kosova of Brigham and Women’s Hospital, Boston.

The 3-year composite event rate of cardiovascular death, MI, or stroke occurred in 11.9% of the 1,471 patients with prior CABG who were randomized to vorapaxar compared with 15.6% of those on placebo. That translates into a 29% relative risk reduction and a number-needed-to-treat of 27, an even stronger result than in the general study population.

Moreover, the clinically relevant composite outcome consisting of cardiovascular death or MI occurred in 10.9% of those on vorapaxar compared with 14.3% of controls, for a 29% relative risk reduction and a number-needed-to-treat of 29, he continued.

The 3-year all-cause mortality was 5.8% in patients with prior CABG who received vorapaxar compared to 8% in those on placebo.

Vorapaxar, which inhibits protease-activated receptor-1 on platelets and vascular endothelium, increased the rate of GUSTO moderate-to-severe bleeding: 6.8% compared with 3.7% in controls.

“Putting together the efficacy and safety data to derive the net clinical outcome – the combined endpoint of all-cause mortality, MI, cerebrovascular accident, and GUSTO severe bleeding – the result was a 28% improvement with vorapaxar compared with placebo,” Dr. Kosova said.

In a separate presentation focused on the 3,787 patients who gained entry into the TIMI 50 trial on the basis of symptomatic PAD, Dr. Antonio Gutierrez reported that acute limb ischemia occurred in 109 of them during the trial. Fifty-four percent of these events were due to acute surgical graft thrombosis, 27% to in situ thrombosis of a native vessel, and lesser numbers were due to thromboembolissm or stent thrombosis.

The 3-year acute limb ischemia rate in patients with baseline PAD was 3.9% with placebo compared to 2.3% with vorapaxar, for a 42% relative risk reduction, according to Dr. Gutierrez of Brigham and Women’s Hospital.

Dr. Ian Gilchrist, also from Brigham and Women’s Hospital, reported that in TIMI 50 participants with a history of PAD, vorapaxar resulted in a 16% reduction in the need for peripheral revascularization procedures for claudication, with rates of 9.4% for vorapaxar and 11.6% for placebo. There was also a statistically significant 41% reduction in the rate of surgical peripheral revascularization procedures, with rates of 4.5% for vorapaxar and 7.7% for placebo.

The TIMI 50 trial was funded by Merck. Drs. Kosova, Gutierrez, and Gilchrist reported having no financial conflicts of interest.

bjancin@frontlinemedcom.com

SAN DIEGO– A fuller picture of the benefits of vorapaxar for secondary cardiovascular prevention emerged from three separate secondary analyses of the pivotal Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischemic Events (TRA 2°P TIMI-50) trial presented at the annual meeting of the American College of Cardiology.

These new reports provided evidence that vorapaxar (Zontivity), a first-in-class, once-daily thrombin inhibitor with rapid onset and a half-life in excess of 7 days, reduces acute limb ischemia and the need for peripheral revascularization in patients with peripheral arterial disease (PAD), and also that the antiplatelet agent is particularly beneficial in patients with a history of coronary artery bypass graft surgery.

That being said, the three secondary analyses were post hoc and as such are inherently exploratory and hypothesis-generating rather than definitive, the investigators noted.

The Food and Drug Administration approved vorapaxar in May 2014 for the reduction of thrombotic cardiovascular events in patients with a history of MI or in patients with PAD in the absence of a previous stroke or TIA. Marketing approval was based chiefly on the results of the landmark 26,449-patient, double-blind, prospective, multinational TIMI 50 trial. In an analysis of the 20,170 randomized patients without a prior stroke or TIA, vorapaxar at 2.5 mg once daily, when added to standard therapy with aspirin and/or clopidogrel, reduced the 3-year rate of a composite outcome – comprised of cardiovascular death, MI, or stroke – by 20% compared with placebo, with a number-needed-to-treat of 63 (J. Am. Heart Assoc. 2015 [doi: 10.1161/JAHA.114.001505]).

At ACC 15, Dr. Ethan C. Kosova presented a subanalysis involving the 2,942 TIMI 50 participants who had undergone CABG surgery prior to the study. The rationale for taking a closer look at this group is that rates of venous graft occlusion and recurrent ischemic events remain high after CABG surgery, so the efficacy and safety of vorapaxar in this population are of particular interest.

Underscoring the high-risk nature of this population, at baseline the patients with a history of CABG were significantly older and had higher rates of hypertension, dyslipidemia, diabetes, PAD, heart failure, and chronic kidney disease than participants without prior CABG who had no history of stroke or TIA, observed Dr. Kosova of Brigham and Women’s Hospital, Boston.

The 3-year composite event rate of cardiovascular death, MI, or stroke occurred in 11.9% of the 1,471 patients with prior CABG who were randomized to vorapaxar compared with 15.6% of those on placebo. That translates into a 29% relative risk reduction and a number-needed-to-treat of 27, an even stronger result than in the general study population.

Moreover, the clinically relevant composite outcome consisting of cardiovascular death or MI occurred in 10.9% of those on vorapaxar compared with 14.3% of controls, for a 29% relative risk reduction and a number-needed-to-treat of 29, he continued.

The 3-year all-cause mortality was 5.8% in patients with prior CABG who received vorapaxar compared to 8% in those on placebo.

Vorapaxar, which inhibits protease-activated receptor-1 on platelets and vascular endothelium, increased the rate of GUSTO moderate-to-severe bleeding: 6.8% compared with 3.7% in controls.

“Putting together the efficacy and safety data to derive the net clinical outcome – the combined endpoint of all-cause mortality, MI, cerebrovascular accident, and GUSTO severe bleeding – the result was a 28% improvement with vorapaxar compared with placebo,” Dr. Kosova said.

In a separate presentation focused on the 3,787 patients who gained entry into the TIMI 50 trial on the basis of symptomatic PAD, Dr. Antonio Gutierrez reported that acute limb ischemia occurred in 109 of them during the trial. Fifty-four percent of these events were due to acute surgical graft thrombosis, 27% to in situ thrombosis of a native vessel, and lesser numbers were due to thromboembolissm or stent thrombosis.

The 3-year acute limb ischemia rate in patients with baseline PAD was 3.9% with placebo compared to 2.3% with vorapaxar, for a 42% relative risk reduction, according to Dr. Gutierrez of Brigham and Women’s Hospital.

Dr. Ian Gilchrist, also from Brigham and Women’s Hospital, reported that in TIMI 50 participants with a history of PAD, vorapaxar resulted in a 16% reduction in the need for peripheral revascularization procedures for claudication, with rates of 9.4% for vorapaxar and 11.6% for placebo. There was also a statistically significant 41% reduction in the rate of surgical peripheral revascularization procedures, with rates of 4.5% for vorapaxar and 7.7% for placebo.

The TIMI 50 trial was funded by Merck. Drs. Kosova, Gutierrez, and Gilchrist reported having no financial conflicts of interest.

bjancin@frontlinemedcom.com

Team performing surgery

Photo by Piotr Bodzek

The US Food and Drug Administration (FDA) has approved the first spray-dried fibrin sealant to help control bleeding during surgery.

The agency approved Raplixa (formerly known as Fibrocaps) for use in adults to control bleeding from small blood vessels when standard surgical techniques are ineffective or impractical.

The standard techniques include suture, ligature, or cautery.

Raplixa contains fibrinogen and thrombin, proteins found in human plasma. When the surgical team applies Raplixa to the bleeding site, the sealant dissolves in the blood, and the fibrinogen and thrombin proteins react, resulting in the formation of blood clots.

The protein components are individually purified using a manufacturing process that includes virus inactivation and removal steps to help reduce the risk for the transmission of blood-borne viruses. The fibrin sealant components are then spray-dried, blended, and packaged in a vial.

Raplixa can be applied directly from the original product vial or by spraying it with a delivery device. Raplixa is used in conjunction with an absorbable gelatin sponge.

“The spray-drying process used to manufacture Raplixa produces dried powders that can be combined into a single vial,” said Karen Midthun, MD, of the FDA’s Center for Biologics Evaluation and Research.

“This eliminates the need to combine the fibrinogen and thrombin before use and allows the product to be stored at room temperature.”

Raplixa was approved for use in the European Union in March, based on the recommendation of the European Medicines Agency’s Committee for Medicinal Products for Human Use.

Phase 3 trial

The FDA approved Raplixa based on data from the FINISH-3 trial, a  randomized, single-blind, controlled, phase 3 study of 719 patients undergoing spinal surgery (n=183), hepatic resection (n=180), vascular surgery (n=175), or soft tissue dissection (n=181) in 4 countries over 11 months.

As reported in the Journal of the American College of Surgeons, adults with mild or moderate surgical bleeding were randomized to recieve Raplixa or the gelatin sponge. Researchers recorded the time to hemostasis over 5 minutes within each surgical indication.

Four hundred and eighty patients were treated with Raplixa, and 239 were treated with the gelatin sponge. Surgeons used the spray device in 53% of Raplixa procedures.

Raplixa used in conjunction with the gelatin sponge significantly reduced time to hemostasis compared to the gelatin sponge alone (P<0.001 for each of the 4 sugical indications).

Raplixa also significantly reduced median time to hemostasis for each indication (P<0.0001).

Adverse events were similar between the treatment arms. The most commonly reported adverse reactions were surgical pain, nausea, constipation, fever, and decreased blood pressure.

Two percent of Raplixa-treated patients developed non-neutralizing anti-thrombin antibodies, as did 3% of patients treated with the gelatin sponge.

Raplixa is manufactured by ProFibrix BV, a wholly owned subsidiary of The Medicines Company, based in Parsippany, New Jersey.

Team performing surgery

Photo by Piotr Bodzek

The US Food and Drug Administration (FDA) has approved the first spray-dried fibrin sealant to help control bleeding during surgery.

The agency approved Raplixa (formerly known as Fibrocaps) for use in adults to control bleeding from small blood vessels when standard surgical techniques are ineffective or impractical.

The standard techniques include suture, ligature, or cautery.

Raplixa contains fibrinogen and thrombin, proteins found in human plasma. When the surgical team applies Raplixa to the bleeding site, the sealant dissolves in the blood, and the fibrinogen and thrombin proteins react, resulting in the formation of blood clots.

The protein components are individually purified using a manufacturing process that includes virus inactivation and removal steps to help reduce the risk for the transmission of blood-borne viruses. The fibrin sealant components are then spray-dried, blended, and packaged in a vial.

Raplixa can be applied directly from the original product vial or by spraying it with a delivery device. Raplixa is used in conjunction with an absorbable gelatin sponge.

“The spray-drying process used to manufacture Raplixa produces dried powders that can be combined into a single vial,” said Karen Midthun, MD, of the FDA’s Center for Biologics Evaluation and Research.

“This eliminates the need to combine the fibrinogen and thrombin before use and allows the product to be stored at room temperature.”

Raplixa was approved for use in the European Union in March, based on the recommendation of the European Medicines Agency’s Committee for Medicinal Products for Human Use.

Phase 3 trial

The FDA approved Raplixa based on data from the FINISH-3 trial, a  randomized, single-blind, controlled, phase 3 study of 719 patients undergoing spinal surgery (n=183), hepatic resection (n=180), vascular surgery (n=175), or soft tissue dissection (n=181) in 4 countries over 11 months.

As reported in the Journal of the American College of Surgeons, adults with mild or moderate surgical bleeding were randomized to recieve Raplixa or the gelatin sponge. Researchers recorded the time to hemostasis over 5 minutes within each surgical indication.

Four hundred and eighty patients were treated with Raplixa, and 239 were treated with the gelatin sponge. Surgeons used the spray device in 53% of Raplixa procedures.

Raplixa used in conjunction with the gelatin sponge significantly reduced time to hemostasis compared to the gelatin sponge alone (P<0.001 for each of the 4 sugical indications).

Raplixa also significantly reduced median time to hemostasis for each indication (P<0.0001).

Adverse events were similar between the treatment arms. The most commonly reported adverse reactions were surgical pain, nausea, constipation, fever, and decreased blood pressure.

Two percent of Raplixa-treated patients developed non-neutralizing anti-thrombin antibodies, as did 3% of patients treated with the gelatin sponge.

Raplixa is manufactured by ProFibrix BV, a wholly owned subsidiary of The Medicines Company, based in Parsippany, New Jersey.

Team performing surgery

Photo by Piotr Bodzek

The US Food and Drug Administration (FDA) has approved the first spray-dried fibrin sealant to help control bleeding during surgery.

The agency approved Raplixa (formerly known as Fibrocaps) for use in adults to control bleeding from small blood vessels when standard surgical techniques are ineffective or impractical.

The standard techniques include suture, ligature, or cautery.

Raplixa contains fibrinogen and thrombin, proteins found in human plasma. When the surgical team applies Raplixa to the bleeding site, the sealant dissolves in the blood, and the fibrinogen and thrombin proteins react, resulting in the formation of blood clots.

The protein components are individually purified using a manufacturing process that includes virus inactivation and removal steps to help reduce the risk for the transmission of blood-borne viruses. The fibrin sealant components are then spray-dried, blended, and packaged in a vial.

Raplixa can be applied directly from the original product vial or by spraying it with a delivery device. Raplixa is used in conjunction with an absorbable gelatin sponge.

“The spray-drying process used to manufacture Raplixa produces dried powders that can be combined into a single vial,” said Karen Midthun, MD, of the FDA’s Center for Biologics Evaluation and Research.

“This eliminates the need to combine the fibrinogen and thrombin before use and allows the product to be stored at room temperature.”

Raplixa was approved for use in the European Union in March, based on the recommendation of the European Medicines Agency’s Committee for Medicinal Products for Human Use.

Phase 3 trial

The FDA approved Raplixa based on data from the FINISH-3 trial, a  randomized, single-blind, controlled, phase 3 study of 719 patients undergoing spinal surgery (n=183), hepatic resection (n=180), vascular surgery (n=175), or soft tissue dissection (n=181) in 4 countries over 11 months.

As reported in the Journal of the American College of Surgeons, adults with mild or moderate surgical bleeding were randomized to recieve Raplixa or the gelatin sponge. Researchers recorded the time to hemostasis over 5 minutes within each surgical indication.

Four hundred and eighty patients were treated with Raplixa, and 239 were treated with the gelatin sponge. Surgeons used the spray device in 53% of Raplixa procedures.

Raplixa used in conjunction with the gelatin sponge significantly reduced time to hemostasis compared to the gelatin sponge alone (P<0.001 for each of the 4 sugical indications).

Raplixa also significantly reduced median time to hemostasis for each indication (P<0.0001).

Adverse events were similar between the treatment arms. The most commonly reported adverse reactions were surgical pain, nausea, constipation, fever, and decreased blood pressure.

Two percent of Raplixa-treated patients developed non-neutralizing anti-thrombin antibodies, as did 3% of patients treated with the gelatin sponge.

Raplixa is manufactured by ProFibrix BV, a wholly owned subsidiary of The Medicines Company, based in Parsippany, New Jersey.

Photographs from Hospital Medicine 2015, which took place March 29-April 1 at the Gaylord National Hotel and Conference Center in National Harbor, Md.

Photos by Manuel Noguera

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Photographs from Hospital Medicine 2015, which took place March 29-April 1 at the Gaylord National Hotel and Conference Center in National Harbor, Md.

Photos by Manuel Noguera

[gallery ids="9197,9196,9195,9194,9193,9192,9191,9190,9189,9188,9187,9186,9185,9184,9183,9182,9181,9180,9179,9178,9177,9176,9175,9171"]

Photographs from Hospital Medicine 2015, which took place March 29-April 1 at the Gaylord National Hotel and Conference Center in National Harbor, Md.

Photos by Manuel Noguera

[gallery ids="9197,9196,9195,9194,9193,9192,9191,9190,9189,9188,9187,9186,9185,9184,9183,9182,9181,9180,9179,9178,9177,9176,9175,9171"]

Excerpts from our interview with Team Hospitalist member David Weidig, MD, director of hospital medicine for Aurora Medical Group in West Allis, Wis., about best practices for multi-site hospital medicine.

[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/05/David-Weidig_HM15_FINAL_050215.mp3"][/audio]

Excerpts from our interview with Team Hospitalist member David Weidig, MD, director of hospital medicine for Aurora Medical Group in West Allis, Wis., about best practices for multi-site hospital medicine.

[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/05/David-Weidig_HM15_FINAL_050215.mp3"][/audio]

Excerpts from our interview with Team Hospitalist member David Weidig, MD, director of hospital medicine for Aurora Medical Group in West Allis, Wis., about best practices for multi-site hospital medicine.

[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/05/David-Weidig_HM15_FINAL_050215.mp3"][/audio]

SHM founder Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners of Darien, Conn., talks about the annual practice management pre-course in an ever-changing healthcare landscape.

SHM founder Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners of Darien, Conn., talks about the annual practice management pre-course in an ever-changing healthcare landscape.

SHM founder Win Whitcomb, MD, MHM, chief medical officer of Remedy Partners of Darien, Conn., talks about the annual practice management pre-course in an ever-changing healthcare landscape.

In the United States, the cosmetic use of botulinum toxin type A (BTX-A) has continued to grow over the last 15 years, according to multispecialty data recently released by the American Society for Aesthetic Plastic Surgery. During these years, many of our patients, if not ourselves, have undergone treatment faithfully every 3 to 6 months to combat the signs of aging. Subsequently, with the monitoring of adverse events (AEs), the US Food and Drug Administration has issued a black box warning that covers serious side effects—respiratory compromise and death—associated with treatment, yet most of what is listed in the black box warning pertains to medical use rather than cosmetic use. However, with the ever-growing indications for BTX-A, we must be cognizant of the fact that our patients may be receiving concomitant treatment with BTX-A for medical conditions (eg, migraines, hyperhidrosis, achalasia, dysphonia, dystonia, strabismus) by other specialists. Thus, there is a need to understand the potential side effects associated with BTX-A treatments and long-term consequences.

In a January 21 article published online in Pharmacology Yiannakopoulou looked at national monitoring programs through the US Food and Drug Administration and the Danish Medicines Agency. Many of the AEs reported were related to medical use of BTX-A, including anaphylaxis, death, generalized weakness, and dysphagia. Serious AEs related to the cosmetic use of BTX-A included thyroid eye disease, sarcoidal granuloma, pseudoaneurysm of the frontal branch of the superior temporal artery, and severe respiratory failure. Additionally, a patient receiving BTX-A for palmar and axillary hyperhidrosis developed botulinumlike generalized weakness. Upon review of epidemiological studies, the incidence and types of AEs were covered. The vast majority of these events were related to the medical use of BTX-A, which could stem from the lack of long-term studies on cosmetic patients and the lack of reporting of many AEs. The author summarized that minimizing potential AEs relies on proper injection technique, proper storage of the medication, proper dosing, and thorough knowledge of the anatomy.

What’s the issue?

Botulinum toxin type A remains one of the most gratifying treatments for both physicians and patients alike. However, with the potential for abuse, as in the case of the recent fake Botox Cosmetic that has shown up on the market in the United States), we must remain vigilant for AEs. Furthermore, we must continue to emphasize to patients that it is a medical treatment and deserves all the attention and respect we give to other medical interventions. However, as the Yiannakopoulou review has shown, proper injection techniques have a low rate of AEs in the cosmetic use of BTX-A. Have you seen an increase in the number of cosmetic BTX-A patients receiving concomitant treatments with BTX-A for medical conditions? If so, how do you manage them?

We want to know your views! Tell us what you think.

In the United States, the cosmetic use of botulinum toxin type A (BTX-A) has continued to grow over the last 15 years, according to multispecialty data recently released by the American Society for Aesthetic Plastic Surgery. During these years, many of our patients, if not ourselves, have undergone treatment faithfully every 3 to 6 months to combat the signs of aging. Subsequently, with the monitoring of adverse events (AEs), the US Food and Drug Administration has issued a black box warning that covers serious side effects—respiratory compromise and death—associated with treatment, yet most of what is listed in the black box warning pertains to medical use rather than cosmetic use. However, with the ever-growing indications for BTX-A, we must be cognizant of the fact that our patients may be receiving concomitant treatment with BTX-A for medical conditions (eg, migraines, hyperhidrosis, achalasia, dysphonia, dystonia, strabismus) by other specialists. Thus, there is a need to understand the potential side effects associated with BTX-A treatments and long-term consequences.

In a January 21 article published online in Pharmacology Yiannakopoulou looked at national monitoring programs through the US Food and Drug Administration and the Danish Medicines Agency. Many of the AEs reported were related to medical use of BTX-A, including anaphylaxis, death, generalized weakness, and dysphagia. Serious AEs related to the cosmetic use of BTX-A included thyroid eye disease, sarcoidal granuloma, pseudoaneurysm of the frontal branch of the superior temporal artery, and severe respiratory failure. Additionally, a patient receiving BTX-A for palmar and axillary hyperhidrosis developed botulinumlike generalized weakness. Upon review of epidemiological studies, the incidence and types of AEs were covered. The vast majority of these events were related to the medical use of BTX-A, which could stem from the lack of long-term studies on cosmetic patients and the lack of reporting of many AEs. The author summarized that minimizing potential AEs relies on proper injection technique, proper storage of the medication, proper dosing, and thorough knowledge of the anatomy.

What’s the issue?

Botulinum toxin type A remains one of the most gratifying treatments for both physicians and patients alike. However, with the potential for abuse, as in the case of the recent fake Botox Cosmetic that has shown up on the market in the United States), we must remain vigilant for AEs. Furthermore, we must continue to emphasize to patients that it is a medical treatment and deserves all the attention and respect we give to other medical interventions. However, as the Yiannakopoulou review has shown, proper injection techniques have a low rate of AEs in the cosmetic use of BTX-A. Have you seen an increase in the number of cosmetic BTX-A patients receiving concomitant treatments with BTX-A for medical conditions? If so, how do you manage them?

We want to know your views! Tell us what you think.

In the United States, the cosmetic use of botulinum toxin type A (BTX-A) has continued to grow over the last 15 years, according to multispecialty data recently released by the American Society for Aesthetic Plastic Surgery. During these years, many of our patients, if not ourselves, have undergone treatment faithfully every 3 to 6 months to combat the signs of aging. Subsequently, with the monitoring of adverse events (AEs), the US Food and Drug Administration has issued a black box warning that covers serious side effects—respiratory compromise and death—associated with treatment, yet most of what is listed in the black box warning pertains to medical use rather than cosmetic use. However, with the ever-growing indications for BTX-A, we must be cognizant of the fact that our patients may be receiving concomitant treatment with BTX-A for medical conditions (eg, migraines, hyperhidrosis, achalasia, dysphonia, dystonia, strabismus) by other specialists. Thus, there is a need to understand the potential side effects associated with BTX-A treatments and long-term consequences.

In a January 21 article published online in Pharmacology Yiannakopoulou looked at national monitoring programs through the US Food and Drug Administration and the Danish Medicines Agency. Many of the AEs reported were related to medical use of BTX-A, including anaphylaxis, death, generalized weakness, and dysphagia. Serious AEs related to the cosmetic use of BTX-A included thyroid eye disease, sarcoidal granuloma, pseudoaneurysm of the frontal branch of the superior temporal artery, and severe respiratory failure. Additionally, a patient receiving BTX-A for palmar and axillary hyperhidrosis developed botulinumlike generalized weakness. Upon review of epidemiological studies, the incidence and types of AEs were covered. The vast majority of these events were related to the medical use of BTX-A, which could stem from the lack of long-term studies on cosmetic patients and the lack of reporting of many AEs. The author summarized that minimizing potential AEs relies on proper injection technique, proper storage of the medication, proper dosing, and thorough knowledge of the anatomy.

What’s the issue?

Botulinum toxin type A remains one of the most gratifying treatments for both physicians and patients alike. However, with the potential for abuse, as in the case of the recent fake Botox Cosmetic that has shown up on the market in the United States), we must remain vigilant for AEs. Furthermore, we must continue to emphasize to patients that it is a medical treatment and deserves all the attention and respect we give to other medical interventions. However, as the Yiannakopoulou review has shown, proper injection techniques have a low rate of AEs in the cosmetic use of BTX-A. Have you seen an increase in the number of cosmetic BTX-A patients receiving concomitant treatments with BTX-A for medical conditions? If so, how do you manage them?

We want to know your views! Tell us what you think.

New SHM President Robert Harrington Jr., MD, SFHM, talks about his views on hospital medicine, the society and the value of diversity and teamwork.

New SHM President Robert Harrington Jr., MD, SFHM, talks about his views on hospital medicine, the society and the value of diversity and teamwork.

New SHM President Robert Harrington Jr., MD, SFHM, talks about his views on hospital medicine, the society and the value of diversity and teamwork.

ASHEVILLE, N.C. – Recent advances in basic science have shown how the local immune environment in tissue surrounding nonmelanoma skin cancer compares to adjacent normal tissue.

New Mexico Health Sciences Center’s Dr. Andrew Ondo reviewed the latest research in an interview at the annual meeting of the Noah Worcester Dermatological Society. “Each step along the way is a possible target for the treatment of squamous cell carcinoma,” said Dr. Ondo, who indicated that he had no financial conflicts to disclose.

hsplete@frontlinemedcom.com

ASHEVILLE, N.C. – Recent advances in basic science have shown how the local immune environment in tissue surrounding nonmelanoma skin cancer compares to adjacent normal tissue.

New Mexico Health Sciences Center’s Dr. Andrew Ondo reviewed the latest research in an interview at the annual meeting of the Noah Worcester Dermatological Society. “Each step along the way is a possible target for the treatment of squamous cell carcinoma,” said Dr. Ondo, who indicated that he had no financial conflicts to disclose.

hsplete@frontlinemedcom.com

ASHEVILLE, N.C. – Recent advances in basic science have shown how the local immune environment in tissue surrounding nonmelanoma skin cancer compares to adjacent normal tissue.

New Mexico Health Sciences Center’s Dr. Andrew Ondo reviewed the latest research in an interview at the annual meeting of the Noah Worcester Dermatological Society. “Each step along the way is a possible target for the treatment of squamous cell carcinoma,” said Dr. Ondo, who indicated that he had no financial conflicts to disclose.

hsplete@frontlinemedcom.com