Douglas Wolf -New Treatments and New Strategies
- More proactive approach is recommended; this leads to less surgery, less hospitalization, and less antibodies to infliximab
- Risk assessment should guide treatment; higher risk indicates a need for more aggressive therapy
- Higher doses of anti-TNFs appropriate in some cases (eg weekly Humira)
- For distal colitis/proctitis, budesonide foam is an alternative to cortifoam
- Azathioprine monotherapy has a low response rate
- Combination therapy may not be needed if good IFX levels obtained. Though, it is possible that development of antibodies precludes achieving good levels; thus, combination therapy may increase likelihood of good levels by reducing antibody formation, particularly earlier in course
- Vedolizumab can be shortened to q4weeks if not improving.
- CALM study: symptom based management compared to management based treat-to-target relying on CRP, and calprotectin. Improved outcomes with treatment based on CRP, calprotectin in addition to symptoms.
- Tofacitinib –will be available in 2018 for ulcerative colitis
Chiristina Ha -Treatment Strategies in the Elderly
Dr. Ha referenced Dr. Sandborn who recently stated that combination therapy should be first-line therapy in moderate-to-severe disease –though this may be different in elderly patients.
- Older age –increases mortality risk
- Immunosenescence -relative immunodeficiency state associated with aging
- Pharmokinetic changes with aging
- Increased susceptibility to drug toxicity (eg. Renal, hepatic)
- Older patients usually excluded from therapeutic trials
- Polypharmacy is more common
- Frequent strategy in elderly has been using 5-ASAs and steroids, even in moderate-to-severe disease. This has been due to increased fear of adverse events with IMM and anti-TNFs. However, using data from rheumatoid arthritis, older patients’ biggest risk is steroids.
- Thiopurines have unfavorable risk profile in the elderly.
- Anti-TNFs are not as effective in the elderly
- Preliminary data on vedolizumab -very limited data, may work better in older patients
- Most common infections by be reduced considerably by immunizations. (eg. ,bacterial pneumonia, herpes zoster)
- Correct anemia, nutritional deficiencies
Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) and changes in diet should be confirmed by prescribing physician. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.
A recent article (JC Anderson et al. Am J Gastroenterol 2017; 112:1356–1359; doi: 10.1038/ajg.2017.251; published online 8 August 2017) also addresses the topic of physician burnout with a focus on gastroenterology, link: Strategies to Combat Physician Burnout
- Physician burnout has reached epidemic proportions, with 54.4% of physicians reporting at least one burnout symptom in 2014, an increase from 45.5% 3 years earlier
A Medscape survey in 2016 showed a burnout rate among gastroenterologists of 49%, up from 41% the year before
Key drivers of burnout are excessive workload, an inefficient environment and
inadequate support, problems with work life integration, loss of value and meaning in work, and the loss of autonomy, flexibility, and control in work
The cost of burnout is high, as these physicians are more likely to leave medicine, retire early, make more medical errors, and have lower patient satisfaction scores
Combating Physician Burnout:
- Leadership : Having good leaders affects the well-being and satisfaction of physicians in health care organizations
Reducing Administrative tasks -scribes, mid-level providers
Control over workflow and work hours
“Peer support is crucial, nothing else can replace it.”
“Physicians who spend at least 20% of their total effort in an activity that they find most meaningful are at a lower risk for burnout”
Self-care: Stress management and mindfulness can reduce burnout
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Last week, I went to our integrated health care network meeting. Among the topics was physician burnout. Lately, this is a “hot” topic with a lot of publicity regarding this increasingly-common problem.
At our meeting, some of the keep points -noted below & in the slides that follow:
- Physician burnout rate is increasing based on most recent studies
- Many physicians, 42%, would not choose medicine as their career today
- Manifestations of burnout include “compassion” fatigue
Physicians may be more at risk for burnout due to the following:
- Frequent personality characteristics: workaholics, accustomed to delayed gratification
- Practice aspects: long hours, huge responsibilities
How to Prevent Burnout:
- Lower stress –recharge with outside activities: hobbies, excursions, charitable work, physical activities, and emotional/spiritual
- Resources: Stop Physician Burnout, Burnout Prevention Matrix both by Dike Drummond
Related blog post: Quality Care = Work Satisfaction for Physicians
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FDA Announcement Aug 3, 2017: FDA approves Mavyret for Hepatitis C
The U.S. Food and Drug Administration today approved Mavyret (glecaprevir and pibrentasvir) to treat adults with chronic hepatitis C virus (HCV) genotypes 1-6 without cirrhosis (liver disease) or with mild cirrhosis, including patients with moderate to severe kidney disease and those who are on dialysis. Mavyret is also approved for adult patients with HCV genotype 1 infection who have been previously treated with a regimen either containing an NS5A inhibitor or an NS3/4A protease inhibitor but not both.
Mavyret is the first treatment of eight weeks duration approved for all HCV genotypes 1-6 in adult patients without cirrhosis who have not been previously treated. Standard treatment length was previously 12 weeks or more.
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Gravelly Point, Arlington, VA
From NY Times: Overtreatment is Common, Doctors Say
Researchers surveyed 2,106 physicians in various specialties regarding their beliefs about unnecessary medical care. On average, the doctors believed that 20.6 percent of all medical care was unnecessary, including 22 percent of prescriptions, 24.9 percent of tests and 11.1 percent of procedures. The study is in PLOS One.
Reasons for overtreatment that were cited:
- Fear of malpractice “that fear is probably exaggerated, the authors say”
- Patient demand
- Financial incentive
My take: It takes more time explaining why a test/medicine/procedure is a waste of time than to order it; even then, many patients/families are unhappy if the physician does not order the test/medicine/procedure that they think is necessary. Changing this dynamic is not easy.
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A recent study (JC Robinson et al. NEJM 2017; 377: 658-65) examined the topic of “reference pricing” and how this could be used to lower costs of medication usage.
“Under reference pricing, the insurer or employer establishes a maximum contribution it will make toward the price of a drug or procedure, and the patient pays the remainder.”
In this study, the authors examined 1302 drugs and more than 1.1 million prescriptions (2010-2014). Specifically, the authors compared RETA Trust, a national association of 55 Catholic organizations, which implemented reference pricing and compared costs with a labor union that maintained a drug formulary with copayments similar to RETA Trust but did not implement reference pricing. Key findings:
- “Implementation of reference pricing was associated with a higher percentage of prescriptions that were filled for the lowest-priced reference drug within its therapeutic class” (increase in 7%) along with a lower average price paid per prescription (-13.9%) than the comparison group.
- Reference pricing was associated with increase in copayment by patients (5.2%)
- Reference pricing was associated with reduced spending for employers by $1.34 million and increase in copays for employees by $0.12 million than in the comparison group.
Reference pricing has been associated with decreases of 10-12% in medication costs in European nations, as well.
The authors conclude: “Reference pricing may be one instrument for influencing drug choices by patients…pharmaceutical manufacturers who wish to charge premium prices may need to supply evidence of commensurately premium performance.”
My take: Although in concept reference pricing makes sense, I do worry that patients may be pushed towards less effective medications as not all medications in the same class are equally-effective.
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This graph shows the percentages of prescriptions for the lowest-priced drugs before and after implementation of reference pricing for RETA Trust. Union Trust is the comparison control.