Treatment Selection for Older Adults with Atrial Fibrillation

SOURCE: Garwood CL, Chaben AC. Best options for stroke prevention therapy for older adults with difficulty using warfarin. Ann Longterm Care 2016;24:31-39.

Risk of stroke in patients with atrial fibrillation (AF) is predicted well by the CHADS2 or CHA2DS2-VASc scores. Anticoagulant treatment should be celebrated since clinical trials document a ≥ 60% reduction in stroke, as well as a ≥ 25% mortality reduction compared to placebo. The addition of four so-called novel anticoagulants (NOACs) in recent years for AF requires that clinicians become more astute about individualizing anticoagulant choices, because there are factors that may have a substantial effect on which agent is best for a particular patient. Newer agents may appear at first glance to have enough superiority over warfarin that they generally should be preferred; to the contrary, it has been shown that for warfarin patients who are consistently (at least 66% of the time) within the desired therapeutic range, the risk-reduction performance of warfarin and the novel anticoagulants is essentially the same.

Additionally, compliance may turn out to be more important for patients taking novel anticoagulants than warfarin. For instance, missing a NOAC dose has a much more prompt and greater effect on risk reduction than missing a single dose of warfarin. Twice-daily dosing required for dabigatran and apixaban might be problematic for some but can be solved by utilizing rivaroxaban or edoxaban instead. Many warfarin patients find that dietary modulation is difficult for them and welcome NOACs, which are free of food interactions. Finally, regular blood monitoring required for warfarin is burdensome for some patients; some cost-effectiveness studies have opined that NOACs, despite their much greater up-front costs at the time of purchase, are no more expensive than warfarin over the long term because clinician visits, international normalized ratio monitoring, and travel for these events are eliminated. The decision to begin anticoagulant therapy is a very important one. The diversity of choices now requires closer attention to individual patient characteristics and preferences to ensure best outcomes.

Sublingual Desensitization Against House Dust Mites

SOURCE: Virchow JC, Backer V, Kuna P, et al. Efficacy of a house dust mite sublingual allergen immunotherapy tablet in adults with allergic asthma: A randomized clinical trial. JAMA 2016;316:1715-1725.

As many as half of asthmatics are sensitized to house dust mites (HDM). Decades of implementation of subcutaneous allergy desensitization have demonstrated two important facts: 1) subcutaneous desensitization can improve asthma in some patients, and 2) although serious adverse reactions to subcutaneous desensitization are rare, asthmatics are the group in which such reactions most often occur. Because of the time and effort necessary to achieve allergen desensitization, only a small minority of asthmatics currently participate in any form of allergen desensitization.

Sublingual immunotherapy is a newer format for allergen desensitization. It can be performed at home and may be preferred by patients who are avoidant of injectable desensitization, but data on asthmatic exacerbations previously has not been studied. Adult asthmatics (n = 834) were randomized to a single sublingual HDM tablet (or placebo) each morning for 18 months. Inclusion required that asthma not be well controlled on inhaled steroids (ICS) or combination inhaled products. Beginning at month 12 of the study, ICS dosing was reduced by half, and at month 15, patients discontinued ICS entirely. The primary endpoint was time to first asthma exacerbation during the ICS-withdrawal phase of the study. HDM sublingual tablets reduced the risk of moderate/severe asthma exacerbations by approximately 30% compared to placebo. HDM was well tolerated, and no serious adverse systemic events occurred. Among the minor adverse effects, oral pruritus was most commonly reported (20% of the high dose HDM treatment group vs. 3% placebo), but all reports of oral pruritus occurred at initiation of treatment onset, and all had disappeared by day five of the clinical trial. Sublingual HDM desensitization is a promising tool for asthmatic patients not well controlled on ICS.

Updated Guidelines on Acne Management

SOURCE: Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol 2016:74:945-973.

There are updated guidelines on the management of acne in adolescents and adults from the American Academy of Dermatology. A multidisciplinary team, which included representatives from dermatology, primary care, pediatrics, and an acne patient participant, generated the guidelines. While it’s not possible to adequately summarize this lengthy document in a few words, several noteworthy principles merit sharing with all primary care clinicians who address acne in their practices.

For mild acne, recommended first-line treatments include benzoyl peroxide, topical retinoids, and topical antibiotics (clindamycin preferred), with topical dapsone considered an alternative. Topicals may be used as monotherapy, dual, or even triple combination, except for topical antibiotics, which are not recommended as monotherapy due to emergence of bacterial resistance. For moderate acne, monotherapy is not considered first line; rather, dual or even triple combination topicals (benzoyl peroxide, antibiotics, retinoids), oral antibiotics plus dual/triple topicals, or (for women) oral contraceptives and spironolactone are options. Although not a usual treatment, isotretinoin becomes a consideration when moderate-to-severe acne has not responded to first-line treatments. Systemic antibiotics (e.g., doxycycline, TMP/SMX, azithromycin, cephalexin) are useful in moderate-to-severe acne, and are recommended to be used in combination with benzoyl peroxide and topical retinoids (but not in combination with topical antibiotics). Tetracycline is the preferred antibiotic class. The new guidelines provide a useful template on which to plan management of acne at all levels of severity.