Sixtieth issue
May 15, 2024
What would the cost of biologics be if medication price was aligned with efficacy?
JAMA Dermatology
JAMA Dermatology
Tired of paying for things that don’t work? Well… efficiency frontiers have your back!
Efficiency frontiers are a statistical approach to cost-effective pricing of therapeutics that maps treatment costs to disease-specific outcome measures. While highly effective, biologics are costly; for example, for plaque psoriasis, out-of-pocket costs range from $4,423 to $6,950 annually. This study conducted an efficiency frontier analysis for plaque psoriasis by plotting the clinical efficacy (measured by PASI 90 response rate) of 11 biologics and 2 biosimilars in the US, Australia, Canada, France, and Germany against the 2023 annual cost (based on manufacturer rebates) for each therapeutic.
What did they find?
Main Takeaway: Taking an efficiency frontier approach could promote the negotiation of therapeutic prices as they correspond with clinical efficacy, potentially resulting in significant price reductions and increased patient accessibility.
Efficiency frontiers are a statistical approach to cost-effective pricing of therapeutics that maps treatment costs to disease-specific outcome measures. While highly effective, biologics are costly; for example, for plaque psoriasis, out-of-pocket costs range from $4,423 to $6,950 annually. This study conducted an efficiency frontier analysis for plaque psoriasis by plotting the clinical efficacy (measured by PASI 90 response rate) of 11 biologics and 2 biosimilars in the US, Australia, Canada, France, and Germany against the 2023 annual cost (based on manufacturer rebates) for each therapeutic.
What did they find?
- Clinical efficacy was lowest for etanercept (17.9%) and highest for risankizumab (71.6%)
- In the US, net annual treatment costs ranged from $1,664 for infliximab-dyyb to $79,277 for risankizumab. The median yearly net treatment cost was higher in the US ($34,965) than the average annual costs in all other countries studied ($12,011)
- Efficiency frontier revealed that prices of psoriasis biologics in the US would need to be lowered by a median of 71% to align with the most cost-effective treatments. The efficiency frontier analyses of Canada, Australia, France, and Germany would also necessitate price reductions, but these reductions were much smaller (median of 27%)
Main Takeaway: Taking an efficiency frontier approach could promote the negotiation of therapeutic prices as they correspond with clinical efficacy, potentially resulting in significant price reductions and increased patient accessibility.
Risk of venous thromboembolism is lower in patients with atopic dermatitis than other immune inflammatory diseases
Journal of American Academy Dermatology
Journal of American Academy Dermatology
Hedge your bets on AD to keep that VTE risk low!
Atopic dermatitis (AD) is a chronic immune-mediated inflammatory disease marked by pruritic, erythematous, scaly patches. Current literature states that those with immune-mediated inflammatory diseases have an increased risk of venous thromboembolism (VTE), but VTE risk in AD has yet to be compared to differing immune-mediated inflammatory diseases.
This retrospective, observational cohort study used health insurance claims data from 2010-2019 to compare patient incidence and VTE risk in patients with AD to patients with other immune-mediated inflammatory diseases such as rheumatoid arthritis (RA), Crohn’s disease (CD), ulcerative colitis (UC), psoriasis (PsO), psoriatic arthritis (PsA), or ankylosing spondylitis (AS).
What did they find?
Main Takeaway: Compared to other immune-mediated inflammatory diseases, atopic dermatitis demonstrated lower incidence and risk for occurrence of VTE.
Atopic dermatitis (AD) is a chronic immune-mediated inflammatory disease marked by pruritic, erythematous, scaly patches. Current literature states that those with immune-mediated inflammatory diseases have an increased risk of venous thromboembolism (VTE), but VTE risk in AD has yet to be compared to differing immune-mediated inflammatory diseases.
This retrospective, observational cohort study used health insurance claims data from 2010-2019 to compare patient incidence and VTE risk in patients with AD to patients with other immune-mediated inflammatory diseases such as rheumatoid arthritis (RA), Crohn’s disease (CD), ulcerative colitis (UC), psoriasis (PsO), psoriatic arthritis (PsA), or ankylosing spondylitis (AS).
What did they find?
- The overall incidence of VTE among patients with AD was higher compared to AD-matched controls (0.73 vs. 0.59 cases per 100 person-years) but lower compared to patients with RA, CD, and UC (1.42, 1.14, and 1.25 cases per 100 person-years, respectively)
- Patients with AD had a lower VTE risk than those with RA, CD, and UC (HR = 1.42 (1.38, 1.46), 1.61 (1.54, 1.69), 1.57 (1.50, 1.76), respectively)
- Excluding patients with confounding VTE risk factors, those with AD had lower VTE risk compared to those with RA, CD, and UC (HR = 1.57 (1.43, 1.72), 1.71 (1.47, 1.99), 1.84 (1.63, 2.09), respectively)
Main Takeaway: Compared to other immune-mediated inflammatory diseases, atopic dermatitis demonstrated lower incidence and risk for occurrence of VTE.
Immune checkpoint inhibitors used in various types of cancer treatments are associated with numerous cutaneous toxicities
British Journal of Dermatology
British Journal of Dermatology
We knew cancer treatment would be rough…but not THAT rough.
Immune checkpoint inhibitors (ICI) are first-line treatment for various cancer types but exhibit high rates of immune-related adverse events (irAEs) in those receiving ICI therapy. Cutaneous toxicities are one of the most prevalent forms of irAEs. This multicenter, retrospective cohort study analyzed cancer patients who developed cutaneous irAEs while on ICI therapy to identify skin toxicities and further characterize patterns between types of cancer, treatment, and toxicity.
What did they find?
Limitations: Participating centers were all oncodermatology clinics, which may have overrepresented psoriasiform rashes due to the complex nature of lesions seen in their patient populations.
Main Takeaway: There are numerous cutaneous toxicities that may be seen in patients receiving ICI therapy, each with its own unique pattern and clinical association.
Immune checkpoint inhibitors (ICI) are first-line treatment for various cancer types but exhibit high rates of immune-related adverse events (irAEs) in those receiving ICI therapy. Cutaneous toxicities are one of the most prevalent forms of irAEs. This multicenter, retrospective cohort study analyzed cancer patients who developed cutaneous irAEs while on ICI therapy to identify skin toxicities and further characterize patterns between types of cancer, treatment, and toxicity.
What did they find?
- 40 different types of cutaneous toxicities were identified among 762 patients
- The seven most common toxicities were psoriasis (23.0%), pruritus (22.4%), macular rash (21.1%), eczematous-type reactions (19.7%), lichenoid dermatitis (10.9%), vitiligo (6.0%), and bullous pemphigoid (3.8%)
- Macular rashes were seen after a smaller number of doses compared to other toxicities (P < 0.001) and were the most frequent cutaneous irAE in melanoma patients (64 of 199 cases)
- Less than 3% of cases had uncommon skin toxicities, including acneiform rashes, granulomatous reactions, and hair disorders other than vitiligo
Limitations: Participating centers were all oncodermatology clinics, which may have overrepresented psoriasiform rashes due to the complex nature of lesions seen in their patient populations.
Main Takeaway: There are numerous cutaneous toxicities that may be seen in patients receiving ICI therapy, each with its own unique pattern and clinical association.
The relationship between acrochordons, obesity, and metabolic syndrome in the pediatric population: A retrospective cohort study
Pediatric Dermatology
Pediatric Dermatology
Small tags, big indicators!
Acrochordons, or “skin tags”, are common benign skin growths, yet their exact cause remains unclear. While studies in adult populations have linked them to obesity and metabolic syndrome, research in the pediatric population is limited. Thus, to assess this relationship, a retrospective single-center study analysis was performed on 55 pediatric patients diagnosed with acrochordons.
What did they find?
Main Takeaway: Acrochordons may serve as potential indicators of metabolic syndrome in children.
Acrochordons, or “skin tags”, are common benign skin growths, yet their exact cause remains unclear. While studies in adult populations have linked them to obesity and metabolic syndrome, research in the pediatric population is limited. Thus, to assess this relationship, a retrospective single-center study analysis was performed on 55 pediatric patients diagnosed with acrochordons.
What did they find?
- Within this cohort of patients with acrochordons, 64% were female and 76% Caucasian
- A significant proportion of the cohort met criteria for metabolic syndrome given higher prevalence rates of obesity (49% vs. 21%), type 2 diabetes mellitus (4.8% vs. 0.6%), hyperlipidemia (8.1% vs. 0%), and hypertension (1.6% vs. 0%) compared to patient-matched controls (P < 0.05) when compared to NHANES (National Health and Nutrition Examination Survey) data
- Patients with acrochordons were more likely to have other skin manifestations of insulin resistance, such as acanthosis nigricans (25.4%)
Main Takeaway: Acrochordons may serve as potential indicators of metabolic syndrome in children.
Can ChatGPT vision diagnose melanoma? An exploratory diagnostic accuracy study
Journal of the American Academy of Dermatology
Journal of the American Academy of Dermatology
ChatGPT EnVISIONING the future of melanoma detection
ChatGPT has gained immense popularity due to its proficient language model and diverse range of capabilities. Recently, ChatGPT released an image-analysis feature called ChatGPT Vision that allows users to upload images for artificially generated responses.
To better understand the abilities of this model in diagnosing skin lesions, 100 dermoscopy images, including histopathology-verified melanomas and benign nevi, were uploaded from the International Skin Imaging Collaboration (ISIC) archive. ChatGPT Vision was asked to determine the top 3 diagnoses and if they represent malignant or benign lesions.
What did they find?
Main Takeaway: ChatGPT Vision currently lacks the ability to both accurately determine whether a lesion is benign or malignant and provide accurate diagnoses through image analysis.
ChatGPT has gained immense popularity due to its proficient language model and diverse range of capabilities. Recently, ChatGPT released an image-analysis feature called ChatGPT Vision that allows users to upload images for artificially generated responses.
To better understand the abilities of this model in diagnosing skin lesions, 100 dermoscopy images, including histopathology-verified melanomas and benign nevi, were uploaded from the International Skin Imaging Collaboration (ISIC) archive. ChatGPT Vision was asked to determine the top 3 diagnoses and if they represent malignant or benign lesions.
What did they find?
- ChatGPT Vision had 32% sensitivity, 40% specificity, and 36% overall diagnostic accuracy in determining the single top diagnosis of an image
- ChatGPT Vision had 56% sensitivity, 53% specificity, and 55% overall diagnostic accuracy in having the correct diagnosis of the image in the top 3 differentials
- ChatGPT Vision had 46% sensitivity, 78% specificity, and 62% overall diagnostic accuracy in determining if a lesion was benign or malignant in the single top diagnosis
- ChatGPT Vision had 78% sensitivity, 47% specificity, and 62% overall diagnostic accuracy in determining if a lesion was benign or malignant in the top 3 diagnoses
Main Takeaway: ChatGPT Vision currently lacks the ability to both accurately determine whether a lesion is benign or malignant and provide accurate diagnoses through image analysis.
How do the clinical characteristics of mpox compare before and during the 2022 outbreak?
Journal of the American Academy of Dermatology
Journal of the American Academy of Dermatology
Remember when mpox was the “new virus” on the block in 2022?
Monkeypox virus (MPXV), a member of the Poxviridae family, causes mpox in humans and animals, primarily in Central and Western Africa. The 2022 global mpox epidemic marked a significant spread of human MPXV, previously considered a neglected zoonotic disease. This meta-analysis of 27 studies published between 2003 and 2022 aimed to investigate the prevalence of mpox globally and differences in clinical manifestations and outcomes before and after the 2022 outbreak.
What did they find?
Limitation: 19 of 27 studies included in this review were conducted during the 2022 mpox outbreak.
Main Takeaways: Despite the increased incidence of mpox during the 2022 outbreak, clinical symptoms and outcomes appeared to be mild compared to pre-2022 cases. However, the 2022 outbreak showed a unique demographic and geographic pattern, disproportionately affecting European Males.
Monkeypox virus (MPXV), a member of the Poxviridae family, causes mpox in humans and animals, primarily in Central and Western Africa. The 2022 global mpox epidemic marked a significant spread of human MPXV, previously considered a neglected zoonotic disease. This meta-analysis of 27 studies published between 2003 and 2022 aimed to investigate the prevalence of mpox globally and differences in clinical manifestations and outcomes before and after the 2022 outbreak.
What did they find?
- Before the 2022 outbreak, 1304 mpox cases were reported (57.36% men; 0.69% HIV positive), with the majority from Africa, particularly Congo (83.07%), Nigeria (12.36%), and Sudan (1.46%), including some cases from the United Kingdom (0.53%) and United States (2.59%)
- During the 2022 mpox outbreak, 4394 individuals were infected (99.32% men; 24.87% HIV positive), with most cases reported in European countries, particularly Spain (52.93%), Germany (12.81%), Italy (5.9%), and the United Kingdom (5.77%)
- 17 distinctive clinical features of MPXV infection were observed across 19 countries
- Patients during the 2022 outbreak showed a significantly increased risk of developing genital lesions (RR: 2.89, 95% CI: 1.70-4.93)
- Patients during the 2022 outbreak exhibited a decreased risk of systemic rash (RR: 0.76, 95% CI: 0.59-0.98), fever (RR: 0.68, 95% CI: 0.49–0.94), headache (RR: 0.56, 95% CI: 0.35–0.88), myalgia (RR: 0.50, 95% CI: 0.31–0.81), skin ulcer (RR: 0.32, 95% CI: 0.17–0.59), pharyngitis (RR: 0.32, 95% CI: 0.18–0.58), abdominal symptoms (RR: 0.29, 95% CI: 0.20–0.42), and pruritus (RR: 0.25, 95% CI: 0.19–0.32)
Limitation: 19 of 27 studies included in this review were conducted during the 2022 mpox outbreak.
Main Takeaways: Despite the increased incidence of mpox during the 2022 outbreak, clinical symptoms and outcomes appeared to be mild compared to pre-2022 cases. However, the 2022 outbreak showed a unique demographic and geographic pattern, disproportionately affecting European Males.
Bullous pemphigoid (BP) is a rare autoimmune blistering disease that presents as pruritic urticarial plaques and tense subepidermal blisters. Nonbullous pemphigoid (NBP) is a variant of pemphigoid presenting with pruritus/eczematous plaques without blisters and is challenging to diagnose. There is often a significant delay in patient presentation and treatment initiation, resulting in increased patient morbidity. This case report highlights a manifestation of NBP mimicking arthropod bite reactions after years of well-controlled classic BP.
Report of Case:
Main Takeaway: This case emphasizes the need for high clinical suspicion of NBP in an elderly patient with refractory pruritus with or without a previous BP diagnosis.
Report of Case:
- 75-year-old female with classic BP well-controlled with methotrexate presents with a 2-week history of pruritus and “mosquito-like bites”
- Exam showed skin-colored papules on the hands, arms, legs, and trunk, with no bullous lesions noted
- Direct immunofluorescence showed IgG and C3 at the epidermal basement membrane, the gold standard for diagnosis of NBP
- The patient’s symptoms showed near-complete resolution after increasing methotrexate dosage
Main Takeaway: This case emphasizes the need for high clinical suspicion of NBP in an elderly patient with refractory pruritus with or without a previous BP diagnosis.
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