EXPERT ANALYSIS FROM THE SDEF HAWAII DERMATOLOGY SEMINAR
WAIKOLOA, HAWAII (FRONTLINE MEDICAL NEWS) – Persuasive recent evidence suggests routine serum potassium monitoring is unnecessary in healthy young women taking spironolactone for acne, Dr. Erik J. Stratman asserted at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.
It’s common dermatologic practice to monitor for hyperkalemia in patients on spironolactone for acne. Dr. Stratman cited this as an example of a practice gap, which he defined as the difference between what physicians are doing in practice and what the best literature indicates should be done.
He provided several other dermatologic examples of practice gaps and the recent studies that exposed them as well as the resultant changes he has made in his own clinical practice.
“I’m talking about what’s new in the literature that might impact your practice. I’m certainly not telling you what to do. I’m telling you my interpretation of what the literature is telling us we should do and sharing that,” explained Dr. Stratman, chairman of the department of dermatology at the Marshfield (Wisc.) Clinic and editor of the dermatologic diagnosis section at UpToDate, an evidence-based clinical decision support resource.
Potassium monitoring during spironolactone therapy for acne: A recent retrospective study of the usefulness of monitoring for hyperkalemia in 974 healthy young women taking spironolactone for acne found no actionable abnormalities in potassium levels (JAMA Dermatol. 2015 Sep;151(9):941-4).
“This has certainly changed my practice,” according to Dr. Stratman. “I’ve discontinued screening for hyperkalemia in healthy acne patients in whom I’m planning to use spironolactone at 100 mg/day or less. I monitor serum potassium only in the occasional acne patient with a history of cardiac or renal disease.”
Monitoring for hyperkalemia in patients on spironolactone makes good sense in older patients taking the medication for high blood pressure or heart failure. But the acne population is an entirely different demographic.
“I don’t know how many of you know the cost of getting a blood draw for a lab test. At my institution, just to sit down with the phlebotomist costs $32 before you even get poked. And a simple lab test like a serum potassium would be another $25-35. When you magnify that over time in your practice, it becomes real money that you’re spending on lab monitoring strategies that possibly aren’t necessary,” he said.
Do you know the retail price of the medications you prescribe? Few dermatologists do, as became abundantly clear when Dr. Stratman posed a couple of questions to the Hawaii Dermatology Seminar audience. Using electronic clickers to reply, 61% of the audience readily admitted they “aren’t confident at all” in knowing the price of the drugs they prescribe regularly. When Dr. Stratman asked a more concrete question — what’s the average retail price of a 60-g tube of Metrogel 1%? — a mere 16% of respondents were able to get within $70 of the correct answer, which is $350.
It’s no wonder dermatologists aren’t keeping up with the cost of their bread-and-butter medications. The prices are increasing at a dizzying pace, as underscored in a recent survey of four national chain pharmacies. For the 19 brand-name drugs surveyed, the mean retail price rose by 401% during 2009-2015. Seven of those 19 drugs more than quadrupled in price. Brand-name acne and rosacea medications rose in price by a mean of 195%, psoriasis medications by 180%, and topical corticosteroids by 290%. Selected generic dermatologic drugs increased in retail price by a mean of 279% during 2011-2014 (JAMA Dermatol. 2016 Feb 1;152(2):158-63).
Probing further, Dr. Stratman asked the audience how often patients phone in to request a change in a prescription because of sticker shock at the price when they get to their pharmacy. Twenty-four percent of physicians said it happens more than 10 times during a typical week of practice. Another 30% said in their office it occurs 4-10 times per week.
“Dealing with this kind of a problem is a drain on your resources,” the dermatologist noted. “Every week I used to have patients come in and I’d be excited to see how the treatment worked, and the patients looked exactly the same. They said, ‘I never filled the prescription, it’s too expensive.’ It was very frustrating.”
The practice gap here is the inability to keep up to date with the retail cost of medications. The solution Dr. Stratman recommended is to get a smartphone app that compares medication costs at pharmacies in the patient’s area. He named several such apps that have received favorable ratings from Consumer Reports: GoodRx, WeRx, and LowestMed. He personally uses LowestMed: he just selects the medication, inputs the patient’s zipcode, and the app spits out the prices of that drug at local pharmacies, which he then shares with the patient sitting next to him.
“It provides an improved patient experience. They get the sense that you’re looking out for them,” according to the dermatologist.
Overmonitoring patients on isotretinoin: Dermatologists vary widely in terms of the type and frequency of lab tests they order in patients on a stable dose of oral isotretinoin for acne. Because isotretinoin is a litigation magnet, many do it monthly. But a recent systematic review and meta-analysis of 26 studies including 1,574 patients on isotretinoin by investigators at Pennsylvania State University concluded that the evidence doesn’t support monthly laboratory monitoring of lipid levels, hepatic function, and complete blood cell count in acne patients on standard doses of isotretinoin (JAMA Dermatol. 2016 Jan 1;152(1);35-44).
The investigators found that while mean values of those parameters underwent statistically significant changes during isotretinoin therapy, the changes weren’t clinically meaningful. An accompanying editorial by dermatologists not involved in the study issued a call to decrease lab testing during isotretinoin therapy, arguing that such a change is not only cost-conscious but also provides higher-value care (JAMA Dermatol. 2016 Jan 1;152(1):17-9).
Impressed by this research and persuaded by the editorial, Dr. Statman has changed his practice. He continues to obtain baseline lab tests but spreads out further testing. Since the Penn State group had previously shown that when mild changes in lab tests occur in patients on isotretinoin, they appear after 6-8 weeks of treatment rather than four, he now orders his first set of on-treatment lab tests after 8 weeks of therapy. And to cut down on the cost, he orders a triglyceride level rather than the full panel, and just one of the -aminases instead of a full liver panel.
Dermatologists are often insufficiently aggressive in treating vulvar lichen planus in older women: Many older women with active vulvar lichen planus take a casual attitude toward their disease. They often seem oblivious to it. So is it all that important to have them treat it even if it isn’t bothering them? The answer is clearly yes, Dr. Statman said, pointing to an Australian prospective study of 507 women with biopsy-proven vulvar lichen planus followed for nearly 5 years.
Remission was achieved in all patients via potent topical corticosteroid therapy. Patients were then advised to follow a preventive regimen of regular application of a topical corticosteroid; 150 were nonadherent to this strategy of long-term maintenance therapy, the other 357 followed physician instructions. The key finding: the rate of biopsy-proven vulvar squamous cell carcinoma or intraepithelial neoplasia during followup was 4.7% in the poorly compliant group compared with zero in patients who stuck to the preventive regimen (JAMA Dermatol. 2015 Oct;151(10):1061-7).
The practice gap here is that many dermatologists underappreciate their ability to reduce patients’ risk of having their vulvar lichen planus transform into squamous cell carcinoma. The way to overcome this practice gap is to monitor the woman’s vulvar disease via physical examination rather than simply relying upon her assurance that everything is fine. It’s important to explain to patients that following preventive therapy recommendations, even if the lichen planus is asymptomatic, will reduce their risk of squamous cell carcinoma, Dr. Stratman said.
He reported having no financial conflicts regarding his presentation.
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