OPIOID ANALGESICS

EMR default modifies prescribing behavior

Overprescribing of opioid analgesics has been implicated in the current opioid addiction crisis. Researchers studied whether programming the electronic medical records (EMR) system in the ED to default to a 10-tablet supply of opioid analgesics for acute pain encouraged prescribers to prescribe lower opioid quantities. Using this system, prescribers entering an ED discharge opioid prescription order first see a preference list with a default quantity of 10 tablets displayed, in keeping with current ED prescribing guidelines. The prescriber must "opt out" to prescribe larger or smaller quantities. This system was put into effect in 2014.

Comparing prescribing behavior before and after this default system was implemented, researchers found a dramatic increase in the number of prescriptions issued for 10 tablets, from 21% before implementation to 43% afterward. At the same time, the number of prescriptions for 20 tablets decreased by about 7% and the number for 11 to 19 tablets decreased by about 13%. An unintended consequence was a drop in the number of prescriptions for fewer than 10 tablets.

Because baseline quantities prescribed were already consistent with ED guidelines, researchers weren't surprised that no clinically significant reduction in the overall quantity of opioids prescribed was found. They say this suggests that default opioid amounts should start at the lowest baseline amount. They conclude that "deploying EMR defaults that include lower-than-baseline default opioid quantities for acute pain is potentially a widely scalable approach for changing prescribing behavior, while still preserving clinician autonomy."

Sources: Delgado MK, Shofer FS, Patel MS, et al. Association between electronic medical record implementation of default opioid prescription quantities and prescribing behavior in two emergency departments. J Gen Intern Med. [e-pub Jan. 16, 2018]. Default setting in electronic medical records 'nudged' emergency department physicians to limit opioid prescriptions to 10 tablets. University of Pennsylvania School of Medicine. News release. January 17, 2018.

VITILIGO

Off-label approach restores living color

A novel combination of tofacitinib and narrowband ultraviolet B phototherapy (NB-UVB) restored skin color in two patients with disfiguring vitiligo, a relatively common chronic disease that destroys epidermal melanocytes, leaving white patches. An inhibitor of Janus kinases, tofacitinib is approved to treat certain adults with rheumatoid or psoriatic arthritis. Multiple theories have been proposed to explain melanocyte destruction in vitiligo, including an autoimmune process.

Both treated patients had long-standing refractory vitiligo lesions affecting 75% or more of their faces as well as other parts of the body. A team of Yale dermatologists treated them with a combination of tofacitinib to inhibit the immune system from attacking cells that produce melanin pigment and low-dose NB-UVB phototherapy to stimulate pigment production. After 3 months of treatment, one patient experienced nearly complete facial repigmentation. The second patient achieved a similar result after 6 months of treatment. Neither patient experienced any adverse reactions.

Currently the only FDA-approved vitiligo treatment is topical monobenzyl ether of hydroquinone, a depigmenting agent. The team believes the new treatment is a promising advance in the treatment of this stigmatizing skin condition.

Sources: Kim SR, Heaton H, Liu LY, King BA. Rapid repigmentation of vitiligo using tofacitinib plus low-dose, narrowband UV-B phototherapy. JAMA Dermatol. [e-pub Jan. 31, 2018]. Vertiligo treated successfully with arthritis drug and light therapy. Yale University. News release. January 31, 2018.

ANTIBIOTIC STEWARDSHIP

With advancing age, more antibiotics

Studying inappropriate antibiotic prescribing behavior in outpatient settings, researchers found a variety of patient, practice, and provider characteristics associated with antibiotic overuse. The study cohort included about 450,000 outpatient visits across 898 providers and 246 outpatient practices from 2014 to 2016. Researchers focused on four conditions for which antimicrobials are generally not recommended based on current practice guidelines: acute respiratory infection, acute bronchitis, bronchiolitis, and nonsuppurative otitis media. Among their findings:

* Acute bronchitis had the highest rate of inappropriate antibiotic prescribing: 703 prescriptions per 1,000 visits. The overall prescribing rate was 407 prescriptions per 1,000 visits.

* Antibiotic prescribing increased incrementally with patient age, with adults ages 40 to 65 having the highest rates of antibiotic prescribing for any upper respiratory tract infection. Among pediatric patients, the prescribing rate for children ages 3 to 9 years was 25% higher than for children age 2 years or younger.

* Pediatric practices had the lowest antibiotic prescribing rate and family practices had the highest.

* Compared with physician prescribing behavior, the antibiotic prescribing rate for advanced practice practitioners was higher for adults but not for pediatric patients.

* Older providers were four times more likely to prescribe an antibiotic for pediatric patients than providers age 30 or younger.

The researchers speculate that the high rate of antibiotic prescribing for adults may reflect pressures from working-age patients who want to get better fast coupled with misunderstandings about what conditions respond to antibiotics. They write that "future research should target antibiotic stewardship programs to specific patient and provider populations to reduce inappropriate prescribing compared to a 'one size fits all' approach."

Sources: Schmidt ML, Spencer MD, Davidson LE. Patient, provider, and practice characteristics associated with inappropriate antimicrobial prescribing in ambulatory practices. Infect Control Hosp Epidemiol. [e-pub Jan. 30, 2018]. Walker M. With aging comes more antibiotics for respiratory conditions. MedPage Today. January 30, 2018.

GI TUMORS

Radioactive drug targets rare cancer

Neuroendocrine carcinomas of the gastrointestinal (GI) tract and pancreas (gastroenteropancreatic [GEP] neuroendocrine carcinomas [NECs]) are diagnosed in an estimated 1 out of 27,000 people annually. The FDA has approved Lutathera (lutetium Lu 177 dotatate) to treat somatostatin receptor-positive GEP-NECs, including foregut, midgut, and hindgut neuroendocrine tumors in adults.

Classified as a radiolabeled somatostatin analogue, Lutathera binds to somatostatin receptors on certain tumor cells. The beta emission from Lutathera induces cellular damage by forming free radicals in somatostatin receptor-positive cells and in neighboring cells. It's administered via I.V. infusion. The most common adverse reactions are lymphopenia; increased gamma-glutamyl transpeptidase, aspartate aminotransferase, and alanine aminotransferase levels; vomiting; nausea; hyperglycemia; and hypokalemia.

Patients treated with Lutathera are exposed to radiation, so contact with other patients, healthcare personnel, and family should be limited. Also, because Lutathera is a radiopharmaceutical, healthcare personnel must take appropriate precautions in accordance with radiation safety procedures (for example, using waterproof gloves and effective radiation shielding when handling the drug).

Sources: FDA approves new treatment for certain digestive tract cancers. U.S. Food and Drug Administration. News release. January 26, 2018. Lutathera (lutetium Lu 177 dotatate) injection, for intravenous use. Prescribing information. http://www.adacap.com.