An x-ray revealed a metal density in the area of concern that was consistent with a bullet fragment or other metallic foreign body. Since there were no lucencies on x-ray or tracking from the area of concern to the metacarpal, the diagnosis was confirmed as an infected foreign body. The history was very concerning for osteomyelitis, given that the patient had sustained a GSW and had undergone surgical repair with hardware. (Shifting hardware can also lead to callus formation and skin breakdown.)

The patient was told that he’d retained a bullet fragment or foreign body that caused a chronic infection and the recurrent drainage. In addition, the hardware spanning the gap between the remnants of his proximal and distal metacarpal had broken as a result of fatigue. He was referred to a surgeon to remove the foreign body and treat the infection. The patient was advised that he might also need replacement hardware and a bone graft.

‌

Images and text courtesy of Daniel Stulberg, MD, FAAFP, Professor and Chair, Department of Family and Community Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo.

An x-ray revealed a metal density in the area of concern that was consistent with a bullet fragment or other metallic foreign body. Since there were no lucencies on x-ray or tracking from the area of concern to the metacarpal, the diagnosis was confirmed as an infected foreign body. The history was very concerning for osteomyelitis, given that the patient had sustained a GSW and had undergone surgical repair with hardware. (Shifting hardware can also lead to callus formation and skin breakdown.)

The patient was told that he’d retained a bullet fragment or foreign body that caused a chronic infection and the recurrent drainage. In addition, the hardware spanning the gap between the remnants of his proximal and distal metacarpal had broken as a result of fatigue. He was referred to a surgeon to remove the foreign body and treat the infection. The patient was advised that he might also need replacement hardware and a bone graft.

‌

Images and text courtesy of Daniel Stulberg, MD, FAAFP, Professor and Chair, Department of Family and Community Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo.

An x-ray revealed a metal density in the area of concern that was consistent with a bullet fragment or other metallic foreign body. Since there were no lucencies on x-ray or tracking from the area of concern to the metacarpal, the diagnosis was confirmed as an infected foreign body. The history was very concerning for osteomyelitis, given that the patient had sustained a GSW and had undergone surgical repair with hardware. (Shifting hardware can also lead to callus formation and skin breakdown.)

The patient was told that he’d retained a bullet fragment or foreign body that caused a chronic infection and the recurrent drainage. In addition, the hardware spanning the gap between the remnants of his proximal and distal metacarpal had broken as a result of fatigue. He was referred to a surgeon to remove the foreign body and treat the infection. The patient was advised that he might also need replacement hardware and a bone graft.

‌

Images and text courtesy of Daniel Stulberg, MD, FAAFP, Professor and Chair, Department of Family and Community Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo.

The last full week of September brought a 4th straight week of declines in the number of new COVID-19 cases reported among children, according to the American Academy of Pediatrics and the Children’s Hospital Association.

The new-case total of 39,200 for the week of Sept. 23-29 was down by almost 28% from the previous week, with the month of September bringing a decline of about 57% in reported cases for the 45 states and territories that are still releasing pediatric COVID data on their health department websites, the AAP and CHA said in their joint weekly report.

New cases dropped in all four regions after the Northeast and West had seen increases the previous week, and the distribution of cases for the latest week was fairly even, with the Midwest and Northeast right around 10,000, the South slightly over 10,000, and the West under 10,000 by about the same amount. At the state level, the largest increases – around 1.5% – over the last 2 weeks occurred in Kentucky and Nevada, the AAP/CHA data show.

The cumulative number of COVID-19 cases in children was almost 14.8 million as of Sept. 29, with children representing 18.4% of all cases since the pandemic began, the AAP and CHA said. The Centers for Disease Control and Prevention, which is able to use a uniform age range of 0-17 years, puts total cases at 15.2 million and the proportion of child cases at 17.4%. Total deaths in children from COVID as of Oct. 3 were 1,745, the CDC reported.

New vaccinations, in the meantime, are being added in numbers only slightly higher than new cases. Initial COVID vaccinations for the week of Sept. 22-28 were about 44,000 for children under 5 years of age (down from 51,000 the week before), 24,000 for children aged 5-11 years (down from 28,000), and 17,000 for those aged 12-17 (down from 18,000), the AAP said in its weekly vaccination report.

To look at it another way, the total proportion of children under 5 years of age who had received at least one dose of COVID vaccine as of Sept. 28 was 6.5%, compared with 6.4% on Sept. 21, while the corresponding rates for children aged 5-11 and 12-17 were unchanged at 38.5% and 70.9%. The 12- to 17-year-olds, in fact, have been stuck at 70.9% since Sept. 13, according to data from the CDC.

In a recent study published in Vaccine, investigators attributed the discrepancies between age groups at least partly to the acceptance of misinformation about vaccine safety in general and the COVID-19 vaccines in particular.

“All of the misconceptions we studied focused in one way or another on the safety of vaccination, and that explains why people’s misbeliefs about vaccinating kids are so highly related to their concerns about vaccines in general. Unfortunately, those concerns weigh even more heavily when adults consider vaccinating children,” lead author Dan Romer, PhD, of the University of Pennsylvania, Philadelphia, said in a written statement.

The last full week of September brought a 4th straight week of declines in the number of new COVID-19 cases reported among children, according to the American Academy of Pediatrics and the Children’s Hospital Association.

The new-case total of 39,200 for the week of Sept. 23-29 was down by almost 28% from the previous week, with the month of September bringing a decline of about 57% in reported cases for the 45 states and territories that are still releasing pediatric COVID data on their health department websites, the AAP and CHA said in their joint weekly report.

New cases dropped in all four regions after the Northeast and West had seen increases the previous week, and the distribution of cases for the latest week was fairly even, with the Midwest and Northeast right around 10,000, the South slightly over 10,000, and the West under 10,000 by about the same amount. At the state level, the largest increases – around 1.5% – over the last 2 weeks occurred in Kentucky and Nevada, the AAP/CHA data show.

The cumulative number of COVID-19 cases in children was almost 14.8 million as of Sept. 29, with children representing 18.4% of all cases since the pandemic began, the AAP and CHA said. The Centers for Disease Control and Prevention, which is able to use a uniform age range of 0-17 years, puts total cases at 15.2 million and the proportion of child cases at 17.4%. Total deaths in children from COVID as of Oct. 3 were 1,745, the CDC reported.

New vaccinations, in the meantime, are being added in numbers only slightly higher than new cases. Initial COVID vaccinations for the week of Sept. 22-28 were about 44,000 for children under 5 years of age (down from 51,000 the week before), 24,000 for children aged 5-11 years (down from 28,000), and 17,000 for those aged 12-17 (down from 18,000), the AAP said in its weekly vaccination report.

To look at it another way, the total proportion of children under 5 years of age who had received at least one dose of COVID vaccine as of Sept. 28 was 6.5%, compared with 6.4% on Sept. 21, while the corresponding rates for children aged 5-11 and 12-17 were unchanged at 38.5% and 70.9%. The 12- to 17-year-olds, in fact, have been stuck at 70.9% since Sept. 13, according to data from the CDC.

In a recent study published in Vaccine, investigators attributed the discrepancies between age groups at least partly to the acceptance of misinformation about vaccine safety in general and the COVID-19 vaccines in particular.

“All of the misconceptions we studied focused in one way or another on the safety of vaccination, and that explains why people’s misbeliefs about vaccinating kids are so highly related to their concerns about vaccines in general. Unfortunately, those concerns weigh even more heavily when adults consider vaccinating children,” lead author Dan Romer, PhD, of the University of Pennsylvania, Philadelphia, said in a written statement.

The last full week of September brought a 4th straight week of declines in the number of new COVID-19 cases reported among children, according to the American Academy of Pediatrics and the Children’s Hospital Association.

The new-case total of 39,200 for the week of Sept. 23-29 was down by almost 28% from the previous week, with the month of September bringing a decline of about 57% in reported cases for the 45 states and territories that are still releasing pediatric COVID data on their health department websites, the AAP and CHA said in their joint weekly report.

New cases dropped in all four regions after the Northeast and West had seen increases the previous week, and the distribution of cases for the latest week was fairly even, with the Midwest and Northeast right around 10,000, the South slightly over 10,000, and the West under 10,000 by about the same amount. At the state level, the largest increases – around 1.5% – over the last 2 weeks occurred in Kentucky and Nevada, the AAP/CHA data show.

The cumulative number of COVID-19 cases in children was almost 14.8 million as of Sept. 29, with children representing 18.4% of all cases since the pandemic began, the AAP and CHA said. The Centers for Disease Control and Prevention, which is able to use a uniform age range of 0-17 years, puts total cases at 15.2 million and the proportion of child cases at 17.4%. Total deaths in children from COVID as of Oct. 3 were 1,745, the CDC reported.

New vaccinations, in the meantime, are being added in numbers only slightly higher than new cases. Initial COVID vaccinations for the week of Sept. 22-28 were about 44,000 for children under 5 years of age (down from 51,000 the week before), 24,000 for children aged 5-11 years (down from 28,000), and 17,000 for those aged 12-17 (down from 18,000), the AAP said in its weekly vaccination report.

To look at it another way, the total proportion of children under 5 years of age who had received at least one dose of COVID vaccine as of Sept. 28 was 6.5%, compared with 6.4% on Sept. 21, while the corresponding rates for children aged 5-11 and 12-17 were unchanged at 38.5% and 70.9%. The 12- to 17-year-olds, in fact, have been stuck at 70.9% since Sept. 13, according to data from the CDC.

In a recent study published in Vaccine, investigators attributed the discrepancies between age groups at least partly to the acceptance of misinformation about vaccine safety in general and the COVID-19 vaccines in particular.

“All of the misconceptions we studied focused in one way or another on the safety of vaccination, and that explains why people’s misbeliefs about vaccinating kids are so highly related to their concerns about vaccines in general. Unfortunately, those concerns weigh even more heavily when adults consider vaccinating children,” lead author Dan Romer, PhD, of the University of Pennsylvania, Philadelphia, said in a written statement.

PARIS – What do doctors know about their patients’ sexual health? Not a lot. What about oncologists who treat women with breast cancer? Not much more. Yet sexual dysfunction has a significant impact on the quality of life of patients during and after cancer.

To determine the extent of sexual dysfunction among women with breast cancer, Maria Alice Franzoi, MD, an oncologist at Gustave Roussy Hospital, Villejuif, France, analyzed data concerning sexuality from the CANTO cohort study. She showed that sexual dysfunction often predates the cancer diagnosis and doesn’t improve but rather worsens in the following 2 years. She presented her results at the annual meeting of the European Society for Medical Oncology.
 

Present at diagnosis

Dr. Franzoi, whose research projects have focused on patient monitoring post cancer, drew her conclusions from the data provided by CANTO, a longitudinal, prospective cohort study that monitors women being treated for localized breast cancer. Study participants answered the EORTC-QLQ-BR23 quality-of-life questionnaire at the time of diagnosis (T0), 1 year after diagnosis (T1), and 2 years after diagnosis (T2). Four factors were employed to better define women’s sex-related problems: poor body image, poor sexual functioning (activity and desire), lack of sexual pleasure, and a complete lack of sexual activity.

The analysis focused on the responses of 7,895 patients in the CANTO cohort study on sexual activity; 4,523 of those patients answered questions about sexual pleasure. Female respondents who reported engaging in no sexual activity did not have to answer the questions in this second section.

“Seventy-five percent of patients reported at least one of the four concerns during the study,” noted Dr. Franzoi during her presentation. This finding highlights the fact that “sexual problems are already present at the time of diagnosis in a considerable number of patients,” she said. More than a third of participants complained of at least one of the four items.
 

Developments after diagnosis

The proportion of women who reported no arousal or poor sexual function remained stable at around 30% over time, meaning that the sexual problems were reported in similar numbers at T0, T1, and T2. “However, after cancer, more patients are worried about a lack of sexual pleasure (38.7% at T1 and 38.1% at T2, vs. 29.1% at T0) or report having a negative body image (57.8% at T1 and 52.5% at T2, vs. 32.1% at T0),” said Dr. Franzoi.

She identified the following three variables as being associated with sexual dysfunction 2 years after diagnosis: the existence of this problem at the time of diagnosis, the use of adjuvant hormone therapy, and severe depression or a very high stress level after the first year of treatment.
 

Inadequate specific treatment

“Sexual dysfunction is a major unmet need with a significant impact on quality of life,” said Maryam Lustberg, MD, an oncologist at Yale School of Medicine, New Haven, Conn., who was invited to discuss the results at the conference.

Dr. Franzoi observed that most participants with sexual dysfunction that had continued 2 years after diagnosis had not been referred to a doctor for this problem. “In terms of sexual function, it’s better at T2 than at T1, but only 41% of these women have been seen by a gynecologist, and only 15% have received specific treatment,” she reported, emphasizing the need to assess and treat these issues “proactively” at the time of diagnosis and during and after treatment.

“Now we need to work out what the best treatment approach is,” commented Dr. Lustberg. She said that cancers other than breast and gynecologic cancers should also be taken into consideration. She cited the Sexual Health Assessment in Women With Lung Cancer study, which recently revealed that after being diagnosed with lung cancer, female patients experienced a drop in sexual desire (31% vs. 15% before diagnosis) and an increase in vaginal discomfort or dryness (43% vs. 13% before diagnosis). This study, presented in August to the 2022 International Association for the Study of Lung Cancer World Conference on Lung Cancer, also revealed that different parameters affect satisfaction in one’s sex life, including fatigue, sadness, relationship problems with a partner, and even breathing. Dr. Lustberg concluded from this study that a multidisciplinary approach is needed for cancer survivors.

Dr. Franzoi received research funding from Resilience Care. Dr. Lustberg has links with AstraZeneca, Pfizer, Novartis, Sanofi, and Lilly.

This article was translated from the Medscape French edition.

PARIS – What do doctors know about their patients’ sexual health? Not a lot. What about oncologists who treat women with breast cancer? Not much more. Yet sexual dysfunction has a significant impact on the quality of life of patients during and after cancer.

To determine the extent of sexual dysfunction among women with breast cancer, Maria Alice Franzoi, MD, an oncologist at Gustave Roussy Hospital, Villejuif, France, analyzed data concerning sexuality from the CANTO cohort study. She showed that sexual dysfunction often predates the cancer diagnosis and doesn’t improve but rather worsens in the following 2 years. She presented her results at the annual meeting of the European Society for Medical Oncology.
 

Present at diagnosis

Dr. Franzoi, whose research projects have focused on patient monitoring post cancer, drew her conclusions from the data provided by CANTO, a longitudinal, prospective cohort study that monitors women being treated for localized breast cancer. Study participants answered the EORTC-QLQ-BR23 quality-of-life questionnaire at the time of diagnosis (T0), 1 year after diagnosis (T1), and 2 years after diagnosis (T2). Four factors were employed to better define women’s sex-related problems: poor body image, poor sexual functioning (activity and desire), lack of sexual pleasure, and a complete lack of sexual activity.

The analysis focused on the responses of 7,895 patients in the CANTO cohort study on sexual activity; 4,523 of those patients answered questions about sexual pleasure. Female respondents who reported engaging in no sexual activity did not have to answer the questions in this second section.

“Seventy-five percent of patients reported at least one of the four concerns during the study,” noted Dr. Franzoi during her presentation. This finding highlights the fact that “sexual problems are already present at the time of diagnosis in a considerable number of patients,” she said. More than a third of participants complained of at least one of the four items.
 

Developments after diagnosis

The proportion of women who reported no arousal or poor sexual function remained stable at around 30% over time, meaning that the sexual problems were reported in similar numbers at T0, T1, and T2. “However, after cancer, more patients are worried about a lack of sexual pleasure (38.7% at T1 and 38.1% at T2, vs. 29.1% at T0) or report having a negative body image (57.8% at T1 and 52.5% at T2, vs. 32.1% at T0),” said Dr. Franzoi.

She identified the following three variables as being associated with sexual dysfunction 2 years after diagnosis: the existence of this problem at the time of diagnosis, the use of adjuvant hormone therapy, and severe depression or a very high stress level after the first year of treatment.
 

Inadequate specific treatment

“Sexual dysfunction is a major unmet need with a significant impact on quality of life,” said Maryam Lustberg, MD, an oncologist at Yale School of Medicine, New Haven, Conn., who was invited to discuss the results at the conference.

Dr. Franzoi observed that most participants with sexual dysfunction that had continued 2 years after diagnosis had not been referred to a doctor for this problem. “In terms of sexual function, it’s better at T2 than at T1, but only 41% of these women have been seen by a gynecologist, and only 15% have received specific treatment,” she reported, emphasizing the need to assess and treat these issues “proactively” at the time of diagnosis and during and after treatment.

“Now we need to work out what the best treatment approach is,” commented Dr. Lustberg. She said that cancers other than breast and gynecologic cancers should also be taken into consideration. She cited the Sexual Health Assessment in Women With Lung Cancer study, which recently revealed that after being diagnosed with lung cancer, female patients experienced a drop in sexual desire (31% vs. 15% before diagnosis) and an increase in vaginal discomfort or dryness (43% vs. 13% before diagnosis). This study, presented in August to the 2022 International Association for the Study of Lung Cancer World Conference on Lung Cancer, also revealed that different parameters affect satisfaction in one’s sex life, including fatigue, sadness, relationship problems with a partner, and even breathing. Dr. Lustberg concluded from this study that a multidisciplinary approach is needed for cancer survivors.

Dr. Franzoi received research funding from Resilience Care. Dr. Lustberg has links with AstraZeneca, Pfizer, Novartis, Sanofi, and Lilly.

This article was translated from the Medscape French edition.

PARIS – What do doctors know about their patients’ sexual health? Not a lot. What about oncologists who treat women with breast cancer? Not much more. Yet sexual dysfunction has a significant impact on the quality of life of patients during and after cancer.

To determine the extent of sexual dysfunction among women with breast cancer, Maria Alice Franzoi, MD, an oncologist at Gustave Roussy Hospital, Villejuif, France, analyzed data concerning sexuality from the CANTO cohort study. She showed that sexual dysfunction often predates the cancer diagnosis and doesn’t improve but rather worsens in the following 2 years. She presented her results at the annual meeting of the European Society for Medical Oncology.
 

Present at diagnosis

Dr. Franzoi, whose research projects have focused on patient monitoring post cancer, drew her conclusions from the data provided by CANTO, a longitudinal, prospective cohort study that monitors women being treated for localized breast cancer. Study participants answered the EORTC-QLQ-BR23 quality-of-life questionnaire at the time of diagnosis (T0), 1 year after diagnosis (T1), and 2 years after diagnosis (T2). Four factors were employed to better define women’s sex-related problems: poor body image, poor sexual functioning (activity and desire), lack of sexual pleasure, and a complete lack of sexual activity.

The analysis focused on the responses of 7,895 patients in the CANTO cohort study on sexual activity; 4,523 of those patients answered questions about sexual pleasure. Female respondents who reported engaging in no sexual activity did not have to answer the questions in this second section.

“Seventy-five percent of patients reported at least one of the four concerns during the study,” noted Dr. Franzoi during her presentation. This finding highlights the fact that “sexual problems are already present at the time of diagnosis in a considerable number of patients,” she said. More than a third of participants complained of at least one of the four items.
 

Developments after diagnosis

The proportion of women who reported no arousal or poor sexual function remained stable at around 30% over time, meaning that the sexual problems were reported in similar numbers at T0, T1, and T2. “However, after cancer, more patients are worried about a lack of sexual pleasure (38.7% at T1 and 38.1% at T2, vs. 29.1% at T0) or report having a negative body image (57.8% at T1 and 52.5% at T2, vs. 32.1% at T0),” said Dr. Franzoi.

She identified the following three variables as being associated with sexual dysfunction 2 years after diagnosis: the existence of this problem at the time of diagnosis, the use of adjuvant hormone therapy, and severe depression or a very high stress level after the first year of treatment.
 

Inadequate specific treatment

“Sexual dysfunction is a major unmet need with a significant impact on quality of life,” said Maryam Lustberg, MD, an oncologist at Yale School of Medicine, New Haven, Conn., who was invited to discuss the results at the conference.

Dr. Franzoi observed that most participants with sexual dysfunction that had continued 2 years after diagnosis had not been referred to a doctor for this problem. “In terms of sexual function, it’s better at T2 than at T1, but only 41% of these women have been seen by a gynecologist, and only 15% have received specific treatment,” she reported, emphasizing the need to assess and treat these issues “proactively” at the time of diagnosis and during and after treatment.

“Now we need to work out what the best treatment approach is,” commented Dr. Lustberg. She said that cancers other than breast and gynecologic cancers should also be taken into consideration. She cited the Sexual Health Assessment in Women With Lung Cancer study, which recently revealed that after being diagnosed with lung cancer, female patients experienced a drop in sexual desire (31% vs. 15% before diagnosis) and an increase in vaginal discomfort or dryness (43% vs. 13% before diagnosis). This study, presented in August to the 2022 International Association for the Study of Lung Cancer World Conference on Lung Cancer, also revealed that different parameters affect satisfaction in one’s sex life, including fatigue, sadness, relationship problems with a partner, and even breathing. Dr. Lustberg concluded from this study that a multidisciplinary approach is needed for cancer survivors.

Dr. Franzoi received research funding from Resilience Care. Dr. Lustberg has links with AstraZeneca, Pfizer, Novartis, Sanofi, and Lilly.

This article was translated from the Medscape French edition.

In my previous article in June, 2022, we plowed through the billing and coding updates regarding critical care services, and, I hope that it helped our readers get more acquainted with the nuances of billing and coding in the ICU. In this piece, I would like to briefly elucidate three other areas of practice, which will be relevant to all physicians across various specialties.

Telehealth services

The Centers for Medicare & Medicaid Services (CMS) graciously added telehealth services temporarily to its list of services due to the COVID-19 public health emergency (PHE). Initially, the plan was to remove these from the list of covered services by the latter end of the COVID-19 PHE, which, created some uncertainty, or by December 31, 2021. Fortunately, CMS finalized that they will extend it through the end of the calendar year (CY) 2023. So, now all the telehealth services will remain on the CMS list until December 31, 2023. The general principle behind this ruling is to allow for more time for CMS and stakeholders to gather data and to submit support for requesting these services to be permanently added to the Medicare telehealth services list.

Not only has CMS extended the deadline for telehealth services but also they have gone far and beyond to extend some of the codes for cardiac and intensive cardiac rehabilitation until December 31, 2023, as well.

There has been a lot of debate regarding the geographic restrictions when it comes to telehealth visits for diagnosis, evaluation, or treatment of a mental health disorder. As per the latest Consolidated Appropriations Act of 2021 (Section 123), the home of the patient is a permissible site. But, the caveat is that there must be an in-person service with the practitioner/physician within 6 months prior to the initial telehealth visit. Additionally, there has to be a set frequency for subsequent in-person visits. And, usually the subsequent visits will need to be provided at least every 12 months. These requirements are not set in stone and can be changed on a case-by-case basis provided there is appropriate documentation in the chart.

Lastly, it is important to understand and use the appropriate telecommunication systems for the telehealth visits and the modifiers that are associated with them. By definition, it has to be audio and video equipment that allows two-way, real-time interactive communication between the patient and the provider when used for telehealth services for the diagnosis, evaluation, or treatment of mental health disorders. But, CMS is in the process of amending it to include audio-only communications technology. At this time, the use of audio-only interactive telecommunications system is limited to practitioners who have the capability to provide two-way audio/video communications but, where the patient is not capable, or does not consent to, the use of two-way audio/video technology. Modifier FQ should be attached to all the mental health services that were furnished using audio-only communications. And, mental health services can include services for treatment of substance use disorders (SUD). Please do not confuse modifier FQ with modifier 93 as FQ is only for behavioral health services. And, remember that the totality of the communication of information exchanged between the provider and the patient during the course of the synchronous telemedicine service (rendered via telephone or other real-time interactive audio only telecommunication system) must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction.

Teaching physician services

As a general rule, a teaching physician can bill for the resident services only if they are present for the critical (key) portion of the service. But, there is one exception called the “primary care exception” under which in certain teaching hospital primary care centers, the teaching physician can bill for certain services as furnished independently by the resident without the teaching physician being physically present, but with the teaching physician’s review.

The current model to bill for office/outpatient E/M visit level is either based on either total time spent (personally) or medical-decision-making (MDM). When time is used to select the visit level only the time spent by the teaching physician in qualifying activities can be included for the purposes of the visit level selection. And, this includes the time the teaching physician was present with the resident performing those qualifying activities. Also, under the primary care exception, time cannot be used to select the visit level. This is to guard against the possibility of inappropriate coding that reflects residents’ inefficiencies rather than a measure of the total medically necessary time required to furnish the E/M services.

ICD-10 updates

Usually, the ICD-10 codes are updated annually and take effect every October 1. Some of the most relevant updates are as follows:

1. U09.9 Post COVID-19 condition, unspecified: This should be used to document sequelae of COVID-19 or “long COVID” conditions, after the acute illness has resolved. But, remember to code the conditions related to COVID-19 first and do not use this code with an active or current COVID-19 infection.

2. U07.0 Vaping-related disorder: This should be used for all vaping-related illnesses. However, additional codes for other diagnoses such as acute respiratory failure, acute respiratory distress syndrome, or pneumonitis can also be used with this code. Other respiratory signs and symptoms such as cough and shortness of breath should not be coded separately.

3. Cough is one of the most common reasons for referral to a pulmonologist. The CDC has expanded these codes so please remember to code the most specific diagnosis as deemed appropriate.

R05.1 Acute cough

R05.2 Subacute cough

R05.3 Chronic cough

R05.4 Cough, syncope

R05.8 Other specified cough

R05.9 Cough, unspecified

We will be back with some more exciting and intriguing billing and coding updates in our next article and hope to see everyone at CHEST 2022 in Nashville., TN.

In my previous article in June, 2022, we plowed through the billing and coding updates regarding critical care services, and, I hope that it helped our readers get more acquainted with the nuances of billing and coding in the ICU. In this piece, I would like to briefly elucidate three other areas of practice, which will be relevant to all physicians across various specialties.

Telehealth services

The Centers for Medicare & Medicaid Services (CMS) graciously added telehealth services temporarily to its list of services due to the COVID-19 public health emergency (PHE). Initially, the plan was to remove these from the list of covered services by the latter end of the COVID-19 PHE, which, created some uncertainty, or by December 31, 2021. Fortunately, CMS finalized that they will extend it through the end of the calendar year (CY) 2023. So, now all the telehealth services will remain on the CMS list until December 31, 2023. The general principle behind this ruling is to allow for more time for CMS and stakeholders to gather data and to submit support for requesting these services to be permanently added to the Medicare telehealth services list.

Not only has CMS extended the deadline for telehealth services but also they have gone far and beyond to extend some of the codes for cardiac and intensive cardiac rehabilitation until December 31, 2023, as well.

There has been a lot of debate regarding the geographic restrictions when it comes to telehealth visits for diagnosis, evaluation, or treatment of a mental health disorder. As per the latest Consolidated Appropriations Act of 2021 (Section 123), the home of the patient is a permissible site. But, the caveat is that there must be an in-person service with the practitioner/physician within 6 months prior to the initial telehealth visit. Additionally, there has to be a set frequency for subsequent in-person visits. And, usually the subsequent visits will need to be provided at least every 12 months. These requirements are not set in stone and can be changed on a case-by-case basis provided there is appropriate documentation in the chart.

Lastly, it is important to understand and use the appropriate telecommunication systems for the telehealth visits and the modifiers that are associated with them. By definition, it has to be audio and video equipment that allows two-way, real-time interactive communication between the patient and the provider when used for telehealth services for the diagnosis, evaluation, or treatment of mental health disorders. But, CMS is in the process of amending it to include audio-only communications technology. At this time, the use of audio-only interactive telecommunications system is limited to practitioners who have the capability to provide two-way audio/video communications but, where the patient is not capable, or does not consent to, the use of two-way audio/video technology. Modifier FQ should be attached to all the mental health services that were furnished using audio-only communications. And, mental health services can include services for treatment of substance use disorders (SUD). Please do not confuse modifier FQ with modifier 93 as FQ is only for behavioral health services. And, remember that the totality of the communication of information exchanged between the provider and the patient during the course of the synchronous telemedicine service (rendered via telephone or other real-time interactive audio only telecommunication system) must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction.

Teaching physician services

As a general rule, a teaching physician can bill for the resident services only if they are present for the critical (key) portion of the service. But, there is one exception called the “primary care exception” under which in certain teaching hospital primary care centers, the teaching physician can bill for certain services as furnished independently by the resident without the teaching physician being physically present, but with the teaching physician’s review.

The current model to bill for office/outpatient E/M visit level is either based on either total time spent (personally) or medical-decision-making (MDM). When time is used to select the visit level only the time spent by the teaching physician in qualifying activities can be included for the purposes of the visit level selection. And, this includes the time the teaching physician was present with the resident performing those qualifying activities. Also, under the primary care exception, time cannot be used to select the visit level. This is to guard against the possibility of inappropriate coding that reflects residents’ inefficiencies rather than a measure of the total medically necessary time required to furnish the E/M services.

ICD-10 updates

Usually, the ICD-10 codes are updated annually and take effect every October 1. Some of the most relevant updates are as follows:

1. U09.9 Post COVID-19 condition, unspecified: This should be used to document sequelae of COVID-19 or “long COVID” conditions, after the acute illness has resolved. But, remember to code the conditions related to COVID-19 first and do not use this code with an active or current COVID-19 infection.

2. U07.0 Vaping-related disorder: This should be used for all vaping-related illnesses. However, additional codes for other diagnoses such as acute respiratory failure, acute respiratory distress syndrome, or pneumonitis can also be used with this code. Other respiratory signs and symptoms such as cough and shortness of breath should not be coded separately.

3. Cough is one of the most common reasons for referral to a pulmonologist. The CDC has expanded these codes so please remember to code the most specific diagnosis as deemed appropriate.

R05.1 Acute cough

R05.2 Subacute cough

R05.3 Chronic cough

R05.4 Cough, syncope

R05.8 Other specified cough

R05.9 Cough, unspecified

We will be back with some more exciting and intriguing billing and coding updates in our next article and hope to see everyone at CHEST 2022 in Nashville., TN.

In my previous article in June, 2022, we plowed through the billing and coding updates regarding critical care services, and, I hope that it helped our readers get more acquainted with the nuances of billing and coding in the ICU. In this piece, I would like to briefly elucidate three other areas of practice, which will be relevant to all physicians across various specialties.

Telehealth services

The Centers for Medicare & Medicaid Services (CMS) graciously added telehealth services temporarily to its list of services due to the COVID-19 public health emergency (PHE). Initially, the plan was to remove these from the list of covered services by the latter end of the COVID-19 PHE, which, created some uncertainty, or by December 31, 2021. Fortunately, CMS finalized that they will extend it through the end of the calendar year (CY) 2023. So, now all the telehealth services will remain on the CMS list until December 31, 2023. The general principle behind this ruling is to allow for more time for CMS and stakeholders to gather data and to submit support for requesting these services to be permanently added to the Medicare telehealth services list.

Not only has CMS extended the deadline for telehealth services but also they have gone far and beyond to extend some of the codes for cardiac and intensive cardiac rehabilitation until December 31, 2023, as well.

There has been a lot of debate regarding the geographic restrictions when it comes to telehealth visits for diagnosis, evaluation, or treatment of a mental health disorder. As per the latest Consolidated Appropriations Act of 2021 (Section 123), the home of the patient is a permissible site. But, the caveat is that there must be an in-person service with the practitioner/physician within 6 months prior to the initial telehealth visit. Additionally, there has to be a set frequency for subsequent in-person visits. And, usually the subsequent visits will need to be provided at least every 12 months. These requirements are not set in stone and can be changed on a case-by-case basis provided there is appropriate documentation in the chart.

Lastly, it is important to understand and use the appropriate telecommunication systems for the telehealth visits and the modifiers that are associated with them. By definition, it has to be audio and video equipment that allows two-way, real-time interactive communication between the patient and the provider when used for telehealth services for the diagnosis, evaluation, or treatment of mental health disorders. But, CMS is in the process of amending it to include audio-only communications technology. At this time, the use of audio-only interactive telecommunications system is limited to practitioners who have the capability to provide two-way audio/video communications but, where the patient is not capable, or does not consent to, the use of two-way audio/video technology. Modifier FQ should be attached to all the mental health services that were furnished using audio-only communications. And, mental health services can include services for treatment of substance use disorders (SUD). Please do not confuse modifier FQ with modifier 93 as FQ is only for behavioral health services. And, remember that the totality of the communication of information exchanged between the provider and the patient during the course of the synchronous telemedicine service (rendered via telephone or other real-time interactive audio only telecommunication system) must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction.

Teaching physician services

As a general rule, a teaching physician can bill for the resident services only if they are present for the critical (key) portion of the service. But, there is one exception called the “primary care exception” under which in certain teaching hospital primary care centers, the teaching physician can bill for certain services as furnished independently by the resident without the teaching physician being physically present, but with the teaching physician’s review.

The current model to bill for office/outpatient E/M visit level is either based on either total time spent (personally) or medical-decision-making (MDM). When time is used to select the visit level only the time spent by the teaching physician in qualifying activities can be included for the purposes of the visit level selection. And, this includes the time the teaching physician was present with the resident performing those qualifying activities. Also, under the primary care exception, time cannot be used to select the visit level. This is to guard against the possibility of inappropriate coding that reflects residents’ inefficiencies rather than a measure of the total medically necessary time required to furnish the E/M services.

ICD-10 updates

Usually, the ICD-10 codes are updated annually and take effect every October 1. Some of the most relevant updates are as follows:

1. U09.9 Post COVID-19 condition, unspecified: This should be used to document sequelae of COVID-19 or “long COVID” conditions, after the acute illness has resolved. But, remember to code the conditions related to COVID-19 first and do not use this code with an active or current COVID-19 infection.

2. U07.0 Vaping-related disorder: This should be used for all vaping-related illnesses. However, additional codes for other diagnoses such as acute respiratory failure, acute respiratory distress syndrome, or pneumonitis can also be used with this code. Other respiratory signs and symptoms such as cough and shortness of breath should not be coded separately.

3. Cough is one of the most common reasons for referral to a pulmonologist. The CDC has expanded these codes so please remember to code the most specific diagnosis as deemed appropriate.

R05.1 Acute cough

R05.2 Subacute cough

R05.3 Chronic cough

R05.4 Cough, syncope

R05.8 Other specified cough

R05.9 Cough, unspecified

We will be back with some more exciting and intriguing billing and coding updates in our next article and hope to see everyone at CHEST 2022 in Nashville., TN.

CHEST is proud to announce the launch of the newest addition to our e-learning options: the CHEST Asthma Curriculum Pathway.

This unique offering combines a variety of bite-sized educational resources from among CHEST’s most popular and effective products, including case-based CHEST SEEK™ questions, podcasts and videos from asthma experts, the latest research from the journal CHEST®, and more.

The pathway comprises several different “paths,” or tracks, that enable clinicians to target their education based on their knowledge gaps and career level. Users can opt to follow the curriculum from start to finish to gain a comprehensive overview of asthma management. Or, they can select individual paths to focus their learning on topics including asthma pathophysiology, diagnosis and classification, exacerbations, phenotypes, and more.

According to early learners of the pathway: “The multiple ways of looking at different therapies in the management of asthma was helpful in remembering the information. It helped a lot with the knowledge check-in.” Another commented: “It is very comprehensive on all aspects of asthma. I enjoyed the higher-level learning on the choice of biologics and asthma mimickers.” The education modalities were highlighted, as well, with this feedback: “I really enjoyed the variety of media (lectures, discussions, papers, games).”

Exploring the education

The Asthma Curriculum Pathway offers targeted education options to fit the career level and clinical interest of clinicians, ranging from trainees and early career physicians to experienced asthma specialists and advanced practice providers.

Paths include:

• Path 1: Pathophysiology

• Path 2: Diagnosis & Classification

• Path 3: Management

• Path 4: Mimickers

• Path 5: Comorbidities

• Path 6: Phenotypes

• Path 7: Exacerbations

• Path 8: Special Situations



Plus, each path offers claiming credit, including CME, for completion—all while driving clinicians to consistently advance best outcomes for their patients with asthma.

Visit (https://bit.ly/asthma-pathway) to access the best of CHEST’s asthma education with the new Asthma Curriculum Pathway, accessible via web or mobile device.

CHEST is proud to announce the launch of the newest addition to our e-learning options: the CHEST Asthma Curriculum Pathway.

This unique offering combines a variety of bite-sized educational resources from among CHEST’s most popular and effective products, including case-based CHEST SEEK™ questions, podcasts and videos from asthma experts, the latest research from the journal CHEST®, and more.

The pathway comprises several different “paths,” or tracks, that enable clinicians to target their education based on their knowledge gaps and career level. Users can opt to follow the curriculum from start to finish to gain a comprehensive overview of asthma management. Or, they can select individual paths to focus their learning on topics including asthma pathophysiology, diagnosis and classification, exacerbations, phenotypes, and more.

According to early learners of the pathway: “The multiple ways of looking at different therapies in the management of asthma was helpful in remembering the information. It helped a lot with the knowledge check-in.” Another commented: “It is very comprehensive on all aspects of asthma. I enjoyed the higher-level learning on the choice of biologics and asthma mimickers.” The education modalities were highlighted, as well, with this feedback: “I really enjoyed the variety of media (lectures, discussions, papers, games).”

Exploring the education

The Asthma Curriculum Pathway offers targeted education options to fit the career level and clinical interest of clinicians, ranging from trainees and early career physicians to experienced asthma specialists and advanced practice providers.

Paths include:

• Path 1: Pathophysiology

• Path 2: Diagnosis & Classification

• Path 3: Management

• Path 4: Mimickers

• Path 5: Comorbidities

• Path 6: Phenotypes

• Path 7: Exacerbations

• Path 8: Special Situations



Plus, each path offers claiming credit, including CME, for completion—all while driving clinicians to consistently advance best outcomes for their patients with asthma.

Visit (https://bit.ly/asthma-pathway) to access the best of CHEST’s asthma education with the new Asthma Curriculum Pathway, accessible via web or mobile device.

CHEST is proud to announce the launch of the newest addition to our e-learning options: the CHEST Asthma Curriculum Pathway.

This unique offering combines a variety of bite-sized educational resources from among CHEST’s most popular and effective products, including case-based CHEST SEEK™ questions, podcasts and videos from asthma experts, the latest research from the journal CHEST®, and more.

The pathway comprises several different “paths,” or tracks, that enable clinicians to target their education based on their knowledge gaps and career level. Users can opt to follow the curriculum from start to finish to gain a comprehensive overview of asthma management. Or, they can select individual paths to focus their learning on topics including asthma pathophysiology, diagnosis and classification, exacerbations, phenotypes, and more.

According to early learners of the pathway: “The multiple ways of looking at different therapies in the management of asthma was helpful in remembering the information. It helped a lot with the knowledge check-in.” Another commented: “It is very comprehensive on all aspects of asthma. I enjoyed the higher-level learning on the choice of biologics and asthma mimickers.” The education modalities were highlighted, as well, with this feedback: “I really enjoyed the variety of media (lectures, discussions, papers, games).”

Exploring the education

The Asthma Curriculum Pathway offers targeted education options to fit the career level and clinical interest of clinicians, ranging from trainees and early career physicians to experienced asthma specialists and advanced practice providers.

Paths include:

• Path 1: Pathophysiology

• Path 2: Diagnosis & Classification

• Path 3: Management

• Path 4: Mimickers

• Path 5: Comorbidities

• Path 6: Phenotypes

• Path 7: Exacerbations

• Path 8: Special Situations



Plus, each path offers claiming credit, including CME, for completion—all while driving clinicians to consistently advance best outcomes for their patients with asthma.

Visit (https://bit.ly/asthma-pathway) to access the best of CHEST’s asthma education with the new Asthma Curriculum Pathway, accessible via web or mobile device.

Point-of-care ultrasound (POCUS) is a useful, practice-changing bedside tool that spans all medical and surgical specialties. While the definition of POCUS varies, most would agree it is an abbreviated exam that helps to answer a specific clinical question. With the expansion of POCUS training, the clinical questions being asked and answered have increased in scope and volume. The types of exams being utilized in “point of care ultrasound” have also increased and include transthoracic echocardiography; trans-esophageal echocardiography; and lung, gastric, abdominal, and ocular ultrasound. POCUS is used across multiple specialties, including critical care, anesthesiology, emergency medicine, and primary care.

CHEST

Not only has POCUS become increasingly important clinically, but specialties now test these skills on their respective board examinations. Anesthesia is one of many such examples. The content outline for the American Board of Anesthesiology includes POCUS as a tested item on both the written and applied components of the exam. POCUS training must be directed toward both optimizing patient management and preparing learners for their board examination. A method for teaching this has yet to be defined (Naji A, et al. Cureus. 2021;13[5]:e15217).

One question – how should different specialties approach this educational challenge and should specialties train together? The answer is complicated. Many POCUS courses and certifications exist, and all vary in their content, didactics, and length. No true gold standard exists for POCUS certification for radiology or noncardiology providers. Additionally, there are no defined expectations or testing processes that certify a provider is “certified” to perform POCUS. While waiting for medical society guidelines to address these issues, many in graduate medical education (GME) are coming up with their own ways to incorporate POCUS into their respective training programs (Atkinson P, et al. CJEM. 2015 Mar;17[2]:161).

Who’s training whom?

Over the past decade, several expert committees, including those in critical care, have developed recommendations and consensus statements urging training facilities to independently create POCUS curriculums. The threshold for many programs to enter this realm of expertise is high and oftentimes unobtainable. We’ve seen emergency medicine and anesthesia raise the bar for ultrasound education in their residencies, but it’s unclear whether all fellowship-trained physicians can and should be tasked with obtaining official POCUS certification.

While specific specialties may require tailored certifications, there’s a considerable overlap in POCUS exam content across specialties. One approach to POCUS training could be developing and implementing a multidisciplinary curriculum. This would allow for pooling of resources (equipment, staff) and harnessing knowledge from providers familiar with different phases of patient care (ICU, perioperative, ED, outpatient clinics). By approaching POCUS from a multidisciplinary perspective, the quality of education may be enhanced (Mayo PH, et al. Intensive Care Med. 2014;40[5]:654). Is it then prudent for providers and trainees alike to share in didactics across all areas of the hospital and clinic? Would this close the knowledge gap between specialties who are facile with ultrasound and those not?

Determining the role of transesophageal echocardiography in a POCUS curriculum

This modality of imaging has been, until recently, reserved for cardiologists and anesthesiologists. More recently transesophageal echocardiography (TEE) has been utilized by emergency and critical care medicine physicians. TEE is part of recommended training for these specialties as a tool for diagnostic and rescue measures, including ventilator management, emergency procedures, and medication titration. Rescue TEE can also be utilized perioperatively where the transthoracic exam is limited by poor windows or the operative procedure precludes access to the chest. While transthoracic echocardiography (TTE) is often used in a point of care fashion, TEE is utilized less often. This may stem from the invasive nature of the procedure but likely also results from lack of equipment and training. Like POCUS overall, TEE POCUS will require incorporation into training programs to achieve widespread use and acceptance.

A deluge of research on TEE for the noncardiologist shows this modality is minimally invasive, safe, and effective. As it becomes more readily available and technology improves, there is no reason why an esophageal probe can’t be used in a patient with a secured airway (Wray TC, et al. J Intensive Care Med. 2021;36[1]:123).

Ultrasound for hemodynamic monitoring

There are many methods employed for hemodynamic monitoring in the ICU. Although echocardiographic and vascular parameters have been validated in the cardiac and perioperative fields, their application in the ICU setting for resuscitation and volume management remain somewhat controversial. The use of TEE and more advanced understanding of spectral doppler and pulmonary ultrasonography using TEE has revolutionized the way providers are managing critically ill patients. (Garcia YA, et al. Chest. 2017;152[4]:736).

In our opinion, physiology and imaging training for residents and fellows should be required for critical care medicine trainees. Delving into the nuances of frank-starling curves, stroke work, and diastolic function will enrich their understanding and highlight the applicability of ultrasonography. Furthermore, all clinicians caring for patients with critical illness should be privy to the nuances of physiologic derangement, and to that end, advanced echocardiographic principles and image acquisition. The heart-lung interactions are demonstrated in real time using POCUS and can clearly delineate treatment goals (Vieillard-Baron A, et al. Intensive Care Med. 2019;45[6]:770).

Documentation and billing

If clinicians are making medical decisions based off imaging gathered at the bedside and interpreted in real-time, documentation should reflect that. That documentation will invariably lead to billing and possibly audit or quality review by colleagues or other healthcare staff. Radiology and cardiology have perfected the billing process for image interpretation, but their form of documentation and interpretation may not easily be implemented in the perioperative or critical care settings. An abbreviated document with focused information should take the place of the formal study. With that, the credentialing and board certification process will allow providers to feel empowered to make clinical decisions based off these focused examinations.

Dr. Goertzen is Chief Fellow, Pulmonary/Critical Care; Dr. Knuf is Program Director, Department of Anesthesia; and Dr. Villalobos is Director of Medical ICU, Department of Internal Medicine, San Antonio Military Medical Center, San Antonio, Texas.

Point-of-care ultrasound (POCUS) is a useful, practice-changing bedside tool that spans all medical and surgical specialties. While the definition of POCUS varies, most would agree it is an abbreviated exam that helps to answer a specific clinical question. With the expansion of POCUS training, the clinical questions being asked and answered have increased in scope and volume. The types of exams being utilized in “point of care ultrasound” have also increased and include transthoracic echocardiography; trans-esophageal echocardiography; and lung, gastric, abdominal, and ocular ultrasound. POCUS is used across multiple specialties, including critical care, anesthesiology, emergency medicine, and primary care.

CHEST

Not only has POCUS become increasingly important clinically, but specialties now test these skills on their respective board examinations. Anesthesia is one of many such examples. The content outline for the American Board of Anesthesiology includes POCUS as a tested item on both the written and applied components of the exam. POCUS training must be directed toward both optimizing patient management and preparing learners for their board examination. A method for teaching this has yet to be defined (Naji A, et al. Cureus. 2021;13[5]:e15217).

One question – how should different specialties approach this educational challenge and should specialties train together? The answer is complicated. Many POCUS courses and certifications exist, and all vary in their content, didactics, and length. No true gold standard exists for POCUS certification for radiology or noncardiology providers. Additionally, there are no defined expectations or testing processes that certify a provider is “certified” to perform POCUS. While waiting for medical society guidelines to address these issues, many in graduate medical education (GME) are coming up with their own ways to incorporate POCUS into their respective training programs (Atkinson P, et al. CJEM. 2015 Mar;17[2]:161).

Who’s training whom?

Over the past decade, several expert committees, including those in critical care, have developed recommendations and consensus statements urging training facilities to independently create POCUS curriculums. The threshold for many programs to enter this realm of expertise is high and oftentimes unobtainable. We’ve seen emergency medicine and anesthesia raise the bar for ultrasound education in their residencies, but it’s unclear whether all fellowship-trained physicians can and should be tasked with obtaining official POCUS certification.

While specific specialties may require tailored certifications, there’s a considerable overlap in POCUS exam content across specialties. One approach to POCUS training could be developing and implementing a multidisciplinary curriculum. This would allow for pooling of resources (equipment, staff) and harnessing knowledge from providers familiar with different phases of patient care (ICU, perioperative, ED, outpatient clinics). By approaching POCUS from a multidisciplinary perspective, the quality of education may be enhanced (Mayo PH, et al. Intensive Care Med. 2014;40[5]:654). Is it then prudent for providers and trainees alike to share in didactics across all areas of the hospital and clinic? Would this close the knowledge gap between specialties who are facile with ultrasound and those not?

Determining the role of transesophageal echocardiography in a POCUS curriculum

This modality of imaging has been, until recently, reserved for cardiologists and anesthesiologists. More recently transesophageal echocardiography (TEE) has been utilized by emergency and critical care medicine physicians. TEE is part of recommended training for these specialties as a tool for diagnostic and rescue measures, including ventilator management, emergency procedures, and medication titration. Rescue TEE can also be utilized perioperatively where the transthoracic exam is limited by poor windows or the operative procedure precludes access to the chest. While transthoracic echocardiography (TTE) is often used in a point of care fashion, TEE is utilized less often. This may stem from the invasive nature of the procedure but likely also results from lack of equipment and training. Like POCUS overall, TEE POCUS will require incorporation into training programs to achieve widespread use and acceptance.

A deluge of research on TEE for the noncardiologist shows this modality is minimally invasive, safe, and effective. As it becomes more readily available and technology improves, there is no reason why an esophageal probe can’t be used in a patient with a secured airway (Wray TC, et al. J Intensive Care Med. 2021;36[1]:123).

Ultrasound for hemodynamic monitoring

There are many methods employed for hemodynamic monitoring in the ICU. Although echocardiographic and vascular parameters have been validated in the cardiac and perioperative fields, their application in the ICU setting for resuscitation and volume management remain somewhat controversial. The use of TEE and more advanced understanding of spectral doppler and pulmonary ultrasonography using TEE has revolutionized the way providers are managing critically ill patients. (Garcia YA, et al. Chest. 2017;152[4]:736).

In our opinion, physiology and imaging training for residents and fellows should be required for critical care medicine trainees. Delving into the nuances of frank-starling curves, stroke work, and diastolic function will enrich their understanding and highlight the applicability of ultrasonography. Furthermore, all clinicians caring for patients with critical illness should be privy to the nuances of physiologic derangement, and to that end, advanced echocardiographic principles and image acquisition. The heart-lung interactions are demonstrated in real time using POCUS and can clearly delineate treatment goals (Vieillard-Baron A, et al. Intensive Care Med. 2019;45[6]:770).

Documentation and billing

If clinicians are making medical decisions based off imaging gathered at the bedside and interpreted in real-time, documentation should reflect that. That documentation will invariably lead to billing and possibly audit or quality review by colleagues or other healthcare staff. Radiology and cardiology have perfected the billing process for image interpretation, but their form of documentation and interpretation may not easily be implemented in the perioperative or critical care settings. An abbreviated document with focused information should take the place of the formal study. With that, the credentialing and board certification process will allow providers to feel empowered to make clinical decisions based off these focused examinations.

Dr. Goertzen is Chief Fellow, Pulmonary/Critical Care; Dr. Knuf is Program Director, Department of Anesthesia; and Dr. Villalobos is Director of Medical ICU, Department of Internal Medicine, San Antonio Military Medical Center, San Antonio, Texas.

Point-of-care ultrasound (POCUS) is a useful, practice-changing bedside tool that spans all medical and surgical specialties. While the definition of POCUS varies, most would agree it is an abbreviated exam that helps to answer a specific clinical question. With the expansion of POCUS training, the clinical questions being asked and answered have increased in scope and volume. The types of exams being utilized in “point of care ultrasound” have also increased and include transthoracic echocardiography; trans-esophageal echocardiography; and lung, gastric, abdominal, and ocular ultrasound. POCUS is used across multiple specialties, including critical care, anesthesiology, emergency medicine, and primary care.

CHEST

Not only has POCUS become increasingly important clinically, but specialties now test these skills on their respective board examinations. Anesthesia is one of many such examples. The content outline for the American Board of Anesthesiology includes POCUS as a tested item on both the written and applied components of the exam. POCUS training must be directed toward both optimizing patient management and preparing learners for their board examination. A method for teaching this has yet to be defined (Naji A, et al. Cureus. 2021;13[5]:e15217).

One question – how should different specialties approach this educational challenge and should specialties train together? The answer is complicated. Many POCUS courses and certifications exist, and all vary in their content, didactics, and length. No true gold standard exists for POCUS certification for radiology or noncardiology providers. Additionally, there are no defined expectations or testing processes that certify a provider is “certified” to perform POCUS. While waiting for medical society guidelines to address these issues, many in graduate medical education (GME) are coming up with their own ways to incorporate POCUS into their respective training programs (Atkinson P, et al. CJEM. 2015 Mar;17[2]:161).

Who’s training whom?

Over the past decade, several expert committees, including those in critical care, have developed recommendations and consensus statements urging training facilities to independently create POCUS curriculums. The threshold for many programs to enter this realm of expertise is high and oftentimes unobtainable. We’ve seen emergency medicine and anesthesia raise the bar for ultrasound education in their residencies, but it’s unclear whether all fellowship-trained physicians can and should be tasked with obtaining official POCUS certification.

While specific specialties may require tailored certifications, there’s a considerable overlap in POCUS exam content across specialties. One approach to POCUS training could be developing and implementing a multidisciplinary curriculum. This would allow for pooling of resources (equipment, staff) and harnessing knowledge from providers familiar with different phases of patient care (ICU, perioperative, ED, outpatient clinics). By approaching POCUS from a multidisciplinary perspective, the quality of education may be enhanced (Mayo PH, et al. Intensive Care Med. 2014;40[5]:654). Is it then prudent for providers and trainees alike to share in didactics across all areas of the hospital and clinic? Would this close the knowledge gap between specialties who are facile with ultrasound and those not?

Determining the role of transesophageal echocardiography in a POCUS curriculum

This modality of imaging has been, until recently, reserved for cardiologists and anesthesiologists. More recently transesophageal echocardiography (TEE) has been utilized by emergency and critical care medicine physicians. TEE is part of recommended training for these specialties as a tool for diagnostic and rescue measures, including ventilator management, emergency procedures, and medication titration. Rescue TEE can also be utilized perioperatively where the transthoracic exam is limited by poor windows or the operative procedure precludes access to the chest. While transthoracic echocardiography (TTE) is often used in a point of care fashion, TEE is utilized less often. This may stem from the invasive nature of the procedure but likely also results from lack of equipment and training. Like POCUS overall, TEE POCUS will require incorporation into training programs to achieve widespread use and acceptance.

A deluge of research on TEE for the noncardiologist shows this modality is minimally invasive, safe, and effective. As it becomes more readily available and technology improves, there is no reason why an esophageal probe can’t be used in a patient with a secured airway (Wray TC, et al. J Intensive Care Med. 2021;36[1]:123).

Ultrasound for hemodynamic monitoring

There are many methods employed for hemodynamic monitoring in the ICU. Although echocardiographic and vascular parameters have been validated in the cardiac and perioperative fields, their application in the ICU setting for resuscitation and volume management remain somewhat controversial. The use of TEE and more advanced understanding of spectral doppler and pulmonary ultrasonography using TEE has revolutionized the way providers are managing critically ill patients. (Garcia YA, et al. Chest. 2017;152[4]:736).

In our opinion, physiology and imaging training for residents and fellows should be required for critical care medicine trainees. Delving into the nuances of frank-starling curves, stroke work, and diastolic function will enrich their understanding and highlight the applicability of ultrasonography. Furthermore, all clinicians caring for patients with critical illness should be privy to the nuances of physiologic derangement, and to that end, advanced echocardiographic principles and image acquisition. The heart-lung interactions are demonstrated in real time using POCUS and can clearly delineate treatment goals (Vieillard-Baron A, et al. Intensive Care Med. 2019;45[6]:770).

Documentation and billing

If clinicians are making medical decisions based off imaging gathered at the bedside and interpreted in real-time, documentation should reflect that. That documentation will invariably lead to billing and possibly audit or quality review by colleagues or other healthcare staff. Radiology and cardiology have perfected the billing process for image interpretation, but their form of documentation and interpretation may not easily be implemented in the perioperative or critical care settings. An abbreviated document with focused information should take the place of the formal study. With that, the credentialing and board certification process will allow providers to feel empowered to make clinical decisions based off these focused examinations.

Dr. Goertzen is Chief Fellow, Pulmonary/Critical Care; Dr. Knuf is Program Director, Department of Anesthesia; and Dr. Villalobos is Director of Medical ICU, Department of Internal Medicine, San Antonio Military Medical Center, San Antonio, Texas.

As the presidency of the American College of Chest Physicians changes hands in January 2023, so will the role of President of the CHEST Foundation. To get to know the incoming President of the CHEST Foundation, we spoke with Robert (Bob) De Marco, MD, FCCP, about his philanthropy work and his goals for the philanthropic arm of CHEST.

Tell me about your history with philanthropy work.

My philanthropy work started long before the CHEST Foundation. While I’ve been a member of CHEST since my second year of fellowship, it wasn’t until much later that I became involved with the philanthropic side of the organization. Earlier in my career, I was involved more so with the American Cancer Society. I had gotten involved with them by chance – participating in an event of theirs – and was encouraged to get more involved by one of their board members. Being involved with them made a lot of sense seeing as a strong percentage of my patients at the time were being treated for lung cancer. My most notable accomplishments with the American Cancer Society were in serving as the Chairmen of my local Relay for Life program for 10 years, as a board member, and then as a president of my local chapter.



When did you get involved with the CHEST Foundation?

I had served in a handful of positions within CHEST, including Chair of the (since reinvented) Practice Management Committee, so I was deeply involved in the association, and I thought to myself, “I have experience in fundraising through my work with the American Cancer Society, why don’t I use it to help our association?” When I moved to Florida, I no longer had the local connection to the American Cancer Society, so it was an opportune time to transition over to the CHEST Foundation.

How has the Foundation changed in the time that you’ve been involved?

The Foundation has changed drastically since I first joined the Board of Trustees 9 years ago. When I first got involved, the primary goal of the Foundation was staying “out of the red.” At that time, we were an organization that gave away more than we made.

After years of building a corpus to fund our own projects, we’re in a really good place now with some phenomenal goals and some excellent initiatives to fundraise around, including a CHEST diversity initiative, First 5 Minutes™, and Bridging Specialties™: Timely Diagnosis for ILD Patients, which seeks to break down silos within medicine to improve patient care.

What will be a focus of your Foundation presidency?

You know, one thing I always appreciated about the American Cancer Society was that there were always notable accomplishments to point back to when supporting fundraising efforts. You could say, “Did you know that bone marrow transplantation was initially funded by the American Cancer Society?” and other examples that would truly inspire someone to want to get involved in supporting those efforts.

The CHEST Foundation may not have funded bone marrow transplantation, but in 25 years of awarding grants, there are equally good stories to share. The impact of the Foundation is tremendous, and we’ve only just begun to share examples of where grant recipients went with their research or community service projects.

A recent grant story that was shared with me was that of Panagis Galiatsatos, MD, MHS, who received a community service grant to start a program educating children in the Baltimore community about lung health. This program was so moving that it inspired one of the Baltimore teachers to pursue a career in medicine and that individual is now a practicing MD.

This is just one example of the Foundation’s impact and it’s through these stories that we share the “why” behind every dollar that is raised, and my first goal is to tell these stories.

Another key focus of not only my presidency, but Dr. Ian Nathanson’s, as well, as we collaborated a lot on our roles, will be on member involvement and awareness. Even I wasn’t involved in the CHEST Foundation until years into my CHEST membership, so I understand that there are competing demands. But I also know that there is a lot to be gained from the work with the Foundation. I want the CHEST members to be excited about the Foundation and to want to support its efforts.

These two goals go hand in hand, and I look forward to sharing the Foundation’s impact with a new audience and reinvigorating the support of our existing donors.

Is there anything else you’d like to say to the reader?

We cannot accomplish anything without the support of our donors, and I want to sincerely thank everyone who has donated to the CHEST Foundation. I also encourage those who have never donated or have yet to donate this year to visit the Foundation’s website (foundation.chestnet.org) and explore some of the inspiring initiatives you can support to strengthen the impact of the CHEST Foundation because the possibilities are truly endless.

As the presidency of the American College of Chest Physicians changes hands in January 2023, so will the role of President of the CHEST Foundation. To get to know the incoming President of the CHEST Foundation, we spoke with Robert (Bob) De Marco, MD, FCCP, about his philanthropy work and his goals for the philanthropic arm of CHEST.

Tell me about your history with philanthropy work.

My philanthropy work started long before the CHEST Foundation. While I’ve been a member of CHEST since my second year of fellowship, it wasn’t until much later that I became involved with the philanthropic side of the organization. Earlier in my career, I was involved more so with the American Cancer Society. I had gotten involved with them by chance – participating in an event of theirs – and was encouraged to get more involved by one of their board members. Being involved with them made a lot of sense seeing as a strong percentage of my patients at the time were being treated for lung cancer. My most notable accomplishments with the American Cancer Society were in serving as the Chairmen of my local Relay for Life program for 10 years, as a board member, and then as a president of my local chapter.



When did you get involved with the CHEST Foundation?

I had served in a handful of positions within CHEST, including Chair of the (since reinvented) Practice Management Committee, so I was deeply involved in the association, and I thought to myself, “I have experience in fundraising through my work with the American Cancer Society, why don’t I use it to help our association?” When I moved to Florida, I no longer had the local connection to the American Cancer Society, so it was an opportune time to transition over to the CHEST Foundation.

How has the Foundation changed in the time that you’ve been involved?

The Foundation has changed drastically since I first joined the Board of Trustees 9 years ago. When I first got involved, the primary goal of the Foundation was staying “out of the red.” At that time, we were an organization that gave away more than we made.

After years of building a corpus to fund our own projects, we’re in a really good place now with some phenomenal goals and some excellent initiatives to fundraise around, including a CHEST diversity initiative, First 5 Minutes™, and Bridging Specialties™: Timely Diagnosis for ILD Patients, which seeks to break down silos within medicine to improve patient care.

What will be a focus of your Foundation presidency?

You know, one thing I always appreciated about the American Cancer Society was that there were always notable accomplishments to point back to when supporting fundraising efforts. You could say, “Did you know that bone marrow transplantation was initially funded by the American Cancer Society?” and other examples that would truly inspire someone to want to get involved in supporting those efforts.

The CHEST Foundation may not have funded bone marrow transplantation, but in 25 years of awarding grants, there are equally good stories to share. The impact of the Foundation is tremendous, and we’ve only just begun to share examples of where grant recipients went with their research or community service projects.

A recent grant story that was shared with me was that of Panagis Galiatsatos, MD, MHS, who received a community service grant to start a program educating children in the Baltimore community about lung health. This program was so moving that it inspired one of the Baltimore teachers to pursue a career in medicine and that individual is now a practicing MD.

This is just one example of the Foundation’s impact and it’s through these stories that we share the “why” behind every dollar that is raised, and my first goal is to tell these stories.

Another key focus of not only my presidency, but Dr. Ian Nathanson’s, as well, as we collaborated a lot on our roles, will be on member involvement and awareness. Even I wasn’t involved in the CHEST Foundation until years into my CHEST membership, so I understand that there are competing demands. But I also know that there is a lot to be gained from the work with the Foundation. I want the CHEST members to be excited about the Foundation and to want to support its efforts.

These two goals go hand in hand, and I look forward to sharing the Foundation’s impact with a new audience and reinvigorating the support of our existing donors.

Is there anything else you’d like to say to the reader?

We cannot accomplish anything without the support of our donors, and I want to sincerely thank everyone who has donated to the CHEST Foundation. I also encourage those who have never donated or have yet to donate this year to visit the Foundation’s website (foundation.chestnet.org) and explore some of the inspiring initiatives you can support to strengthen the impact of the CHEST Foundation because the possibilities are truly endless.

As the presidency of the American College of Chest Physicians changes hands in January 2023, so will the role of President of the CHEST Foundation. To get to know the incoming President of the CHEST Foundation, we spoke with Robert (Bob) De Marco, MD, FCCP, about his philanthropy work and his goals for the philanthropic arm of CHEST.

Tell me about your history with philanthropy work.

My philanthropy work started long before the CHEST Foundation. While I’ve been a member of CHEST since my second year of fellowship, it wasn’t until much later that I became involved with the philanthropic side of the organization. Earlier in my career, I was involved more so with the American Cancer Society. I had gotten involved with them by chance – participating in an event of theirs – and was encouraged to get more involved by one of their board members. Being involved with them made a lot of sense seeing as a strong percentage of my patients at the time were being treated for lung cancer. My most notable accomplishments with the American Cancer Society were in serving as the Chairmen of my local Relay for Life program for 10 years, as a board member, and then as a president of my local chapter.



When did you get involved with the CHEST Foundation?

I had served in a handful of positions within CHEST, including Chair of the (since reinvented) Practice Management Committee, so I was deeply involved in the association, and I thought to myself, “I have experience in fundraising through my work with the American Cancer Society, why don’t I use it to help our association?” When I moved to Florida, I no longer had the local connection to the American Cancer Society, so it was an opportune time to transition over to the CHEST Foundation.

How has the Foundation changed in the time that you’ve been involved?

The Foundation has changed drastically since I first joined the Board of Trustees 9 years ago. When I first got involved, the primary goal of the Foundation was staying “out of the red.” At that time, we were an organization that gave away more than we made.

After years of building a corpus to fund our own projects, we’re in a really good place now with some phenomenal goals and some excellent initiatives to fundraise around, including a CHEST diversity initiative, First 5 Minutes™, and Bridging Specialties™: Timely Diagnosis for ILD Patients, which seeks to break down silos within medicine to improve patient care.

What will be a focus of your Foundation presidency?

You know, one thing I always appreciated about the American Cancer Society was that there were always notable accomplishments to point back to when supporting fundraising efforts. You could say, “Did you know that bone marrow transplantation was initially funded by the American Cancer Society?” and other examples that would truly inspire someone to want to get involved in supporting those efforts.

The CHEST Foundation may not have funded bone marrow transplantation, but in 25 years of awarding grants, there are equally good stories to share. The impact of the Foundation is tremendous, and we’ve only just begun to share examples of where grant recipients went with their research or community service projects.

A recent grant story that was shared with me was that of Panagis Galiatsatos, MD, MHS, who received a community service grant to start a program educating children in the Baltimore community about lung health. This program was so moving that it inspired one of the Baltimore teachers to pursue a career in medicine and that individual is now a practicing MD.

This is just one example of the Foundation’s impact and it’s through these stories that we share the “why” behind every dollar that is raised, and my first goal is to tell these stories.

Another key focus of not only my presidency, but Dr. Ian Nathanson’s, as well, as we collaborated a lot on our roles, will be on member involvement and awareness. Even I wasn’t involved in the CHEST Foundation until years into my CHEST membership, so I understand that there are competing demands. But I also know that there is a lot to be gained from the work with the Foundation. I want the CHEST members to be excited about the Foundation and to want to support its efforts.

These two goals go hand in hand, and I look forward to sharing the Foundation’s impact with a new audience and reinvigorating the support of our existing donors.

Is there anything else you’d like to say to the reader?

We cannot accomplish anything without the support of our donors, and I want to sincerely thank everyone who has donated to the CHEST Foundation. I also encourage those who have never donated or have yet to donate this year to visit the Foundation’s website (foundation.chestnet.org) and explore some of the inspiring initiatives you can support to strengthen the impact of the CHEST Foundation because the possibilities are truly endless.

Practice Gap

One of the most important elements of successful reconstruction is effective undermining prior to placement of buried sutures. The main benefit of an evenly undermined plane is that tension is reduced, thus permitting seamless tissue mobilization and wound edge approximation.¹

However, achieving a consistent and appropriate plane can present challenges in certain blind spots within one’s field of work. A right hand–dominant surgeon might find it difficult to undermine tissue between the 3-o’clock and 6-o’clock positions (Figure 1) and often must resort to unnatural positioning to obtain adequate reach.

We propose a technique of reversing the grip on undermining scissors that improves efficiency without sacrificing technique.

Technique

The surgeon simply grasps the ring handles with the ring finger and thumb with the tip pointing to the wrist (Figure 2). Most of the control comes from rotating the wrist while spreading with the thumb (Figure 3).

The main advantage of the reverse-grip technique is that it prevents abduction of the arm at the shoulder joint, which reduces shoulder fatigue and keeps the elbow close to the trunk and away from the sterile surgical field. Achieving optimal ergonomics during surgery has been shown to reduce pain and likely prolong the surgeon’s career.²

A limitation of the reverse-grip technique is that direct visualization of the undermining plane is not achieved; however, direct visualization also is not obtained when undermining in the standard fashion unless the instruments are passed to the surgical assistant or the surgeon moves to the other side of the table.

Undermining can be performed safely without direct visualization as long as several rules are followed:

• The undermining plane is first established under direct visualization on the far side of the wound—at the 6-o’clock to 12-o’clock positions—and then followed to the area where direct visualization is not obtained.

• A blunt-tipped scissor is used to prevent penetrating trauma to neurovascular bundles. Blunt-tipped instruments allow more “feel” through tactile feedback to the surgeon and prevent accidental injury to these critical structures.

• A curved scissor is used with “tips up,” such that the surgeon does not unintentionally make the undermining plane deeper than anticipated.

Practice Implications

With practice, one can perform circumferential undermining independently with few alterations in stance and while maintaining a natural position throughout. Use of skin hooks to elevate the skin can further aid in visualizing the correct depth of undermining. If executed correctly, the reverse-grip technique can expand the surgeon’s work field, thus providing ease of dissection in difficult-to-reach areas.

Practice Gap

One of the most important elements of successful reconstruction is effective undermining prior to placement of buried sutures. The main benefit of an evenly undermined plane is that tension is reduced, thus permitting seamless tissue mobilization and wound edge approximation.¹

However, achieving a consistent and appropriate plane can present challenges in certain blind spots within one’s field of work. A right hand–dominant surgeon might find it difficult to undermine tissue between the 3-o’clock and 6-o’clock positions (Figure 1) and often must resort to unnatural positioning to obtain adequate reach.

We propose a technique of reversing the grip on undermining scissors that improves efficiency without sacrificing technique.

Technique

The surgeon simply grasps the ring handles with the ring finger and thumb with the tip pointing to the wrist (Figure 2). Most of the control comes from rotating the wrist while spreading with the thumb (Figure 3).

The main advantage of the reverse-grip technique is that it prevents abduction of the arm at the shoulder joint, which reduces shoulder fatigue and keeps the elbow close to the trunk and away from the sterile surgical field. Achieving optimal ergonomics during surgery has been shown to reduce pain and likely prolong the surgeon’s career.²

A limitation of the reverse-grip technique is that direct visualization of the undermining plane is not achieved; however, direct visualization also is not obtained when undermining in the standard fashion unless the instruments are passed to the surgical assistant or the surgeon moves to the other side of the table.

Undermining can be performed safely without direct visualization as long as several rules are followed:

• The undermining plane is first established under direct visualization on the far side of the wound—at the 6-o’clock to 12-o’clock positions—and then followed to the area where direct visualization is not obtained.

• A blunt-tipped scissor is used to prevent penetrating trauma to neurovascular bundles. Blunt-tipped instruments allow more “feel” through tactile feedback to the surgeon and prevent accidental injury to these critical structures.

• A curved scissor is used with “tips up,” such that the surgeon does not unintentionally make the undermining plane deeper than anticipated.

Practice Implications

With practice, one can perform circumferential undermining independently with few alterations in stance and while maintaining a natural position throughout. Use of skin hooks to elevate the skin can further aid in visualizing the correct depth of undermining. If executed correctly, the reverse-grip technique can expand the surgeon’s work field, thus providing ease of dissection in difficult-to-reach areas.

Practice Gap

One of the most important elements of successful reconstruction is effective undermining prior to placement of buried sutures. The main benefit of an evenly undermined plane is that tension is reduced, thus permitting seamless tissue mobilization and wound edge approximation.¹

However, achieving a consistent and appropriate plane can present challenges in certain blind spots within one’s field of work. A right hand–dominant surgeon might find it difficult to undermine tissue between the 3-o’clock and 6-o’clock positions (Figure 1) and often must resort to unnatural positioning to obtain adequate reach.

We propose a technique of reversing the grip on undermining scissors that improves efficiency without sacrificing technique.

Technique

The surgeon simply grasps the ring handles with the ring finger and thumb with the tip pointing to the wrist (Figure 2). Most of the control comes from rotating the wrist while spreading with the thumb (Figure 3).

The main advantage of the reverse-grip technique is that it prevents abduction of the arm at the shoulder joint, which reduces shoulder fatigue and keeps the elbow close to the trunk and away from the sterile surgical field. Achieving optimal ergonomics during surgery has been shown to reduce pain and likely prolong the surgeon’s career.²

A limitation of the reverse-grip technique is that direct visualization of the undermining plane is not achieved; however, direct visualization also is not obtained when undermining in the standard fashion unless the instruments are passed to the surgical assistant or the surgeon moves to the other side of the table.

Undermining can be performed safely without direct visualization as long as several rules are followed:

• The undermining plane is first established under direct visualization on the far side of the wound—at the 6-o’clock to 12-o’clock positions—and then followed to the area where direct visualization is not obtained.

• A blunt-tipped scissor is used to prevent penetrating trauma to neurovascular bundles. Blunt-tipped instruments allow more “feel” through tactile feedback to the surgeon and prevent accidental injury to these critical structures.

• A curved scissor is used with “tips up,” such that the surgeon does not unintentionally make the undermining plane deeper than anticipated.

Practice Implications

With practice, one can perform circumferential undermining independently with few alterations in stance and while maintaining a natural position throughout. Use of skin hooks to elevate the skin can further aid in visualizing the correct depth of undermining. If executed correctly, the reverse-grip technique can expand the surgeon’s work field, thus providing ease of dissection in difficult-to-reach areas.

To the Editor:

Brodalumab, a monoclonal antibody targeting IL-17RA, was approved by the US Food and Drug Administration (FDA) in 2017 for the treatment of moderate to severe chronic plaque psoriasis. The drug is the only biologic agent available for the treatment of psoriasis for which a psoriasis area severity index score of 100 is a primary end point.^1,2 Brodalumab is associated with an FDA boxed warning due to an increased risk for suicidal ideation and behavior (SIB), including completed suicides, during clinical trials.

We sought to characterize national utilization of this effective yet underutilized drug among Medicare beneficiaries by surveying the Medicare Part D Prescriber dataset.³ We tabulated brodalumab utilization statistics and characteristics of high-volume prescribers who had 11 or more annual claims for brodalumab.

Despite its associated boxed warning, the number of Medicare D claims for brodalumab increased by 1756 from 2017 to 2019, surpassing $7 million in costs by 2019. The number of beneficiaries also increased from 11 to 292—a 415.2% annual increase in beneficiaries for whom brodalumab was prescribed (Table 1).

In addition, states in the West and South had the highest utilization rates of brodalumab in 2019. There also was an increasing trend toward high-volume prescribers of brodalumab, with private practice clinicians constituting the majority (Table 2).

There was a substantial increase in advanced practice providers including nurse practitioners and physician assistants who were brodalumab prescribers. Although this trend might promote greater access to brodalumab, it is vital to ensure that advanced practice providers receive targeted training to properly understand the complexities of treatment with brodalumab.

Although the utilization of brodalumab has increased since 2017 (P<.001), it is still underutilized compared to the other IL-17 inhibitors secukinumab and ixekizumab. Secukinumab was FDA approved for the treatment of moderate to severe plaque psoriasis in 2015, followed by ixekizumab in 2016.⁴

According to the Medicare Part D database, both secukinumab and ixekizumab had a higher number of total claims and prescribers compared to brodalumab in the years of their debut.³ In 2015, there were 3593 claims for and 862 prescribers of secukinumab; in 2016, there were 1731 claims for and 681 prescribers of ixekizumab. In contrast, there were only 29 claims for and 11 prescribers of brodalumab in 2017, the year that the drug was approved by the FDA. During the same 3-year period, secukinumab and ixekizumab had a substantially greater number of claims—totals of 176,823 and 55,289, respectively—than brodalumab. The higher number of claims for secukinumab and ixekizumab compared to brodalumab may reflect clinicians’ increasing confidence in prescribing those drugs, given their long-term safety and efficacy. In addition, secukinumab and ixekizumab do not require completion of a Risk Evaluation and Mitigation Strategy (REMS) program, which makes them more readily prescribable.³

Overall, most experts agree that there is no increase in the risk for suicide associated with brodalumab compared to the general population. A 2-year pharmacovigilance report on brodalumab supports the safety of this drug.⁵ All participants who completed suicide during the clinical trials harbored an underlying psychiatric disorder or stressor(s).⁶

Although causation between brodalumab and SIB has not been demonstrated, it remains imperative that prescribers diligently assess patients’ risk of SIB and subsequently their access to appropriate psychiatric services as a precaution, if necessary. This is particularly important for private practice prescribers, who constitute the majority of Medicare D brodalumab claims, because they must ensure collaboration with a multidisciplinary team involving mental health providers. Lastly, considering that the highest number of brodalumab Medicare D claims were in western and southern states, it is critical to note that those 2 regions also harbor comparatively fewer mental health facilities that accept Medicare than other regions of the country.⁷ Prescribers in western and southern states must be mindful of mental health coverage limitations when treating psoriasis patients with brodalumab.

The increase in the number of claims, beneficiaries, and prescribers of brodalumab during its first 3 years of availability might be attributed to its efficacy and safety. On the other hand, the boxed warning and REMS associated with brodalumab might have led to underutilization of this drug compared to other IL-17 inhibitors.

Our analysis is limited by its representative restriction to Medicare patients. There also are limited data on brodalumab given its novelty. Individual attributes of prescribers with fewer than 11 annual claims for brodalumab could not be obtained because of dataset regulations; however, aggregated utilization statistics provide an indication of brodalumab prescribing patterns among all providers. Furthermore, during this analysis, data on the Medicare D database were limited to 2013 through 2020. Studies are needed to determine prescribing patterns of brodalumab since this study period.

To the Editor:

Brodalumab, a monoclonal antibody targeting IL-17RA, was approved by the US Food and Drug Administration (FDA) in 2017 for the treatment of moderate to severe chronic plaque psoriasis. The drug is the only biologic agent available for the treatment of psoriasis for which a psoriasis area severity index score of 100 is a primary end point.^1,2 Brodalumab is associated with an FDA boxed warning due to an increased risk for suicidal ideation and behavior (SIB), including completed suicides, during clinical trials.

We sought to characterize national utilization of this effective yet underutilized drug among Medicare beneficiaries by surveying the Medicare Part D Prescriber dataset.³ We tabulated brodalumab utilization statistics and characteristics of high-volume prescribers who had 11 or more annual claims for brodalumab.

Despite its associated boxed warning, the number of Medicare D claims for brodalumab increased by 1756 from 2017 to 2019, surpassing $7 million in costs by 2019. The number of beneficiaries also increased from 11 to 292—a 415.2% annual increase in beneficiaries for whom brodalumab was prescribed (Table 1).

In addition, states in the West and South had the highest utilization rates of brodalumab in 2019. There also was an increasing trend toward high-volume prescribers of brodalumab, with private practice clinicians constituting the majority (Table 2).

There was a substantial increase in advanced practice providers including nurse practitioners and physician assistants who were brodalumab prescribers. Although this trend might promote greater access to brodalumab, it is vital to ensure that advanced practice providers receive targeted training to properly understand the complexities of treatment with brodalumab.

Although the utilization of brodalumab has increased since 2017 (P<.001), it is still underutilized compared to the other IL-17 inhibitors secukinumab and ixekizumab. Secukinumab was FDA approved for the treatment of moderate to severe plaque psoriasis in 2015, followed by ixekizumab in 2016.⁴

According to the Medicare Part D database, both secukinumab and ixekizumab had a higher number of total claims and prescribers compared to brodalumab in the years of their debut.³ In 2015, there were 3593 claims for and 862 prescribers of secukinumab; in 2016, there were 1731 claims for and 681 prescribers of ixekizumab. In contrast, there were only 29 claims for and 11 prescribers of brodalumab in 2017, the year that the drug was approved by the FDA. During the same 3-year period, secukinumab and ixekizumab had a substantially greater number of claims—totals of 176,823 and 55,289, respectively—than brodalumab. The higher number of claims for secukinumab and ixekizumab compared to brodalumab may reflect clinicians’ increasing confidence in prescribing those drugs, given their long-term safety and efficacy. In addition, secukinumab and ixekizumab do not require completion of a Risk Evaluation and Mitigation Strategy (REMS) program, which makes them more readily prescribable.³

Overall, most experts agree that there is no increase in the risk for suicide associated with brodalumab compared to the general population. A 2-year pharmacovigilance report on brodalumab supports the safety of this drug.⁵ All participants who completed suicide during the clinical trials harbored an underlying psychiatric disorder or stressor(s).⁶

Although causation between brodalumab and SIB has not been demonstrated, it remains imperative that prescribers diligently assess patients’ risk of SIB and subsequently their access to appropriate psychiatric services as a precaution, if necessary. This is particularly important for private practice prescribers, who constitute the majority of Medicare D brodalumab claims, because they must ensure collaboration with a multidisciplinary team involving mental health providers. Lastly, considering that the highest number of brodalumab Medicare D claims were in western and southern states, it is critical to note that those 2 regions also harbor comparatively fewer mental health facilities that accept Medicare than other regions of the country.⁷ Prescribers in western and southern states must be mindful of mental health coverage limitations when treating psoriasis patients with brodalumab.

The increase in the number of claims, beneficiaries, and prescribers of brodalumab during its first 3 years of availability might be attributed to its efficacy and safety. On the other hand, the boxed warning and REMS associated with brodalumab might have led to underutilization of this drug compared to other IL-17 inhibitors.

Our analysis is limited by its representative restriction to Medicare patients. There also are limited data on brodalumab given its novelty. Individual attributes of prescribers with fewer than 11 annual claims for brodalumab could not be obtained because of dataset regulations; however, aggregated utilization statistics provide an indication of brodalumab prescribing patterns among all providers. Furthermore, during this analysis, data on the Medicare D database were limited to 2013 through 2020. Studies are needed to determine prescribing patterns of brodalumab since this study period.

To the Editor:

Brodalumab, a monoclonal antibody targeting IL-17RA, was approved by the US Food and Drug Administration (FDA) in 2017 for the treatment of moderate to severe chronic plaque psoriasis. The drug is the only biologic agent available for the treatment of psoriasis for which a psoriasis area severity index score of 100 is a primary end point.^1,2 Brodalumab is associated with an FDA boxed warning due to an increased risk for suicidal ideation and behavior (SIB), including completed suicides, during clinical trials.

We sought to characterize national utilization of this effective yet underutilized drug among Medicare beneficiaries by surveying the Medicare Part D Prescriber dataset.³ We tabulated brodalumab utilization statistics and characteristics of high-volume prescribers who had 11 or more annual claims for brodalumab.

Despite its associated boxed warning, the number of Medicare D claims for brodalumab increased by 1756 from 2017 to 2019, surpassing $7 million in costs by 2019. The number of beneficiaries also increased from 11 to 292—a 415.2% annual increase in beneficiaries for whom brodalumab was prescribed (Table 1).

In addition, states in the West and South had the highest utilization rates of brodalumab in 2019. There also was an increasing trend toward high-volume prescribers of brodalumab, with private practice clinicians constituting the majority (Table 2).

There was a substantial increase in advanced practice providers including nurse practitioners and physician assistants who were brodalumab prescribers. Although this trend might promote greater access to brodalumab, it is vital to ensure that advanced practice providers receive targeted training to properly understand the complexities of treatment with brodalumab.

Although the utilization of brodalumab has increased since 2017 (P<.001), it is still underutilized compared to the other IL-17 inhibitors secukinumab and ixekizumab. Secukinumab was FDA approved for the treatment of moderate to severe plaque psoriasis in 2015, followed by ixekizumab in 2016.⁴

According to the Medicare Part D database, both secukinumab and ixekizumab had a higher number of total claims and prescribers compared to brodalumab in the years of their debut.³ In 2015, there were 3593 claims for and 862 prescribers of secukinumab; in 2016, there were 1731 claims for and 681 prescribers of ixekizumab. In contrast, there were only 29 claims for and 11 prescribers of brodalumab in 2017, the year that the drug was approved by the FDA. During the same 3-year period, secukinumab and ixekizumab had a substantially greater number of claims—totals of 176,823 and 55,289, respectively—than brodalumab. The higher number of claims for secukinumab and ixekizumab compared to brodalumab may reflect clinicians’ increasing confidence in prescribing those drugs, given their long-term safety and efficacy. In addition, secukinumab and ixekizumab do not require completion of a Risk Evaluation and Mitigation Strategy (REMS) program, which makes them more readily prescribable.³

Overall, most experts agree that there is no increase in the risk for suicide associated with brodalumab compared to the general population. A 2-year pharmacovigilance report on brodalumab supports the safety of this drug.⁵ All participants who completed suicide during the clinical trials harbored an underlying psychiatric disorder or stressor(s).⁶

Although causation between brodalumab and SIB has not been demonstrated, it remains imperative that prescribers diligently assess patients’ risk of SIB and subsequently their access to appropriate psychiatric services as a precaution, if necessary. This is particularly important for private practice prescribers, who constitute the majority of Medicare D brodalumab claims, because they must ensure collaboration with a multidisciplinary team involving mental health providers. Lastly, considering that the highest number of brodalumab Medicare D claims were in western and southern states, it is critical to note that those 2 regions also harbor comparatively fewer mental health facilities that accept Medicare than other regions of the country.⁷ Prescribers in western and southern states must be mindful of mental health coverage limitations when treating psoriasis patients with brodalumab.

The increase in the number of claims, beneficiaries, and prescribers of brodalumab during its first 3 years of availability might be attributed to its efficacy and safety. On the other hand, the boxed warning and REMS associated with brodalumab might have led to underutilization of this drug compared to other IL-17 inhibitors.

Our analysis is limited by its representative restriction to Medicare patients. There also are limited data on brodalumab given its novelty. Individual attributes of prescribers with fewer than 11 annual claims for brodalumab could not be obtained because of dataset regulations; however, aggregated utilization statistics provide an indication of brodalumab prescribing patterns among all providers. Furthermore, during this analysis, data on the Medicare D database were limited to 2013 through 2020. Studies are needed to determine prescribing patterns of brodalumab since this study period.

Glucocorticoids (GCs) are among the most widely prescribed medications in dermatologic practice. Although GCs are highly effective anti-inflammatory agents, long-term systemic therapy can result in dangerous adverse effects, including GC-induced osteoporosis (GIO), a bone disease associated with a heightened risk for fragility fractures.^1,2 In the United States, an estimated 10.2 million adults have osteoporosis—defined as a T-score lower than −2.5 measured via a bone densitometry scan—and 43.4 million adults have low bone mineral density (BMD).^3,4 The prevalence of osteoporosis is increasing, and the diagnosis is more common in females and adults 55 years and older.² More than 2 million individuals have osteoporosis-related fractures annually, and the mortality risk is increased at 5 and 10 years following low-energy osteoporosis-related fractures.^3-5

Glucocorticoid therapy is the leading iatrogenic cause of secondary osteoporosis. As many as 30% of all patients treated with systemic GCs for more than 6 months develop GIO.^1,6,7 Glucocorticoid-induced BMD loss occurs at a rate of 6% to 12% of total BMD during the first year, slowing to approximately 3% per year during subsequent therapy.¹ The risk for insufficiency fractures increases by as much as 75% from baseline in adults with rheumatic, pulmonary, and skin disorders within the first 3 months of therapy and peaks at approximately 12 months.^1,2

Despite the risks, many long-term GC users never receive therapy to prevent bone loss; others are only started on therapy once they have sustained an insufficiency fracture. A 5-year international observational study including more than 40,000 postmenopausal women found that only 51% of patients who were on continuous GC therapy were undergoing BMD testing and appropriate medical management.⁸ This review highlights the existing evidence on the risks of osteoporosis and osteoporotic (OP) fractures in the setting of topical, intralesional, intramuscular, and systemic GC treatment, as well as recommendations for nutritional supplementation to reduce these risks.

Pathophysiology

The pathophysiology of GIO is multifactorial and occurs in both early and late phases.^9,10 The early phase is characterized by rapid BMD reduction due to excessive bone resorption. The late phase is characterized by slower and more progressive BMD reduction due to impaired bone formation.⁹ At the osteocyte level, GCs decrease cell viability and induce apoptosis.¹¹ At the osteoblast level, GCs impair cell replication and differentiation and have proapoptotic effects, resulting in decreased cell numbers and subsequent bone formation.¹⁰ At the osteoclast level, GCs increase expression of pro-osteoclastic cytokines and decrease mature osteoclast apoptosis, resulting in an expanded osteoclastic life span and prolonged bone resorption.^12,13 Indirectly, GCs alter calcium metabolism by decreasing gastrointestinal calcium absorption and impairing renal absorption.^14,15

GCs and Osteoporosis

Oral GCs—Glucocorticoid-induced osteoporosis and fracture risk are dose and duration dependent.⁶ A study of 244,235 patients taking GCs and 244,235 controls found the relative risk of vertebral fracture was 1.55 (range, 1.20–2.01) for daily prednisone use at less than 2.5 mg, 2.59 (range, 2.16–3.10) for daily prednisone use from 2.5 to 7.4 mg, and 5.18 (range, 4.25–6.31) for daily doses of 7.5 mg or higher; the relative risk for hip fractures was 0.99 (range, 0.82–1.20), 1.77 (range, 1.55–2.02), and 2.27 (range, 1.94–2.66), respectively.¹⁶ Another large retrospective cohort study found that continuous treatment with prednisone 10 mg/d for more than 90 days compared to no GC exposure increased the risk for hip fractures 7-fold and 17-fold for vertebral fractures.¹⁷ Although the minimum cumulative dose of GCs known to cause osteoporosis is not clearly established, the American College of Rheumatology has proposed an algorithm as a basic approach to anticipate, prevent, and treat GIO (Figure).^18,19 Fracture risk should be assessed in all patients who are prescribed prednisone 2.5 mg/d for 3 months or longer or an anticipated cumulative dose of more than 1 g per year. Patients 40 years and older with anticipated GC use of 3 months or longer should have both a bone densitometry scan and a Fracture Risk Assessment (FRAX) score. The FRAX tool estimates the 10-year probability of fracture in patients aged 40 to 80 years, and those patients can be further risk stratified as low (FRAX <10%), moderate (FRAX 10%–19%), or high (FRAX ≥20%) risk. In patients with moderate to high risk of fracture (FRAX >10%), initiation of pharmacologic treatment or referral to a metabolic bone specialist should be considered.^18,19 First-line therapy is an oral bisphosphonate, and second-line therapies include intravenous bisphosphonates, teriparatide, denosumab, or raloxifene for patients at high risk for GIO.¹⁹ Adults younger than 40 years with a history of OP fracture or considerable risk factors for OP fractures should have a bone densitometry scan, and, if results are abnormal, the patient should be referred to a metabolic bone specialist. Those with low fracture risk based on bone densitometry and FRAX and those with no risk factors should be assessed annually for bone health (additional risk factors, GC dose and duration, bone densitometry/FRAX if indicated).¹⁸ In addition to GC dose and duration, additional risk factors for GIO, which are factored into the FRAX tool, include advanced age, low body mass index, history of bone fracture, smoking, excessive alcohol use (≥3 drinks/d), history of falls, low BMD, family history of bone fracture, and hypovitaminosis D.⁶

Topical GCs—Although there is strong evidence and clear guidelines regarding oral GIO, there is a dearth of data surrounding OP risk due to treatment with topical GCs. A recent retrospective nationwide Danish study evaluating the risk of osteoporosis and major OP fracture in 723,251 adults treated with potent or very potent topical steroids sought to evaluate these risks.²⁰ Patients were included if they had filled prescriptions of at least 500 g of topical mometasone or an equivalent alternative. The investigators reported a 3% increase in relative risk of osteoporosis and major OP fracture with doubling of the cumulative topical GC dose (hazard ratio [HR], 1.03 [95% CI, 1.02-1.04] for both). The overall population-attributable risk was 4.3% (95% CI, 2.7%-5.8%) for osteoporosis and 2.7% (95% CI, 1.7%-3.8%) for major OP fracture. Notably, at least 10,000 g of mometasone was required for 1 additional patient to have a major OP fracture.²⁰ In a commentary based on this study, Jackson²¹ noted that the number of patient-years of topical GC use needed for 1 fracture was 4-fold higher than that for high-dose oral GCs (40 mg/d prednisolone for ≥30 days). Another study assessed the effects of topical GCs on BMD in adults with moderate to severe atopic dermatitis over a 2-year period.²² No significant difference in BMD assessed via bone densitometry of either the lumbar spine or total hip at baseline or at 2-year follow-up was reported for either group treated with corticosteroids (<75 g per month or ≥75 g per month). Of note, the authors did not account for steroid potency, which ranged from class 1 through class 4.²² Although limited data exist, these studies suggest topical GCs used at conventional doses with appropriate breaks in therapy will not substantially increase risk for GIO or OP fracture; however, in the small subset of patients requiring chronic use of superpotent topical corticosteroids with other OP risk factors, transitioning to non–GC-based therapy or initiating bone health therapy may be advised to improve patient outcomes. Risk assessment, as in cases of chronic topical GC use, may be beneficial.

Intralesional GCs—Intralesional GCs are indicated for numerous inflammatory conditions including alopecia areata, discoid lupus erythematosus, keloids, and granuloma annulare. It generally is accepted that doses of triamcinolone acetonide should not exceed 20 mg per session spaced at least 3 weeks apart or up to 40 mg per month.¹⁸ One study demonstrated that doses of triamcinolone diacetate of 25 mg or less were unlikely to produce systemic effects and were determined to be a safe dose for intralesional injections.²³ A retrospective cross-sectional case series including 18 patients with alopecia areata reported decreased BMD in 9 patients receiving intralesional triamcinolone acetonide 10 mg/mL at 4- to 8-week intervals for at least 20 months, with cumulative doses greater than 500 mg. This was particularly notable in postmenopausal women and men older than 50 years; participants with a body mass index less than 18.5 kg/m², history of a stress fracture, family history of osteopenia or osteoporosis, and history of smoking; and those who did not regularly engage in weight-bearing exercises.²⁴ Patients receiving long-term (ie, >1 year) intralesional steroids should be evaluated for osteoporosis risk and preventative strategies should be considered (ie, regular weight-bearing exercises, calcium and vitamin D supplementation, bisphosphate therapy). As with topical GCs, there are no clear guidelines for risk assessment or treatment recommendations for GIO.

Intramuscular GCs—The data regarding intramuscular (IM) GCs and dermatologic disease is severely limited, and to the best of our knowledge, no studies specifically assess the risk for GIO or fracture secondary to intramuscular GCs; however, a retrospective study of 27 patients (4 female, 23 male; mean age, 33 years [range, 12–61 years]) with refractory alopecia areata receiving IM triamcinolone acetonide (40 mg every 4 weeks for 3–6 months) reported 1 patient (a 56-year-old woman) with notably decreased bone densitometry from baseline requiring treatment discontinuation.²⁵ No other patients at risk for osteoporosis had decreased BMD from treatment with IM triamcinolone; however, it was noted that 1 month following treatment, 10 of 11 assessed patients demonstrated decreased levels of morning serum cortisol and plasma adrenocorticotropic hormone—despite baseline levels within reference range—that resolved 3 months after treatment completion,²⁵ which suggests a prolonged release of IM triamcinolone and sustained systemic effect. One systematic review of 342 patients with dermatologic diseases treated with IM corticosteroids found the primary side effects included dysmenorrhea, injection-site lipoatrophy, and adrenocortical suppression, with only a single reported case of low BMD.²⁶ Given the paucity of evidence, additional studies are required to assess the effect of IM triamcinolone on BMD and risk for major OP fractures with regard to dosing and frequency. As there are no clear guidelines for osteoporosis evaluation in the setting of intramuscular GCs, it may be prudent to follow the algorithmic model recommended for oral steroids when anticipating at least 3 months of intramuscular GCs.

Diet and Prevention of Bone Loss

Given the profound impact that systemic GCs have on osteoporosis and fracture risk and the sparse data regarding risk from topical, intralesional, or intramuscular GCs, diet and nutrition represent a simple, safe, and potentially preventative method of slowing BMD loss and minimizing fracture risk. In higher-risk patients, nutritional assessment in combination with medical therapy also is likely warranted.

Calcium and Vitamin D₃—Patients treated with any GC dose longer than 3 months should undergo calcium and vitamin D optimization.¹⁹ Exceptions for supplementation include certain patients with sarcoidosis, which can be associated with high vitamin D levels; patients with a history of hypercalcemia or hypercalciuria; and patients with chronic kidney disease.⁶ In a meta-analysis including 30,970 patients in 8 randomized controlled trials, calcium (500–1200 mg/d) and vitamin D (400–800 IU/d) supplementation reduced the risk of total fractures by 15% (summary relative risk estimate, 0.85 [95% CI, 0.73-0.98]) and hip fractures by 30% (summary relative risk estimate, 0.70 [95% CI, 0.56-0.87]).⁴ One double-blind, placebo-controlled clinical trial conducted by the Women’s Health Initiative that included 36,282 postmenopausal women who were taking 1000 mg of calcium and 400 IU of vitamin D₃ daily for more than 5 years reported an HR of 0.62 (95% CI, 0.38-1.00) for hip fracture for supplementation vs placebo.²⁷ Lastly, a 2016 Cochrane Review including 12 randomized trials and 1343 participants reported a 43% lower risk of new vertebral fractures following supplementation with calcium, vitamin D, or both compared with controls.²⁸

Specific recommendations for calcium and vitamin D₃ supplementation vary based on age and sex. The US Preventive Services Task Force concluded that insufficient evidence exists to support calcium and vitamin D₃ supplementation in asymptomatic men and premenopausal women.²⁹ The National Osteoporosis Foundation (NOF) supports the use of calcium supplementation for fracture risk reduction in middle-aged and older adults.⁴ Furthermore, the NOF supports the Institute of Medicine recommendations³¹ that men aged 50 to 70 years consume 1000 mg/d of calcium and that women 51 years and older as well as men 71 years and older consume 1200 mg/d of calcium.³⁰ The NOF recommends 800 to 1000 IU/d of vitamin D in adults 50 years and older, while the Institute of Medicine recommends 600 IU/d in adults 70 years and younger and 800 IU/d in adults 71 years and older.³¹ These recommendations are similar to both the Endocrine Society and the American Geriatric Society.^32,33 Total calcium should not exceed 2000 mg/d due to risk of adverse effects.

Dietary sources of vitamin D include fatty fish, mushrooms, and fortified dairy products, though recommended doses rarely can be achieved through diet alone.³⁴ Dairy products are the primary source of dietary calcium. Other high-calcium foods include green leafy vegetables, nuts and seeds, soft-boned fish, and fortified beverages and cereals.³⁵

Probiotics—A growing body of evidence suggests that probiotics may be beneficial in promoting bone health by improving calcium homeostasis, reducing risk for hyperparathyroidism secondary to GC therapy, and decreasing age-related bone resorption.³⁶ An animal study demonstrated that probiotics can regulate bone resorption and formation as well as reduce bone loss secondary to GC therapy.³⁷ A randomized, double-blind, placebo-controlled, multicenter trial randomly assigned 249 healthy, early postmenopausal women to receive probiotic treatment containing 3 lactobacillus strains (Lactobacillus paracasei DSM 13434, Lactobacillus plantarum DSM 15312, and L plantarum DSM 15313) or placebo once daily for 12 months.³⁸ Bone mineral density was measured at baseline and at 12 months. Of the 234 participants who completed the study, lactobacillus treatment reduced lumbosacral BMD loss compared to the placebo group (mean difference, 0.71% [95% CI, 0.06-1.35]). They also reported significant lumbosacral BMD loss in the placebo group (−0.72% [95% CI, −1.22 to −0.22]) compared to no BMD loss in the group treated with lactobacillus (−0.01% [95% CI, −0.50 to 0.48]).³⁸ Although the data may be encouraging, more studies are needed to determine if probiotics should be regarded as an adjuvant treatment to calcium, vitamin D, and pharmacologic therapy for long-term prevention of bone loss in the setting of GIO.³⁹ Because existing studies on probiotics include varying compositions and doses, larger studies with consistent supplementation are required. Encouraging probiotic intake through fermented dairy products may represent a simple low-risk intervention to support bone health.

Anti-inflammatory Diet—The traditional Mediterranean diet is rich in fruits, vegetables, fish, nuts, whole grains, legumes, and monounsaturated fats and low in meat and dairy products. The Mediterranean diet has been shown to be modestly protective against osteoporosis and fracture risk. A large US observational study including 93,676 women showed that those with the highest quintile of the alternate Mediterranean diet score had a lower risk for hip fracture (HR, 0.80 [95% CI, 0.66-0.97]), with an absolute risk reduction of 0.29% and number needed to treat at 342.⁴⁰ A multicenter study involving adults from 8 European countries found that increased adherence to the Mediterranean diet was associated with a 7% reduction in hip fracture incidence (HR per 1 unit increase in Mediterranean diet, 0.93 [95% CI, 0.89-0.98]). High vegetable and fruit intake was associated with decreased hip fracture incidence (HR, 0.86 and 0.89 [95% CI, 0.79-0.94 and 0.82-0.97, respectively]), and high meat and excessive ethanol consumption were associated with increased fracture incidence (HR, 1.18 and 1.74 [95% CI, 1.06-1.31 and 1.32-2.31, respectively]).⁴¹ Similarly, a large observational study in Sweden that included 37,903 men and 33,403 women reported similar findings, noting a 6% lower hip fracture rate per one unit increase in alternate Mediterranean diet score (adjusted HR, 0.94 [95% CI, 0.92-0.96]).⁴² This is thought to be due in part to higher levels of dietary vitamin D present in many foods traditionally included in the Mediterranean diet.⁴³ Additionally, olive oil, a staple in the Mediterranean diet, appears to reduce bone loss by promoting osteoblast proliferation and maturation, inhibiting bone resorption, suppressing oxidative stress and inflammation, and increasing calcium deposition in the extracellular matrix.^44,45 Fruits, vegetables, legumes, and nuts also are rich in minerals including potassium and magnesium, which are important in bone health to promote osteoblast proliferation and vitamin D activation.^36,46-48

Final Thoughts

Osteoporosis-related fractures are common and are associated with high morbidity and health care costs. Dermatologists using and prescribing corticosteroids must be aware of the risk for GIO, particularly in patients with a pre-existing diagnosis of osteopenia or osteoporosis. There likely is no oral corticosteroid dose that does not increase a patient’s risk for osteoporosis; therefore, oral GCs should be used at the lowest effective daily dose for the shortest duration possible. Patients with an anticipated duration of at least 3 months—regardless of dose—should be assessed for their risk for GIO. Patients using topical and intralesional corticosteroids are unlikely to develop GIO; however, those with risk factors and a considerable cumulative dose may warrant further evaluation. In all cases, we advocate for supplementing with calcium and vitamin D as well as promoting probiotic intake and the Mediterranean diet. Those at moderate to high risk for fracture may require additional medical therapy. Dermatologists are uniquely positioned to identify this at-risk population, and because osteoporosis is a chronic illness, primary care providers should be notified of prolonged GC therapy to help with risk assessment, initiation of vitamin and mineral supplementation, and follow-up with metabolic bone health specialists. Through a multidisciplinary approach and patient education, GIO and the potential risk for fracture can be successfully mitigated in most patients.

Glucocorticoids (GCs) are among the most widely prescribed medications in dermatologic practice. Although GCs are highly effective anti-inflammatory agents, long-term systemic therapy can result in dangerous adverse effects, including GC-induced osteoporosis (GIO), a bone disease associated with a heightened risk for fragility fractures.^1,2 In the United States, an estimated 10.2 million adults have osteoporosis—defined as a T-score lower than −2.5 measured via a bone densitometry scan—and 43.4 million adults have low bone mineral density (BMD).^3,4 The prevalence of osteoporosis is increasing, and the diagnosis is more common in females and adults 55 years and older.² More than 2 million individuals have osteoporosis-related fractures annually, and the mortality risk is increased at 5 and 10 years following low-energy osteoporosis-related fractures.^3-5

Glucocorticoid therapy is the leading iatrogenic cause of secondary osteoporosis. As many as 30% of all patients treated with systemic GCs for more than 6 months develop GIO.^1,6,7 Glucocorticoid-induced BMD loss occurs at a rate of 6% to 12% of total BMD during the first year, slowing to approximately 3% per year during subsequent therapy.¹ The risk for insufficiency fractures increases by as much as 75% from baseline in adults with rheumatic, pulmonary, and skin disorders within the first 3 months of therapy and peaks at approximately 12 months.^1,2

Despite the risks, many long-term GC users never receive therapy to prevent bone loss; others are only started on therapy once they have sustained an insufficiency fracture. A 5-year international observational study including more than 40,000 postmenopausal women found that only 51% of patients who were on continuous GC therapy were undergoing BMD testing and appropriate medical management.⁸ This review highlights the existing evidence on the risks of osteoporosis and osteoporotic (OP) fractures in the setting of topical, intralesional, intramuscular, and systemic GC treatment, as well as recommendations for nutritional supplementation to reduce these risks.

Pathophysiology

The pathophysiology of GIO is multifactorial and occurs in both early and late phases.^9,10 The early phase is characterized by rapid BMD reduction due to excessive bone resorption. The late phase is characterized by slower and more progressive BMD reduction due to impaired bone formation.⁹ At the osteocyte level, GCs decrease cell viability and induce apoptosis.¹¹ At the osteoblast level, GCs impair cell replication and differentiation and have proapoptotic effects, resulting in decreased cell numbers and subsequent bone formation.¹⁰ At the osteoclast level, GCs increase expression of pro-osteoclastic cytokines and decrease mature osteoclast apoptosis, resulting in an expanded osteoclastic life span and prolonged bone resorption.^12,13 Indirectly, GCs alter calcium metabolism by decreasing gastrointestinal calcium absorption and impairing renal absorption.^14,15

GCs and Osteoporosis

Oral GCs—Glucocorticoid-induced osteoporosis and fracture risk are dose and duration dependent.⁶ A study of 244,235 patients taking GCs and 244,235 controls found the relative risk of vertebral fracture was 1.55 (range, 1.20–2.01) for daily prednisone use at less than 2.5 mg, 2.59 (range, 2.16–3.10) for daily prednisone use from 2.5 to 7.4 mg, and 5.18 (range, 4.25–6.31) for daily doses of 7.5 mg or higher; the relative risk for hip fractures was 0.99 (range, 0.82–1.20), 1.77 (range, 1.55–2.02), and 2.27 (range, 1.94–2.66), respectively.¹⁶ Another large retrospective cohort study found that continuous treatment with prednisone 10 mg/d for more than 90 days compared to no GC exposure increased the risk for hip fractures 7-fold and 17-fold for vertebral fractures.¹⁷ Although the minimum cumulative dose of GCs known to cause osteoporosis is not clearly established, the American College of Rheumatology has proposed an algorithm as a basic approach to anticipate, prevent, and treat GIO (Figure).^18,19 Fracture risk should be assessed in all patients who are prescribed prednisone 2.5 mg/d for 3 months or longer or an anticipated cumulative dose of more than 1 g per year. Patients 40 years and older with anticipated GC use of 3 months or longer should have both a bone densitometry scan and a Fracture Risk Assessment (FRAX) score. The FRAX tool estimates the 10-year probability of fracture in patients aged 40 to 80 years, and those patients can be further risk stratified as low (FRAX <10%), moderate (FRAX 10%–19%), or high (FRAX ≥20%) risk. In patients with moderate to high risk of fracture (FRAX >10%), initiation of pharmacologic treatment or referral to a metabolic bone specialist should be considered.^18,19 First-line therapy is an oral bisphosphonate, and second-line therapies include intravenous bisphosphonates, teriparatide, denosumab, or raloxifene for patients at high risk for GIO.¹⁹ Adults younger than 40 years with a history of OP fracture or considerable risk factors for OP fractures should have a bone densitometry scan, and, if results are abnormal, the patient should be referred to a metabolic bone specialist. Those with low fracture risk based on bone densitometry and FRAX and those with no risk factors should be assessed annually for bone health (additional risk factors, GC dose and duration, bone densitometry/FRAX if indicated).¹⁸ In addition to GC dose and duration, additional risk factors for GIO, which are factored into the FRAX tool, include advanced age, low body mass index, history of bone fracture, smoking, excessive alcohol use (≥3 drinks/d), history of falls, low BMD, family history of bone fracture, and hypovitaminosis D.⁶

Topical GCs—Although there is strong evidence and clear guidelines regarding oral GIO, there is a dearth of data surrounding OP risk due to treatment with topical GCs. A recent retrospective nationwide Danish study evaluating the risk of osteoporosis and major OP fracture in 723,251 adults treated with potent or very potent topical steroids sought to evaluate these risks.²⁰ Patients were included if they had filled prescriptions of at least 500 g of topical mometasone or an equivalent alternative. The investigators reported a 3% increase in relative risk of osteoporosis and major OP fracture with doubling of the cumulative topical GC dose (hazard ratio [HR], 1.03 [95% CI, 1.02-1.04] for both). The overall population-attributable risk was 4.3% (95% CI, 2.7%-5.8%) for osteoporosis and 2.7% (95% CI, 1.7%-3.8%) for major OP fracture. Notably, at least 10,000 g of mometasone was required for 1 additional patient to have a major OP fracture.²⁰ In a commentary based on this study, Jackson²¹ noted that the number of patient-years of topical GC use needed for 1 fracture was 4-fold higher than that for high-dose oral GCs (40 mg/d prednisolone for ≥30 days). Another study assessed the effects of topical GCs on BMD in adults with moderate to severe atopic dermatitis over a 2-year period.²² No significant difference in BMD assessed via bone densitometry of either the lumbar spine or total hip at baseline or at 2-year follow-up was reported for either group treated with corticosteroids (<75 g per month or ≥75 g per month). Of note, the authors did not account for steroid potency, which ranged from class 1 through class 4.²² Although limited data exist, these studies suggest topical GCs used at conventional doses with appropriate breaks in therapy will not substantially increase risk for GIO or OP fracture; however, in the small subset of patients requiring chronic use of superpotent topical corticosteroids with other OP risk factors, transitioning to non–GC-based therapy or initiating bone health therapy may be advised to improve patient outcomes. Risk assessment, as in cases of chronic topical GC use, may be beneficial.

Intralesional GCs—Intralesional GCs are indicated for numerous inflammatory conditions including alopecia areata, discoid lupus erythematosus, keloids, and granuloma annulare. It generally is accepted that doses of triamcinolone acetonide should not exceed 20 mg per session spaced at least 3 weeks apart or up to 40 mg per month.¹⁸ One study demonstrated that doses of triamcinolone diacetate of 25 mg or less were unlikely to produce systemic effects and were determined to be a safe dose for intralesional injections.²³ A retrospective cross-sectional case series including 18 patients with alopecia areata reported decreased BMD in 9 patients receiving intralesional triamcinolone acetonide 10 mg/mL at 4- to 8-week intervals for at least 20 months, with cumulative doses greater than 500 mg. This was particularly notable in postmenopausal women and men older than 50 years; participants with a body mass index less than 18.5 kg/m², history of a stress fracture, family history of osteopenia or osteoporosis, and history of smoking; and those who did not regularly engage in weight-bearing exercises.²⁴ Patients receiving long-term (ie, >1 year) intralesional steroids should be evaluated for osteoporosis risk and preventative strategies should be considered (ie, regular weight-bearing exercises, calcium and vitamin D supplementation, bisphosphate therapy). As with topical GCs, there are no clear guidelines for risk assessment or treatment recommendations for GIO.

Intramuscular GCs—The data regarding intramuscular (IM) GCs and dermatologic disease is severely limited, and to the best of our knowledge, no studies specifically assess the risk for GIO or fracture secondary to intramuscular GCs; however, a retrospective study of 27 patients (4 female, 23 male; mean age, 33 years [range, 12–61 years]) with refractory alopecia areata receiving IM triamcinolone acetonide (40 mg every 4 weeks for 3–6 months) reported 1 patient (a 56-year-old woman) with notably decreased bone densitometry from baseline requiring treatment discontinuation.²⁵ No other patients at risk for osteoporosis had decreased BMD from treatment with IM triamcinolone; however, it was noted that 1 month following treatment, 10 of 11 assessed patients demonstrated decreased levels of morning serum cortisol and plasma adrenocorticotropic hormone—despite baseline levels within reference range—that resolved 3 months after treatment completion,²⁵ which suggests a prolonged release of IM triamcinolone and sustained systemic effect. One systematic review of 342 patients with dermatologic diseases treated with IM corticosteroids found the primary side effects included dysmenorrhea, injection-site lipoatrophy, and adrenocortical suppression, with only a single reported case of low BMD.²⁶ Given the paucity of evidence, additional studies are required to assess the effect of IM triamcinolone on BMD and risk for major OP fractures with regard to dosing and frequency. As there are no clear guidelines for osteoporosis evaluation in the setting of intramuscular GCs, it may be prudent to follow the algorithmic model recommended for oral steroids when anticipating at least 3 months of intramuscular GCs.

Diet and Prevention of Bone Loss

Given the profound impact that systemic GCs have on osteoporosis and fracture risk and the sparse data regarding risk from topical, intralesional, or intramuscular GCs, diet and nutrition represent a simple, safe, and potentially preventative method of slowing BMD loss and minimizing fracture risk. In higher-risk patients, nutritional assessment in combination with medical therapy also is likely warranted.

Calcium and Vitamin D₃—Patients treated with any GC dose longer than 3 months should undergo calcium and vitamin D optimization.¹⁹ Exceptions for supplementation include certain patients with sarcoidosis, which can be associated with high vitamin D levels; patients with a history of hypercalcemia or hypercalciuria; and patients with chronic kidney disease.⁶ In a meta-analysis including 30,970 patients in 8 randomized controlled trials, calcium (500–1200 mg/d) and vitamin D (400–800 IU/d) supplementation reduced the risk of total fractures by 15% (summary relative risk estimate, 0.85 [95% CI, 0.73-0.98]) and hip fractures by 30% (summary relative risk estimate, 0.70 [95% CI, 0.56-0.87]).⁴ One double-blind, placebo-controlled clinical trial conducted by the Women’s Health Initiative that included 36,282 postmenopausal women who were taking 1000 mg of calcium and 400 IU of vitamin D₃ daily for more than 5 years reported an HR of 0.62 (95% CI, 0.38-1.00) for hip fracture for supplementation vs placebo.²⁷ Lastly, a 2016 Cochrane Review including 12 randomized trials and 1343 participants reported a 43% lower risk of new vertebral fractures following supplementation with calcium, vitamin D, or both compared with controls.²⁸

Specific recommendations for calcium and vitamin D₃ supplementation vary based on age and sex. The US Preventive Services Task Force concluded that insufficient evidence exists to support calcium and vitamin D₃ supplementation in asymptomatic men and premenopausal women.²⁹ The National Osteoporosis Foundation (NOF) supports the use of calcium supplementation for fracture risk reduction in middle-aged and older adults.⁴ Furthermore, the NOF supports the Institute of Medicine recommendations³¹ that men aged 50 to 70 years consume 1000 mg/d of calcium and that women 51 years and older as well as men 71 years and older consume 1200 mg/d of calcium.³⁰ The NOF recommends 800 to 1000 IU/d of vitamin D in adults 50 years and older, while the Institute of Medicine recommends 600 IU/d in adults 70 years and younger and 800 IU/d in adults 71 years and older.³¹ These recommendations are similar to both the Endocrine Society and the American Geriatric Society.^32,33 Total calcium should not exceed 2000 mg/d due to risk of adverse effects.

Dietary sources of vitamin D include fatty fish, mushrooms, and fortified dairy products, though recommended doses rarely can be achieved through diet alone.³⁴ Dairy products are the primary source of dietary calcium. Other high-calcium foods include green leafy vegetables, nuts and seeds, soft-boned fish, and fortified beverages and cereals.³⁵

Probiotics—A growing body of evidence suggests that probiotics may be beneficial in promoting bone health by improving calcium homeostasis, reducing risk for hyperparathyroidism secondary to GC therapy, and decreasing age-related bone resorption.³⁶ An animal study demonstrated that probiotics can regulate bone resorption and formation as well as reduce bone loss secondary to GC therapy.³⁷ A randomized, double-blind, placebo-controlled, multicenter trial randomly assigned 249 healthy, early postmenopausal women to receive probiotic treatment containing 3 lactobacillus strains (Lactobacillus paracasei DSM 13434, Lactobacillus plantarum DSM 15312, and L plantarum DSM 15313) or placebo once daily for 12 months.³⁸ Bone mineral density was measured at baseline and at 12 months. Of the 234 participants who completed the study, lactobacillus treatment reduced lumbosacral BMD loss compared to the placebo group (mean difference, 0.71% [95% CI, 0.06-1.35]). They also reported significant lumbosacral BMD loss in the placebo group (−0.72% [95% CI, −1.22 to −0.22]) compared to no BMD loss in the group treated with lactobacillus (−0.01% [95% CI, −0.50 to 0.48]).³⁸ Although the data may be encouraging, more studies are needed to determine if probiotics should be regarded as an adjuvant treatment to calcium, vitamin D, and pharmacologic therapy for long-term prevention of bone loss in the setting of GIO.³⁹ Because existing studies on probiotics include varying compositions and doses, larger studies with consistent supplementation are required. Encouraging probiotic intake through fermented dairy products may represent a simple low-risk intervention to support bone health.

Anti-inflammatory Diet—The traditional Mediterranean diet is rich in fruits, vegetables, fish, nuts, whole grains, legumes, and monounsaturated fats and low in meat and dairy products. The Mediterranean diet has been shown to be modestly protective against osteoporosis and fracture risk. A large US observational study including 93,676 women showed that those with the highest quintile of the alternate Mediterranean diet score had a lower risk for hip fracture (HR, 0.80 [95% CI, 0.66-0.97]), with an absolute risk reduction of 0.29% and number needed to treat at 342.⁴⁰ A multicenter study involving adults from 8 European countries found that increased adherence to the Mediterranean diet was associated with a 7% reduction in hip fracture incidence (HR per 1 unit increase in Mediterranean diet, 0.93 [95% CI, 0.89-0.98]). High vegetable and fruit intake was associated with decreased hip fracture incidence (HR, 0.86 and 0.89 [95% CI, 0.79-0.94 and 0.82-0.97, respectively]), and high meat and excessive ethanol consumption were associated with increased fracture incidence (HR, 1.18 and 1.74 [95% CI, 1.06-1.31 and 1.32-2.31, respectively]).⁴¹ Similarly, a large observational study in Sweden that included 37,903 men and 33,403 women reported similar findings, noting a 6% lower hip fracture rate per one unit increase in alternate Mediterranean diet score (adjusted HR, 0.94 [95% CI, 0.92-0.96]).⁴² This is thought to be due in part to higher levels of dietary vitamin D present in many foods traditionally included in the Mediterranean diet.⁴³ Additionally, olive oil, a staple in the Mediterranean diet, appears to reduce bone loss by promoting osteoblast proliferation and maturation, inhibiting bone resorption, suppressing oxidative stress and inflammation, and increasing calcium deposition in the extracellular matrix.^44,45 Fruits, vegetables, legumes, and nuts also are rich in minerals including potassium and magnesium, which are important in bone health to promote osteoblast proliferation and vitamin D activation.^36,46-48

Final Thoughts

Osteoporosis-related fractures are common and are associated with high morbidity and health care costs. Dermatologists using and prescribing corticosteroids must be aware of the risk for GIO, particularly in patients with a pre-existing diagnosis of osteopenia or osteoporosis. There likely is no oral corticosteroid dose that does not increase a patient’s risk for osteoporosis; therefore, oral GCs should be used at the lowest effective daily dose for the shortest duration possible. Patients with an anticipated duration of at least 3 months—regardless of dose—should be assessed for their risk for GIO. Patients using topical and intralesional corticosteroids are unlikely to develop GIO; however, those with risk factors and a considerable cumulative dose may warrant further evaluation. In all cases, we advocate for supplementing with calcium and vitamin D as well as promoting probiotic intake and the Mediterranean diet. Those at moderate to high risk for fracture may require additional medical therapy. Dermatologists are uniquely positioned to identify this at-risk population, and because osteoporosis is a chronic illness, primary care providers should be notified of prolonged GC therapy to help with risk assessment, initiation of vitamin and mineral supplementation, and follow-up with metabolic bone health specialists. Through a multidisciplinary approach and patient education, GIO and the potential risk for fracture can be successfully mitigated in most patients.

Glucocorticoids (GCs) are among the most widely prescribed medications in dermatologic practice. Although GCs are highly effective anti-inflammatory agents, long-term systemic therapy can result in dangerous adverse effects, including GC-induced osteoporosis (GIO), a bone disease associated with a heightened risk for fragility fractures.^1,2 In the United States, an estimated 10.2 million adults have osteoporosis—defined as a T-score lower than −2.5 measured via a bone densitometry scan—and 43.4 million adults have low bone mineral density (BMD).^3,4 The prevalence of osteoporosis is increasing, and the diagnosis is more common in females and adults 55 years and older.² More than 2 million individuals have osteoporosis-related fractures annually, and the mortality risk is increased at 5 and 10 years following low-energy osteoporosis-related fractures.^3-5

Glucocorticoid therapy is the leading iatrogenic cause of secondary osteoporosis. As many as 30% of all patients treated with systemic GCs for more than 6 months develop GIO.^1,6,7 Glucocorticoid-induced BMD loss occurs at a rate of 6% to 12% of total BMD during the first year, slowing to approximately 3% per year during subsequent therapy.¹ The risk for insufficiency fractures increases by as much as 75% from baseline in adults with rheumatic, pulmonary, and skin disorders within the first 3 months of therapy and peaks at approximately 12 months.^1,2

Despite the risks, many long-term GC users never receive therapy to prevent bone loss; others are only started on therapy once they have sustained an insufficiency fracture. A 5-year international observational study including more than 40,000 postmenopausal women found that only 51% of patients who were on continuous GC therapy were undergoing BMD testing and appropriate medical management.⁸ This review highlights the existing evidence on the risks of osteoporosis and osteoporotic (OP) fractures in the setting of topical, intralesional, intramuscular, and systemic GC treatment, as well as recommendations for nutritional supplementation to reduce these risks.

Pathophysiology

The pathophysiology of GIO is multifactorial and occurs in both early and late phases.^9,10 The early phase is characterized by rapid BMD reduction due to excessive bone resorption. The late phase is characterized by slower and more progressive BMD reduction due to impaired bone formation.⁹ At the osteocyte level, GCs decrease cell viability and induce apoptosis.¹¹ At the osteoblast level, GCs impair cell replication and differentiation and have proapoptotic effects, resulting in decreased cell numbers and subsequent bone formation.¹⁰ At the osteoclast level, GCs increase expression of pro-osteoclastic cytokines and decrease mature osteoclast apoptosis, resulting in an expanded osteoclastic life span and prolonged bone resorption.^12,13 Indirectly, GCs alter calcium metabolism by decreasing gastrointestinal calcium absorption and impairing renal absorption.^14,15

GCs and Osteoporosis

Oral GCs—Glucocorticoid-induced osteoporosis and fracture risk are dose and duration dependent.⁶ A study of 244,235 patients taking GCs and 244,235 controls found the relative risk of vertebral fracture was 1.55 (range, 1.20–2.01) for daily prednisone use at less than 2.5 mg, 2.59 (range, 2.16–3.10) for daily prednisone use from 2.5 to 7.4 mg, and 5.18 (range, 4.25–6.31) for daily doses of 7.5 mg or higher; the relative risk for hip fractures was 0.99 (range, 0.82–1.20), 1.77 (range, 1.55–2.02), and 2.27 (range, 1.94–2.66), respectively.¹⁶ Another large retrospective cohort study found that continuous treatment with prednisone 10 mg/d for more than 90 days compared to no GC exposure increased the risk for hip fractures 7-fold and 17-fold for vertebral fractures.¹⁷ Although the minimum cumulative dose of GCs known to cause osteoporosis is not clearly established, the American College of Rheumatology has proposed an algorithm as a basic approach to anticipate, prevent, and treat GIO (Figure).^18,19 Fracture risk should be assessed in all patients who are prescribed prednisone 2.5 mg/d for 3 months or longer or an anticipated cumulative dose of more than 1 g per year. Patients 40 years and older with anticipated GC use of 3 months or longer should have both a bone densitometry scan and a Fracture Risk Assessment (FRAX) score. The FRAX tool estimates the 10-year probability of fracture in patients aged 40 to 80 years, and those patients can be further risk stratified as low (FRAX <10%), moderate (FRAX 10%–19%), or high (FRAX ≥20%) risk. In patients with moderate to high risk of fracture (FRAX >10%), initiation of pharmacologic treatment or referral to a metabolic bone specialist should be considered.^18,19 First-line therapy is an oral bisphosphonate, and second-line therapies include intravenous bisphosphonates, teriparatide, denosumab, or raloxifene for patients at high risk for GIO.¹⁹ Adults younger than 40 years with a history of OP fracture or considerable risk factors for OP fractures should have a bone densitometry scan, and, if results are abnormal, the patient should be referred to a metabolic bone specialist. Those with low fracture risk based on bone densitometry and FRAX and those with no risk factors should be assessed annually for bone health (additional risk factors, GC dose and duration, bone densitometry/FRAX if indicated).¹⁸ In addition to GC dose and duration, additional risk factors for GIO, which are factored into the FRAX tool, include advanced age, low body mass index, history of bone fracture, smoking, excessive alcohol use (≥3 drinks/d), history of falls, low BMD, family history of bone fracture, and hypovitaminosis D.⁶

Topical GCs—Although there is strong evidence and clear guidelines regarding oral GIO, there is a dearth of data surrounding OP risk due to treatment with topical GCs. A recent retrospective nationwide Danish study evaluating the risk of osteoporosis and major OP fracture in 723,251 adults treated with potent or very potent topical steroids sought to evaluate these risks.²⁰ Patients were included if they had filled prescriptions of at least 500 g of topical mometasone or an equivalent alternative. The investigators reported a 3% increase in relative risk of osteoporosis and major OP fracture with doubling of the cumulative topical GC dose (hazard ratio [HR], 1.03 [95% CI, 1.02-1.04] for both). The overall population-attributable risk was 4.3% (95% CI, 2.7%-5.8%) for osteoporosis and 2.7% (95% CI, 1.7%-3.8%) for major OP fracture. Notably, at least 10,000 g of mometasone was required for 1 additional patient to have a major OP fracture.²⁰ In a commentary based on this study, Jackson²¹ noted that the number of patient-years of topical GC use needed for 1 fracture was 4-fold higher than that for high-dose oral GCs (40 mg/d prednisolone for ≥30 days). Another study assessed the effects of topical GCs on BMD in adults with moderate to severe atopic dermatitis over a 2-year period.²² No significant difference in BMD assessed via bone densitometry of either the lumbar spine or total hip at baseline or at 2-year follow-up was reported for either group treated with corticosteroids (<75 g per month or ≥75 g per month). Of note, the authors did not account for steroid potency, which ranged from class 1 through class 4.²² Although limited data exist, these studies suggest topical GCs used at conventional doses with appropriate breaks in therapy will not substantially increase risk for GIO or OP fracture; however, in the small subset of patients requiring chronic use of superpotent topical corticosteroids with other OP risk factors, transitioning to non–GC-based therapy or initiating bone health therapy may be advised to improve patient outcomes. Risk assessment, as in cases of chronic topical GC use, may be beneficial.

Intralesional GCs—Intralesional GCs are indicated for numerous inflammatory conditions including alopecia areata, discoid lupus erythematosus, keloids, and granuloma annulare. It generally is accepted that doses of triamcinolone acetonide should not exceed 20 mg per session spaced at least 3 weeks apart or up to 40 mg per month.¹⁸ One study demonstrated that doses of triamcinolone diacetate of 25 mg or less were unlikely to produce systemic effects and were determined to be a safe dose for intralesional injections.²³ A retrospective cross-sectional case series including 18 patients with alopecia areata reported decreased BMD in 9 patients receiving intralesional triamcinolone acetonide 10 mg/mL at 4- to 8-week intervals for at least 20 months, with cumulative doses greater than 500 mg. This was particularly notable in postmenopausal women and men older than 50 years; participants with a body mass index less than 18.5 kg/m², history of a stress fracture, family history of osteopenia or osteoporosis, and history of smoking; and those who did not regularly engage in weight-bearing exercises.²⁴ Patients receiving long-term (ie, >1 year) intralesional steroids should be evaluated for osteoporosis risk and preventative strategies should be considered (ie, regular weight-bearing exercises, calcium and vitamin D supplementation, bisphosphate therapy). As with topical GCs, there are no clear guidelines for risk assessment or treatment recommendations for GIO.

Intramuscular GCs—The data regarding intramuscular (IM) GCs and dermatologic disease is severely limited, and to the best of our knowledge, no studies specifically assess the risk for GIO or fracture secondary to intramuscular GCs; however, a retrospective study of 27 patients (4 female, 23 male; mean age, 33 years [range, 12–61 years]) with refractory alopecia areata receiving IM triamcinolone acetonide (40 mg every 4 weeks for 3–6 months) reported 1 patient (a 56-year-old woman) with notably decreased bone densitometry from baseline requiring treatment discontinuation.²⁵ No other patients at risk for osteoporosis had decreased BMD from treatment with IM triamcinolone; however, it was noted that 1 month following treatment, 10 of 11 assessed patients demonstrated decreased levels of morning serum cortisol and plasma adrenocorticotropic hormone—despite baseline levels within reference range—that resolved 3 months after treatment completion,²⁵ which suggests a prolonged release of IM triamcinolone and sustained systemic effect. One systematic review of 342 patients with dermatologic diseases treated with IM corticosteroids found the primary side effects included dysmenorrhea, injection-site lipoatrophy, and adrenocortical suppression, with only a single reported case of low BMD.²⁶ Given the paucity of evidence, additional studies are required to assess the effect of IM triamcinolone on BMD and risk for major OP fractures with regard to dosing and frequency. As there are no clear guidelines for osteoporosis evaluation in the setting of intramuscular GCs, it may be prudent to follow the algorithmic model recommended for oral steroids when anticipating at least 3 months of intramuscular GCs.

Diet and Prevention of Bone Loss

Given the profound impact that systemic GCs have on osteoporosis and fracture risk and the sparse data regarding risk from topical, intralesional, or intramuscular GCs, diet and nutrition represent a simple, safe, and potentially preventative method of slowing BMD loss and minimizing fracture risk. In higher-risk patients, nutritional assessment in combination with medical therapy also is likely warranted.

Calcium and Vitamin D₃—Patients treated with any GC dose longer than 3 months should undergo calcium and vitamin D optimization.¹⁹ Exceptions for supplementation include certain patients with sarcoidosis, which can be associated with high vitamin D levels; patients with a history of hypercalcemia or hypercalciuria; and patients with chronic kidney disease.⁶ In a meta-analysis including 30,970 patients in 8 randomized controlled trials, calcium (500–1200 mg/d) and vitamin D (400–800 IU/d) supplementation reduced the risk of total fractures by 15% (summary relative risk estimate, 0.85 [95% CI, 0.73-0.98]) and hip fractures by 30% (summary relative risk estimate, 0.70 [95% CI, 0.56-0.87]).⁴ One double-blind, placebo-controlled clinical trial conducted by the Women’s Health Initiative that included 36,282 postmenopausal women who were taking 1000 mg of calcium and 400 IU of vitamin D₃ daily for more than 5 years reported an HR of 0.62 (95% CI, 0.38-1.00) for hip fracture for supplementation vs placebo.²⁷ Lastly, a 2016 Cochrane Review including 12 randomized trials and 1343 participants reported a 43% lower risk of new vertebral fractures following supplementation with calcium, vitamin D, or both compared with controls.²⁸

Specific recommendations for calcium and vitamin D₃ supplementation vary based on age and sex. The US Preventive Services Task Force concluded that insufficient evidence exists to support calcium and vitamin D₃ supplementation in asymptomatic men and premenopausal women.²⁹ The National Osteoporosis Foundation (NOF) supports the use of calcium supplementation for fracture risk reduction in middle-aged and older adults.⁴ Furthermore, the NOF supports the Institute of Medicine recommendations³¹ that men aged 50 to 70 years consume 1000 mg/d of calcium and that women 51 years and older as well as men 71 years and older consume 1200 mg/d of calcium.³⁰ The NOF recommends 800 to 1000 IU/d of vitamin D in adults 50 years and older, while the Institute of Medicine recommends 600 IU/d in adults 70 years and younger and 800 IU/d in adults 71 years and older.³¹ These recommendations are similar to both the Endocrine Society and the American Geriatric Society.^32,33 Total calcium should not exceed 2000 mg/d due to risk of adverse effects.

Dietary sources of vitamin D include fatty fish, mushrooms, and fortified dairy products, though recommended doses rarely can be achieved through diet alone.³⁴ Dairy products are the primary source of dietary calcium. Other high-calcium foods include green leafy vegetables, nuts and seeds, soft-boned fish, and fortified beverages and cereals.³⁵

Probiotics—A growing body of evidence suggests that probiotics may be beneficial in promoting bone health by improving calcium homeostasis, reducing risk for hyperparathyroidism secondary to GC therapy, and decreasing age-related bone resorption.³⁶ An animal study demonstrated that probiotics can regulate bone resorption and formation as well as reduce bone loss secondary to GC therapy.³⁷ A randomized, double-blind, placebo-controlled, multicenter trial randomly assigned 249 healthy, early postmenopausal women to receive probiotic treatment containing 3 lactobacillus strains (Lactobacillus paracasei DSM 13434, Lactobacillus plantarum DSM 15312, and L plantarum DSM 15313) or placebo once daily for 12 months.³⁸ Bone mineral density was measured at baseline and at 12 months. Of the 234 participants who completed the study, lactobacillus treatment reduced lumbosacral BMD loss compared to the placebo group (mean difference, 0.71% [95% CI, 0.06-1.35]). They also reported significant lumbosacral BMD loss in the placebo group (−0.72% [95% CI, −1.22 to −0.22]) compared to no BMD loss in the group treated with lactobacillus (−0.01% [95% CI, −0.50 to 0.48]).³⁸ Although the data may be encouraging, more studies are needed to determine if probiotics should be regarded as an adjuvant treatment to calcium, vitamin D, and pharmacologic therapy for long-term prevention of bone loss in the setting of GIO.³⁹ Because existing studies on probiotics include varying compositions and doses, larger studies with consistent supplementation are required. Encouraging probiotic intake through fermented dairy products may represent a simple low-risk intervention to support bone health.

Anti-inflammatory Diet—The traditional Mediterranean diet is rich in fruits, vegetables, fish, nuts, whole grains, legumes, and monounsaturated fats and low in meat and dairy products. The Mediterranean diet has been shown to be modestly protective against osteoporosis and fracture risk. A large US observational study including 93,676 women showed that those with the highest quintile of the alternate Mediterranean diet score had a lower risk for hip fracture (HR, 0.80 [95% CI, 0.66-0.97]), with an absolute risk reduction of 0.29% and number needed to treat at 342.⁴⁰ A multicenter study involving adults from 8 European countries found that increased adherence to the Mediterranean diet was associated with a 7% reduction in hip fracture incidence (HR per 1 unit increase in Mediterranean diet, 0.93 [95% CI, 0.89-0.98]). High vegetable and fruit intake was associated with decreased hip fracture incidence (HR, 0.86 and 0.89 [95% CI, 0.79-0.94 and 0.82-0.97, respectively]), and high meat and excessive ethanol consumption were associated with increased fracture incidence (HR, 1.18 and 1.74 [95% CI, 1.06-1.31 and 1.32-2.31, respectively]).⁴¹ Similarly, a large observational study in Sweden that included 37,903 men and 33,403 women reported similar findings, noting a 6% lower hip fracture rate per one unit increase in alternate Mediterranean diet score (adjusted HR, 0.94 [95% CI, 0.92-0.96]).⁴² This is thought to be due in part to higher levels of dietary vitamin D present in many foods traditionally included in the Mediterranean diet.⁴³ Additionally, olive oil, a staple in the Mediterranean diet, appears to reduce bone loss by promoting osteoblast proliferation and maturation, inhibiting bone resorption, suppressing oxidative stress and inflammation, and increasing calcium deposition in the extracellular matrix.^44,45 Fruits, vegetables, legumes, and nuts also are rich in minerals including potassium and magnesium, which are important in bone health to promote osteoblast proliferation and vitamin D activation.^36,46-48

Final Thoughts

Osteoporosis-related fractures are common and are associated with high morbidity and health care costs. Dermatologists using and prescribing corticosteroids must be aware of the risk for GIO, particularly in patients with a pre-existing diagnosis of osteopenia or osteoporosis. There likely is no oral corticosteroid dose that does not increase a patient’s risk for osteoporosis; therefore, oral GCs should be used at the lowest effective daily dose for the shortest duration possible. Patients with an anticipated duration of at least 3 months—regardless of dose—should be assessed for their risk for GIO. Patients using topical and intralesional corticosteroids are unlikely to develop GIO; however, those with risk factors and a considerable cumulative dose may warrant further evaluation. In all cases, we advocate for supplementing with calcium and vitamin D as well as promoting probiotic intake and the Mediterranean diet. Those at moderate to high risk for fracture may require additional medical therapy. Dermatologists are uniquely positioned to identify this at-risk population, and because osteoporosis is a chronic illness, primary care providers should be notified of prolonged GC therapy to help with risk assessment, initiation of vitamin and mineral supplementation, and follow-up with metabolic bone health specialists. Through a multidisciplinary approach and patient education, GIO and the potential risk for fracture can be successfully mitigated in most patients.