Caroline Helwick

NEW ORLEANS — Aspirin therapy is commonly used for primary prevention of cardiovascular events in persons with type 2 diabetes, but a Japanese study of 2,539 subjects found no statistically significant reduction in the primary end point of total atherosclerotic events, except in patients aged at least 65 years.

The study, which is the largest primary prevention trial of aspirin in type 2 diabetes, was reported at the annual scientific sessions of the American Heart Association.

In the Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes (JPAD) trial, the use of daily low-dose aspirin was associated with a 20% nonsignificant reduction in the risk of the combined end point of coronary, cerebrovascular, and peripheral vascular events in the population as a whole, and a 32% statistically significant reduction in events among those aged 65 and older, reported Dr. Hisao Ogawa of the Kumamoto (Japan) University.

Aspirin use also significantly reduced the composite of fatal coronary and fatal cerebrovascular events.

“Although the effect of low-dose aspirin was not statistically significant for the primary end point, a significant effect was demonstrated on fatal coronary and fatal cerebrovascular events. The trial also suggests that low-dose aspirin might reduce total events in older patients,” he said at a late-breaking trials session.

The results were reported online simultaneously with Dr. Ogawa's presentation (JAMA 2008;300:2134-41).

Japanese investigators from 163 institutions examined the benefit of low-dose aspirin for preventing cardiovascular events in 2,539 patients with type 2 diabetes who had no history of atherosclerotic disease. Average age of the patients was 65 years and 55% were men.

The investigators randomly assigned 1,262 patients to receive 81–100 mg aspirin per day and 1,277 to receive no aspirin. The primary end point was the composite of all coronary, cerebrovascular, and peripheral vascular events.

After a median follow-up of 4.4 years, a total of 154 fatal and nonfatal atherosclerotic events had occurred: 68 in the aspirin group and 86 in the nonaspirin group. This represented a rate of 13.6 events 1,000 person-years, compared with 17.0 events per 1,000 person-years, for a 20% reduction in risk that was not statistically significant, Dr. Ogawa reported.

Benefit was, however, demonstrated in older patients taking aspirin. Among the 719 patients aged at least 65 in the aspirin arm, 45 events (6.3%) atherosclerotic events occurred, compared with 59 events (9.2%) in the 644 older patients in the nonaspirin group, representing a statistically significant 32% reduction in risk with aspirin use.

The combined secondary end point of fatal coronary events and fatal cerebrovascular events occurred in 1 patient (stroke) in the aspirin group and 10 patients (5 fatal myocardial infarctions and 5 fatal strokes) in the nonaspirin group, for a 90% statistically significant reduction in risk for that outcome.

Adverse effects occurred in 86 persons taking aspirin and in 14 who were not on aspirin. Hemorrhagic events were greater with aspirin (34 events, compared with 10), including an increase in gastrointestinal bleeding and the need for transfusion for severe GI bleeding in four patients, but there was no increase in hemorrhagic stroke.

“JPAD supports the safety of using low-dose aspirin in diabetics for primary prevention,” he said.

The investigators cautioned that the findings should be interpreted in context of the low incidence of atherosclerotic disease in Japan and the aggressive management of cardiovascular risk factors.

“The event rate was lower than anticipated because the patients were so well treated,” Dr. Ogawa said. “They saw their physicians every 2–4 weeks.”

Dr. Marian Limacher, professor of medicine at the University of Florida, Gainesville, said JPAD was “a well-designed and well-conducted study” that aimed to address a question that “some may have thought did not need to be answered,” given the widespread recommendation for the use of aspirin in diabetic patients.

“However, the evidence basis for this has been lacking until recently, and JPAD adds to this considerably,” she commented at a press conference.

The findings are congruent with the recently completed Progression of Arterial Disease and Diabetes (POPADAD) study from Great Britain, she noted. POPADAD, involving 1,276 patients with asymptomatic peripheral arterial disease, found no evidence for aspirin's benefit on cardiovascular events and mortality.

As discussant of the paper, Dr. Limacher offered several possible explanations for the lack of effect on the study's primary end point. Among her suggestions were: the choice of population, which included a number of women who may respond differently to aspirin when compared with men; the dose, which may have been too low to be protective in some patients; a too-short duration of intervention; the effect of aspirin resistance in some patients; the use of concomitant risk factor-modifying medications; and lack of power to show an effect when event rates were so low.

“We may need to rethink the guidelines,” she suggested, “especially for patients younger than 65.

“To come up with recommendations we also need to assess the risk/benefit ratio,” she continued.

“Diabetes is a high-risk group for cardiovascular events, and Japanese patients are a high-risk group for the use of aspirin because of their risk of hemorrhagic stroke. Conducting this study in Japan, therefore, makes sense. … The safety [in JPAD] was quite reasonable for low-dose aspirin,” she said.

NEW ORLEANS — Aspirin therapy is commonly used for primary prevention of cardiovascular events in persons with type 2 diabetes, but a Japanese study of 2,539 subjects found no statistically significant reduction in the primary end point of total atherosclerotic events, except in patients aged at least 65 years.

The study, which is the largest primary prevention trial of aspirin in type 2 diabetes, was reported at the annual scientific sessions of the American Heart Association.

In the Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes (JPAD) trial, the use of daily low-dose aspirin was associated with a 20% nonsignificant reduction in the risk of the combined end point of coronary, cerebrovascular, and peripheral vascular events in the population as a whole, and a 32% statistically significant reduction in events among those aged 65 and older, reported Dr. Hisao Ogawa of the Kumamoto (Japan) University.

Aspirin use also significantly reduced the composite of fatal coronary and fatal cerebrovascular events.

“Although the effect of low-dose aspirin was not statistically significant for the primary end point, a significant effect was demonstrated on fatal coronary and fatal cerebrovascular events. The trial also suggests that low-dose aspirin might reduce total events in older patients,” he said at a late-breaking trials session.

The results were reported online simultaneously with Dr. Ogawa's presentation (JAMA 2008;300:2134-41).

Japanese investigators from 163 institutions examined the benefit of low-dose aspirin for preventing cardiovascular events in 2,539 patients with type 2 diabetes who had no history of atherosclerotic disease. Average age of the patients was 65 years and 55% were men.

The investigators randomly assigned 1,262 patients to receive 81–100 mg aspirin per day and 1,277 to receive no aspirin. The primary end point was the composite of all coronary, cerebrovascular, and peripheral vascular events.

After a median follow-up of 4.4 years, a total of 154 fatal and nonfatal atherosclerotic events had occurred: 68 in the aspirin group and 86 in the nonaspirin group. This represented a rate of 13.6 events 1,000 person-years, compared with 17.0 events per 1,000 person-years, for a 20% reduction in risk that was not statistically significant, Dr. Ogawa reported.

Benefit was, however, demonstrated in older patients taking aspirin. Among the 719 patients aged at least 65 in the aspirin arm, 45 events (6.3%) atherosclerotic events occurred, compared with 59 events (9.2%) in the 644 older patients in the nonaspirin group, representing a statistically significant 32% reduction in risk with aspirin use.

The combined secondary end point of fatal coronary events and fatal cerebrovascular events occurred in 1 patient (stroke) in the aspirin group and 10 patients (5 fatal myocardial infarctions and 5 fatal strokes) in the nonaspirin group, for a 90% statistically significant reduction in risk for that outcome.

Adverse effects occurred in 86 persons taking aspirin and in 14 who were not on aspirin. Hemorrhagic events were greater with aspirin (34 events, compared with 10), including an increase in gastrointestinal bleeding and the need for transfusion for severe GI bleeding in four patients, but there was no increase in hemorrhagic stroke.

“JPAD supports the safety of using low-dose aspirin in diabetics for primary prevention,” he said.

The investigators cautioned that the findings should be interpreted in context of the low incidence of atherosclerotic disease in Japan and the aggressive management of cardiovascular risk factors.

“The event rate was lower than anticipated because the patients were so well treated,” Dr. Ogawa said. “They saw their physicians every 2–4 weeks.”

Dr. Marian Limacher, professor of medicine at the University of Florida, Gainesville, said JPAD was “a well-designed and well-conducted study” that aimed to address a question that “some may have thought did not need to be answered,” given the widespread recommendation for the use of aspirin in diabetic patients.

“However, the evidence basis for this has been lacking until recently, and JPAD adds to this considerably,” she commented at a press conference.

The findings are congruent with the recently completed Progression of Arterial Disease and Diabetes (POPADAD) study from Great Britain, she noted. POPADAD, involving 1,276 patients with asymptomatic peripheral arterial disease, found no evidence for aspirin's benefit on cardiovascular events and mortality.

As discussant of the paper, Dr. Limacher offered several possible explanations for the lack of effect on the study's primary end point. Among her suggestions were: the choice of population, which included a number of women who may respond differently to aspirin when compared with men; the dose, which may have been too low to be protective in some patients; a too-short duration of intervention; the effect of aspirin resistance in some patients; the use of concomitant risk factor-modifying medications; and lack of power to show an effect when event rates were so low.

“We may need to rethink the guidelines,” she suggested, “especially for patients younger than 65.

“To come up with recommendations we also need to assess the risk/benefit ratio,” she continued.

“Diabetes is a high-risk group for cardiovascular events, and Japanese patients are a high-risk group for the use of aspirin because of their risk of hemorrhagic stroke. Conducting this study in Japan, therefore, makes sense. … The safety [in JPAD] was quite reasonable for low-dose aspirin,” she said.

NEW ORLEANS — Aspirin therapy is commonly used for primary prevention of cardiovascular events in persons with type 2 diabetes, but a Japanese study of 2,539 subjects found no statistically significant reduction in the primary end point of total atherosclerotic events, except in patients aged at least 65 years.

The study, which is the largest primary prevention trial of aspirin in type 2 diabetes, was reported at the annual scientific sessions of the American Heart Association.

In the Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes (JPAD) trial, the use of daily low-dose aspirin was associated with a 20% nonsignificant reduction in the risk of the combined end point of coronary, cerebrovascular, and peripheral vascular events in the population as a whole, and a 32% statistically significant reduction in events among those aged 65 and older, reported Dr. Hisao Ogawa of the Kumamoto (Japan) University.

Aspirin use also significantly reduced the composite of fatal coronary and fatal cerebrovascular events.

“Although the effect of low-dose aspirin was not statistically significant for the primary end point, a significant effect was demonstrated on fatal coronary and fatal cerebrovascular events. The trial also suggests that low-dose aspirin might reduce total events in older patients,” he said at a late-breaking trials session.

The results were reported online simultaneously with Dr. Ogawa's presentation (JAMA 2008;300:2134-41).

Japanese investigators from 163 institutions examined the benefit of low-dose aspirin for preventing cardiovascular events in 2,539 patients with type 2 diabetes who had no history of atherosclerotic disease. Average age of the patients was 65 years and 55% were men.

The investigators randomly assigned 1,262 patients to receive 81–100 mg aspirin per day and 1,277 to receive no aspirin. The primary end point was the composite of all coronary, cerebrovascular, and peripheral vascular events.

After a median follow-up of 4.4 years, a total of 154 fatal and nonfatal atherosclerotic events had occurred: 68 in the aspirin group and 86 in the nonaspirin group. This represented a rate of 13.6 events 1,000 person-years, compared with 17.0 events per 1,000 person-years, for a 20% reduction in risk that was not statistically significant, Dr. Ogawa reported.

Benefit was, however, demonstrated in older patients taking aspirin. Among the 719 patients aged at least 65 in the aspirin arm, 45 events (6.3%) atherosclerotic events occurred, compared with 59 events (9.2%) in the 644 older patients in the nonaspirin group, representing a statistically significant 32% reduction in risk with aspirin use.

The combined secondary end point of fatal coronary events and fatal cerebrovascular events occurred in 1 patient (stroke) in the aspirin group and 10 patients (5 fatal myocardial infarctions and 5 fatal strokes) in the nonaspirin group, for a 90% statistically significant reduction in risk for that outcome.

Adverse effects occurred in 86 persons taking aspirin and in 14 who were not on aspirin. Hemorrhagic events were greater with aspirin (34 events, compared with 10), including an increase in gastrointestinal bleeding and the need for transfusion for severe GI bleeding in four patients, but there was no increase in hemorrhagic stroke.

“JPAD supports the safety of using low-dose aspirin in diabetics for primary prevention,” he said.

The investigators cautioned that the findings should be interpreted in context of the low incidence of atherosclerotic disease in Japan and the aggressive management of cardiovascular risk factors.

“The event rate was lower than anticipated because the patients were so well treated,” Dr. Ogawa said. “They saw their physicians every 2–4 weeks.”

Dr. Marian Limacher, professor of medicine at the University of Florida, Gainesville, said JPAD was “a well-designed and well-conducted study” that aimed to address a question that “some may have thought did not need to be answered,” given the widespread recommendation for the use of aspirin in diabetic patients.

“However, the evidence basis for this has been lacking until recently, and JPAD adds to this considerably,” she commented at a press conference.

The findings are congruent with the recently completed Progression of Arterial Disease and Diabetes (POPADAD) study from Great Britain, she noted. POPADAD, involving 1,276 patients with asymptomatic peripheral arterial disease, found no evidence for aspirin's benefit on cardiovascular events and mortality.

As discussant of the paper, Dr. Limacher offered several possible explanations for the lack of effect on the study's primary end point. Among her suggestions were: the choice of population, which included a number of women who may respond differently to aspirin when compared with men; the dose, which may have been too low to be protective in some patients; a too-short duration of intervention; the effect of aspirin resistance in some patients; the use of concomitant risk factor-modifying medications; and lack of power to show an effect when event rates were so low.

“We may need to rethink the guidelines,” she suggested, “especially for patients younger than 65.

“To come up with recommendations we also need to assess the risk/benefit ratio,” she continued.

“Diabetes is a high-risk group for cardiovascular events, and Japanese patients are a high-risk group for the use of aspirin because of their risk of hemorrhagic stroke. Conducting this study in Japan, therefore, makes sense. … The safety [in JPAD] was quite reasonable for low-dose aspirin,” she said.

NEW ORLEANS — “Masked hypertension,” thought to affect about one in eight persons, can be identified through repeated office blood pressure measurements in those who show discrepancy between office and home blood pressure levels, according to Italian investigators.

“We were able to diagnose masked hypertension by using repeated office measurements. It matches what our patients found in home monitoring,” said principal investigator Dr. Giuseppe Crippa of Guglielmo da Saliceto Hospital, Piacenza, Italy.

Masked hypertension is defined as normal office BP but high ambulatory or home BP. The condition is thought to be as prevalent as white-coat hypertension and is often missed in clinical practice, said Dr. Crippa at the annual meeting of the American Society of Hypertension.

His study compared the level of agreement between office blood pressure (OBP), repeated office blood pressure (ROBP), and daytime ambulatory blood pressure (ABP) in 48 pharmacologically untreated patients with normal OBP (less than 140/90 mm Hg) but elevated daytime ABP (at least 135/85 mm Hg).

Since ABP averages multiple measurements, it is the accepted standard for diagnosing masked hypertension. For follow-up, home BP measurement is regarded as a simpler, reliable, and cost-effective alternative, he said.

OBP values were derived from the average of at least three sphygmomanometric measurements obtained during at least three separate visits, over a 3-week period. ABP values were calculated as the average of daytime readings taken every 15 minutes and nighttime readings obtained every 30 minutes. ROBP was performed after 20 minutes of rest with the patient seated comfortably alone; 10 consecutive measurements were taken every 2.5 minutes, with the average of the final six readings considered the final value.

The average blood pressure varies highly over 20 consecutive measurements, Dr. Crippa noted. For example, in one patient, the initial reading taken at 8:02 a.m. was 210/121 mm Hg and pulse rate was 96 bpm; midway through the ROBP it dropped to 140/79 mm Hg and 80 bpm; and concluded at 137/77 mm Hg and 72 bpm.

In the study, the OBP readings (both systolic and diastolic) were slightly but significantly lower than those achieved with ABP or ROBP. The differences between OBP and both ABP and ROBP were statistically significant. The ABP and ROBP readings were not significantly different and, in fact, were highly correlated with each other, Dr. Crippa reported.

With ABP as a reference for the diagnosis of masked hypertension, ROBP failed to identify this condition in just 2 out of the 48 patients.

ELSEVIER GLOBAL MEDICAL NEWS

NEW ORLEANS — “Masked hypertension,” thought to affect about one in eight persons, can be identified through repeated office blood pressure measurements in those who show discrepancy between office and home blood pressure levels, according to Italian investigators.

“We were able to diagnose masked hypertension by using repeated office measurements. It matches what our patients found in home monitoring,” said principal investigator Dr. Giuseppe Crippa of Guglielmo da Saliceto Hospital, Piacenza, Italy.

Masked hypertension is defined as normal office BP but high ambulatory or home BP. The condition is thought to be as prevalent as white-coat hypertension and is often missed in clinical practice, said Dr. Crippa at the annual meeting of the American Society of Hypertension.

His study compared the level of agreement between office blood pressure (OBP), repeated office blood pressure (ROBP), and daytime ambulatory blood pressure (ABP) in 48 pharmacologically untreated patients with normal OBP (less than 140/90 mm Hg) but elevated daytime ABP (at least 135/85 mm Hg).

Since ABP averages multiple measurements, it is the accepted standard for diagnosing masked hypertension. For follow-up, home BP measurement is regarded as a simpler, reliable, and cost-effective alternative, he said.

OBP values were derived from the average of at least three sphygmomanometric measurements obtained during at least three separate visits, over a 3-week period. ABP values were calculated as the average of daytime readings taken every 15 minutes and nighttime readings obtained every 30 minutes. ROBP was performed after 20 minutes of rest with the patient seated comfortably alone; 10 consecutive measurements were taken every 2.5 minutes, with the average of the final six readings considered the final value.

The average blood pressure varies highly over 20 consecutive measurements, Dr. Crippa noted. For example, in one patient, the initial reading taken at 8:02 a.m. was 210/121 mm Hg and pulse rate was 96 bpm; midway through the ROBP it dropped to 140/79 mm Hg and 80 bpm; and concluded at 137/77 mm Hg and 72 bpm.

In the study, the OBP readings (both systolic and diastolic) were slightly but significantly lower than those achieved with ABP or ROBP. The differences between OBP and both ABP and ROBP were statistically significant. The ABP and ROBP readings were not significantly different and, in fact, were highly correlated with each other, Dr. Crippa reported.

With ABP as a reference for the diagnosis of masked hypertension, ROBP failed to identify this condition in just 2 out of the 48 patients.

ELSEVIER GLOBAL MEDICAL NEWS

NEW ORLEANS — “Masked hypertension,” thought to affect about one in eight persons, can be identified through repeated office blood pressure measurements in those who show discrepancy between office and home blood pressure levels, according to Italian investigators.

“We were able to diagnose masked hypertension by using repeated office measurements. It matches what our patients found in home monitoring,” said principal investigator Dr. Giuseppe Crippa of Guglielmo da Saliceto Hospital, Piacenza, Italy.

Masked hypertension is defined as normal office BP but high ambulatory or home BP. The condition is thought to be as prevalent as white-coat hypertension and is often missed in clinical practice, said Dr. Crippa at the annual meeting of the American Society of Hypertension.

His study compared the level of agreement between office blood pressure (OBP), repeated office blood pressure (ROBP), and daytime ambulatory blood pressure (ABP) in 48 pharmacologically untreated patients with normal OBP (less than 140/90 mm Hg) but elevated daytime ABP (at least 135/85 mm Hg).

Since ABP averages multiple measurements, it is the accepted standard for diagnosing masked hypertension. For follow-up, home BP measurement is regarded as a simpler, reliable, and cost-effective alternative, he said.

OBP values were derived from the average of at least three sphygmomanometric measurements obtained during at least three separate visits, over a 3-week period. ABP values were calculated as the average of daytime readings taken every 15 minutes and nighttime readings obtained every 30 minutes. ROBP was performed after 20 minutes of rest with the patient seated comfortably alone; 10 consecutive measurements were taken every 2.5 minutes, with the average of the final six readings considered the final value.

The average blood pressure varies highly over 20 consecutive measurements, Dr. Crippa noted. For example, in one patient, the initial reading taken at 8:02 a.m. was 210/121 mm Hg and pulse rate was 96 bpm; midway through the ROBP it dropped to 140/79 mm Hg and 80 bpm; and concluded at 137/77 mm Hg and 72 bpm.

In the study, the OBP readings (both systolic and diastolic) were slightly but significantly lower than those achieved with ABP or ROBP. The differences between OBP and both ABP and ROBP were statistically significant. The ABP and ROBP readings were not significantly different and, in fact, were highly correlated with each other, Dr. Crippa reported.

With ABP as a reference for the diagnosis of masked hypertension, ROBP failed to identify this condition in just 2 out of the 48 patients.

ELSEVIER GLOBAL MEDICAL NEWS

NEW ORLEANS — Obstructive sleep apnea appears to contribute significantly to both the development and severity of hypertension and may play a role in heart failure as well. The good news is that regular use of continuous positive airway pressure not only treats the apnea but also lowers blood pressure in some patients, according to speakers at the annual meeting of the American Society of Hypertension.

Obstructive sleep apnea (OSA) has been observed in approximately 40% of persons with treatable hypertension, compared with approximately 25% of men and 10% of women in the general population, according to Dr. David Calhoun of the department of medicine at the University of Alabama at Birmingham.

“A number of studies suggest that nocturnal blood pressure may be a better predictor of cardiovascular outcomes than daytime elevations in blood pressure, so there is growing interest in what is happening during the night, especially when blood pressure fails to decrease. One factor in this is obstructive sleep apnea,” Dr. Calhoun said at a press conference on the topic.

Others have found a dose-dependent increased risk of developing hypertension in relationship to OSA. In a prospective evaluation of normotensive patients, those with the most severe OSA at baseline had more than twice the risk of developing hypertension over 4 years (JAMA 2000;283:1829-36).

“This confirmed the relationship between OSA and hypertension, establishing sleep apnea as a potential cause,” he said.

Other studies also have found that, the more severe the sleep apnea, the higher a patient's nocturnal and daytime blood pressure, as well. One important study documented the overall prevalence of OSA (defined as more than 10 events per hour) to be 83% among persons with drug-resistant hypertension, including 96% among men and 65% among women.

“You are seemingly at much higher risk of having sleep apnea if you have difficult to control hypertension. And it suggests that having sleep apnea contributes to difficulties in treating hypertension,” Dr. Calhoun noted.

OSA also has been associated with heart failure, according to Dr. Alexander G. Logan of Mount Sinai Hospital, Toronto, and the University of Toronto. In the Sleep Heart Health Study (Am. J. Resp. Crit. Care Med. 2001;163:19-25), persons with sleep-disordered breathing had an odds ratio of 2.38 for developing heart failure, as well as an increased risk of stroke and coronary heart disease, versus those without. Numerous other studies have also shown an increased risk of OSA in persons with heart failure, he said.

Treatment of OSA with continuous positive airway pressure (CPAP) may help some patients, a number of studies have shown, the speakers said.

While the data may not be “very compelling,” according to Dr. Calhoun, randomized studies have shown that about 5 hours of CPAP per night is associated with small reductions in mean arterial pressure and about a 10-mm Hg reduction in systolic and diastolic pressures. In one study of patients with resistant hypertension, regular use of CPAP for 2 months was associated with substantial reductions in 24-hour, daytime, and nocturnal blood pressures (Eur. Respir. J. 2003;21:241-7), a finding that established CPAP as an important adjunct to treatment of patients with resistant hypertension, he said.

“The benefit of CPAP appears to be strongest in nocturnal blood pressures,” he added. “CPAP appears to help restore the 'dipping' pattern (10% decrease in blood pressure) overnight.”

Dr. Calhoun believes this translates into cardiovascular benefits. French investigators found fewer cardiovascular events among hypertensive patients who adhered to CPAP for 5 years, vs. those patients who discontinued CPAP (Eur. Heart J. 2004;25:728-734). Event rates were 24% vs. 58%, respectively.

Dr. Logan noted that in medically treated heart failure patients with OSA, the use of CPAP reduces blood systolic blood pressure, partly as a result of a decrease in sympathetic vasoconstrictor tone; improves left ventricular systolic function; improves baroreflex sensitivity; decreases the frequency of ventricular premature beats; and improves the quality of life in hypersomnolent patients.

NEW ORLEANS — Obstructive sleep apnea appears to contribute significantly to both the development and severity of hypertension and may play a role in heart failure as well. The good news is that regular use of continuous positive airway pressure not only treats the apnea but also lowers blood pressure in some patients, according to speakers at the annual meeting of the American Society of Hypertension.

Obstructive sleep apnea (OSA) has been observed in approximately 40% of persons with treatable hypertension, compared with approximately 25% of men and 10% of women in the general population, according to Dr. David Calhoun of the department of medicine at the University of Alabama at Birmingham.

“A number of studies suggest that nocturnal blood pressure may be a better predictor of cardiovascular outcomes than daytime elevations in blood pressure, so there is growing interest in what is happening during the night, especially when blood pressure fails to decrease. One factor in this is obstructive sleep apnea,” Dr. Calhoun said at a press conference on the topic.

Others have found a dose-dependent increased risk of developing hypertension in relationship to OSA. In a prospective evaluation of normotensive patients, those with the most severe OSA at baseline had more than twice the risk of developing hypertension over 4 years (JAMA 2000;283:1829-36).

“This confirmed the relationship between OSA and hypertension, establishing sleep apnea as a potential cause,” he said.

Other studies also have found that, the more severe the sleep apnea, the higher a patient's nocturnal and daytime blood pressure, as well. One important study documented the overall prevalence of OSA (defined as more than 10 events per hour) to be 83% among persons with drug-resistant hypertension, including 96% among men and 65% among women.

“You are seemingly at much higher risk of having sleep apnea if you have difficult to control hypertension. And it suggests that having sleep apnea contributes to difficulties in treating hypertension,” Dr. Calhoun noted.

OSA also has been associated with heart failure, according to Dr. Alexander G. Logan of Mount Sinai Hospital, Toronto, and the University of Toronto. In the Sleep Heart Health Study (Am. J. Resp. Crit. Care Med. 2001;163:19-25), persons with sleep-disordered breathing had an odds ratio of 2.38 for developing heart failure, as well as an increased risk of stroke and coronary heart disease, versus those without. Numerous other studies have also shown an increased risk of OSA in persons with heart failure, he said.

Treatment of OSA with continuous positive airway pressure (CPAP) may help some patients, a number of studies have shown, the speakers said.

While the data may not be “very compelling,” according to Dr. Calhoun, randomized studies have shown that about 5 hours of CPAP per night is associated with small reductions in mean arterial pressure and about a 10-mm Hg reduction in systolic and diastolic pressures. In one study of patients with resistant hypertension, regular use of CPAP for 2 months was associated with substantial reductions in 24-hour, daytime, and nocturnal blood pressures (Eur. Respir. J. 2003;21:241-7), a finding that established CPAP as an important adjunct to treatment of patients with resistant hypertension, he said.

“The benefit of CPAP appears to be strongest in nocturnal blood pressures,” he added. “CPAP appears to help restore the 'dipping' pattern (10% decrease in blood pressure) overnight.”

Dr. Calhoun believes this translates into cardiovascular benefits. French investigators found fewer cardiovascular events among hypertensive patients who adhered to CPAP for 5 years, vs. those patients who discontinued CPAP (Eur. Heart J. 2004;25:728-734). Event rates were 24% vs. 58%, respectively.

Dr. Logan noted that in medically treated heart failure patients with OSA, the use of CPAP reduces blood systolic blood pressure, partly as a result of a decrease in sympathetic vasoconstrictor tone; improves left ventricular systolic function; improves baroreflex sensitivity; decreases the frequency of ventricular premature beats; and improves the quality of life in hypersomnolent patients.

NEW ORLEANS — Obstructive sleep apnea appears to contribute significantly to both the development and severity of hypertension and may play a role in heart failure as well. The good news is that regular use of continuous positive airway pressure not only treats the apnea but also lowers blood pressure in some patients, according to speakers at the annual meeting of the American Society of Hypertension.

Obstructive sleep apnea (OSA) has been observed in approximately 40% of persons with treatable hypertension, compared with approximately 25% of men and 10% of women in the general population, according to Dr. David Calhoun of the department of medicine at the University of Alabama at Birmingham.

“A number of studies suggest that nocturnal blood pressure may be a better predictor of cardiovascular outcomes than daytime elevations in blood pressure, so there is growing interest in what is happening during the night, especially when blood pressure fails to decrease. One factor in this is obstructive sleep apnea,” Dr. Calhoun said at a press conference on the topic.

Others have found a dose-dependent increased risk of developing hypertension in relationship to OSA. In a prospective evaluation of normotensive patients, those with the most severe OSA at baseline had more than twice the risk of developing hypertension over 4 years (JAMA 2000;283:1829-36).

“This confirmed the relationship between OSA and hypertension, establishing sleep apnea as a potential cause,” he said.

Other studies also have found that, the more severe the sleep apnea, the higher a patient's nocturnal and daytime blood pressure, as well. One important study documented the overall prevalence of OSA (defined as more than 10 events per hour) to be 83% among persons with drug-resistant hypertension, including 96% among men and 65% among women.

“You are seemingly at much higher risk of having sleep apnea if you have difficult to control hypertension. And it suggests that having sleep apnea contributes to difficulties in treating hypertension,” Dr. Calhoun noted.

OSA also has been associated with heart failure, according to Dr. Alexander G. Logan of Mount Sinai Hospital, Toronto, and the University of Toronto. In the Sleep Heart Health Study (Am. J. Resp. Crit. Care Med. 2001;163:19-25), persons with sleep-disordered breathing had an odds ratio of 2.38 for developing heart failure, as well as an increased risk of stroke and coronary heart disease, versus those without. Numerous other studies have also shown an increased risk of OSA in persons with heart failure, he said.

Treatment of OSA with continuous positive airway pressure (CPAP) may help some patients, a number of studies have shown, the speakers said.

While the data may not be “very compelling,” according to Dr. Calhoun, randomized studies have shown that about 5 hours of CPAP per night is associated with small reductions in mean arterial pressure and about a 10-mm Hg reduction in systolic and diastolic pressures. In one study of patients with resistant hypertension, regular use of CPAP for 2 months was associated with substantial reductions in 24-hour, daytime, and nocturnal blood pressures (Eur. Respir. J. 2003;21:241-7), a finding that established CPAP as an important adjunct to treatment of patients with resistant hypertension, he said.

“The benefit of CPAP appears to be strongest in nocturnal blood pressures,” he added. “CPAP appears to help restore the 'dipping' pattern (10% decrease in blood pressure) overnight.”

Dr. Calhoun believes this translates into cardiovascular benefits. French investigators found fewer cardiovascular events among hypertensive patients who adhered to CPAP for 5 years, vs. those patients who discontinued CPAP (Eur. Heart J. 2004;25:728-734). Event rates were 24% vs. 58%, respectively.

Dr. Logan noted that in medically treated heart failure patients with OSA, the use of CPAP reduces blood systolic blood pressure, partly as a result of a decrease in sympathetic vasoconstrictor tone; improves left ventricular systolic function; improves baroreflex sensitivity; decreases the frequency of ventricular premature beats; and improves the quality of life in hypersomnolent patients.

NEW ORLEANS — “Masked hypertension,” thought to affect about one in eight individuals, can be identified through repeated office blood pressure measurements in persons who show discrepancy between office and home blood pressure levels, according to Italian investigators.

“We were able to diagnose masked hypertension by using repeated office measurements. It matches what our patients found in home monitoring,” said principal investigator Dr. Giuseppe Crippa of Guglielmo da Saliceto Hospital, Piacenza, Italy.

Masked hypertension is defined as normal office blood pressure but high ambulatory blood pressure or home blood pressure. It is estimated that the condition is as prevalent as white-coat hypertension and is often missed in clinical practice, Dr. Crippa explained at the annual meeting of the American Society of Hypertension.

His study compared the level of agreement between office blood pressure (OBP), repeated office blood pressure (ROBP), and daytime ambulatory blood pressure (ABP) in 48 pharmacologically untreated patients with normal office blood pressure (less than 140/90 mm Hg) but elevated daytime ABP (at least 135/85 mm Hg).

Since ABP averages multiple measurements, it is the accepted standard for diagnosing masked hypertension. For follow-up, home blood pressure measurement is regarded as a simpler, reliable, and cost-effective alternative, he said.

OBP values were derived from the average of at least three sphygmomanometric measurements obtained during at least three separate visits over a 3-week period. ABP values were calculated as the average of daytime readings taken every 15 minutes and nighttime readings obtained every 30 minutes. ROBP was performed after 20 minutes of rest with the patient seated comfortably alone; 10 consecutive measurements were taken every 2.5 minutes, with the average of the final six readings considered the final value.

This is important, Dr. Crippa noted, since the average blood pressure varies highly over 20 consecutive measurements. For example, in one patient, the initial reading taken at 8:02 a.m. was 210/121 mm Hg and pulse rate was 96 beats per minute (bpm); midway through the ROBP it dropped to 140/79 mm Hg and 80 bpm; and concluded at 137/77 mm Hg and 72 bpm. Over the 20 readings, the average of the first 4 was 185/106 mm Hg, while the average of the final 6 readings was 138/77 mm Hg.

In the study, the OBP readings (both systolic and diastolic) were slightly but significantly lower than those achieved with ABP or ROBP. The differences between OBP and both ABP and ROBP were statistically significant. The ABP and ROBP readings were not significantly different and, in fact, were highly correlated with each other, Dr. Crippa reported.

With ABP as a reference for the diagnosis of masked hypertension, ROBP failed to identify this condition in just 2 out of the 48 patients.

“According to our results, ROBP seems to provide reliable information on blood pressure status that compares favorably with the most precise and exhaustive technique for the diagnosis of masked hypertension, i.e. [ambulatory blood pressure monitoring],” he said. “In a population of untreated subjects, ROBP and ABP monitoring provided a very similar proportion of individuals with masked hypertension, and the level of agreement, for the same subject, was more than acceptable. The precision and power of detection by ROBP seems very high, with an attractive cost/efficacy ratio.”

The majority of subjects (94% according to ABP monitoring values) had OBP values in the prehypertensive range, he added, suggesting that masked hypertension might be regarded as a high-risk subset of prehypertension.

NEW ORLEANS — “Masked hypertension,” thought to affect about one in eight individuals, can be identified through repeated office blood pressure measurements in persons who show discrepancy between office and home blood pressure levels, according to Italian investigators.

“We were able to diagnose masked hypertension by using repeated office measurements. It matches what our patients found in home monitoring,” said principal investigator Dr. Giuseppe Crippa of Guglielmo da Saliceto Hospital, Piacenza, Italy.

Masked hypertension is defined as normal office blood pressure but high ambulatory blood pressure or home blood pressure. It is estimated that the condition is as prevalent as white-coat hypertension and is often missed in clinical practice, Dr. Crippa explained at the annual meeting of the American Society of Hypertension.

His study compared the level of agreement between office blood pressure (OBP), repeated office blood pressure (ROBP), and daytime ambulatory blood pressure (ABP) in 48 pharmacologically untreated patients with normal office blood pressure (less than 140/90 mm Hg) but elevated daytime ABP (at least 135/85 mm Hg).

Since ABP averages multiple measurements, it is the accepted standard for diagnosing masked hypertension. For follow-up, home blood pressure measurement is regarded as a simpler, reliable, and cost-effective alternative, he said.

OBP values were derived from the average of at least three sphygmomanometric measurements obtained during at least three separate visits over a 3-week period. ABP values were calculated as the average of daytime readings taken every 15 minutes and nighttime readings obtained every 30 minutes. ROBP was performed after 20 minutes of rest with the patient seated comfortably alone; 10 consecutive measurements were taken every 2.5 minutes, with the average of the final six readings considered the final value.

This is important, Dr. Crippa noted, since the average blood pressure varies highly over 20 consecutive measurements. For example, in one patient, the initial reading taken at 8:02 a.m. was 210/121 mm Hg and pulse rate was 96 beats per minute (bpm); midway through the ROBP it dropped to 140/79 mm Hg and 80 bpm; and concluded at 137/77 mm Hg and 72 bpm. Over the 20 readings, the average of the first 4 was 185/106 mm Hg, while the average of the final 6 readings was 138/77 mm Hg.

In the study, the OBP readings (both systolic and diastolic) were slightly but significantly lower than those achieved with ABP or ROBP. The differences between OBP and both ABP and ROBP were statistically significant. The ABP and ROBP readings were not significantly different and, in fact, were highly correlated with each other, Dr. Crippa reported.

With ABP as a reference for the diagnosis of masked hypertension, ROBP failed to identify this condition in just 2 out of the 48 patients.

“According to our results, ROBP seems to provide reliable information on blood pressure status that compares favorably with the most precise and exhaustive technique for the diagnosis of masked hypertension, i.e. [ambulatory blood pressure monitoring],” he said. “In a population of untreated subjects, ROBP and ABP monitoring provided a very similar proportion of individuals with masked hypertension, and the level of agreement, for the same subject, was more than acceptable. The precision and power of detection by ROBP seems very high, with an attractive cost/efficacy ratio.”

The majority of subjects (94% according to ABP monitoring values) had OBP values in the prehypertensive range, he added, suggesting that masked hypertension might be regarded as a high-risk subset of prehypertension.

NEW ORLEANS — “Masked hypertension,” thought to affect about one in eight individuals, can be identified through repeated office blood pressure measurements in persons who show discrepancy between office and home blood pressure levels, according to Italian investigators.

“We were able to diagnose masked hypertension by using repeated office measurements. It matches what our patients found in home monitoring,” said principal investigator Dr. Giuseppe Crippa of Guglielmo da Saliceto Hospital, Piacenza, Italy.

Masked hypertension is defined as normal office blood pressure but high ambulatory blood pressure or home blood pressure. It is estimated that the condition is as prevalent as white-coat hypertension and is often missed in clinical practice, Dr. Crippa explained at the annual meeting of the American Society of Hypertension.

His study compared the level of agreement between office blood pressure (OBP), repeated office blood pressure (ROBP), and daytime ambulatory blood pressure (ABP) in 48 pharmacologically untreated patients with normal office blood pressure (less than 140/90 mm Hg) but elevated daytime ABP (at least 135/85 mm Hg).

Since ABP averages multiple measurements, it is the accepted standard for diagnosing masked hypertension. For follow-up, home blood pressure measurement is regarded as a simpler, reliable, and cost-effective alternative, he said.

OBP values were derived from the average of at least three sphygmomanometric measurements obtained during at least three separate visits over a 3-week period. ABP values were calculated as the average of daytime readings taken every 15 minutes and nighttime readings obtained every 30 minutes. ROBP was performed after 20 minutes of rest with the patient seated comfortably alone; 10 consecutive measurements were taken every 2.5 minutes, with the average of the final six readings considered the final value.

This is important, Dr. Crippa noted, since the average blood pressure varies highly over 20 consecutive measurements. For example, in one patient, the initial reading taken at 8:02 a.m. was 210/121 mm Hg and pulse rate was 96 beats per minute (bpm); midway through the ROBP it dropped to 140/79 mm Hg and 80 bpm; and concluded at 137/77 mm Hg and 72 bpm. Over the 20 readings, the average of the first 4 was 185/106 mm Hg, while the average of the final 6 readings was 138/77 mm Hg.

In the study, the OBP readings (both systolic and diastolic) were slightly but significantly lower than those achieved with ABP or ROBP. The differences between OBP and both ABP and ROBP were statistically significant. The ABP and ROBP readings were not significantly different and, in fact, were highly correlated with each other, Dr. Crippa reported.

With ABP as a reference for the diagnosis of masked hypertension, ROBP failed to identify this condition in just 2 out of the 48 patients.

“According to our results, ROBP seems to provide reliable information on blood pressure status that compares favorably with the most precise and exhaustive technique for the diagnosis of masked hypertension, i.e. [ambulatory blood pressure monitoring],” he said. “In a population of untreated subjects, ROBP and ABP monitoring provided a very similar proportion of individuals with masked hypertension, and the level of agreement, for the same subject, was more than acceptable. The precision and power of detection by ROBP seems very high, with an attractive cost/efficacy ratio.”

The majority of subjects (94% according to ABP monitoring values) had OBP values in the prehypertensive range, he added, suggesting that masked hypertension might be regarded as a high-risk subset of prehypertension.

NEW ORLEANS — “Masked hypertension,” which is thought to affect about one in eight individuals, can be identified through repeated office blood pressure measurements in persons who show discrepancy between office and home blood pressure levels, according to Italian investigators.

“We were able to diagnose masked hypertension by using repeated office measurements. It matches what our patients found in home monitoring,” reported principal investigator Dr. Giuseppe Crippa of Guglielmo da Saliceto Hospital, Piacenza, Italy.

Masked hypertension is defined as normal office blood pressure but high ambulatory blood pressure or home blood pressure. It is estimated that the condition is as prevalent as white-coat hypertension and is often missed in clinical practice, Dr. Crippa explained at the annual meeting of the American Society of Hypertension.

His study compared the level of agreement between office blood pressure (OBP), repeated office blood pressure (ROBP), and daytime ambulatory blood pressure (ABP) in 48 patients pharmacologically untreated with subjects with normal office blood pressure (less than 140/90 mm Hg) but elevated daytime ABP (at least 135/85 mm Hg).

Since ABP averages multiple measurements, it is the accepted standard for diagnosing masked hypertension. For follow-up, home blood pressure measurement is regarded as a simpler, reliable, and cost-effective alternative, he said.

OBP values were derived from the average of at least three sphygmomanometric measurements obtained during at least three separate visits, over a 3-week period. ABP values were calculated as the average of daytime readings taken every 15 minutes and nighttime readings obtained every 30 minutes. ROBP was performed after 20 minutes of rest with the patient seated comfortably alone; 10 consecutive measurements were taken every 2.5 minutes, with the average of the final six readings considered the final value.

This is important, Dr. Crippa noted, because the average blood pressure varies highly over 20 consecutive measurements. For example, in one patient, the initial reading taken at 8:02 a.m. was 210/121 mm Hg and pulse rate was 96 beats per minute (bpm); midway through the ROBP it dropped to 140/79 mm Hg and 80 bpm; and concluded at 137/77 mm Hg and 72 bpm. Over the 20 readings, the average of the first 4 was 185/106 mm Hg, while the average of the final 6 readings was 138/77 mm Hg.

In the study, the OBP readings (both systolic and diastolic) were slightly but significantly lower than those achieved with ABP or ROBP.

The differences between OBP and both ABP and ROBP were statistically significant. The ABP and ROBP readings were not significantly different and, in fact, were highly correlated with each other, Dr. Crippa reported.

With ABP as a reference for the diagnosis of masked hypertension, ROBP failed to identify this condition in just 2 out of the 48 patients.

“According to our results, ROBP seems to provide reliable information on blood pressure status that compares favorably with the most precise and exhaustive technique for the diagnosis of masked hypertension, that is, [ambulatory blood pressure monitoring],” Dr. Crippa explained. “In a population of untreated subjects, ROBP and ABP monitoring provided a very similar proportion of individuals with masked hypertension, and the level of agreement, for the same subject, was more than acceptable. The precision and power of detection by ROBP seems very high, with an attractive cost/efficacy ratio.”

The majority of subjects (94% according to ABP monitoring values) had OBP values in the prehypertensive range, he added, suggesting that masked hypertension might be regarded as a high-risk subset of prehypertension.

NEW ORLEANS — “Masked hypertension,” which is thought to affect about one in eight individuals, can be identified through repeated office blood pressure measurements in persons who show discrepancy between office and home blood pressure levels, according to Italian investigators.

“We were able to diagnose masked hypertension by using repeated office measurements. It matches what our patients found in home monitoring,” reported principal investigator Dr. Giuseppe Crippa of Guglielmo da Saliceto Hospital, Piacenza, Italy.

Masked hypertension is defined as normal office blood pressure but high ambulatory blood pressure or home blood pressure. It is estimated that the condition is as prevalent as white-coat hypertension and is often missed in clinical practice, Dr. Crippa explained at the annual meeting of the American Society of Hypertension.

His study compared the level of agreement between office blood pressure (OBP), repeated office blood pressure (ROBP), and daytime ambulatory blood pressure (ABP) in 48 patients pharmacologically untreated with subjects with normal office blood pressure (less than 140/90 mm Hg) but elevated daytime ABP (at least 135/85 mm Hg).

Since ABP averages multiple measurements, it is the accepted standard for diagnosing masked hypertension. For follow-up, home blood pressure measurement is regarded as a simpler, reliable, and cost-effective alternative, he said.

OBP values were derived from the average of at least three sphygmomanometric measurements obtained during at least three separate visits, over a 3-week period. ABP values were calculated as the average of daytime readings taken every 15 minutes and nighttime readings obtained every 30 minutes. ROBP was performed after 20 minutes of rest with the patient seated comfortably alone; 10 consecutive measurements were taken every 2.5 minutes, with the average of the final six readings considered the final value.

This is important, Dr. Crippa noted, because the average blood pressure varies highly over 20 consecutive measurements. For example, in one patient, the initial reading taken at 8:02 a.m. was 210/121 mm Hg and pulse rate was 96 beats per minute (bpm); midway through the ROBP it dropped to 140/79 mm Hg and 80 bpm; and concluded at 137/77 mm Hg and 72 bpm. Over the 20 readings, the average of the first 4 was 185/106 mm Hg, while the average of the final 6 readings was 138/77 mm Hg.

In the study, the OBP readings (both systolic and diastolic) were slightly but significantly lower than those achieved with ABP or ROBP.

The differences between OBP and both ABP and ROBP were statistically significant. The ABP and ROBP readings were not significantly different and, in fact, were highly correlated with each other, Dr. Crippa reported.

With ABP as a reference for the diagnosis of masked hypertension, ROBP failed to identify this condition in just 2 out of the 48 patients.

“According to our results, ROBP seems to provide reliable information on blood pressure status that compares favorably with the most precise and exhaustive technique for the diagnosis of masked hypertension, that is, [ambulatory blood pressure monitoring],” Dr. Crippa explained. “In a population of untreated subjects, ROBP and ABP monitoring provided a very similar proportion of individuals with masked hypertension, and the level of agreement, for the same subject, was more than acceptable. The precision and power of detection by ROBP seems very high, with an attractive cost/efficacy ratio.”

The majority of subjects (94% according to ABP monitoring values) had OBP values in the prehypertensive range, he added, suggesting that masked hypertension might be regarded as a high-risk subset of prehypertension.

NEW ORLEANS — “Masked hypertension,” which is thought to affect about one in eight individuals, can be identified through repeated office blood pressure measurements in persons who show discrepancy between office and home blood pressure levels, according to Italian investigators.

“We were able to diagnose masked hypertension by using repeated office measurements. It matches what our patients found in home monitoring,” reported principal investigator Dr. Giuseppe Crippa of Guglielmo da Saliceto Hospital, Piacenza, Italy.

Masked hypertension is defined as normal office blood pressure but high ambulatory blood pressure or home blood pressure. It is estimated that the condition is as prevalent as white-coat hypertension and is often missed in clinical practice, Dr. Crippa explained at the annual meeting of the American Society of Hypertension.

His study compared the level of agreement between office blood pressure (OBP), repeated office blood pressure (ROBP), and daytime ambulatory blood pressure (ABP) in 48 patients pharmacologically untreated with subjects with normal office blood pressure (less than 140/90 mm Hg) but elevated daytime ABP (at least 135/85 mm Hg).

Since ABP averages multiple measurements, it is the accepted standard for diagnosing masked hypertension. For follow-up, home blood pressure measurement is regarded as a simpler, reliable, and cost-effective alternative, he said.

OBP values were derived from the average of at least three sphygmomanometric measurements obtained during at least three separate visits, over a 3-week period. ABP values were calculated as the average of daytime readings taken every 15 minutes and nighttime readings obtained every 30 minutes. ROBP was performed after 20 minutes of rest with the patient seated comfortably alone; 10 consecutive measurements were taken every 2.5 minutes, with the average of the final six readings considered the final value.

This is important, Dr. Crippa noted, because the average blood pressure varies highly over 20 consecutive measurements. For example, in one patient, the initial reading taken at 8:02 a.m. was 210/121 mm Hg and pulse rate was 96 beats per minute (bpm); midway through the ROBP it dropped to 140/79 mm Hg and 80 bpm; and concluded at 137/77 mm Hg and 72 bpm. Over the 20 readings, the average of the first 4 was 185/106 mm Hg, while the average of the final 6 readings was 138/77 mm Hg.

In the study, the OBP readings (both systolic and diastolic) were slightly but significantly lower than those achieved with ABP or ROBP.

The differences between OBP and both ABP and ROBP were statistically significant. The ABP and ROBP readings were not significantly different and, in fact, were highly correlated with each other, Dr. Crippa reported.

With ABP as a reference for the diagnosis of masked hypertension, ROBP failed to identify this condition in just 2 out of the 48 patients.

“According to our results, ROBP seems to provide reliable information on blood pressure status that compares favorably with the most precise and exhaustive technique for the diagnosis of masked hypertension, that is, [ambulatory blood pressure monitoring],” Dr. Crippa explained. “In a population of untreated subjects, ROBP and ABP monitoring provided a very similar proportion of individuals with masked hypertension, and the level of agreement, for the same subject, was more than acceptable. The precision and power of detection by ROBP seems very high, with an attractive cost/efficacy ratio.”

The majority of subjects (94% according to ABP monitoring values) had OBP values in the prehypertensive range, he added, suggesting that masked hypertension might be regarded as a high-risk subset of prehypertension.

NEW ORLEANS — Although the focus of checking for melanoma is usually on finding “the ugly duckling,” the real challenge is to identify the signature nevus to determine the patient's particular phenotype, said Dr. Jean Bolognia.

“Identifying the signature nevus will reduce the number of biopsies you perform,” said Dr. Bolognia, who discussed several varieties of signature melanocytic nevi at a dermatology update sponsored by Tulane University. She highlighted the two most challenging phenotypes—numerous lentiginous nevi, the “cheetah” phenotype, and multiple solid pink nevi—and some of the more common types, such as solid brown, eclipse, and multiple halo nevi.

The cheetah phenotype, represented by numerous small, dark nevi, can be difficult to manage, said Dr. Bolognia, professor of dermatology at Yale University, New Haven, Conn. The signature nevus is a brown-black compound or junctional lentiginous nevus that may or may not have a thin medium brown rim. The center of the lesion is extremely dark and solid, without a visible pigment pattern by dermoscopy.

“The patient can have 200 or more of these nevi. The anticipation is that this patient will undergo multiple biopsies, with a lower 'hit rate' for cutaneous melanoma than with other types of nevi. I share these patients with another dermatologist. Having two sets of eyes doing a skin examination is my solution to [this] phenotype.”

Another difficult, though rare, phenotype is represented by multiple pink nevi. Patients with these tend to be skin type 1 or 2 and produce little, if any, melanin in their nevi.

Dr. Bolognia examines for texture and degree of erythema in these nevi. “I also look for the nevus with the darkest pink color or any red lesion [and] biopsy the latter, unless it is clearly acneiform.” Again, she has another dermatologist also check the patient.

In contrast, solid brown nevi are easier to follow because they are symmetric and uniform in color, she noted. The large moles resembling fried eggs are often found on the back and are a source of concern to patients and nondermatologists. However, they are benign, and rather than labeling them as precursors of melanoma, they should be viewed as a phenotypic marker, alerting the physician the patient is at risk and should be closely examined.

A melanoma can arise in this type of nevus, so one should look for superimposed changes. Prophylactic excision is not recommended because scarring can be significant given their size and truncal location. In addition, these nevi age over time with gradual fading and formation of a skin-colored intradermal nevus centrally.

The eclipse nevi resemble a solar eclipse, with a solid tan center and a brown rim that may be stellate and discontinuous, leading to asymmetry. They are often seen on the scalp of children. “These nevi are benign but get attention because of their irregular outline and variation in color. Unless there is a superimposed change, they should not elicit concern. When the signature nevus is an eclipse nevus, you should focus on the 10 to 15 other nevi that are not in this 'family' and look for the one with the most atypical features,” said Dr. Bolognia. She does not recommend surgically removing eclipse nevi because others will probably develop, but if she does biopsy, she makes sure to send the tissue to a dermatopathologist.

Multiple halo nevi are seen most often in younger patients. There are four stages of halo nevi: stages I and II, characterized by a depigmented halo surrounding either a pigmented nevus (I) or a pink nevus (II); stage III, an oval or circular area of depigmentation (with no central nevus), thus resembling a patch of vitiligo; and stage IV, which represents complete repigmentation. Getting from stage I to IV usually takes years and occurs in almost all patients. Everyone with multiple halo nevi deserves a total body skin examination. In older adults presenting with these nevi, one should also consider the possibility of an immune reaction to an ocular or cutaneous melanoma, Dr. Bolognia said.

In the cheetah phenotype, seen here as a cluster of small, dark nevi, the signature nevus may have a thin, lighter brown rim. Courtesy Dr. Jean Bolognia

NEW ORLEANS — Although the focus of checking for melanoma is usually on finding “the ugly duckling,” the real challenge is to identify the signature nevus to determine the patient's particular phenotype, said Dr. Jean Bolognia.

“Identifying the signature nevus will reduce the number of biopsies you perform,” said Dr. Bolognia, who discussed several varieties of signature melanocytic nevi at a dermatology update sponsored by Tulane University. She highlighted the two most challenging phenotypes—numerous lentiginous nevi, the “cheetah” phenotype, and multiple solid pink nevi—and some of the more common types, such as solid brown, eclipse, and multiple halo nevi.

The cheetah phenotype, represented by numerous small, dark nevi, can be difficult to manage, said Dr. Bolognia, professor of dermatology at Yale University, New Haven, Conn. The signature nevus is a brown-black compound or junctional lentiginous nevus that may or may not have a thin medium brown rim. The center of the lesion is extremely dark and solid, without a visible pigment pattern by dermoscopy.

“The patient can have 200 or more of these nevi. The anticipation is that this patient will undergo multiple biopsies, with a lower 'hit rate' for cutaneous melanoma than with other types of nevi. I share these patients with another dermatologist. Having two sets of eyes doing a skin examination is my solution to [this] phenotype.”

Another difficult, though rare, phenotype is represented by multiple pink nevi. Patients with these tend to be skin type 1 or 2 and produce little, if any, melanin in their nevi.

Dr. Bolognia examines for texture and degree of erythema in these nevi. “I also look for the nevus with the darkest pink color or any red lesion [and] biopsy the latter, unless it is clearly acneiform.” Again, she has another dermatologist also check the patient.

In contrast, solid brown nevi are easier to follow because they are symmetric and uniform in color, she noted. The large moles resembling fried eggs are often found on the back and are a source of concern to patients and nondermatologists. However, they are benign, and rather than labeling them as precursors of melanoma, they should be viewed as a phenotypic marker, alerting the physician the patient is at risk and should be closely examined.

A melanoma can arise in this type of nevus, so one should look for superimposed changes. Prophylactic excision is not recommended because scarring can be significant given their size and truncal location. In addition, these nevi age over time with gradual fading and formation of a skin-colored intradermal nevus centrally.

The eclipse nevi resemble a solar eclipse, with a solid tan center and a brown rim that may be stellate and discontinuous, leading to asymmetry. They are often seen on the scalp of children. “These nevi are benign but get attention because of their irregular outline and variation in color. Unless there is a superimposed change, they should not elicit concern. When the signature nevus is an eclipse nevus, you should focus on the 10 to 15 other nevi that are not in this 'family' and look for the one with the most atypical features,” said Dr. Bolognia. She does not recommend surgically removing eclipse nevi because others will probably develop, but if she does biopsy, she makes sure to send the tissue to a dermatopathologist.

Multiple halo nevi are seen most often in younger patients. There are four stages of halo nevi: stages I and II, characterized by a depigmented halo surrounding either a pigmented nevus (I) or a pink nevus (II); stage III, an oval or circular area of depigmentation (with no central nevus), thus resembling a patch of vitiligo; and stage IV, which represents complete repigmentation. Getting from stage I to IV usually takes years and occurs in almost all patients. Everyone with multiple halo nevi deserves a total body skin examination. In older adults presenting with these nevi, one should also consider the possibility of an immune reaction to an ocular or cutaneous melanoma, Dr. Bolognia said.

In the cheetah phenotype, seen here as a cluster of small, dark nevi, the signature nevus may have a thin, lighter brown rim. Courtesy Dr. Jean Bolognia

NEW ORLEANS — Although the focus of checking for melanoma is usually on finding “the ugly duckling,” the real challenge is to identify the signature nevus to determine the patient's particular phenotype, said Dr. Jean Bolognia.

“Identifying the signature nevus will reduce the number of biopsies you perform,” said Dr. Bolognia, who discussed several varieties of signature melanocytic nevi at a dermatology update sponsored by Tulane University. She highlighted the two most challenging phenotypes—numerous lentiginous nevi, the “cheetah” phenotype, and multiple solid pink nevi—and some of the more common types, such as solid brown, eclipse, and multiple halo nevi.

The cheetah phenotype, represented by numerous small, dark nevi, can be difficult to manage, said Dr. Bolognia, professor of dermatology at Yale University, New Haven, Conn. The signature nevus is a brown-black compound or junctional lentiginous nevus that may or may not have a thin medium brown rim. The center of the lesion is extremely dark and solid, without a visible pigment pattern by dermoscopy.

“The patient can have 200 or more of these nevi. The anticipation is that this patient will undergo multiple biopsies, with a lower 'hit rate' for cutaneous melanoma than with other types of nevi. I share these patients with another dermatologist. Having two sets of eyes doing a skin examination is my solution to [this] phenotype.”

Another difficult, though rare, phenotype is represented by multiple pink nevi. Patients with these tend to be skin type 1 or 2 and produce little, if any, melanin in their nevi.

Dr. Bolognia examines for texture and degree of erythema in these nevi. “I also look for the nevus with the darkest pink color or any red lesion [and] biopsy the latter, unless it is clearly acneiform.” Again, she has another dermatologist also check the patient.

In contrast, solid brown nevi are easier to follow because they are symmetric and uniform in color, she noted. The large moles resembling fried eggs are often found on the back and are a source of concern to patients and nondermatologists. However, they are benign, and rather than labeling them as precursors of melanoma, they should be viewed as a phenotypic marker, alerting the physician the patient is at risk and should be closely examined.

A melanoma can arise in this type of nevus, so one should look for superimposed changes. Prophylactic excision is not recommended because scarring can be significant given their size and truncal location. In addition, these nevi age over time with gradual fading and formation of a skin-colored intradermal nevus centrally.

The eclipse nevi resemble a solar eclipse, with a solid tan center and a brown rim that may be stellate and discontinuous, leading to asymmetry. They are often seen on the scalp of children. “These nevi are benign but get attention because of their irregular outline and variation in color. Unless there is a superimposed change, they should not elicit concern. When the signature nevus is an eclipse nevus, you should focus on the 10 to 15 other nevi that are not in this 'family' and look for the one with the most atypical features,” said Dr. Bolognia. She does not recommend surgically removing eclipse nevi because others will probably develop, but if she does biopsy, she makes sure to send the tissue to a dermatopathologist.

Multiple halo nevi are seen most often in younger patients. There are four stages of halo nevi: stages I and II, characterized by a depigmented halo surrounding either a pigmented nevus (I) or a pink nevus (II); stage III, an oval or circular area of depigmentation (with no central nevus), thus resembling a patch of vitiligo; and stage IV, which represents complete repigmentation. Getting from stage I to IV usually takes years and occurs in almost all patients. Everyone with multiple halo nevi deserves a total body skin examination. In older adults presenting with these nevi, one should also consider the possibility of an immune reaction to an ocular or cutaneous melanoma, Dr. Bolognia said.

In the cheetah phenotype, seen here as a cluster of small, dark nevi, the signature nevus may have a thin, lighter brown rim. Courtesy Dr. Jean Bolognia

NEW ORLEANS — Obstructive sleep apnea appears to contribute importantly to both the development and severity of hypertension and may play a role in heart failure as well. The good news is that regular use of continuous positive airway pressure not only treats the apnea but also lowers blood pressure in some patients, according to speakers at the annual meeting of the American Society of Hypertension.

Obstructive sleep apnea (OSA) has been observed in approximately 40% of persons with treatable hypertension, compared with approximately 25% of men and 10% of women in the general population, according to Dr. David Calhoun of the department of medicine at the University of Alabama at Birmingham.

“A number of studies suggest that nocturnal blood pressure may be a better predictor of cardiovascular outcomes than daytime elevations in blood pressure, so there is growing interest in what is happening during the night, especially when blood pressure fails to decrease. One factor in this is obstructive sleep apnea,” Dr. Calhoun said at a press conference on the topic.

Others have found a dose-dependent increased risk of developing hypertension in relationship to OSA. In a prospective evaluation of normotensive patients, those with the most severe OSA at baseline had more than twice the risk of developing hypertension over 4 years (JAMA 2000;283:1829–36).

“This confirmed the relationship between OSA and hypertension, establishing sleep apnea as a potential cause,” he said.

Other studies also have found that, the more severe the sleep apnea, the higher a patient's nocturnal and daytime blood pressure, as well. One important study documented the overall prevalence of OSA (defined as more than 10 events per hour) to be 83% among persons with drug-resistant hypertension, including 96% among men and 65% among women.

“You are seemingly at much higher risk of having sleep apnea if you have difficult to control hypertension. And it suggests that having sleep apnea contributes to difficulties in treating hypertension,” Dr. Calhoun noted.

OSA also has been associated with heart failure, according to Dr. Alexander G. Logan of Mount Sinai Hospital, Toronto, and the University of Toronto. In the Sleep Heart Health Study (Am. J. Resp. Crit. Care Med. 2001;163:19–25), persons with sleep-disordered breathing had an odds ratio of 2.38 for developing heart failure, as well as an increased risk of stroke and coronary heart disease, versus those without. Numerous other studies have also shown an increased risk of OSA in persons with heart failure, he said.

Treatment of OSA with continuous positive airway pressure (CPAP) may help some patients, a number of studies have shown, the speakers said.

While the data may not be “very compelling,” according to Dr. Calhoun, randomized studies have shown that about 5 hours of CPAP per night is associated with small reductions in mean arterial pressure and about 10 mm Hg reduction in systolic and diastolic pressures. In one study of patients with resistant hypertension, regular use of CPAP for 2 months was associated with substantial reductions in 24-hour, daytime, and nocturnal blood pressures (Eur. Respir. J. 2003;21:241–7), a finding that established CPAP as an important adjunct to treatment of patients with resistant hypertension, he said.

“The benefit of CPAP appears to be strongest in nocturnal blood pressures,” he added. “CPAP appears to help restore the 'dipping' pattern (10% decrease in blood pressure) overnight.”

Dr. Calhoun believes this translates into cardiovascular benefits. French investigators found fewer cardiovascular events among hypertensive patients who adhered to CPAP for 5 years, vs. those patients who discontinued CPAP (Eur. Heart J. 2004;25:728–734). Event rates were 24% vs. 58%, respectively.

Dr. Logan noted that in medically treated heart failure patients with OSA, the use of CPAP reduces systolic blood pressure, partly as a result of a decrease in sympathetic vasoconstrictor tone; improves left ventricular systolic function; improves baroreflex sensitivity; decreases the frequency of ventricular premature beats; and improves the quality of life in hypersomnolent patients.

NEW ORLEANS — Obstructive sleep apnea appears to contribute importantly to both the development and severity of hypertension and may play a role in heart failure as well. The good news is that regular use of continuous positive airway pressure not only treats the apnea but also lowers blood pressure in some patients, according to speakers at the annual meeting of the American Society of Hypertension.

Obstructive sleep apnea (OSA) has been observed in approximately 40% of persons with treatable hypertension, compared with approximately 25% of men and 10% of women in the general population, according to Dr. David Calhoun of the department of medicine at the University of Alabama at Birmingham.

“A number of studies suggest that nocturnal blood pressure may be a better predictor of cardiovascular outcomes than daytime elevations in blood pressure, so there is growing interest in what is happening during the night, especially when blood pressure fails to decrease. One factor in this is obstructive sleep apnea,” Dr. Calhoun said at a press conference on the topic.

Others have found a dose-dependent increased risk of developing hypertension in relationship to OSA. In a prospective evaluation of normotensive patients, those with the most severe OSA at baseline had more than twice the risk of developing hypertension over 4 years (JAMA 2000;283:1829–36).

“This confirmed the relationship between OSA and hypertension, establishing sleep apnea as a potential cause,” he said.

Other studies also have found that, the more severe the sleep apnea, the higher a patient's nocturnal and daytime blood pressure, as well. One important study documented the overall prevalence of OSA (defined as more than 10 events per hour) to be 83% among persons with drug-resistant hypertension, including 96% among men and 65% among women.

“You are seemingly at much higher risk of having sleep apnea if you have difficult to control hypertension. And it suggests that having sleep apnea contributes to difficulties in treating hypertension,” Dr. Calhoun noted.

OSA also has been associated with heart failure, according to Dr. Alexander G. Logan of Mount Sinai Hospital, Toronto, and the University of Toronto. In the Sleep Heart Health Study (Am. J. Resp. Crit. Care Med. 2001;163:19–25), persons with sleep-disordered breathing had an odds ratio of 2.38 for developing heart failure, as well as an increased risk of stroke and coronary heart disease, versus those without. Numerous other studies have also shown an increased risk of OSA in persons with heart failure, he said.

Treatment of OSA with continuous positive airway pressure (CPAP) may help some patients, a number of studies have shown, the speakers said.

While the data may not be “very compelling,” according to Dr. Calhoun, randomized studies have shown that about 5 hours of CPAP per night is associated with small reductions in mean arterial pressure and about 10 mm Hg reduction in systolic and diastolic pressures. In one study of patients with resistant hypertension, regular use of CPAP for 2 months was associated with substantial reductions in 24-hour, daytime, and nocturnal blood pressures (Eur. Respir. J. 2003;21:241–7), a finding that established CPAP as an important adjunct to treatment of patients with resistant hypertension, he said.

“The benefit of CPAP appears to be strongest in nocturnal blood pressures,” he added. “CPAP appears to help restore the 'dipping' pattern (10% decrease in blood pressure) overnight.”

Dr. Calhoun believes this translates into cardiovascular benefits. French investigators found fewer cardiovascular events among hypertensive patients who adhered to CPAP for 5 years, vs. those patients who discontinued CPAP (Eur. Heart J. 2004;25:728–734). Event rates were 24% vs. 58%, respectively.

Dr. Logan noted that in medically treated heart failure patients with OSA, the use of CPAP reduces systolic blood pressure, partly as a result of a decrease in sympathetic vasoconstrictor tone; improves left ventricular systolic function; improves baroreflex sensitivity; decreases the frequency of ventricular premature beats; and improves the quality of life in hypersomnolent patients.

NEW ORLEANS — Obstructive sleep apnea appears to contribute importantly to both the development and severity of hypertension and may play a role in heart failure as well. The good news is that regular use of continuous positive airway pressure not only treats the apnea but also lowers blood pressure in some patients, according to speakers at the annual meeting of the American Society of Hypertension.

Obstructive sleep apnea (OSA) has been observed in approximately 40% of persons with treatable hypertension, compared with approximately 25% of men and 10% of women in the general population, according to Dr. David Calhoun of the department of medicine at the University of Alabama at Birmingham.

“A number of studies suggest that nocturnal blood pressure may be a better predictor of cardiovascular outcomes than daytime elevations in blood pressure, so there is growing interest in what is happening during the night, especially when blood pressure fails to decrease. One factor in this is obstructive sleep apnea,” Dr. Calhoun said at a press conference on the topic.

Others have found a dose-dependent increased risk of developing hypertension in relationship to OSA. In a prospective evaluation of normotensive patients, those with the most severe OSA at baseline had more than twice the risk of developing hypertension over 4 years (JAMA 2000;283:1829–36).

“This confirmed the relationship between OSA and hypertension, establishing sleep apnea as a potential cause,” he said.

Other studies also have found that, the more severe the sleep apnea, the higher a patient's nocturnal and daytime blood pressure, as well. One important study documented the overall prevalence of OSA (defined as more than 10 events per hour) to be 83% among persons with drug-resistant hypertension, including 96% among men and 65% among women.

“You are seemingly at much higher risk of having sleep apnea if you have difficult to control hypertension. And it suggests that having sleep apnea contributes to difficulties in treating hypertension,” Dr. Calhoun noted.

OSA also has been associated with heart failure, according to Dr. Alexander G. Logan of Mount Sinai Hospital, Toronto, and the University of Toronto. In the Sleep Heart Health Study (Am. J. Resp. Crit. Care Med. 2001;163:19–25), persons with sleep-disordered breathing had an odds ratio of 2.38 for developing heart failure, as well as an increased risk of stroke and coronary heart disease, versus those without. Numerous other studies have also shown an increased risk of OSA in persons with heart failure, he said.

Treatment of OSA with continuous positive airway pressure (CPAP) may help some patients, a number of studies have shown, the speakers said.

While the data may not be “very compelling,” according to Dr. Calhoun, randomized studies have shown that about 5 hours of CPAP per night is associated with small reductions in mean arterial pressure and about 10 mm Hg reduction in systolic and diastolic pressures. In one study of patients with resistant hypertension, regular use of CPAP for 2 months was associated with substantial reductions in 24-hour, daytime, and nocturnal blood pressures (Eur. Respir. J. 2003;21:241–7), a finding that established CPAP as an important adjunct to treatment of patients with resistant hypertension, he said.

“The benefit of CPAP appears to be strongest in nocturnal blood pressures,” he added. “CPAP appears to help restore the 'dipping' pattern (10% decrease in blood pressure) overnight.”

Dr. Calhoun believes this translates into cardiovascular benefits. French investigators found fewer cardiovascular events among hypertensive patients who adhered to CPAP for 5 years, vs. those patients who discontinued CPAP (Eur. Heart J. 2004;25:728–734). Event rates were 24% vs. 58%, respectively.

Dr. Logan noted that in medically treated heart failure patients with OSA, the use of CPAP reduces systolic blood pressure, partly as a result of a decrease in sympathetic vasoconstrictor tone; improves left ventricular systolic function; improves baroreflex sensitivity; decreases the frequency of ventricular premature beats; and improves the quality of life in hypersomnolent patients.

NEW ORLEANS — Obstructive sleep apnea appears to contribute importantly to both the development and severity of hypertension and may play a role in heart failure as well. The good news is that regular use of continuous positive airway pressure not only treats the apnea but also lowers blood pressure in some patients, according to speakers at the annual meeting of the American Society of Hypertension.

Obstructive sleep apnea (OSA) has been observed in approximately 40% of persons with treatable hypertension, compared with approximately 25% of men and 10% of women in the general population, according to Dr. David Calhoun of the department of medicine at the University of Alabama at Birmingham.

“A number of studies suggest that nocturnal blood pressure may be a better predictor of cardiovascular outcomes than daytime elevations in blood pressure, so there is growing interest in what is happening during the night, especially when blood pressure fails to decrease. One factor in this is obstructive sleep apnea,” Dr. Calhoun said at a press conference on the topic.

Others have found a dose-dependent increased risk of developing hypertension in relationship to OSA. In a prospective evaluation of normotensive patients, those with the most severe OSA at baseline had more than twice the risk of developing hypertension over 4 years (JAMA 2000;283:1829–36).

“This confirmed the relationship between OSA and hypertension, establishing sleep apnea as a potential cause,” he said.

Other studies also have found that the more severe the sleep apnea, the higher a patient's nocturnal and daytime blood pressure, as well. One important study documented the overall prevalence of OSA (defined as more than 10 events per hour) to be 83% among persons with drug-resistant hypertension, including 96% among men and 65% among women.

“You are seemingly at much higher risk of having sleep apnea if you have difficult-to-control hypertension. And it suggests that having sleep apnea contributes to difficulties in treating hypertension,” Dr. Calhoun noted.

OSA also has been associated with heart failure, according to Dr. Alexander G. Logan of Mount Sinai Hospital, Toronto, and the University of Toronto. In the Sleep Heart Health Study (Am. J. Resp. Crit. Care Med. 2001;163:19–25), persons with sleep-disordered breathing had an odds ratio of 2.38 for developing heart failure, as well as an increased risk of stroke and coronary heart disease, vs. those without. Many other studies have also shown an increased risk of OSA in persons with heart failure, he said.

Treatment of OSA with continuous positive airway pressure (CPAP) may help some patients, a number of studies have shown, the speakers said.

Although the data may not be “very compelling,” according to Dr. Calhoun, randomized studies have shown that about 5 hours of CPAP per night is associated with small reductions in mean arterial pressure and about 10 mm Hg reduction in systolic and diastolic pressures. In one study of patients with resistant hypertension, regular use of CPAP for 2 months was associated with substantial reductions in 24-hour, daytime, and nocturnal blood pressures (Eur. Respir. J. 2003;21:241–7), a finding that established CPAP as an important adjunct to treatment of patients with resistant hypertension, he said.

“The benefit of CPAP appears to be strongest in nocturnal blood pressures,” he added. “CPAP appears to help restore the 'dipping' pattern (10% decrease in blood pressure) overnight.”

Dr. Calhoun believes this translates into cardiovascular benefits. French investigators found fewer cardiovascular events among hypertensive patients who adhered to CPAP for 5 years vs. those patients who discontinued CPAP (Eur. Heart J. 2004;25:728–34). Event rates were 24% vs. 58%, respectively.

Dr. Logan noted that in medically treated heart failure patients with OSA, the use of CPAP reduces blood systolic blood pressure, partly as a result of a decrease in sympathetic vasoconstrictor tone; improves left ventricular systolic function; improves baroreflex sensitivity; decreases the frequency of ventricular premature beats; and improves the quality of life in hypersomnolent patients.

NEW ORLEANS — Obstructive sleep apnea appears to contribute importantly to both the development and severity of hypertension and may play a role in heart failure as well. The good news is that regular use of continuous positive airway pressure not only treats the apnea but also lowers blood pressure in some patients, according to speakers at the annual meeting of the American Society of Hypertension.

Obstructive sleep apnea (OSA) has been observed in approximately 40% of persons with treatable hypertension, compared with approximately 25% of men and 10% of women in the general population, according to Dr. David Calhoun of the department of medicine at the University of Alabama at Birmingham.

“A number of studies suggest that nocturnal blood pressure may be a better predictor of cardiovascular outcomes than daytime elevations in blood pressure, so there is growing interest in what is happening during the night, especially when blood pressure fails to decrease. One factor in this is obstructive sleep apnea,” Dr. Calhoun said at a press conference on the topic.

Others have found a dose-dependent increased risk of developing hypertension in relationship to OSA. In a prospective evaluation of normotensive patients, those with the most severe OSA at baseline had more than twice the risk of developing hypertension over 4 years (JAMA 2000;283:1829–36).

“This confirmed the relationship between OSA and hypertension, establishing sleep apnea as a potential cause,” he said.

Other studies also have found that the more severe the sleep apnea, the higher a patient's nocturnal and daytime blood pressure, as well. One important study documented the overall prevalence of OSA (defined as more than 10 events per hour) to be 83% among persons with drug-resistant hypertension, including 96% among men and 65% among women.

“You are seemingly at much higher risk of having sleep apnea if you have difficult-to-control hypertension. And it suggests that having sleep apnea contributes to difficulties in treating hypertension,” Dr. Calhoun noted.

OSA also has been associated with heart failure, according to Dr. Alexander G. Logan of Mount Sinai Hospital, Toronto, and the University of Toronto. In the Sleep Heart Health Study (Am. J. Resp. Crit. Care Med. 2001;163:19–25), persons with sleep-disordered breathing had an odds ratio of 2.38 for developing heart failure, as well as an increased risk of stroke and coronary heart disease, vs. those without. Many other studies have also shown an increased risk of OSA in persons with heart failure, he said.

Treatment of OSA with continuous positive airway pressure (CPAP) may help some patients, a number of studies have shown, the speakers said.

Although the data may not be “very compelling,” according to Dr. Calhoun, randomized studies have shown that about 5 hours of CPAP per night is associated with small reductions in mean arterial pressure and about 10 mm Hg reduction in systolic and diastolic pressures. In one study of patients with resistant hypertension, regular use of CPAP for 2 months was associated with substantial reductions in 24-hour, daytime, and nocturnal blood pressures (Eur. Respir. J. 2003;21:241–7), a finding that established CPAP as an important adjunct to treatment of patients with resistant hypertension, he said.

“The benefit of CPAP appears to be strongest in nocturnal blood pressures,” he added. “CPAP appears to help restore the 'dipping' pattern (10% decrease in blood pressure) overnight.”

Dr. Calhoun believes this translates into cardiovascular benefits. French investigators found fewer cardiovascular events among hypertensive patients who adhered to CPAP for 5 years vs. those patients who discontinued CPAP (Eur. Heart J. 2004;25:728–34). Event rates were 24% vs. 58%, respectively.

Dr. Logan noted that in medically treated heart failure patients with OSA, the use of CPAP reduces blood systolic blood pressure, partly as a result of a decrease in sympathetic vasoconstrictor tone; improves left ventricular systolic function; improves baroreflex sensitivity; decreases the frequency of ventricular premature beats; and improves the quality of life in hypersomnolent patients.

NEW ORLEANS — Obstructive sleep apnea appears to contribute importantly to both the development and severity of hypertension and may play a role in heart failure as well. The good news is that regular use of continuous positive airway pressure not only treats the apnea but also lowers blood pressure in some patients, according to speakers at the annual meeting of the American Society of Hypertension.

Obstructive sleep apnea (OSA) has been observed in approximately 40% of persons with treatable hypertension, compared with approximately 25% of men and 10% of women in the general population, according to Dr. David Calhoun of the department of medicine at the University of Alabama at Birmingham.

“A number of studies suggest that nocturnal blood pressure may be a better predictor of cardiovascular outcomes than daytime elevations in blood pressure, so there is growing interest in what is happening during the night, especially when blood pressure fails to decrease. One factor in this is obstructive sleep apnea,” Dr. Calhoun said at a press conference on the topic.

Others have found a dose-dependent increased risk of developing hypertension in relationship to OSA. In a prospective evaluation of normotensive patients, those with the most severe OSA at baseline had more than twice the risk of developing hypertension over 4 years (JAMA 2000;283:1829–36).

“This confirmed the relationship between OSA and hypertension, establishing sleep apnea as a potential cause,” he said.

Other studies also have found that the more severe the sleep apnea, the higher a patient's nocturnal and daytime blood pressure, as well. One important study documented the overall prevalence of OSA (defined as more than 10 events per hour) to be 83% among persons with drug-resistant hypertension, including 96% among men and 65% among women.

“You are seemingly at much higher risk of having sleep apnea if you have difficult-to-control hypertension. And it suggests that having sleep apnea contributes to difficulties in treating hypertension,” Dr. Calhoun noted.

OSA also has been associated with heart failure, according to Dr. Alexander G. Logan of Mount Sinai Hospital, Toronto, and the University of Toronto. In the Sleep Heart Health Study (Am. J. Resp. Crit. Care Med. 2001;163:19–25), persons with sleep-disordered breathing had an odds ratio of 2.38 for developing heart failure, as well as an increased risk of stroke and coronary heart disease, vs. those without. Many other studies have also shown an increased risk of OSA in persons with heart failure, he said.

Treatment of OSA with continuous positive airway pressure (CPAP) may help some patients, a number of studies have shown, the speakers said.

Although the data may not be “very compelling,” according to Dr. Calhoun, randomized studies have shown that about 5 hours of CPAP per night is associated with small reductions in mean arterial pressure and about 10 mm Hg reduction in systolic and diastolic pressures. In one study of patients with resistant hypertension, regular use of CPAP for 2 months was associated with substantial reductions in 24-hour, daytime, and nocturnal blood pressures (Eur. Respir. J. 2003;21:241–7), a finding that established CPAP as an important adjunct to treatment of patients with resistant hypertension, he said.

“The benefit of CPAP appears to be strongest in nocturnal blood pressures,” he added. “CPAP appears to help restore the 'dipping' pattern (10% decrease in blood pressure) overnight.”

Dr. Calhoun believes this translates into cardiovascular benefits. French investigators found fewer cardiovascular events among hypertensive patients who adhered to CPAP for 5 years vs. those patients who discontinued CPAP (Eur. Heart J. 2004;25:728–34). Event rates were 24% vs. 58%, respectively.

Dr. Logan noted that in medically treated heart failure patients with OSA, the use of CPAP reduces blood systolic blood pressure, partly as a result of a decrease in sympathetic vasoconstrictor tone; improves left ventricular systolic function; improves baroreflex sensitivity; decreases the frequency of ventricular premature beats; and improves the quality of life in hypersomnolent patients.

NEW ORLEANS — Although the concept of checking the skin for melanoma may be to "find the ugly duckling," the first challenge is to identify the signature nevus in order to determine the patient's particular phenotype, said Dr. Jean Bolognia.

"Identifying the signature nevus will reduce the number of biopsies you perform," said Dr. Bolognia.

She discussed several varieties of signature melanocytic nevi at a dermatology update sponsored by Tulane University. She highlighted a few of the more common types as well as the two most challenging.

Solid brown nevi, she said, are easier to manage. "This type of signature nevus is easy to follow, as it is symmetric and uniform in color," noted Dr. Bolognia, professor of dermatology at Yale University, New Haven, Conn.

Because of their size, the large moles that resemble fried eggs and are often found on the back are frequently of concern to patients and their relatives as well as to non-dermatologists. These "sensational" nevi are benign, and rather than being labeled as precursors of melanoma, they should be viewed as a phenotypic marker, alerting the physician that the patient's entire skin is at risk and should therefore be carefully examined.

"A melanoma can arise in this type of nevus, just as it can any other compound nevus," she said. "Do look for superimposed changes, but in and of themselves, these nevi are benign." Prophylactic excision is not recommended for fried-egg nevi, as scarring can be significant given their size and truncal location. In addition, these nevi age over time with gradual fading of the shoulder component into the surrounding skin and formation of a skin-colored intradermal nevus centrally.

On other hand, the "cheetah" phenotype, represented by numerous small, dark nevi, can be very difficult to manage, she noted. The signature nevus is a dark brown-black compound or junctional lentiginous nevus that may or may not have a thin medium brown rim. The center of the lesion is extremely dark and solid, without a visible pigment pattern by dermoscopy.

"Usually, the patient has 200 or more of these nevi, often admixed with solar lentigines. The anticipation is that this patient will undergo multiple biopsies, with a lower 'hit rate' for cutaneous melanoma than with other types of nevi," she said. "I share these patients with another dermatologist. Having two sets of eyes doing a skin examination is my solution to the difficult 'cheetah' phenotype."

The "eclipse" nevi resemble a solar eclipse, with a solid tan center and a brown rim that is often stellate. The rim may also be discontinuous, leading to asymmetry. They are often seen on the scalp of children, and can be the first sign that a child will be "moley."

"These nevi are benign but they get attention because of their irregular outline and variation in color. Unless there is a superimposed change, they should not elicit concern," she noted. "When the signature nevus is an eclipse nevus, you should focus on the 10 to 15 other nevi that are not in this 'family' and look for the one with the most atypical features."

Dr. Bolognia does not recommend surgically removing eclipse nevi on the scalp because others will probably develop and parents will expect these to be removed as well. Cockarde or "target" nevi are in the same family as eclipse nevi; these types are often seen together.

Another difficult, though rare, phenotype is represented by multiple pink nevi. These patients tend to be skin type 1 or 2 and they produce little, if any, melanin in their nevi. "In this patient the pigment pattern is missing, the road signs are gone, and these nevi can be difficult to evaluate clinically," she said.

"If the nevus has substance (not soft like an aging dermal nevus), I take a second look. And I also look for the nevus with the darkest pink color or any red lesion. I usually biopsy the latter, unless it is clearly acneiform, and like with the 'cheetah' phenotype, share these patients with another dermatologist," she said.

Multiple halo nevi, seen most often in patients in their late teens and early 20s, can also be problematic. There are four stages of halo nevi, with stages I and II being characterized by a depigmented halo surrounding either a pigmented nevus (I) or a pink nevus (II). Stage III appears as an area of depigmentation that is oval or circular in shape (with no central nevus), thus resembling a patch of vitiligo, while stage IV represents complete repigmentation. While everyone with multiple halo nevi deserves a total body examination, if an older adult presents with multiple halo nevi, the possibility of an immune reaction to an ocular (or cutaneous) melanoma needs to be considered, Dr. Bolognia said.

Exams of the "cheetah" phenotype, represented by numerous small, dark nevi, are best conducted with two sets of eyes. Courtesy Dr. Jean Bolognia

NEW ORLEANS — Although the concept of checking the skin for melanoma may be to "find the ugly duckling," the first challenge is to identify the signature nevus in order to determine the patient's particular phenotype, said Dr. Jean Bolognia.

"Identifying the signature nevus will reduce the number of biopsies you perform," said Dr. Bolognia.

She discussed several varieties of signature melanocytic nevi at a dermatology update sponsored by Tulane University. She highlighted a few of the more common types as well as the two most challenging.

Solid brown nevi, she said, are easier to manage. "This type of signature nevus is easy to follow, as it is symmetric and uniform in color," noted Dr. Bolognia, professor of dermatology at Yale University, New Haven, Conn.

Because of their size, the large moles that resemble fried eggs and are often found on the back are frequently of concern to patients and their relatives as well as to non-dermatologists. These "sensational" nevi are benign, and rather than being labeled as precursors of melanoma, they should be viewed as a phenotypic marker, alerting the physician that the patient's entire skin is at risk and should therefore be carefully examined.

"A melanoma can arise in this type of nevus, just as it can any other compound nevus," she said. "Do look for superimposed changes, but in and of themselves, these nevi are benign." Prophylactic excision is not recommended for fried-egg nevi, as scarring can be significant given their size and truncal location. In addition, these nevi age over time with gradual fading of the shoulder component into the surrounding skin and formation of a skin-colored intradermal nevus centrally.

On other hand, the "cheetah" phenotype, represented by numerous small, dark nevi, can be very difficult to manage, she noted. The signature nevus is a dark brown-black compound or junctional lentiginous nevus that may or may not have a thin medium brown rim. The center of the lesion is extremely dark and solid, without a visible pigment pattern by dermoscopy.

"Usually, the patient has 200 or more of these nevi, often admixed with solar lentigines. The anticipation is that this patient will undergo multiple biopsies, with a lower 'hit rate' for cutaneous melanoma than with other types of nevi," she said. "I share these patients with another dermatologist. Having two sets of eyes doing a skin examination is my solution to the difficult 'cheetah' phenotype."

The "eclipse" nevi resemble a solar eclipse, with a solid tan center and a brown rim that is often stellate. The rim may also be discontinuous, leading to asymmetry. They are often seen on the scalp of children, and can be the first sign that a child will be "moley."

"These nevi are benign but they get attention because of their irregular outline and variation in color. Unless there is a superimposed change, they should not elicit concern," she noted. "When the signature nevus is an eclipse nevus, you should focus on the 10 to 15 other nevi that are not in this 'family' and look for the one with the most atypical features."

Dr. Bolognia does not recommend surgically removing eclipse nevi on the scalp because others will probably develop and parents will expect these to be removed as well. Cockarde or "target" nevi are in the same family as eclipse nevi; these types are often seen together.

Another difficult, though rare, phenotype is represented by multiple pink nevi. These patients tend to be skin type 1 or 2 and they produce little, if any, melanin in their nevi. "In this patient the pigment pattern is missing, the road signs are gone, and these nevi can be difficult to evaluate clinically," she said.

"If the nevus has substance (not soft like an aging dermal nevus), I take a second look. And I also look for the nevus with the darkest pink color or any red lesion. I usually biopsy the latter, unless it is clearly acneiform, and like with the 'cheetah' phenotype, share these patients with another dermatologist," she said.

Multiple halo nevi, seen most often in patients in their late teens and early 20s, can also be problematic. There are four stages of halo nevi, with stages I and II being characterized by a depigmented halo surrounding either a pigmented nevus (I) or a pink nevus (II). Stage III appears as an area of depigmentation that is oval or circular in shape (with no central nevus), thus resembling a patch of vitiligo, while stage IV represents complete repigmentation. While everyone with multiple halo nevi deserves a total body examination, if an older adult presents with multiple halo nevi, the possibility of an immune reaction to an ocular (or cutaneous) melanoma needs to be considered, Dr. Bolognia said.

Exams of the "cheetah" phenotype, represented by numerous small, dark nevi, are best conducted with two sets of eyes. Courtesy Dr. Jean Bolognia

NEW ORLEANS — Although the concept of checking the skin for melanoma may be to "find the ugly duckling," the first challenge is to identify the signature nevus in order to determine the patient's particular phenotype, said Dr. Jean Bolognia.

"Identifying the signature nevus will reduce the number of biopsies you perform," said Dr. Bolognia.

She discussed several varieties of signature melanocytic nevi at a dermatology update sponsored by Tulane University. She highlighted a few of the more common types as well as the two most challenging.

Solid brown nevi, she said, are easier to manage. "This type of signature nevus is easy to follow, as it is symmetric and uniform in color," noted Dr. Bolognia, professor of dermatology at Yale University, New Haven, Conn.

Because of their size, the large moles that resemble fried eggs and are often found on the back are frequently of concern to patients and their relatives as well as to non-dermatologists. These "sensational" nevi are benign, and rather than being labeled as precursors of melanoma, they should be viewed as a phenotypic marker, alerting the physician that the patient's entire skin is at risk and should therefore be carefully examined.

"A melanoma can arise in this type of nevus, just as it can any other compound nevus," she said. "Do look for superimposed changes, but in and of themselves, these nevi are benign." Prophylactic excision is not recommended for fried-egg nevi, as scarring can be significant given their size and truncal location. In addition, these nevi age over time with gradual fading of the shoulder component into the surrounding skin and formation of a skin-colored intradermal nevus centrally.

On other hand, the "cheetah" phenotype, represented by numerous small, dark nevi, can be very difficult to manage, she noted. The signature nevus is a dark brown-black compound or junctional lentiginous nevus that may or may not have a thin medium brown rim. The center of the lesion is extremely dark and solid, without a visible pigment pattern by dermoscopy.

"Usually, the patient has 200 or more of these nevi, often admixed with solar lentigines. The anticipation is that this patient will undergo multiple biopsies, with a lower 'hit rate' for cutaneous melanoma than with other types of nevi," she said. "I share these patients with another dermatologist. Having two sets of eyes doing a skin examination is my solution to the difficult 'cheetah' phenotype."

The "eclipse" nevi resemble a solar eclipse, with a solid tan center and a brown rim that is often stellate. The rim may also be discontinuous, leading to asymmetry. They are often seen on the scalp of children, and can be the first sign that a child will be "moley."

"These nevi are benign but they get attention because of their irregular outline and variation in color. Unless there is a superimposed change, they should not elicit concern," she noted. "When the signature nevus is an eclipse nevus, you should focus on the 10 to 15 other nevi that are not in this 'family' and look for the one with the most atypical features."

Dr. Bolognia does not recommend surgically removing eclipse nevi on the scalp because others will probably develop and parents will expect these to be removed as well. Cockarde or "target" nevi are in the same family as eclipse nevi; these types are often seen together.

Another difficult, though rare, phenotype is represented by multiple pink nevi. These patients tend to be skin type 1 or 2 and they produce little, if any, melanin in their nevi. "In this patient the pigment pattern is missing, the road signs are gone, and these nevi can be difficult to evaluate clinically," she said.

"If the nevus has substance (not soft like an aging dermal nevus), I take a second look. And I also look for the nevus with the darkest pink color or any red lesion. I usually biopsy the latter, unless it is clearly acneiform, and like with the 'cheetah' phenotype, share these patients with another dermatologist," she said.

Multiple halo nevi, seen most often in patients in their late teens and early 20s, can also be problematic. There are four stages of halo nevi, with stages I and II being characterized by a depigmented halo surrounding either a pigmented nevus (I) or a pink nevus (II). Stage III appears as an area of depigmentation that is oval or circular in shape (with no central nevus), thus resembling a patch of vitiligo, while stage IV represents complete repigmentation. While everyone with multiple halo nevi deserves a total body examination, if an older adult presents with multiple halo nevi, the possibility of an immune reaction to an ocular (or cutaneous) melanoma needs to be considered, Dr. Bolognia said.

Exams of the "cheetah" phenotype, represented by numerous small, dark nevi, are best conducted with two sets of eyes. Courtesy Dr. Jean Bolognia

NEW ORLEANS — Dermatologists who prescribe biologics for psoriasis need to be able to navigate the insurance maze so that most patients can benefit.

It is important to fully understand the patient and his or her needs, to adequately document the patient's condition, to submit adequate documentation to the insurer, to know the specifics of the insurance company and the patient copayments, and to be able to make a strong appeal when claims are denied, Carol F. Guidry, R.N., said at a dermatology update sponsored by Tulane University.

Each patient should complete a psoriasis questionnaire that describes his or her condition, comorbidities, and prior treatments, said Ms. Guidry of the department of dermatology at Tulane University, New Orleans, where she helps procure coverage for psoriasis patients needing biologics. This helps select the most appropriate agent and provides information that will be useful in seeking preauthorization. Body surface area should be adequately calculated, as many companies use this number to approve or deny a drug. Patients should expose palms, soles, and genital areas, which might be missed.

Because almost all insurance companies require prior authorization for injectables, forms for preauthorization should be completed while the patient is in the office; the patient's next visit should be scheduled no sooner than 2 weeks later to allow time for a response.

To submit a request, the nurse or office staff will need the chart and physician's notes, lab work and x-ray results, insurance demographics sheet, psoriasis questionnaire, and specific drug paperwork.

"Because most insurance clerks receiving this lack medical knowledge, I recommend completing the form yourself, rather than having the clerk take the information over the phone," Ms. Guidry said.

Most insurers require that the following criteria be met for approval of biologics: diagnosis of chronic moderate to severe plaque psoriasis; failure of phototherapy and/or at least one systemic therapy; for psoriatic arthritis, failure on at least one disease-modifying agent; and documentation of a negative tuberculin skin test. Most will deny injectables for plaque psoriasis in pediatric patients, she said.

"Make sure [body surface area] is written or dictated in the physician's documentation or referral form, and make sure to specify if the condition is plaque or guttate," she said. "Also, document dactylitis, enthesitis, and joint pain for psoriatic arthritis patients. Submit any x-ray findings that document erosions, joint deformities, and so forth, and submit laboratory values."

Ms. Guidry emphasized the need to be proactive and fully informative about the patient. Insurance companies will generally push for conventional systemic therapies to be administered instead of biologics. This should be anticipated, and the preauthorization request should present a strong case against it.

"Note preexisting comorbidities that may be contraindications for systemic therapy. You can make comorbidities [such as obesity and fatty liver] work in your favor," she said. "If the patient has to commute more than 50 miles for phototherapy, or if the patient's occupation requires travel or shift work that would make monthly monitoring difficult, this should be stated."

Although Medicaid does pay for injectables, Medicare is not likely to. Medicare patients usually cannot afford biologics because they must meet their initial yearly deductible, and after the deductible is met, the patient must satisfy the "doughnut hole"—the $2,200 out-of-pocket gap. After the gap is satisfied, the patient is eligible to receive the drug, but 10% of the cost is the patient's responsibility.

Medicare recipients also are not eligible to use copay cards. They must go through the chosen drug company and complete that company's paperwork. The drug company will contract out for patient assistance. This process can take 6 weeks or longer. Infliximab might be an option for Medicare patients because it is usually considered under the major medical plan.

When preauthorization is denied, find out why. If conventional therapies have not been pursued, the patient might need to undergo a trial of these and then reapply. Decisions can be appealed, or physicians can request a "peer-to-peer" review if a decision seems unjust. The benefit of this is an immediate answer from the medical director.

More Prescribing Tips for Biologics

▸ To save time, check the patient's insurance coverage before starting to complete forms.

▸ Get to know drug company representatives who can help obtain copay assistance for patients.

▸ For infliximab, use an infusion center if possible; they do the legwork with the insurance company. Find one at

www.2infuse.com

▸ Use specialty pharmacies when possible. They help with paperwork, ship the drug to the patient (keeping physicians informed), and help obtain copay assistance.

▸ Use drug samples to augment treatment when response is waning.

Source: Ms. Guidry

NEW ORLEANS — Dermatologists who prescribe biologics for psoriasis need to be able to navigate the insurance maze so that most patients can benefit.

It is important to fully understand the patient and his or her needs, to adequately document the patient's condition, to submit adequate documentation to the insurer, to know the specifics of the insurance company and the patient copayments, and to be able to make a strong appeal when claims are denied, Carol F. Guidry, R.N., said at a dermatology update sponsored by Tulane University.

Each patient should complete a psoriasis questionnaire that describes his or her condition, comorbidities, and prior treatments, said Ms. Guidry of the department of dermatology at Tulane University, New Orleans, where she helps procure coverage for psoriasis patients needing biologics. This helps select the most appropriate agent and provides information that will be useful in seeking preauthorization. Body surface area should be adequately calculated, as many companies use this number to approve or deny a drug. Patients should expose palms, soles, and genital areas, which might be missed.

Because almost all insurance companies require prior authorization for injectables, forms for preauthorization should be completed while the patient is in the office; the patient's next visit should be scheduled no sooner than 2 weeks later to allow time for a response.

To submit a request, the nurse or office staff will need the chart and physician's notes, lab work and x-ray results, insurance demographics sheet, psoriasis questionnaire, and specific drug paperwork.

"Because most insurance clerks receiving this lack medical knowledge, I recommend completing the form yourself, rather than having the clerk take the information over the phone," Ms. Guidry said.

Most insurers require that the following criteria be met for approval of biologics: diagnosis of chronic moderate to severe plaque psoriasis; failure of phototherapy and/or at least one systemic therapy; for psoriatic arthritis, failure on at least one disease-modifying agent; and documentation of a negative tuberculin skin test. Most will deny injectables for plaque psoriasis in pediatric patients, she said.

"Make sure [body surface area] is written or dictated in the physician's documentation or referral form, and make sure to specify if the condition is plaque or guttate," she said. "Also, document dactylitis, enthesitis, and joint pain for psoriatic arthritis patients. Submit any x-ray findings that document erosions, joint deformities, and so forth, and submit laboratory values."

Ms. Guidry emphasized the need to be proactive and fully informative about the patient. Insurance companies will generally push for conventional systemic therapies to be administered instead of biologics. This should be anticipated, and the preauthorization request should present a strong case against it.

"Note preexisting comorbidities that may be contraindications for systemic therapy. You can make comorbidities [such as obesity and fatty liver] work in your favor," she said. "If the patient has to commute more than 50 miles for phototherapy, or if the patient's occupation requires travel or shift work that would make monthly monitoring difficult, this should be stated."

Although Medicaid does pay for injectables, Medicare is not likely to. Medicare patients usually cannot afford biologics because they must meet their initial yearly deductible, and after the deductible is met, the patient must satisfy the "doughnut hole"—the $2,200 out-of-pocket gap. After the gap is satisfied, the patient is eligible to receive the drug, but 10% of the cost is the patient's responsibility.

Medicare recipients also are not eligible to use copay cards. They must go through the chosen drug company and complete that company's paperwork. The drug company will contract out for patient assistance. This process can take 6 weeks or longer. Infliximab might be an option for Medicare patients because it is usually considered under the major medical plan.

When preauthorization is denied, find out why. If conventional therapies have not been pursued, the patient might need to undergo a trial of these and then reapply. Decisions can be appealed, or physicians can request a "peer-to-peer" review if a decision seems unjust. The benefit of this is an immediate answer from the medical director.

More Prescribing Tips for Biologics

▸ To save time, check the patient's insurance coverage before starting to complete forms.

▸ Get to know drug company representatives who can help obtain copay assistance for patients.

▸ For infliximab, use an infusion center if possible; they do the legwork with the insurance company. Find one at

www.2infuse.com

▸ Use specialty pharmacies when possible. They help with paperwork, ship the drug to the patient (keeping physicians informed), and help obtain copay assistance.

▸ Use drug samples to augment treatment when response is waning.

Source: Ms. Guidry

NEW ORLEANS — Dermatologists who prescribe biologics for psoriasis need to be able to navigate the insurance maze so that most patients can benefit.

It is important to fully understand the patient and his or her needs, to adequately document the patient's condition, to submit adequate documentation to the insurer, to know the specifics of the insurance company and the patient copayments, and to be able to make a strong appeal when claims are denied, Carol F. Guidry, R.N., said at a dermatology update sponsored by Tulane University.

Each patient should complete a psoriasis questionnaire that describes his or her condition, comorbidities, and prior treatments, said Ms. Guidry of the department of dermatology at Tulane University, New Orleans, where she helps procure coverage for psoriasis patients needing biologics. This helps select the most appropriate agent and provides information that will be useful in seeking preauthorization. Body surface area should be adequately calculated, as many companies use this number to approve or deny a drug. Patients should expose palms, soles, and genital areas, which might be missed.

Because almost all insurance companies require prior authorization for injectables, forms for preauthorization should be completed while the patient is in the office; the patient's next visit should be scheduled no sooner than 2 weeks later to allow time for a response.

To submit a request, the nurse or office staff will need the chart and physician's notes, lab work and x-ray results, insurance demographics sheet, psoriasis questionnaire, and specific drug paperwork.

"Because most insurance clerks receiving this lack medical knowledge, I recommend completing the form yourself, rather than having the clerk take the information over the phone," Ms. Guidry said.

Most insurers require that the following criteria be met for approval of biologics: diagnosis of chronic moderate to severe plaque psoriasis; failure of phototherapy and/or at least one systemic therapy; for psoriatic arthritis, failure on at least one disease-modifying agent; and documentation of a negative tuberculin skin test. Most will deny injectables for plaque psoriasis in pediatric patients, she said.

"Make sure [body surface area] is written or dictated in the physician's documentation or referral form, and make sure to specify if the condition is plaque or guttate," she said. "Also, document dactylitis, enthesitis, and joint pain for psoriatic arthritis patients. Submit any x-ray findings that document erosions, joint deformities, and so forth, and submit laboratory values."

Ms. Guidry emphasized the need to be proactive and fully informative about the patient. Insurance companies will generally push for conventional systemic therapies to be administered instead of biologics. This should be anticipated, and the preauthorization request should present a strong case against it.

"Note preexisting comorbidities that may be contraindications for systemic therapy. You can make comorbidities [such as obesity and fatty liver] work in your favor," she said. "If the patient has to commute more than 50 miles for phototherapy, or if the patient's occupation requires travel or shift work that would make monthly monitoring difficult, this should be stated."

Although Medicaid does pay for injectables, Medicare is not likely to. Medicare patients usually cannot afford biologics because they must meet their initial yearly deductible, and after the deductible is met, the patient must satisfy the "doughnut hole"—the $2,200 out-of-pocket gap. After the gap is satisfied, the patient is eligible to receive the drug, but 10% of the cost is the patient's responsibility.

Medicare recipients also are not eligible to use copay cards. They must go through the chosen drug company and complete that company's paperwork. The drug company will contract out for patient assistance. This process can take 6 weeks or longer. Infliximab might be an option for Medicare patients because it is usually considered under the major medical plan.

When preauthorization is denied, find out why. If conventional therapies have not been pursued, the patient might need to undergo a trial of these and then reapply. Decisions can be appealed, or physicians can request a "peer-to-peer" review if a decision seems unjust. The benefit of this is an immediate answer from the medical director.

More Prescribing Tips for Biologics

▸ To save time, check the patient's insurance coverage before starting to complete forms.

▸ Get to know drug company representatives who can help obtain copay assistance for patients.

▸ For infliximab, use an infusion center if possible; they do the legwork with the insurance company. Find one at

www.2infuse.com

▸ Use specialty pharmacies when possible. They help with paperwork, ship the drug to the patient (keeping physicians informed), and help obtain copay assistance.

▸ Use drug samples to augment treatment when response is waning.

Source: Ms. Guidry