Drug Topics- August 11, 2008

24 DRUG TOPICS AUGUST 11, 2008 www.drugtopics.com Rx Care New eczema guidelines promote use of emollients, then topical corticosteroids Julio Fernandez, Pharm.D. I n December 2007 the National Institute for Health and Clinical Excellence (NICE) published its clinical guidelines on the diagnosis, evaluation, and management of atopic eczema in children 12 years of age, replacing the 2006 British Association of Dermatology and Primary Care Dermatology Society guidelines. Atopic eczema is a chronic inflammatory skin condition that commonly begins in early childhood. “There are many potential triggers. These include genetics, irritants, environmental factors, food allergies, or infectious colonization,” said Anita Siu, Pharm. D., clinical neonatal/pediatric pharmacotherapy specialist and assistant and clinical professor at the Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey. The NICE guidelines promote a stepwise approach to management, with regular emollients and intermittent topical corticosteroids forming the basis of treatment and topical calcineurin inhibitors as second-line treatments. Some recommendations have strong evidence to support them, indicated by a Level 1+ or Level 1++, depending on the meta-analysis or randomized clinical trials used to support the recommendations. The guidelines are evidence-based and also use a modified Delphi technique to formulate recommendations when substantial research evidence is lacking. The guidelines have been developed for the diagnosis and assessment of the impact of the condition, management during and between flares, and education of children and their parents about the condition. A stepped approach is emphasized for managing eczema in children, tailoring the treatment step to the severity of the eczema. According to the guidelines, emollients should be the basis of management and should always be used, even when the eczema is clear. Based on the severity of symptoms, management can then be stepped up or down with the addition of treatments, such as corticosteroids, topical calcineurin inhibitors, and bandages. There are some instances in which emollients and other topical products are used at the same time of the day. In these cases, the guidelines recommend that the different products be applied one at a time with several minutes THE AUTHOR is a writer based in New Jersey. Photo: Jambula/ Wikimedia Commons between applications, with no preference as to which product should be applied first. Per the guidelines, topical corticosteroids should only be applied to areas of active eczema, which may include areas of broken skin. There is a strong level of evidence to support tailoring the potency of topical corticosteroids based on the severity of a child’s eczema. Mild-potency corticosteroids are recommended for the face and neck, except for the short-term (three- to five-day) use of moderate-potency steroids for severe flares. Moderate or potent preparations are recommended for short periods (seven to 14 days) for flares in vulnerable sites such as the axillae and groin. Topical steroids are also recommended to prevent flares in children with frequent flares after the eczema has been controlled. According to the guidelines, patients should be offered information on how to recognize flares and should be given clear instructions on how to manage them. This is a topic in which Siu believes pharmacists can play an important role. For patients whose eczema is not controlled by topical corticosteroids or when there is a serious risk of adverse events from topical corticosteroids, there is a strong level of evidence to support the use of topical tacrolimus or pimecrolimus. The guidelines do not recommend the use of oral antihistamines for routine use. In children with mild or moderate eczema in which there is severe itching or urticaria, a one-month trial of a non-sedating antihistamine could be utilized. In children with infections, the guidelines recommend that flucloxacillin be used as a first-line treatment to treat active Staphylococcus aureus and streptococcus for one to two weeks according to clinical response. If children are allergic or have resistance to flucloxacillin, the guidelines recommend the use of erythromycin. There are numerous over-the-counter products used to treat eczema in children. The complete NICE guidelines are published by the National Collaborating Centre for Women’s and Children’s Health, and are available at www.nice.org.uk/CG057fullguideline and the National Library for Health (www.library.nhs.uk/rss/). http://www.drugtopics.com http://www.nice.org.uk/CG057fullguideline http://www.library.nhs.uk/rss/

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Drug Topics- August 11, 2008 Contents Latebreakers Letters DEA Proposes Rule To Allow Electronic Prescriptions for Controlled Substances Merger, Medicare Reform Could Mean Broader E-Prescribing Adoption New Combination Pill Approved for Type 2 Diabetes New Eczema Guildlines Promote Use of Emollients, Then Topical Corticosteroids Agencies Flush Original Strategies in Favor of Promoting Drug Take-Back Programs JP at Large: You Laughing at Me? Pharmacists Find Themselves at Mercy of Prior Authorization State Law Requiring PBM Transparency See Some Gains, Some Losses Global Counterfeiting Still Growing, Says U.S. Commerce Official FDA Saftey Page: Prophylthiouracil Still Confused with Purinethol (mercaptopurine) New Products Bring Lice Treatment to a Head NACDS Marketplace Showcases New Product that Fill Unmet Needs Update on Respiratory Tract Infections Execs Share War Stories About Adopting Technology in their Stores New Products Advertisters Index Classified Viewpoint: Medicare Part D Revisions sorely needed

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