Cameron West

The effect of reminder systems on patients’ adherence to treatment

Background Patient adherence is an important component of the treatment of chronic disease. An understanding of patient adherence and its modulating factors is necessary to correctly interpret treatment efficacy and barriers to therapeutic success. Purpose This meta-analysis aims to systematically review published randomized controlled trials of reminder interventions to assist patient adherence to prescribed medications. Methods A Medline search was performed for randomized controlled trials published between 1968 and June 2011, which studied the effect of reminder-based interventions on adherence to self-administered daily medications. Results Eleven published randomized controlled trials were found between 1999 and 2009 which measured adherence to a daily medication in a group receiving reminder interventions compared to controls receiving no reminders. Medication adherence was measured as the number of doses taken compared to the number prescribed within a set period of time. Meta- analysis showed a statistically significant increase in adherence in groups receiving a reminder intervention compared to controls (66.61% versus 54.71%, 95% CI for mean: 0.8% to 22.4%). Self-reported and electronically monitored adherence rates did not significantly differ (68.04% versus 63.67%, P = 1.0). Eight of eleven studies showed a statistically significant increase in adherence for at least one of the reminder group arms compared to the control groups receiving no reminder intervention. Limitations The data are limited by imperfect measures of adherence due to variability in data collection methods. It is also likely that concomitant educational efforts in the study populations, such as instructions regarding proper administration and importance of correct dosing schedules, contributed to improved patient adherence, both in reminder and control arms. The search strategy could have missed relevant studies which were categorized by disease rather than adherence. Conclusions Reminder-based interventions may improve adherence to daily medications. However, the interventions used in these studies, which included reminder phone calls, text messages, pagers, interactive voice response systems, videotelephone calls, and programmed electronic audiovisual reminder devices, are impractical for widespread implementation, and their efficacy may be optimized when combined with alternative adherence-modifying strategies. More practical reminder-based interventions should be assessed to determine their value in improving patient adherence and treatment outcomes.

Comparative Efficacy of Biologics in Psoriasis

AbstractBackground: Psoriasis is a chronic, immune-mediated skin disease that also has systemic manifestations. Safe and effective long-term treatments are needed. Biologic treatments that inhibit the immunopatho-genesis of psoriasis have helped meet this need. Purpose: The purpose of this study was to compare the efficacy of biologic therapies used for psoriasis. Methods: A literature search was performed using PubMed and the keywords ‘(PASI-75 OR efficacy) AND psoriasis AND (adalimumab OR alefacept OR etanercept OR infliximab OR ustekinumab).’ Randomized, double-blind, and placebo-controlled studies on US FDA-approved biologics were selected. Studies assessing the proportion of subjects achieving 75% improvement in Psoriasis Area and Severity Index (PASI-75) within a 12-week period were included. Studies on pediatric populations and psoriatic arthritis were excluded. The weighted average of PASI-75 for each reported regimen was calculated to determine the efficacy of biologic agents used for moderate-to-severe psoriasis. Tolerance and secondary efficacy measures were also examined for the selected studies. Results: FDA-approved regimens of adalimumab, infliximab, ustekinumab, and alefacept were effective in treating moderate-to-severe psoriasis. Weighted average PASI-75 scores for infliximab, ustekinumab, adalimumab, etanercept, and alefacept were 78.6%, 72.1%, 70.5%, 48.1%, and 21%, respectively. Limitations: The comparative efficacy of biologic agents data was limited to 12 weeks, thus generalizing the results to longer treatment periods may not be accurate. Conclusions: Various biologic agents for psoriasis were effective at 12 weeks in placebo-controlled trials. Available data cannot fully account for situations in clinical practice, in which combination and longer duration of therapy may be required. When choosing the most effective or best agent, multiple factors should be considered including patient preference, cost, tolerance, adverse effects, dosing schedule, and mode of administration.

Incidence, Risk Factors, and Preventative Management of Skin Cancers in Organ Transplant Recipients: A Review of Single‐ and Multicenter Retrospective Studies from 2006 to 2010

Background Organ transplant recipients (OTRs) taking immunosuppressants are at high risk of skin cancer, which is the most common malignant condition in OTRs, so dermatologic surveillance is important for OTRs. Objectives To characterize the most common skin cancers arising from chronic immunosuppression in OTRs. Methods A PubMed search for retrospective single‐ and multicenter studies reporting skin cancer incidence from 2006 to 2010 was undertaken. Data regarding each studys immunosuppressive regimen, affected skin cancer cohort, and associated risk factors were extracted. Results Thirty‐six articles that met our inclusion criteria reported incidences of nonmelanoma skin cancer (NMSC), Kaposis sarcoma, melanoma, and Merkel cell carcinoma. NMSC was the most commonly reported cancer of all skin cancers after transplantation. Common risk factors were sex, age, sunlight exposure, and immunosuppressive agent‐related (duration, type). Conclusion Sun education programs and frequent screenings in organ transplant clinics have provided the best preventative strategies after transplantation, although the characteristics of the immunosuppressive regimen also play an important role. Thus, the adjuvant strategy of modifying immunosuppression may be effective when confronting severe transplant‐associated skin cancer. Although the decision‐making process for curbing levels of immunosuppression is difficult, further long‐term, randomized controlled studies should assess the effect of using less immunosuppressant medication while preserving graft function.

Apremilast as a treatment for psoriasis

Introduction: Psoriasis is a common skin disorder characterized by chronic inflammatory lesions that are frequently vexing for patients and difficult for physicians to treat. Although multiple therapeutic options are available, all have limitations. Topical preparations have issues with patient adherence, as compared to oral routes of administration. Currently available oral medications, such as methotrexate, possess unfavorable toxicity profiles that limit use. There is a large unmet need for an effective, safe oral treatment for psoriasis. Apremilast is an oral medication that inhibits the activity of multiple inflammatory markers involved in the pathogenesis of psoriasis. Areas covered: The present review article presents the pharmacokinetic properties of apremilast, as well as available preliminary pre-clinical and clinical trial data, and gives an overview of its safety and efficacy. Expert opinion: Apremilast has been well tolerated in phase I and II clinical trials. It has favorable safety and toxicity profiles at doses that are also effective for the treatment of plaque psoriasis. Phase III clinical trials are currently underway and will better elucidate appropriate dosing of apremilast and further illuminate its side effect profile. In future studies, a comparison of apremilast to other psoriasis medications administered through different routes would be beneficial, to document whether patient adherence is better with an oral medication. Depending on the price of the agent, efficacy and perhaps most importantly its safety profile, apremilast may fill a key need as a safe, first-line oral treatment for patients with psoriasis.

Phototherapy trends in dermatology

Background: Use of phototherapy in the United States declined during the 1990s, largely due to unfavorable economic incentives. The trends in phototherapy since then are not well characterized. Methods: We analyzed the National Ambulatory Medical Care Survey (NAMCS) data on quantity of phototherapy visits and associated diagnoses and payment sources. Trends were assessed by linear regression. Results: There were an estimated 230 000 outpatient phototherapy visits per year, with an increasing trend over time (p = 0.03). Dermatologists managed 87% of the visits. Leading diagnoses associated with phototherapy included psoriasis (25%), dermatitis NOS (6%), vitiligo (6%), other dyschromia (6%), and actinic keratosis (5%). Conclusions: Use of phototherapy for psoriasis has remained relatively low up to 2010. However, phototherapy may be becoming more frequent for conditions other than psoriasis.

Patterns of disease and treatment of cold sores

Background: Cold sores are a common condition that can cause significant morbidity and mortality. Antivirals are the typical treatment for cold sores, but the ways in which these medications are used to treat cold sores are not well studied. Purpose: To determine the main treatments prescribed for cold sores and trends in their management over time. Methods: A retrospective analysis of the National Ambulatory Medical Care Survey database was used to analyze outpatient visits for cold sores from 1993 to 2009. Patients were included in the data analysis if they had one of the following three diagnoses reported for their reason-for-visit codes: cold sores (CS), herpes simplex (HS) or herpes simplex with cold sores (HS/CS). Results: There was a decreasing trend in the number of annual patient visits for cold sores. The majority of patients were mainly young to middle adulthood, white women. The top two most commonly prescribed medications were acyclovir followed by valacyclovir. Valacyclovir use increased in all three populations, while acyclovir use decreased. Conclusions: The trends observed may indicate that physicians are evolving their treatment strategies to implement newer antiviral medications. This may prove more efficacious for the treatment of cold sores.

Self-management in patients with psoriasis

Psoriasis is a chronic inflammatory disorder effecting the skin and joints. Additionally, multiple comorbidities exist, including cardiovascular, metabolic, and psychiatric. The chronic nature of psoriasis is often frustrating for both patients and physicians alike. Many options for treatment exist, though successful disease management rests largely on patients through the application of topical corticosteroids, Vitamin D analogs, and calcineurin inhibitors, amongst others and the administration of systemic medications such as biologics and methotrexate. Pho- totherapy is another option that also requires active participation from the patient. Many barriers to effective self-management of psoriasis exist. Successful treatment requires the establishment of a strong doctor-patient relationship and patient empowerment in order to maximize adher- ence to a treatment regimen and improve outcomes. Improving patient adherence to treatment is necessary in effective self-management. Many tools exist to educate and empower patients, including online sources such as the National Psoriasis Foundation and online support group, Talk Psoriasis, amongst others. Effective self management is critical in decreasing the physical burden of psoriasis and mitigating its multiple physical, psychological, and social comorbidi- ties, which include obesity, cardiovascular disease, alcohol dependence, depression, anxiety,

Summary of Published Treatment Guidelines

The treatment of psoriasis can be challenging with multiple therapeutic modalities from which to choose. Various organizations around the world have developed treatment guidelines to help with these challenges with recommendations intended to assist clinicians in their decision-making. While some of these guidelines are detailed in their treatment recommendations providing comprehensive options including the multiple topical and systemic medications available, as well as phototherapy, others offer very limited recommendations. Additionally, the use of biologics has been incorporated into many, but not all, treatment guidelines. Most of the published guidelines were established using evidence based medicine and the consensus of expert panels. The treatment of psoriasis ultimately needs to be individualized to patients’ needs and preferences, but guidelines are available to aid clinicians as they formulate personalized treatment plans from the many existing therapeutic options and to influence better treatment outcomes.