Dr Keegan, what are some patient-specific characteristics that you consider when you’re choosing an agent or a regimen for atopic dermatitis?

One of the first criteria one would want to think about is what’s the age of the patient? How severe is their condition? What have they tried before, etc.? Things like that are all important criteria, and they can range from it’s the first time a patient’s ever come in and they just need some education about what things can be helpful, and what things they should be staying away from to here are topical medicines to try, if this is just going to be intermittent, and let me know how things go to I’ve already failed this and I failed that before to the I come with a grocery bag full of tubes and creams that have a variety of prescriptions that are inside of them and a whole litany of over-the-counter medicines. Then putting the bottles in my face, “Is this one OK? Is this one OK?” Me just trying to be able to move through the conversation with them in order to get down to the nuts and bolts of what’s going on. There’s definitely a range of patients and a range of patient ages.

Then you just mentioned, we were just discussing the concept of killing 2 birds with 1 stone. So what other concurrent medical conditions do they have that they might potentially benefit from? They make a decision, back again, Dupixent [dupilumab], and someone who has asthma and atopic dermatitis, can they benefit from 1 medicine that will treat both things? Both from the simplicity for the patient, cost for the insurance company, and the mitigation of risk from the perspective of prescribing the medicines vs maybe 2 medicines where we don’t always know what the risk is when we’re combining those 2 medicines together. We just have theoretical concepts of how it might work, so that may be criteria. And then, as I mentioned before, sometimes one of the biggest challenges that patients have is they say they want something, but they really want to get better, and they may sidestep us and say that they want something else or, “I’d like just this type of a medicine because my friend told me this cream is really great.” You look at it and you’re like, “But you’ve got 3 tubes of it already in that grocery bag there that you’ve given me, and that’s really not going to make a lot of progress for you.” So sometimes what buy-in can you get from patients?

I don’t want to say that I always let them make the decision about what they’re going to give, but I’ve had plenty of patients that come in and say, “My sister takes this and she’s doing great. My aunt is on this medicine and doing great,” and if I have 3 or 4 medicines in my mind that are potentials, and they lock in on 1 of them and have a positive experience before they’ve even come in the door to me, that might be enough to try, for me to help them get over the hump of getting started on a medicine, whether it’s topic or systemic. Whatever it can take to help them get onto that next step and get better would be something that I would latch on to and use to my advantage as well too. So those are a couple of them. I’m sure Dr Cameron has a few more strategies or thoughts.

I thought that was really well said. I think that clearly a patient’s perception before they come in the office is huge. There’s a reason why…

What commercial did you see on TV last night?

There’s a reason why direct-to-consumer advertising plays such an important role still. And so clearly, if there are a couple of good options, patient satisfaction is always a priority for me as well as building trust. If they come in and they want to try therapy, if I let them try that therapy, if it doesn’t work, they trust me even more, and so it’s all about just building that physician-patient relationship. In terms of your thinking about which treatments, I completely agree. I think that a lot of times we have several good options now, which is great.

Jumping back on that direct-to-consumer advertising, I think one of the things that we should all recognize is that all these medicines that we’ve talked about today are made-up words. Opzelura [ruxolitinib], Dupixent, dupilumab, these are all made-up words, and we in healthcare are really used to using those made-up words and they make up our own language. We use a lot of made-up words all day long, and patients, when they hear those made-up words in the commercials, they can’t always differentiate them, so they may come to me sometimes with concern. 

“I want to put you on Dupixent,” and they’ll say, “I don’t want to go on that. I heard that I’m going to have a heart attack and get cancer.” And I love it when they tell me what they’re thinking because then I’m thinking, “Oh my gosh, that’s not actually anywhere in the package insert and nothing that we have to be concerned about.” But when they voice their concerns for maybe another commercial that they’ve heard and aren’t really sure of what that medicine is, we can help them to navigate that foreign language that is medicine.

Drs Keegan and Cameron discuss patient-specific considerations for selecting optimal atopic dermatitis treatment strategies.

Patient-Specific Characteristics Driving AD Treatment Regimen

Amy Brennan

Andrew Blauvelt, MD, discusses switching therapies for atopic dermatitis (AD) treatment. 

Switching Therapies in AD

Andrew Blauvelt, MD 

Christian T. Ruff, MD, MPH is the Director of General Cardiology in the Cardiovascular Division at Brigham and Women's Hospital.

Christian T. Ruff, MD, MPH: Abelacimab Minimizes Bleeding Risk of Anticoagulants   

A new analysis of the AZALEA-TIMI 71 study showed abelacimab, a novel factor XI inhibitor, achieved consistent reductions in bleeding risk for patients on or off 

American Heart Association (AHA) Scientific Sessions 2024

, these findings on the effect of abelacimab may offer a potentially safer option for patients with 

 who experience an elevated bleeding risk with traditional anticoagulants.

“I think what a drug like abelacimab allows us to do is confidently be able to treat patients with the antithrombotic therapy that both maximizes their stroke potential from AF, but also protects them from coronary disease,” Christian T. Ruff, MD, MPH, senior investigator of the TIMI Group and director of general cardiology at Brigham and Women’s Hospital, told 

. “Even when you add an antiplatelet agent, so combination anti-thrombotic therapy, you don't see any increased risk of bleeding. That allows us to optimally manage not only our patient's AF but also their comorbidities.”

Abelacimab, a novel, investigational, highly selective, fully human monoclonal antibody, binds to factor XI to block activation and prevent the generation of the activated factor XIa form. AZALEA-TIMI 71, launched in February 2021, enrolled 1287 for a head-to-head comparison of the factor XI inhibitor to a standard-of-care anticoagulant.

Among the study population, 318 (25%) had already received antiplatelet therapy, including aspirin alone (16%), P2Y12 (7%), or dual antiplatelet therapy combining both (2%). Among the population, those treated with antiplatelet therapy had a higher rate of coronary artery disease (70% vs. 42%), previous heart attacks (36% vs. 16%), and peripheral artery disease (15% vs. 11%).

The prespecified analysis revealed a 67% reduction in bleeding for patients on antiplatelet therapy receiving abelacimab 150 mg, compared with rivaroxaban (incidence rate, 3.5% vs. 10.6%). Absolute bleeding rates were higher with the combination of rivaroxaban and antiplatelet therapy, compared with rivaroxaban alone (10.6% vs. 7.7%).

However, Ruff and colleagues noted the bleeding rates treated with abelacimab 150 mg were similar irrespective of antiplatelet therapy use (3.5% vs. 3.1%). Overall, the absolute risk difference between abelacimab 150 mg and rivaroxaban was greater in those on antiplatelet therapy, compared with those not receiving antiplatelet therapy (7.1% vs. 4.6%).

“The promise of factor XI inhibition was to deliver effective therapy to reduce thromboembolic events, but far safer,” Ruff told 

 “I think the AZALEA-TIMI 71 study cements the safety of factor XI inhibition, particularly with abelacimab, that this therapy is far safer than anything we've seen with an anticoagulant.”

Disclosures: Ruff reports no relevant disclosures.

Said SA, Patel SM, Giugliana R, Morrow DA, et al. Bleeding with the FXI Inhibitor Abelacimab compared with Rivaroxaban in Patients on Antiplatelet therapy: A Prespecified Analysis of the AZALEA-TIMI 71 Trial. Presented at the American Heart Association (AHA) Scientific Sessions 2024. Chicago, Illinois. November 16-18, 2024.

Abelacimab, a novel factor XI inhibitor, demonstrated significant reductions in bleeding risk compared to rivaroxaban in the AZALEA-TIMI 71 study, even for patients on antiplatelet therapy. This investigational monoclonal antibody offers a potentially safer anticoagulant option for atrial fibrillation patients, particularly those with elevated bleeding risks. The study showed a 67% reduction in bleeding for patients on antiplatelet therapy with abelacimab. The findings suggest that factor XI inhibition with abelacimab could provide effective thromboembolic event reduction with improved safety over traditional anticoagulants.

Christian. T. Ruff, MD, MPH describes an analysis of AZALEA-TIMI 71 demonstrating the substantial benefit of abelacimab on bleeding outcomes in patients on antiplatelet therapy.





 

Christian T. Ruff, MD, MPH: Abelacimab Cuts Bleeding Risk Versus Rivaroxaban

Christian T. Ruff, MD, MPH

On February 10, 2022, the US Centers for Disease Control and Prevention (CDC) 

 of their revised guideline for prescribing opioids for chronic pain. While the 

 is more than 200 pages, the most important part is the actual guideline itself, which is 12 statements that take the place of the 12 statements that comprised the 2016 version that this draft is intended to replace.

Because it is likely that the primary intended audience of clinicians will not read the full document but will focus on the 12 statements, it’s key to examine what has changed, what has not, and the potential impact of this new guideline on the lives of millions of patients with chronic pain whose lives have been 

The biggest change is the removal of specific dosage cautions and limits in statement 4 and 5 and specific days duration of opioid therapy for acute pain in statement 6.These dosage and duration limits were arbitrary and unsupported by clinical evidence yet widely implemented across the country and even codified in law in at least 33 states. Prescribers, insurers, and even pharmacies, implemented them as strict limits. They have caused the most egregious harms over the past six years including forced tapering, hundreds of documented suicides, sudden loss of access to medication triggering withdrawal, dismissal from physician practices, inability to find medical care, and loss of function and quality of life.

In an acknowledgement of these harms to patients with chronic pain from abrupt discontinuation of opioid therapy, statement 5 now includes repeated cautions to “exercise care”, “gradually taper” and “not discontinue abruptly or rapidly” when reducing dosage.

The other less significant changes in the guideline itself are slightly easing the directives on patient surveillance and softening the absolute restriction on concurrent prescribing of benzodiazepines. Statement 9 changed checking the prescription drug monitoring program (PDMP) “ranging from every prescription to every 3 months” to when starting opioid therapy and periodically thereafter.Statement 10 changed the recommendation to use urine drug testing when starting opioid therapy and annually to “consider toxicology testing”.Statement 11 changed “avoid” concurrent prescribing of benzodiazepines and opioids to “use extreme caution” if doing so.

What has not changed in the revised guideline is the lack of balance in the discussion of whether to initiate, continue or discontinue opioid therapy.As in the 2016 version there is a focus on the risks and harms of opioids without any mention of the benefits of opioids for pain control when medically supervised or the risks and harms of inadequately managed pain, especially when other therapies have proven inadequate or contraindicated.

With their focus on patient surveillance through regularly checking the PDMP and using toxicology, the risk the guideline is most concerned about is the risk of addiction.Yet, repeated research has shown the risk of addiction in medically supervised pain patients on opioid therapy to be very small – between less than 1% to 8%. Stated another way, between 99% and 92% of chronic pain patients on opioid therapy do not become addicted to their medication.

However, millions of patients on stable doses of their medication have been forced to taper off their medication since 2016 due in large part to the widespread adoption of the CDC Guideline and the consequent fear of scrutiny and loss of licensure they have created in the minds of U.S. physicians. In 2015, the National Institutes of Health (NIH) reported that there were between 5 and 8 million Americans on opioid therapy for chronic pain.

Further, what has also not changed is the weak body of evidence most of the 12 statements are based on, as in the 2016 version.Using the Group Reading Assessment and Diagnostic Evaluation (GRADE) system which rates the strength of the evidence underlying each guideline statement, 7 out of 12 statements have a rating of 4 on a 1 – 4 scale, where 4 is the weakest level of evidence considered “very weak”. Three additional statements have an evidence rating of 3 or “weak”. Yet, 4 out of the 7 statements with very weak evidence were given the strongest “A” level recommendation rating by the CDC Guideline authors. That is, simply put, intellectual dishonesty.

This revised guideline again excludes certain pain conditions (cancer, sickle cell disease, palliative care, and end-of-life care) as more worthy of pain control where the stated risks and harms don’t apply. Pain is pain, and chronic pain is fundamentally a disease of the nervous system and brain regardless of the etiology. Due to great variation in individual differences regarding disease progression, severity of condition, sensitivity to pain, metabolic variables and more, benefits and risks must be considered on an individual basis. A person with any given pain condition could be in much worse pain for longer duration than a person with one of the excluded conditions.

Will the Revised Guideline Change Practice?

I think it’s unlikely that there will be a renewed willingness on the part of physicians to prescribe opioids again to chronic pain patients who were removed from opioid treatment against their will. According to a report from the US Department of Health and Human Services (HSS) to Congress in April 2020, at least 33 states have adopted statutory limits on opioid analgesic prescriptions. It’s doubtful that any of these codified restrictions will be repealed anytime soon. Once laws are on the books it’s very hard to change them. And, as long as the intense scrutiny of opioid prescribing continues as a result of these laws, regulations and US Drug Enforcement Administration (DEA) investigations of prescribers, I don’t anticipate that access will improve for chronic pain sufferers.

Of course, nothing will bring back all the pain sufferers who committed suicide as a result of being forced off their medication. And nothing can give back all the years lost to relentless pain and suffering of the innocent people living with debilitating chronic pain who were forced off their medication since 2016.

What is more likely to improve in the short term is payer coverage of non-opioid restorative, behavioral and complementary treatments, and medical devices for those with chronic pain, and perhaps with increased recognition of the harms caused by the guideline, a lessening of the punishing stigma associated with being a person in pain in the US. In the long term, I remain hopeful that the current trend of significant increases in public and private investments in neuroscience pain research will lead to novel therapeutics to more effectively treat chronic pain.

Listen to Cindy Steinberg discuss the implications of these changes in an 

interview featured on our DocTalk podcast.

Cindy Steinberg is the Director of Policy and Advocacy for the 

and Policy Council Chair for the Massachusetts Pain Initiative. She is a nationally prominent and articulate spokesperson for the needs of people living with pain and has won numerous awards for her pain policy accomplishments. In 2018, she was appointed by HHS Secretary Alex Azar to serve on the 

HHS Pain Management Best Practices Task Force 

and in 2019 she was invited to testify before the US Senate HELP Committee.

The Director of Policy and Advocacy for the US Pain Foundation addresses the important changes made to the updated draft of the CDC Clinical Practical Guideline for Prescribing Opioids 2022.

Assessing the Draft Revised CDC Clinical Practice Guideline for Prescribing Opioids 2022

Cindy Steinberg

The panel concludes the discussion with key takeaways on the evolving treatment landscape for COPD.

Key Takeaways on the Evolving COPD Treatment Landscape

Video content above is prompted by the following question:

What are your key takeaways on the evolving COPD treatment landscape?

Fernando J. Martinez, MD, MS

 In the little time that we have left, I want to go around and get some final thoughts from each one of you. I would like you to address the whole issue of using naloxone. How do you address this with patients? How do you address this with clinicians, and what is your view about going forward? How is this going to change the landscape of opioid use in the United States? Why don’t we start with Jeremy, and we will keep going from there? Take 30 seconds, and we will just keep going.

 I think we have covered a lot of ground today. We know, and have known for a long time, that opioids have certain risks. They pose risks to patients, and they pose risks in the community when they are taken unsupervised or misused. From a safety measure perspective, there are things we can do. We can do a better job identifying the patients at risk or when identifying those patients who should or should not receive opioids. At the same time, I think we need more community awareness, and we can do this by using the naloxone program or some of the other programs discussed today. Rhode Island sounds amazing, and I am interested to learn more about what is happening out there. The tools we have today can enhance the safety of what we are doing on the medical side and help out there in the community with the substance misuse and illicit side. That is outside of the reach for some of us who do not work in settings where one can reach out to the community, but I think that these types of tools are underutilized. If these tools are utilized on a more frequent basis, and in a more normalized way, we have the potential to reverse what we have seen here with opioids and the subsequent harm caused by them.

 While acknowledging that opioids are still commonly used as part of a multidisciplinary approach to pain management and that opiates are still being misused illicitly, we need to have strategies that emphasize the availability of naloxone so that people can be as safe as possible. As Dr Adler said, this must be normalized, and we need to realize, when we think about this, it is going to take more years than we would like before it will become normalized, but we need to step it up and work toward that.

 I cannot agree more with my colleagues. I think that, when it comes to normalizing naloxone, we need to take the lessons we have learned from what successfully normalizes this method of treatment. Whether it is enacting policy interventions, having naloxone everywhere, putting up billboards, or getting that access. What we are doing is studying people, saying what makes you dispense naloxone, to pharmacists? Saying what makes you dispense it, to primary care physicians? What makes you want to give it, to a caregiver? What are those barriers? How do we break them down? I look forward to the day of over-the-counter naloxone that is still covered by insurance so we do not have financial barriers. There is a lot that we know, areas where we have been successful, and I think that yes, it is going to be around a long time. We have seen how COVID-19 has created these divisions. I think, by solving those divisions during COVID-19, we will solve some of the divisions in access to care for people with opioid use disorder or people who use opioids.

I see naloxone as one part of the puzzle here, one part of the comprehensive approach that we try to take in the emergency department [ED], and that is decreasing the barriers that patients need to overcome to get naloxone. This is improving their access to naloxone not only in the ED but also in other areas of life where they have access to health care, and in their daily lives. Having it available works, whether it is having a naloxone box sitting next to an AED [automated external defibrillator] box somewhere or offering it to patients proactively and not requiring them to have to ask for it.

Additionally, I think that, as science for medication-assisted treatment continues to be redefined every day—how effective that is for treatment—it is our responsibility to not only make sure that our patients are safe as they go out and use this, or that their community is safer because naloxone is out there. But we also need to provide multiple opportunities for patients to get linked to treatment, to be linked to peers, and to have access to medication-assisted treatment. I think this is equally important and should be offered as routinely as possible.

Theresa, some people hate to be the last one to speak when all the good stuff is taken.

Theresa Mallick-Searle, MS, RN-BC, ANP-BC:

heresa Mallick-Searle, MS, RN-BC, ANP-BC: 

As the token nurse on the platform here, I am really big into listening to my patients. It is not that my colleagues are not, but I want to hear what is important to the patient. I want to be able to have them partner with me in their health care. I want to be able to encourage my peers to look at the bigger community and be in it for the long term, to decrease the amount of fear out there. As a health care provider, for anything that we do, we are trying to do the best we can to take care of our patients.

Thank you all very much. I want to thank you at home as well for watching this HCPLive® Peer Exchange. If you enjoyed this content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your inbox.

I am Dr Peter Salgo, and I will see you again next time.

The multidisciplinary panel of experts share final thoughts on strategies to normalize naloxone and decrease barriers to its obtainment and utilization. 

Final Thoughts on the Opioid Crisis and Normalizing Naloxone

Jeremy Adler, DMSc, PA-C, DFAAPA, Pacific Pain Medicine Consultants 

Kimberly A. Davidow, MD, pediatric hematology/oncology, Nemours Children’s Health

Davidow discussed how a new cohort study has helped support findings of an older European study and the need for a prospective trial to confirm the increased risk.

Kimberly A. Davidow, MD: Elucidating Risk of Autoimmune Disease in Childhood Cancer Survivors

A new, real-world cohort study has further identified an increased risk of autoimmune disease in childhood cancer survivors after an initial Scandinavian cohort study suggested this increased risk.

Findings from the study were presented at the

 66th American Society of Hematology (ASH) Annual Meeting and Exposition

, held December 7-10, 2024, in San Diego, California, by Kimberly A. Davidow, MD, pediatric hematology/oncology, Nemours Children’s Health.

“With the increased availability of these different kinds of large data platforms, Jefferson [Health] had access to Trinetics, which pulls in a large amount of healthcare data, and [they] wanted to use that to try to look at autoimmune diseases and try to cancer survivors,” Davidow told 

Although limited by constraints inherent to many electronic healthcare records, Davidow and colleagues found that childhood cancer survivors had an increased risk of rheumatoid arthritis, Sjogren disease, ulcerative colitis, and Crohn disease. Davidow shared that these associations should be looked further into in prospective trials, and primary care providers should keep in mind these increased risks when treating adult childhood cancer survivors.

“If you are a primary care provider who's taking care of someone who's a childhood cancer survivor, there's a lot of things you need to know, but this is also important to know. If they're starting to have complaints about joint pains or unusual rashes that, in another patient who didn't have this history, you might not think much of it yet, you need to think more about it for them, because there is this increased risk, and so you should screen sooner than you might for someone else,” Davidow stressed.A new, real-world cohort study has further identified an increased risk of autoimmune disease in childhood cancer survivors after an initial Scandinavian cohort study suggested this increased risk.

“If you are a primary care provider who's taking care of someone who's a childhood cancer survivor, there's a lot of things you need to know, but this is also important to know. If they're starting to have complaints about joint pains or unusual rashes that, in another patient who didn't have this history, you might not think much of it yet, you need to think more about it for them, because there is this increased risk, and so you should screen sooner than you might for someone else,” Davidow stressed.

Davidow KA, Rohan TZ, Roslund CR, et al. Real-World Data Shows Increased Incidence of Autoimmune Disease in Survivors of Childhood Lymphoid Malignancies. Presented at: ASH Annual meeting; December 7-10; San Diego, California. Abstract 5094

Kimberly A. Davidow, MD

Margaret Bobonich, DNP, FNP-C, DCNP, FAANP: 

What do we do? How can we assist our colleagues in helping them look at one, how do we choose therapies, and when do we collaborate and refer these patients, and what kind of patient education can we provide for these patients?

Well, I think just to kind of bring this all the way back around, first off an accurate diagnosis always leads to successful treatments. So, make the diagnosis. Familiarize yourself with the different presentations of atopic dermatitis and the neonate versus the toddler versus the teen versus the elderly. And I think have a high clinical index of suspicion. If it is coming back, if it is very pruritic, if it’s life-altering, even if it doesn’t look like classic atopic dermatitis, it likely is a phenotypic presentation of that even if it’s not what’s inside your dermatology textbook. So, get the right diagnosis because the right diagnosis will then lead you to begin to move into the more, what I call the empathic side of treating this How is this impacting your life? How would your life change, how are the treatments that you’ve been using working? And so, begin that dialogue with patients and just kind of let them open up a little bit. It doesn’t have to be two-hour long visits for them to really feel like why this is different than other people have seen. Just asking a few questions lets them know that you're into the diagnosis, that you're not just going to run for a cream and send them out the door, and that you can make a difference. And if you don’t have that time to really tell them everything; you're not going to unload everything on the first visit. Tell them about comorbidities, tell them about every single systemic option, you're going to get their acute flare under control with topicals. And then you're going to bring them back in, you're going to earn their trust, you're going to continue to talk to them about it, and then you're going to begin – I’m always introducing non-steroidal options to patients right up front. If I feel like I have to use a topical steroid to calm it down – I may not need to once we get this new topical JAK out but I’m always introducing the idea of us moving off the topical steroids. I don’t use them much but systemics onto these new treatments. So it’s kind of a progressive revelation of talking to them about the disease, what you believe it is, how you want to open up the box and let them know that you know how this impacts you and the family, that we’ve got good treatments out there, we’re going to start off with this, but it’s important for me to see you back because we want to look into other treatments that are on the horizon that can control this for long periods of time without having to lead the anxiety about when am I going to break out next time. 

You know I think you summarized it very well Doug. I think it’s exciting where we’ve been and where we’re going. We don’t have to use systemic agents with these high toxicities that are really rescue agents, like the cyclosporine. We have choices now. And letting the patients know that and one of the interesting things is I’ve heard people say well that’s an injection. But guess what, let’s let our patients make that choice. Let’s give a fair representation of all the treatment options that we have and the ones that are coming because the truth is that an injection may be nothing compared to the quality of life that atopic dermatitis is having on these patients. A lot more to come for us especially our adult, some of the newer agents will be anticipated FDA-approved for adults. Some of the resources you like to give your patients Doug, what are they? 

Well certainly the National Eczema Association, the NEA, I think is an excellent resource with information about clinical trials that we may have mentioned in this presentation, great patient support, practical data that’s there, practical recommendations on bathing and moisturizing. I really, really like the NEA as a great resource. Do you have others? 

Margaret Bobonich, DNP, FNP-C, DCNP, FAANP:

 The National Eczema Foundation is my choice. But I think as far as resources for you as clinicians, I think one of the best ammunitions I would have for you is if you're in primary care or if you're in derm and you're not comfortable with prescribing some of these agents that are here now or the newer ones that we anticipate that will be FDA-approved in the near future, if you're not comfortable, reach out to a local dermatologist or dermatology NPPA and let us help you. One, we’ll help you with that patient and supporting them and getting them the best treatment and optimal outcomes, but also to help you learn about it. We really, really want to support you as colleagues and that’s my suggestion. Any last words Doug? 

 I just want to echo that. You know the study is a few years old, but it showed that only 19 percent of patients with severe atopic dermatitis got referred from primary care to dermatology. I think that’s improved, especially with some of the commercials that have been out about eczema and dupilumab’s campaigns. But we just want to say that this is – our medicine is a collaborative effort. We’re not living in silos here. We want to – we in dermatology want to partner with our primary care providers, we want to partner with our allergy specialists, we want to partner with the folks that are going to help us out too. I want to tell Margaret, you're helping your patients and you're helping yourself because these folks are living with infections, they’re living with scratching, they’re living with anxiety and depression. And we now have treatments out there that can radically change and improve that. So that’s the biggest message of today’s time together is that there is help out there, that we can get these medicines covered by most insurances, and that they can really change patients’ lives. 

 Thank you so much Professor Doug. This is why we call him Professor Doug. And thank you so much. Thank you for watching 

. If you’ve enjoyed this content, please subscribe to our newsletters to receive the upcoming programs and great content right in your inbox. So thank you everyone. Be safe and live well.

Experts in dermatology discuss patient education and clinical pearls to assist colleagues in the management of atopic dermatitis.  

Care Collaboration in Atopic Dermatitis 

Margaret Bobonich, DNP, FNP-C, DCNP, FAANP

 I want to give us all an opportunity to give some advice or practice pearls to all of our viewers including other hematologists, maybe focusing a bit on red blood cell health or other areas that you think are important including decreasing long term organ damage. I’ll start with you Elna. What advice or practice pearls do you have for our audience?

 I think it is the shifting paradigm that yes sickle cell is an anemia and it causes pain, but the thing that reduces survival and still has maintained the early mortality in sickle cell disease patients compared to the general population is not necessarily the pain or the pain episodes. It is the progressive organ dysfunction and so we should slowly move away from the deception of sickle cell being a mild disease. We should consider it like diabetes or hypertension and that the organ damage is also a silent killer. If we shift that paradigm the way we approach them and how we approach our practice even towards them, we will shift an emphasis in embracing and offering disease-modifying agents to almost all of our patients and having the discussion of the impact of end organ dysfunction and damage in overall longevity and mortality.

 Thank you so much, Elna. Nirmish, you’re next.

 I would just extend the conversation in the sense that educate and be real, continue to educate. I love the descriptions that came up in our conversation today. As I told Matt, I’m going to use some of those. I’m very graphic about drawing pictures and being in the room and getting them to really understand and see what’s happening inside of them because that gives them a little bit of control of knowing what’s happening to themselves. Otherwise, it’s a chronic disease that they have no control of. What control can you give them? It’s educating them about the disease and being able to tell others about what’s happening to them. I think the pearl for me is to educate them and that includes education about these new therapies, and the new drugs that are available now. I even actually started to talk to them about the new drugs that potentially could come.

When we talk about gene therapy, I still kind of give a teaser about it. We’re not there yet. It’s all about being real with them. We don’t have the data. I’m trying to get them to understand that’s why research studies are occurring; this is what we hope that patients can be involved enough with. The patients, I can’t say this enough, they’re really smart. They’re really savvy about connecting to others and they want the information. They just take it up and soak up this information and I think it’s good for the community. Those are some of the pearls. And I mentioned it before, talk about these new medicines when they don’t need it. Talk about everything but pain until you have to talk about pain. Elna brought this up, that there might be the pediatrician inside of us trying to think about the whole world and not the adult side, but I think that our adult colleagues, and I know Biree you do this as well, I think we’re understanding that the quality of life is a big deal. Thus, I think those are some things to consider as we have our colleagues continue to see patients with these new drugs.

 I’ll leave you with 2 more images or analogies that I use because I think that there’s nothing sexy about having a chronic disease and a lot of it is just persistence of the patients, families, and providers in meeting the treatment goals and treatment plan. As I tell families when they’re going for their annual ophthalmology visit or their annual TCD [Trans Cranial Doppler], there’s nothing sexy about this. It’s like changing the oil in your car. It’s a pain. It’s annoying. It costs a little money. But if you don’t do it, what happens to the car? All the kids know the answer to that. It breaks down. Thus, that’s why [there is] this constant persistent pressure to keep on the plan is really very important.

The other one that I find useful to try and sometimes improve adherence to the treatment plan is the idea that organs are like a rock on the beach and the waves every day hit the beach, and they hit that rock and every day you don’t see anything. It’s just like the damage which is done every day with sickling even though you have no symptoms. There’s some clinical inexorable accrual of organ damage is what my mentor used to call it. There’s a little bit of damage every day that’s imperceptible. When you come back to that beach at the end of high school and you see the rock there, it’s still getting pounded by the wave and then you go away to college and then you have kids and you come back and all of a sudden there’s no rock on the beach. It’s just sand. It’s that daily pounding of that rock by a wave that you don’t notice the rock changes, but it’s becoming sand slowly and that’s what we’re trying to prevent with the daily damage of sickle cell disease on your organs.

Hydroxyurea and other disease-modifying agents are trying to prevent that from the daily point of view so that, as Nirmish pointed out or Elna pointed out, we’re trying to improve the overall health and organs of our patients who we present to our adult colleagues so that they can ultimately hopefully have a prolonged life and that sickle will no longer be an either immediately life-threatening or life-limiting disease, but hopefully have normal lifespan and quality of life. That’s really the goal. It’s hard. It’s hard to do that as a child, as a teen, and as an adult with so many other pressures on us but to encourage them to continue to follow the treatment plan with what we have while also being cognizant of what’s coming and what might be until something better comes along, as I say. Let’s follow this plan now. My promise is to keep them informed of what’s potentially available, both experimental and approved, and then they can choose collaboratively with us to potentially take on some of those new therapies.

Thank you, Matt. I really love the imagery in those analogies. I think we’ll all start to use them. I just wanted to add that I think when I speak to colleagues, clinicians of any specialty, patients, the community, family members who help to support their loves ones living with sickle cell disease; I really tell them that the tide is changing in sickle cell disease and it’s changing pretty quickly. Not only do we have more therapies available now, but our understanding of new potential targets is also growing exponentially and we’re seeing that playing out in the clinical trials that are available and that will be emerging in the near future. I think that sickle cell disease as we know it is changing. It is changing. Our patients may not feel that way today, but I do talk to my pediatric colleagues including some of you on the webinar today and I’m always heart-warmed when I hear the hydroxyurea story, for example. My colleagues say that ever since we’ve been giving it to babies starting at 9 months of age, we have such a healthier kindergarten class when we see those 5-year-old’s go off. That just warms my heart.

I think as an adult practitioner I’ve not yet begun fully to that extent to see the effects of novel agents or disease-modifying therapies or even transplant for that matter because we don’t do enough of it in the adult world. But I think that that tide is really changing. Just like hemophilia, for example, where we’ve come a long way, the expectation in hemophilia management is no leads. When we think about HIV care and we were making people toxic, sick with therapy as we knew it a few decades ago, and now people can be on 1 pill once a day. I think that there’s the potential in the very near future, hopefully in all of our lifetimes, to see that amazing impact on those affected by sickle cell disease. I’d say the future is definitely bright. I want to thank Elna, Nirmish, and Matt. And I want to thank you all for watching this 

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A panel of experts in hematology discuss the future directions for sickle cell disease and share practice pearls for disease management. 

Practice Pearls for the Management of SCD

Matthew M. Heeney, MD

Experts discuss this class of agents for treatment of insomnia and discuss other therapeutic advancements in the field.

Dual-Orexin Receptor Antagonists for Treatment of Insomnia

This is a video synopsis of a discussion involving Dr Paul Doghramji, a distinguished family physician practicing at Collegeville Family Practice and serving as the Medical Director of Health Services at Ursinus College, both located in Collegeville, Pennsylvania. Dr Doghramji introduces an upcoming Peer Exchange program titled "Dual Orexin Receptor Antagonists for Treatment of Insomnia."

In this program, Dr Doghramji will moderate a conversation with esteemed colleagues regarding the use of dual orexin receptor antagonists and other therapeutic advancements in treating insomnia. The discussion covers several key topics, starting with the standard of care for insomnia and the associated challenges.

Dr Doghramji emphasizes that cognitive behavioral therapy is considered the best treatment for chronic insomnia. However, challenges arise as many patients struggle to find therapists or commit to the recommended duration of therapy. Consequently, medication becomes a prominent option, and Dr Doghramji outlines various FDA-approved categories, including benzodiazepines, selective benzodiazepine receptor agonists, melatonin receptor agonists, and others.

The discussion introduces the newest entrants in insomnia treatment—dual orexin receptor antagonists. Dr Doghramji explains that these medications block the effects of orexin, a neurotransmitter promoting wakefulness. The three approved medications in this category, suvorexant, lemborexant, and daridorexant, have shown efficacy in helping patients both initiate and maintain sleep.

Dr Doghramji provides a comprehensive comparison of traditional treatments and dual orexin receptor antagonists, emphasizing the latter's advantages, including no tolerance, no rebound effects, and no withdrawal symptoms. Additionally, he highlights unique features of daridorexant, such as improved efficacy over time and a positive impact on next day sleepiness at higher doses.

In conclusion, Dr Doghramji introduces these dual orexin receptor antagonists as a promising category of medications with potential benefits for patients experiencing insomnia, addressing some of the challenges associated with traditional treatments.

Video synopsis is AI-generated and reviewed by HCPLive® editorial staff.

In an upcoming Peer Exchange program entitled “Dual-Orexin Receptor Antagonists for Treatment of Insomnia” Dr Paul Doghramji will moderate a conversation with physicians about this class of agents for treatment of insomnia and discuss other therapeutic advancements in the field.

Authors