- Email: [email protected]
Generic, twice-daily minocycline versus branded, extended-release minocycline for acne: A retrospective comparison of treatment escalation
J AM ACAD DERMATOL VOLUME 76, NUMBER 6
University of North Carolina, Chapel Hill, North Carolinaf Funding sources: This study was supported in part by the Departments of Dermatology at the University of Texas Southwestern Medical Center and the University of North Carolina School of Medicine. Conflicts of interest: None declared. Reprints not available from the authors. Correspondence to: Adewole S. Adamson, MD, MPP, University of North Carolina, Department of Dermatology, Genome Science Building, 250 Bell Tower Dr, campus box 7287, Chapel Hill, NC 27599. E-mail: [email protected] REFERENCES 1. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999; 282(6):583-589. 2. Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003;139(11):907-915. 3. Pandya AG, Alexis AF, Berger TG, Wintroub BU. Increasing racial and ethnic diversity in dermatology: a call to action. J Am Acad Dermatol. 2016;74(3):584-587. 4. Ahn CS, Culp L, Huang WW, Davis SA, Feldman SR. Adherence in dermatology. J Dermatolog Treat. 2016:1-10. 5. Iuga AO, McGuire MJ. Adherence and health care costs. Risk Manag Healthc Policy. 2014;7:35-44. http://dx.doi.org/10.1016/j.jaad.2017.01.039
Generic, twice-daily minocycline versus branded, extended-release minocycline for acne: A retrospective comparison of treatment escalation To the Editor: Minocycline, the most frequently prescribed oral antibiotic for acne treatment,1 is available in an extended-release (ERM), once-daily branded formulation and a twice-daily generic formulation (GM).2 The branded formulation might allow for improved patient adherence due to its dosing. Patient adherence to medication can lead to improved outcomes in resolution of acne.3,4 However, head-to-head studies comparing ERM to GM have not been published. Our study objective is two-fold: to compare real world treatment failure, defined as progression to isotretinoin,5 among the ERM and GM formulations, and to compare administrative burden ( patient phone calls, pharmacy messages) between these 2 formulations.
Research Letters 1195
The Ohio State University Medical Center information warehouse was queried for patients who visited the Ohio State University dermatology clinic, were coded acne vulgaris (706.1) on first encounter, were not previously treated with antibiotics for acne, and given a [30-day minocycline prescription between May 2011-September 2015. Patients were categorized by their initial prescription: ERM or GM. Two hundred sixteen patients met inclusion criteria. The ERM and GM groups were generally well matched at baseline, with a similar frequency of patients prescribed concomitant topical therapies and a similar frequency of female patients prescribed oral contraceptives and spironolactone (Table I). The difference in acne types between the groups was not reliably collected. There was a notable difference in insurance type; 100% of patients prescribed ERM were insured on managed care versus 84.3% of patients prescribed GM, with the rest insured through Medicaid or other government insurance. Median length between initial prescription date and follow-up was shorter for ERM than for GM patients (115 days vs 178 days) (Table I). A higher percentage of patients prescribed GM continued their originally prescribed minocycline after follow-up (GM vs ERM; 88.9% vs 50%); 45.5% of ERM patients were switched to GM, and 4.5% of ERM patients were switched from their initial prescription to another oral antibiotic (Table II). Based on the intention-to-treat analysis, 29.6% of ERM patients were prescribed isotretinoin, and 9.3% of GM patients were prescribed isotretinoin (P ¼ .0019). The mean number of administrative encounters for patients prescribed ERM versus GM was consistently higher at 3 months (1.00 vs 0.35), 6 months (2.04 vs 0.61), and 12 months (2.95 vs 1.06), despite no significant difference in the 6-month period before prescription start date. Limitations of this study are discrepancy in sample sizes between patients prescribed ERM and GM and the high dropout rate in the ERM group. Because ERM and GM patients differed by insurance type, it is unclear if these variables potentially reflect the confounder affordability and thus affect the frequency of follow-up care or ease of treatment escalation. The ERM prescriptions were prescribed primarily by 2-3 dermatologists; however, these dermatologists did not appear to prescribe isotretinoin significantly more often. While ERM might be more convenient for patients, it did not appear to offer a significant clinical advantage over GM, at least as measured by rates of treatment escalation. ERM also showed potential for
J AM ACAD DERMATOL
1196 Research Letters
JUNE 2017
Table I. Population characteristics of patients prescribed extended-release and generic minocycline Demographic
Mean age at prescription, years Sex Height, m Weight, kg Race
% Prescribed retinoid % Prescribed benzoyl peroxide % Prescribed topical antibiotic other than benzoyl peroxide % Female patients prescribed OCPs or spironolactone Insurance type Median follow-up after prescription start, days
Generic minocycline (n = 172)
Extended-release minocycline (n = 44)
P value ( = .05)
18.227 Female: 43.6% Male: 56.4% 1.715 (n = 69) 67.616 (n = 77) White: 87.79% Black: 4.65% Other: 7.56% 62.21% 54.65% 7.56% 17.33% (n = 75) Managed care: 84.30% Other: 15.70% 178
18.614 Female: 56.8% Male: 53.7% 1.709 (n = 12) 67.389 (n = 15) White: 90.91% Black: 4.55% Other: 4.55% 65.91% 65.91% 9.09% 20.00% (n = 25) Managed care: 100.00% Other: 0% 115
.4679 .1296 .8649 .9659 .7612
.7279 .2323 .7551 .7753 .0018* .0067*
OCP, Oral contraceptives. *Statistically significant.
Table II. Select outcomes of patients prescribed extended-release and generic minocycline Outcome
Prescription course
Median prescription length, days
Generic minocycline (n = 172)
Extended-release minocycline (n = 44)
88.89% (Continue GM) 3.51% (Switch to ERM) 7.60% (Switch to other antibiotic) 239.5 (n = 172)
50.00% (Continue ERM) 45.45% (Switch to GM) 4.55% (Switch to other antibiotic) 153.25 (n = 36)
P value ( = .05)
.001*
.0563
ERM, Extended-release minocycline; GM, generic minocycline. *Statistically significant.
increased office administrative burden. Prospective studies should be conducted to confirm whether patient convenience, adherence, and most importantly acne outcomes are truly improved using ERM instead of GM. Preeta Gupta, BS,a Timothy Shin, BS,a Jennifer Sopkovich, MD,b Susan Massick, MD,b and Benjamin H. Kaffenberger, MDb Ohio State University College of Medicine, Columbus, OHa; and Division of Dermatology, Ohio State University Wexner Medical Center, Columbus, OHb Funding sources: Preeta Gupta received funding from The Ohio State University College of Medicine Medical Student Research Scholarship. Conflicts of interest: Dr Kaffenberger has received grant funding from the American Acne and Rosacea Society for an unrelated project as well as research funding from Xoma, XBiotech,
Biogen, and Celgene for clinical trials and is on the advisory board for Castle Biosciences. The other authors declared no conflicts of interest. Correspondence to: Preeta Gupta, BS, 915 Olentangy River Rd, Suite 4000, Columbus, OH 43212 Reprint requests: Benjamin H. Kaffenberger, MD, Ohio State Univeristy Dermatology, 915 Olentangy River Rd, Suite 4000, Columbus, OH 43212 E-mail: [email protected], [email protected] REFERENCES 1. Lee YH, Liu G, Thiboutot DM, Leslie DL, Kirby JS. A retrospective analysis of the duration of oral antibiotic therapy for the treatment of acne among adolescents: investigating practice gaps and potential cost-savings. J Am Acad Dermatol. 2014; 71(1):70-76.
J AM ACAD DERMATOL
Research Letters 1197
VOLUME 76, NUMBER 6
2. Fleischer AB, Dinehart S, Stough D, et al. Safety and efficacy of a new extended-release formulation of minocycline. Cutis. 2006;78:21-31. 3. Snyder S, Crandell I, Davis SA, Feldman SR. Medical adherence to acne therapy: a systematic review. Am J Clin Dermatol. 2014; 15(2):87-94. http://dx.doi.org/10.1007/s40257-014-0063-y. 4. Dr eno B, Thiboutot D, Gollnick H, et al. Large-scale worldwide observational study of adherence with acne therapy. Int J Dermatol. 2010;49(4):448-456. 5. Garner SE, Eady A, Bennett C, Newton JN, Thomas K, Popescu CM. Minocycline for acne vulgaris: efficacy and safety. Cochrane Database of Syst Rev. 2012;8:CD002086. http://dx.doi.org/10.1016/j.jaad.2017.01.013
The Internet for patient education on atopic dermatitis: Friend or foe? To the Editor: The growing impact of online information on health care decision-making by patients raises concern about the reliability of health information published on the web. We sought to evaluate Google search trends for atopic dermatitis (AD) and to investigate the accuracy of online information related to its treatment by simulating a Google search experience. We performed 2 search queries on www.google.com using the key phrases ‘‘atopic dermatitis treatment’’ and ‘‘eczema treatment’’ and analyzed the content of websites on the first 4 pages of search results for accuracy of information based on consistency with the American Academy of Dermatology (AAD) guidelines on the management of AD.1-3 We also used Google Trends (www.google.com/trends) to evaluate Google search trends related to AD. The search terms ‘‘atopic dermatitis’’ and ‘‘eczema’’ were used and data for relative search volumes from December 2003 through August 2016 in the United States were obtained. Google Trends revealed that the term eczema is used in preference to atopic dermatitis when searching for information related to AD (Fig 1).4 There was a pronounced seasonal variation in search volumes related to the term eczema, with interest peaking in January of every year and declining in the early fall. In terms of accuracy of information, only 25 (31.3%) of the 80 websites identified were completely consistent with the AAD guidelines, 35 (43.8%) were inconsistent, and 20 (25.0%) were unrelated to the subject of the query (Table I). Websites contained within the first page of search results were more likely to offer information consistent with the AAD guidelines compared with websites found on later pages. Government websites were most likely to contain reliable information. All individual websites and blogs were inconsistent with the AAD guidelines.
The main points of discordance were related to the use of bath additives, dietary supplements, and elimination diets. Online health information can be valuable for patients with AD, but it might also be a source of misinformation. Understanding Internet search trends through tools such as Google Trends provides insight into temporal and geographic patterns of skin disease and population-level health seeking behavior and can also allow for improved targeting of health education. It appears that the term eczema is used preferentially when searching for information on the treatment of AD. Therefore, to better tailor communication to patients, health organizations should incorporate the word eczema into online educational materials. Our study indicates that the probability of finding accurate information on the web could be improved by advising patients or parents to focus on the first 10 websites within a search. Clinicians could preemptively address common online misinformation related to the treatment of AD and offer recommendations on reliable online-based health resources. By understanding online health seeking behavior and becoming familiar with online-based resources, both clinicians and health organizations can leverage the use of the Internet in patient education to improve AD outcomes. Ana Corcimaru, BS,a Dean S. Morrell, MD,b and Craig N. Burkhart, MDb From the University of North Carolina School of Medicinea and the Department of Dermatology, University of North Carolina, Chapel Hill, North Carolinab Funding sources: None. Conflicts of interest: None declared. Correspondence to: Ana Corcimaru, BS, 3621 Sweeten Creek Road, Chapel Hill, NC 27514 E-mail: [email protected] REFERENCES 1. Eichenfield LF, Tom WL, Berger TG, et al. Guidelines of care for the management of atopic dermatitis: part 2: management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol. 2014;71(1):116-132. 2. Sidbury R, Davis DM, Cohen DE, et al. Guidelines of care for the management of atopic dermatitis: part 3: management and treatment with phototherapy and systemic agents. J Am Acad Dermatol. 2014;71(2):327-349. 3. Sidbury R, Tom WL, Bergman JN, et al. Guidelines of care for the management of atopic dermatitis part 4: prevention of disease flares and use of adjunctive therapies and approaches. J Am Acad Dermatol. 2014; 71(6):1218-1233.
University of North Carolina, Chapel Hill, North Carolinaf Funding sources: This study was supported in part by the Departments of Dermatology at the University of Texas Southwestern Medical Center and the University of North Carolina School of Medicine. Conflicts of interest: None declared. Reprints not available from the authors. Correspondence to: Adewole S. Adamson, MD, MPP, University of North Carolina, Department of Dermatology, Genome Science Building, 250 Bell Tower Dr, campus box 7287, Chapel Hill, NC 27599. E-mail: [email protected] REFERENCES 1. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999; 282(6):583-589. 2. Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003;139(11):907-915. 3. Pandya AG, Alexis AF, Berger TG, Wintroub BU. Increasing racial and ethnic diversity in dermatology: a call to action. J Am Acad Dermatol. 2016;74(3):584-587. 4. Ahn CS, Culp L, Huang WW, Davis SA, Feldman SR. Adherence in dermatology. J Dermatolog Treat. 2016:1-10. 5. Iuga AO, McGuire MJ. Adherence and health care costs. Risk Manag Healthc Policy. 2014;7:35-44. http://dx.doi.org/10.1016/j.jaad.2017.01.039
Generic, twice-daily minocycline versus branded, extended-release minocycline for acne: A retrospective comparison of treatment escalation To the Editor: Minocycline, the most frequently prescribed oral antibiotic for acne treatment,1 is available in an extended-release (ERM), once-daily branded formulation and a twice-daily generic formulation (GM).2 The branded formulation might allow for improved patient adherence due to its dosing. Patient adherence to medication can lead to improved outcomes in resolution of acne.3,4 However, head-to-head studies comparing ERM to GM have not been published. Our study objective is two-fold: to compare real world treatment failure, defined as progression to isotretinoin,5 among the ERM and GM formulations, and to compare administrative burden ( patient phone calls, pharmacy messages) between these 2 formulations.
Research Letters 1195
The Ohio State University Medical Center information warehouse was queried for patients who visited the Ohio State University dermatology clinic, were coded acne vulgaris (706.1) on first encounter, were not previously treated with antibiotics for acne, and given a [30-day minocycline prescription between May 2011-September 2015. Patients were categorized by their initial prescription: ERM or GM. Two hundred sixteen patients met inclusion criteria. The ERM and GM groups were generally well matched at baseline, with a similar frequency of patients prescribed concomitant topical therapies and a similar frequency of female patients prescribed oral contraceptives and spironolactone (Table I). The difference in acne types between the groups was not reliably collected. There was a notable difference in insurance type; 100% of patients prescribed ERM were insured on managed care versus 84.3% of patients prescribed GM, with the rest insured through Medicaid or other government insurance. Median length between initial prescription date and follow-up was shorter for ERM than for GM patients (115 days vs 178 days) (Table I). A higher percentage of patients prescribed GM continued their originally prescribed minocycline after follow-up (GM vs ERM; 88.9% vs 50%); 45.5% of ERM patients were switched to GM, and 4.5% of ERM patients were switched from their initial prescription to another oral antibiotic (Table II). Based on the intention-to-treat analysis, 29.6% of ERM patients were prescribed isotretinoin, and 9.3% of GM patients were prescribed isotretinoin (P ¼ .0019). The mean number of administrative encounters for patients prescribed ERM versus GM was consistently higher at 3 months (1.00 vs 0.35), 6 months (2.04 vs 0.61), and 12 months (2.95 vs 1.06), despite no significant difference in the 6-month period before prescription start date. Limitations of this study are discrepancy in sample sizes between patients prescribed ERM and GM and the high dropout rate in the ERM group. Because ERM and GM patients differed by insurance type, it is unclear if these variables potentially reflect the confounder affordability and thus affect the frequency of follow-up care or ease of treatment escalation. The ERM prescriptions were prescribed primarily by 2-3 dermatologists; however, these dermatologists did not appear to prescribe isotretinoin significantly more often. While ERM might be more convenient for patients, it did not appear to offer a significant clinical advantage over GM, at least as measured by rates of treatment escalation. ERM also showed potential for
J AM ACAD DERMATOL
1196 Research Letters
JUNE 2017
Table I. Population characteristics of patients prescribed extended-release and generic minocycline Demographic
Mean age at prescription, years Sex Height, m Weight, kg Race
% Prescribed retinoid % Prescribed benzoyl peroxide % Prescribed topical antibiotic other than benzoyl peroxide % Female patients prescribed OCPs or spironolactone Insurance type Median follow-up after prescription start, days
Generic minocycline (n = 172)
Extended-release minocycline (n = 44)
P value ( = .05)
18.227 Female: 43.6% Male: 56.4% 1.715 (n = 69) 67.616 (n = 77) White: 87.79% Black: 4.65% Other: 7.56% 62.21% 54.65% 7.56% 17.33% (n = 75) Managed care: 84.30% Other: 15.70% 178
18.614 Female: 56.8% Male: 53.7% 1.709 (n = 12) 67.389 (n = 15) White: 90.91% Black: 4.55% Other: 4.55% 65.91% 65.91% 9.09% 20.00% (n = 25) Managed care: 100.00% Other: 0% 115
.4679 .1296 .8649 .9659 .7612
.7279 .2323 .7551 .7753 .0018* .0067*
OCP, Oral contraceptives. *Statistically significant.
Table II. Select outcomes of patients prescribed extended-release and generic minocycline Outcome
Prescription course
Median prescription length, days
Generic minocycline (n = 172)
Extended-release minocycline (n = 44)
88.89% (Continue GM) 3.51% (Switch to ERM) 7.60% (Switch to other antibiotic) 239.5 (n = 172)
50.00% (Continue ERM) 45.45% (Switch to GM) 4.55% (Switch to other antibiotic) 153.25 (n = 36)
P value ( = .05)
.001*
.0563
ERM, Extended-release minocycline; GM, generic minocycline. *Statistically significant.
increased office administrative burden. Prospective studies should be conducted to confirm whether patient convenience, adherence, and most importantly acne outcomes are truly improved using ERM instead of GM. Preeta Gupta, BS,a Timothy Shin, BS,a Jennifer Sopkovich, MD,b Susan Massick, MD,b and Benjamin H. Kaffenberger, MDb Ohio State University College of Medicine, Columbus, OHa; and Division of Dermatology, Ohio State University Wexner Medical Center, Columbus, OHb Funding sources: Preeta Gupta received funding from The Ohio State University College of Medicine Medical Student Research Scholarship. Conflicts of interest: Dr Kaffenberger has received grant funding from the American Acne and Rosacea Society for an unrelated project as well as research funding from Xoma, XBiotech,
Biogen, and Celgene for clinical trials and is on the advisory board for Castle Biosciences. The other authors declared no conflicts of interest. Correspondence to: Preeta Gupta, BS, 915 Olentangy River Rd, Suite 4000, Columbus, OH 43212 Reprint requests: Benjamin H. Kaffenberger, MD, Ohio State Univeristy Dermatology, 915 Olentangy River Rd, Suite 4000, Columbus, OH 43212 E-mail: [email protected], [email protected] REFERENCES 1. Lee YH, Liu G, Thiboutot DM, Leslie DL, Kirby JS. A retrospective analysis of the duration of oral antibiotic therapy for the treatment of acne among adolescents: investigating practice gaps and potential cost-savings. J Am Acad Dermatol. 2014; 71(1):70-76.
J AM ACAD DERMATOL
Research Letters 1197
VOLUME 76, NUMBER 6
2. Fleischer AB, Dinehart S, Stough D, et al. Safety and efficacy of a new extended-release formulation of minocycline. Cutis. 2006;78:21-31. 3. Snyder S, Crandell I, Davis SA, Feldman SR. Medical adherence to acne therapy: a systematic review. Am J Clin Dermatol. 2014; 15(2):87-94. http://dx.doi.org/10.1007/s40257-014-0063-y. 4. Dr eno B, Thiboutot D, Gollnick H, et al. Large-scale worldwide observational study of adherence with acne therapy. Int J Dermatol. 2010;49(4):448-456. 5. Garner SE, Eady A, Bennett C, Newton JN, Thomas K, Popescu CM. Minocycline for acne vulgaris: efficacy and safety. Cochrane Database of Syst Rev. 2012;8:CD002086. http://dx.doi.org/10.1016/j.jaad.2017.01.013
The Internet for patient education on atopic dermatitis: Friend or foe? To the Editor: The growing impact of online information on health care decision-making by patients raises concern about the reliability of health information published on the web. We sought to evaluate Google search trends for atopic dermatitis (AD) and to investigate the accuracy of online information related to its treatment by simulating a Google search experience. We performed 2 search queries on www.google.com using the key phrases ‘‘atopic dermatitis treatment’’ and ‘‘eczema treatment’’ and analyzed the content of websites on the first 4 pages of search results for accuracy of information based on consistency with the American Academy of Dermatology (AAD) guidelines on the management of AD.1-3 We also used Google Trends (www.google.com/trends) to evaluate Google search trends related to AD. The search terms ‘‘atopic dermatitis’’ and ‘‘eczema’’ were used and data for relative search volumes from December 2003 through August 2016 in the United States were obtained. Google Trends revealed that the term eczema is used in preference to atopic dermatitis when searching for information related to AD (Fig 1).4 There was a pronounced seasonal variation in search volumes related to the term eczema, with interest peaking in January of every year and declining in the early fall. In terms of accuracy of information, only 25 (31.3%) of the 80 websites identified were completely consistent with the AAD guidelines, 35 (43.8%) were inconsistent, and 20 (25.0%) were unrelated to the subject of the query (Table I). Websites contained within the first page of search results were more likely to offer information consistent with the AAD guidelines compared with websites found on later pages. Government websites were most likely to contain reliable information. All individual websites and blogs were inconsistent with the AAD guidelines.
The main points of discordance were related to the use of bath additives, dietary supplements, and elimination diets. Online health information can be valuable for patients with AD, but it might also be a source of misinformation. Understanding Internet search trends through tools such as Google Trends provides insight into temporal and geographic patterns of skin disease and population-level health seeking behavior and can also allow for improved targeting of health education. It appears that the term eczema is used preferentially when searching for information on the treatment of AD. Therefore, to better tailor communication to patients, health organizations should incorporate the word eczema into online educational materials. Our study indicates that the probability of finding accurate information on the web could be improved by advising patients or parents to focus on the first 10 websites within a search. Clinicians could preemptively address common online misinformation related to the treatment of AD and offer recommendations on reliable online-based health resources. By understanding online health seeking behavior and becoming familiar with online-based resources, both clinicians and health organizations can leverage the use of the Internet in patient education to improve AD outcomes. Ana Corcimaru, BS,a Dean S. Morrell, MD,b and Craig N. Burkhart, MDb From the University of North Carolina School of Medicinea and the Department of Dermatology, University of North Carolina, Chapel Hill, North Carolinab Funding sources: None. Conflicts of interest: None declared. Correspondence to: Ana Corcimaru, BS, 3621 Sweeten Creek Road, Chapel Hill, NC 27514 E-mail: [email protected] REFERENCES 1. Eichenfield LF, Tom WL, Berger TG, et al. Guidelines of care for the management of atopic dermatitis: part 2: management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol. 2014;71(1):116-132. 2. Sidbury R, Davis DM, Cohen DE, et al. Guidelines of care for the management of atopic dermatitis: part 3: management and treatment with phototherapy and systemic agents. J Am Acad Dermatol. 2014;71(2):327-349. 3. Sidbury R, Tom WL, Bergman JN, et al. Guidelines of care for the management of atopic dermatitis part 4: prevention of disease flares and use of adjunctive therapies and approaches. J Am Acad Dermatol. 2014; 71(6):1218-1233.