Sherry Boschert

SAN FRANCISCO — Kaposi's sarcoma in HIV patients is turning up again—sometimes in a surprisingly deadly form and other times in an indolent, nonthreatening form—according to two experts.

Kaposi's sarcoma (KS) used to be one of AIDS' signature complications before antiretroviral therapy, Dr. Deborah Greenspan said at a meeting on the medical management of HIV and AIDS sponsored by the University of California, San Francisco “We're starting to see Kaposi's sarcoma again,” presenting as oral lesions in patients who have started antiretroviral therapy for HIV but who still have low CD4 cell counts.

KS in the setting of HIV has a predilection for the palate, for reasons that have never been understood, said Dr. Greenspan, professor and chair of orofacial sciences and distinguished professor of dentistry at UCSF. Oral KS typically appears as a flat, plaque-like lesion on the hard or soft palate. Looking in the mouth can be a key step to diagnosing KS, she said.

“Years ago, KS seemed to disappear right off the radar screen, but it is back. We are seeing a lot of Kaposi's sarcoma,” Dr. Toby A. Maurer, an associate professor of clinical dermatology at UCSF said in a separate presentation.

She and her colleagues were surprised recently by the lethality of KS after they followed 65 of their patients being treated with antiretroviral therapy for HIV and with chemotherapy for KS. “We were shocked to find out that 25% of that cohort died of their Kaposi's sarcoma, even when they had chemotherapy,” she said.

A separate case series in Seattle found that 23% of patients who were on antiretroviral therapy for HIV and who received adequate chemotherapy for KS died of the cancer. “This is quite alarming,” Dr. Maurer said.

Physicians should always biopsy lesions they think might be KS, she advised. On darker-pigmented skin, it can be difficult to differentiate KS from other lesions without a biopsy.

Most patients who have not started treatment for HIV or KS should see their KS resolve within 9 months of starting antiretrovirals. Dr. Maurer and her associates are collecting immunology and laboratory test results at baseline and after 9 months of therapy in a study to compare response in patients. “Please send us your KS patients” who have not started antiretroviral therapy. “We would be very happy to biopsy them,” she said.

A less threatening form of KS is also starting to turn up in relatively young patients with HIV. “They develop what looks to us like 'old man's Kaposi's sarcoma'—that is, Mediterranean, classical-type KS,” Dr. Maurer said.

These are patients who develop small areas of KS, usually on the lower legs and feet, after having HIV for 17–20 years. Their HIV has been suppressed for at least 2 years on antiretroviral therapy, and they have relatively healthy CD4 counts of 300–600 cells/mm

“We think that they are showing signs of immune aging” and preliminary studies suggest this is the case, she said. In several years of follow-up, none have had exacerbations or internal involvement of KS, and none have needed chemotherapy, Dr. Maurer said.

Dr. Maurer and Dr. Greenspan reported having no relevant conflicts of interest.

Lesions believed to be Kaposi's—like the one shown above in an AIDS patient—should be biopsied.

Source Courtesy National Cancer Institute

SAN FRANCISCO — Kaposi's sarcoma in HIV patients is turning up again—sometimes in a surprisingly deadly form and other times in an indolent, nonthreatening form—according to two experts.

Kaposi's sarcoma (KS) used to be one of AIDS' signature complications before antiretroviral therapy, Dr. Deborah Greenspan said at a meeting on the medical management of HIV and AIDS sponsored by the University of California, San Francisco “We're starting to see Kaposi's sarcoma again,” presenting as oral lesions in patients who have started antiretroviral therapy for HIV but who still have low CD4 cell counts.

KS in the setting of HIV has a predilection for the palate, for reasons that have never been understood, said Dr. Greenspan, professor and chair of orofacial sciences and distinguished professor of dentistry at UCSF. Oral KS typically appears as a flat, plaque-like lesion on the hard or soft palate. Looking in the mouth can be a key step to diagnosing KS, she said.

“Years ago, KS seemed to disappear right off the radar screen, but it is back. We are seeing a lot of Kaposi's sarcoma,” Dr. Toby A. Maurer, an associate professor of clinical dermatology at UCSF said in a separate presentation.

She and her colleagues were surprised recently by the lethality of KS after they followed 65 of their patients being treated with antiretroviral therapy for HIV and with chemotherapy for KS. “We were shocked to find out that 25% of that cohort died of their Kaposi's sarcoma, even when they had chemotherapy,” she said.

A separate case series in Seattle found that 23% of patients who were on antiretroviral therapy for HIV and who received adequate chemotherapy for KS died of the cancer. “This is quite alarming,” Dr. Maurer said.

Physicians should always biopsy lesions they think might be KS, she advised. On darker-pigmented skin, it can be difficult to differentiate KS from other lesions without a biopsy.

Most patients who have not started treatment for HIV or KS should see their KS resolve within 9 months of starting antiretrovirals. Dr. Maurer and her associates are collecting immunology and laboratory test results at baseline and after 9 months of therapy in a study to compare response in patients. “Please send us your KS patients” who have not started antiretroviral therapy. “We would be very happy to biopsy them,” she said.

A less threatening form of KS is also starting to turn up in relatively young patients with HIV. “They develop what looks to us like 'old man's Kaposi's sarcoma'—that is, Mediterranean, classical-type KS,” Dr. Maurer said.

These are patients who develop small areas of KS, usually on the lower legs and feet, after having HIV for 17–20 years. Their HIV has been suppressed for at least 2 years on antiretroviral therapy, and they have relatively healthy CD4 counts of 300–600 cells/mm

“We think that they are showing signs of immune aging” and preliminary studies suggest this is the case, she said. In several years of follow-up, none have had exacerbations or internal involvement of KS, and none have needed chemotherapy, Dr. Maurer said.

Dr. Maurer and Dr. Greenspan reported having no relevant conflicts of interest.

Lesions believed to be Kaposi's—like the one shown above in an AIDS patient—should be biopsied.

Source Courtesy National Cancer Institute

SAN FRANCISCO — Kaposi's sarcoma in HIV patients is turning up again—sometimes in a surprisingly deadly form and other times in an indolent, nonthreatening form—according to two experts.

Kaposi's sarcoma (KS) used to be one of AIDS' signature complications before antiretroviral therapy, Dr. Deborah Greenspan said at a meeting on the medical management of HIV and AIDS sponsored by the University of California, San Francisco “We're starting to see Kaposi's sarcoma again,” presenting as oral lesions in patients who have started antiretroviral therapy for HIV but who still have low CD4 cell counts.

KS in the setting of HIV has a predilection for the palate, for reasons that have never been understood, said Dr. Greenspan, professor and chair of orofacial sciences and distinguished professor of dentistry at UCSF. Oral KS typically appears as a flat, plaque-like lesion on the hard or soft palate. Looking in the mouth can be a key step to diagnosing KS, she said.

“Years ago, KS seemed to disappear right off the radar screen, but it is back. We are seeing a lot of Kaposi's sarcoma,” Dr. Toby A. Maurer, an associate professor of clinical dermatology at UCSF said in a separate presentation.

She and her colleagues were surprised recently by the lethality of KS after they followed 65 of their patients being treated with antiretroviral therapy for HIV and with chemotherapy for KS. “We were shocked to find out that 25% of that cohort died of their Kaposi's sarcoma, even when they had chemotherapy,” she said.

A separate case series in Seattle found that 23% of patients who were on antiretroviral therapy for HIV and who received adequate chemotherapy for KS died of the cancer. “This is quite alarming,” Dr. Maurer said.

Physicians should always biopsy lesions they think might be KS, she advised. On darker-pigmented skin, it can be difficult to differentiate KS from other lesions without a biopsy.

Most patients who have not started treatment for HIV or KS should see their KS resolve within 9 months of starting antiretrovirals. Dr. Maurer and her associates are collecting immunology and laboratory test results at baseline and after 9 months of therapy in a study to compare response in patients. “Please send us your KS patients” who have not started antiretroviral therapy. “We would be very happy to biopsy them,” she said.

A less threatening form of KS is also starting to turn up in relatively young patients with HIV. “They develop what looks to us like 'old man's Kaposi's sarcoma'—that is, Mediterranean, classical-type KS,” Dr. Maurer said.

These are patients who develop small areas of KS, usually on the lower legs and feet, after having HIV for 17–20 years. Their HIV has been suppressed for at least 2 years on antiretroviral therapy, and they have relatively healthy CD4 counts of 300–600 cells/mm

“We think that they are showing signs of immune aging” and preliminary studies suggest this is the case, she said. In several years of follow-up, none have had exacerbations or internal involvement of KS, and none have needed chemotherapy, Dr. Maurer said.

Dr. Maurer and Dr. Greenspan reported having no relevant conflicts of interest.

Lesions believed to be Kaposi's—like the one shown above in an AIDS patient—should be biopsied.

Source Courtesy National Cancer Institute

Major Findings: Since 2000, the proportion of children receiving the standard recommended vaccine series in the first 18 months of life has increased; disparities in coverage among population subgroups have decreased.

Data Source: Federal analysis of Centers for Disease Control and Prevention data on 185,516 children in the 2000–2008 National Immunization Surveys.

Disclosures: The research was funded by the CDC and the Department of Health and Human Services. The authors reported having no disclosures.

A federal goal of vaccinating 80% of children to protect against 10 preventable diseases by 2010 may be on the verge of being met in all sectors of society, an analysis of national data found.

The proportion of children in various subgroups who received the 4:3:1:3:3:1 vaccine series in the first 18 months of life improved from rates of 47%–59% in 2000 (depending on the sociodemographic group) to 72%–81% in 2008. Discrepancies in vaccination rates decreased in 9 of 12 subgroups that were analyzed using data on 185,516 children in the 2000–2008 National Immunization Surveys. For example, significantly fewer rural residents (52%) received the complete vaccination series in 2000, compared with suburban residents (56%), but by 2008 76% of both rural and suburban children were vaccinated. Although the rate of vaccination among children serviced by public providers improved from 48% in 2000 to 73% in 2008, the 2008 rate remained significantly lower than the vaccination rate among children serviced by private providers (77%).

Each of the 12 subgroups studied showed significant disparities in vaccine coverage in 2000, but this decreased to 4 subgroups by 2008. In all of the subgroups, the discrepancies in vaccination rates that remained in 2008 were relatively small and none exceeded 6%, Zen Zhao, Ph.D., and Elizabeth T. Luman, Ph.D., reported.

By 2008, one subgroup had reached the Healthy People 2010 goal of at least 80% of children vaccinated with at least four doses of diphtheria-tetanus-pertussis, three doses of poliovirus, one of measles-mumps-rubella, three of hepatitis B, three of Haemophilus influenzae type B, and one of varicella vaccine. In that subgroup—children with no siblings—81% were vaccinated.

The study was published online (10.1016/j.amepre/2009.10.035

The investigators, both researchers at the Centers for Disease Control and Prevention in Atlanta, analyzed data from phone surveys of parents with children aged 19–35 months followed by mail contact with vaccination providers to confirm the immunizations.

Hispanic children consistently had significantly higher vaccination rates (just under 80% in 2008), compared with white children (75% in 2008). The 81% vaccination rate in 2008 for children with no siblings was significantly higher than the rate for children with one or more siblings (75%). Significant differences also were seen between children who lived in poverty (74%), compared with those not in poverty (78%); children of mothers with less than 12 years of education (75%), compared with those whose mothers had more education (78%); and children enrolled in the Vaccines for Children program (78%), compared with children not in the program (73%).

Vaccination rates were no different for black and white children (75% each in 2008) in a multivariable analysis that adjusted for the effects of the other factors studied. Rates for urban and suburban children were statistically similar (77% and 76%, respectively), as were rates for children whose parents were married (77%) or not married (76%), children whose mother was younger than 30 years (75%) or older (78%), and children with one vaccine provider (77%), compared with those who got vaccinated by two or more providers in 2008 (76%).

The increased vaccination rates may be due to a combination of factors in the past decade including improved public knowledge of the importance of immunizations and efforts by pediatricians and public health officials to educate parents about vaccines, suggested Dr. George W. Rutherford, a pediatrician who is head of the preventive medicine and public health group at the University of California, San Francisco (UCSF).

Another factor may be the use of Health Effectiveness Data and Information Set (HEDIS) indicators to audit managed care plans, he said in an interview.

Dr. Jay Tureen, a pediatric infectious disease specialist and hospitalist at UCSF, said in an interview that programs including Vaccines for Children and State Children's Health Insurance Program surely helped increase immunizations. Also, patient reminder systems became more widely used after a 2000 Cochrane review of 41 studies showed that patient reminders (using calls, postcards, or letters) increased vaccination rates by 5%–20% in 33 of the 41 studies (JAMA 2000;284:1820–7).

Dr. Rutherford, and Dr. Tureen, ere not affiliated with the study and said they had no financial conflicts of interest relevant to this topic.

Major Findings: Since 2000, the proportion of children receiving the standard recommended vaccine series in the first 18 months of life has increased; disparities in coverage among population subgroups have decreased.

Data Source: Federal analysis of Centers for Disease Control and Prevention data on 185,516 children in the 2000–2008 National Immunization Surveys.

Disclosures: The research was funded by the CDC and the Department of Health and Human Services. The authors reported having no disclosures.

A federal goal of vaccinating 80% of children to protect against 10 preventable diseases by 2010 may be on the verge of being met in all sectors of society, an analysis of national data found.

The proportion of children in various subgroups who received the 4:3:1:3:3:1 vaccine series in the first 18 months of life improved from rates of 47%–59% in 2000 (depending on the sociodemographic group) to 72%–81% in 2008. Discrepancies in vaccination rates decreased in 9 of 12 subgroups that were analyzed using data on 185,516 children in the 2000–2008 National Immunization Surveys. For example, significantly fewer rural residents (52%) received the complete vaccination series in 2000, compared with suburban residents (56%), but by 2008 76% of both rural and suburban children were vaccinated. Although the rate of vaccination among children serviced by public providers improved from 48% in 2000 to 73% in 2008, the 2008 rate remained significantly lower than the vaccination rate among children serviced by private providers (77%).

Each of the 12 subgroups studied showed significant disparities in vaccine coverage in 2000, but this decreased to 4 subgroups by 2008. In all of the subgroups, the discrepancies in vaccination rates that remained in 2008 were relatively small and none exceeded 6%, Zen Zhao, Ph.D., and Elizabeth T. Luman, Ph.D., reported.

By 2008, one subgroup had reached the Healthy People 2010 goal of at least 80% of children vaccinated with at least four doses of diphtheria-tetanus-pertussis, three doses of poliovirus, one of measles-mumps-rubella, three of hepatitis B, three of Haemophilus influenzae type B, and one of varicella vaccine. In that subgroup—children with no siblings—81% were vaccinated.

The study was published online (10.1016/j.amepre/2009.10.035

The investigators, both researchers at the Centers for Disease Control and Prevention in Atlanta, analyzed data from phone surveys of parents with children aged 19–35 months followed by mail contact with vaccination providers to confirm the immunizations.

Hispanic children consistently had significantly higher vaccination rates (just under 80% in 2008), compared with white children (75% in 2008). The 81% vaccination rate in 2008 for children with no siblings was significantly higher than the rate for children with one or more siblings (75%). Significant differences also were seen between children who lived in poverty (74%), compared with those not in poverty (78%); children of mothers with less than 12 years of education (75%), compared with those whose mothers had more education (78%); and children enrolled in the Vaccines for Children program (78%), compared with children not in the program (73%).

Vaccination rates were no different for black and white children (75% each in 2008) in a multivariable analysis that adjusted for the effects of the other factors studied. Rates for urban and suburban children were statistically similar (77% and 76%, respectively), as were rates for children whose parents were married (77%) or not married (76%), children whose mother was younger than 30 years (75%) or older (78%), and children with one vaccine provider (77%), compared with those who got vaccinated by two or more providers in 2008 (76%).

The increased vaccination rates may be due to a combination of factors in the past decade including improved public knowledge of the importance of immunizations and efforts by pediatricians and public health officials to educate parents about vaccines, suggested Dr. George W. Rutherford, a pediatrician who is head of the preventive medicine and public health group at the University of California, San Francisco (UCSF).

Another factor may be the use of Health Effectiveness Data and Information Set (HEDIS) indicators to audit managed care plans, he said in an interview.

Dr. Jay Tureen, a pediatric infectious disease specialist and hospitalist at UCSF, said in an interview that programs including Vaccines for Children and State Children's Health Insurance Program surely helped increase immunizations. Also, patient reminder systems became more widely used after a 2000 Cochrane review of 41 studies showed that patient reminders (using calls, postcards, or letters) increased vaccination rates by 5%–20% in 33 of the 41 studies (JAMA 2000;284:1820–7).

Dr. Rutherford, and Dr. Tureen, ere not affiliated with the study and said they had no financial conflicts of interest relevant to this topic.

Major Findings: Since 2000, the proportion of children receiving the standard recommended vaccine series in the first 18 months of life has increased; disparities in coverage among population subgroups have decreased.

Data Source: Federal analysis of Centers for Disease Control and Prevention data on 185,516 children in the 2000–2008 National Immunization Surveys.

Disclosures: The research was funded by the CDC and the Department of Health and Human Services. The authors reported having no disclosures.

A federal goal of vaccinating 80% of children to protect against 10 preventable diseases by 2010 may be on the verge of being met in all sectors of society, an analysis of national data found.

The proportion of children in various subgroups who received the 4:3:1:3:3:1 vaccine series in the first 18 months of life improved from rates of 47%–59% in 2000 (depending on the sociodemographic group) to 72%–81% in 2008. Discrepancies in vaccination rates decreased in 9 of 12 subgroups that were analyzed using data on 185,516 children in the 2000–2008 National Immunization Surveys. For example, significantly fewer rural residents (52%) received the complete vaccination series in 2000, compared with suburban residents (56%), but by 2008 76% of both rural and suburban children were vaccinated. Although the rate of vaccination among children serviced by public providers improved from 48% in 2000 to 73% in 2008, the 2008 rate remained significantly lower than the vaccination rate among children serviced by private providers (77%).

Each of the 12 subgroups studied showed significant disparities in vaccine coverage in 2000, but this decreased to 4 subgroups by 2008. In all of the subgroups, the discrepancies in vaccination rates that remained in 2008 were relatively small and none exceeded 6%, Zen Zhao, Ph.D., and Elizabeth T. Luman, Ph.D., reported.

By 2008, one subgroup had reached the Healthy People 2010 goal of at least 80% of children vaccinated with at least four doses of diphtheria-tetanus-pertussis, three doses of poliovirus, one of measles-mumps-rubella, three of hepatitis B, three of Haemophilus influenzae type B, and one of varicella vaccine. In that subgroup—children with no siblings—81% were vaccinated.

The study was published online (10.1016/j.amepre/2009.10.035

The investigators, both researchers at the Centers for Disease Control and Prevention in Atlanta, analyzed data from phone surveys of parents with children aged 19–35 months followed by mail contact with vaccination providers to confirm the immunizations.

Hispanic children consistently had significantly higher vaccination rates (just under 80% in 2008), compared with white children (75% in 2008). The 81% vaccination rate in 2008 for children with no siblings was significantly higher than the rate for children with one or more siblings (75%). Significant differences also were seen between children who lived in poverty (74%), compared with those not in poverty (78%); children of mothers with less than 12 years of education (75%), compared with those whose mothers had more education (78%); and children enrolled in the Vaccines for Children program (78%), compared with children not in the program (73%).

Vaccination rates were no different for black and white children (75% each in 2008) in a multivariable analysis that adjusted for the effects of the other factors studied. Rates for urban and suburban children were statistically similar (77% and 76%, respectively), as were rates for children whose parents were married (77%) or not married (76%), children whose mother was younger than 30 years (75%) or older (78%), and children with one vaccine provider (77%), compared with those who got vaccinated by two or more providers in 2008 (76%).

The increased vaccination rates may be due to a combination of factors in the past decade including improved public knowledge of the importance of immunizations and efforts by pediatricians and public health officials to educate parents about vaccines, suggested Dr. George W. Rutherford, a pediatrician who is head of the preventive medicine and public health group at the University of California, San Francisco (UCSF).

Another factor may be the use of Health Effectiveness Data and Information Set (HEDIS) indicators to audit managed care plans, he said in an interview.

Dr. Jay Tureen, a pediatric infectious disease specialist and hospitalist at UCSF, said in an interview that programs including Vaccines for Children and State Children's Health Insurance Program surely helped increase immunizations. Also, patient reminder systems became more widely used after a 2000 Cochrane review of 41 studies showed that patient reminders (using calls, postcards, or letters) increased vaccination rates by 5%–20% in 33 of the 41 studies (JAMA 2000;284:1820–7).

Dr. Rutherford, and Dr. Tureen, ere not affiliated with the study and said they had no financial conflicts of interest relevant to this topic.

SAN FRANCISCO — Substance abuse is such a common cause of anxiety or depression in HIV-infected patients that Dr. Robert B. Daroff advises getting a toxicology screen in every patient with HIV and a mood disorder.

“It's the only objective measure I have in psychiatry. I might as well use it,” said Dr. Daroff, director of the HIV Psychiatry Program at the San Francisco VA Medical Center.

Social factors also may cause or contribute to mood disorders. Feelings of helplessness and dependency, social isolation, or difficulty communicating with significant others can lead to anxiety or depression, he said at a meeting on the medical management of HIV and AIDS sponsored by the University of California, San Francisco.

Biologic factors such as metabolic or endocrine abnormalities and side effects from antiretroviral therapy can also cause psychiatric disorders in patients with HIV. When anti-HIV drugs may be causing the mood disorder, consider possibly subtracting a drug, he said. (See box.)

Approximately 36% of patients with HIV had major depression and 16% had generalized anxiety disorder, one study found (Arch. Gen. Psychiatry 2001;58:721–8). Mood disorders may impair compliance with antiretroviral therapy.

In a survey of psychiatrists with AIDS expertise, the top choices for first-line treatment of depression in patients with HIV who had not yet started antiretrovirals were desipramine, amitriptyline, fluvoxamine, or a monoamine oxidase inhibitor, Dr. Daroff said. For patients already on highly active antiretroviral therapy with a ritonavir-boosted protease inhibitor, the top choices for an antidepressant were citalopram or escitalopram, and Dr. Daroff would put sertraline among these top choices if efficacy, acceptability, and cost are all considered.

Few psychiatric drugs are contraindicated in patients on antiretrovirals. Patients taking protease inhibitors should avoid pimozide, midazolam, triazolam, and St. John's wort. Patients taking non-nucleoside reductase inhibitors should avoid alprazolam, midazolam, triazolam, and St. John's wort.

If a patient may have bipolar depression, avoid tricyclic antidepressants and dual-acting medications such as venlafaxine or duloxetine. Quetiapine or lamotrigine may be better than an antidepressant in these patients. Treatment for anxiety disorders most often involves SSRIs, venlafaxine, benzodiazepines, or buspirone. he said.

Psychotherapy should be considered, he said. “I think we're underprescribing psychotherapy in HIV.”

The kind of psychotherapy seems to be less important than the quality of the relationship between the therapist and the patient, “which suggests that there is great power in the relationship you build with your patients,” he added.

Dr. Daroff reported having no relevant disclosures.

Few psychiatric drugs are contraindicated in patients on antiretrovirals.

Source DR. DAROFF

Side Effects of Antiretrovirals

Didanosine: Nervousness, anxiety, confusion, insomnia.

Lamivudine: Insomnia, mania.

Stavudine: Confusion, depression, anxiety, mania, insomnia.

Zidovudine (AZT): Mania, depression, anxiety, insomnia, confusion.

Raltegravir: May worsen preexisting depression.

Efavirenz: Stepped-up dosing reduces neuropsychiatric side effects seen in clinical trials.

Source: Dr. Daroff

SAN FRANCISCO — Substance abuse is such a common cause of anxiety or depression in HIV-infected patients that Dr. Robert B. Daroff advises getting a toxicology screen in every patient with HIV and a mood disorder.

“It's the only objective measure I have in psychiatry. I might as well use it,” said Dr. Daroff, director of the HIV Psychiatry Program at the San Francisco VA Medical Center.

Social factors also may cause or contribute to mood disorders. Feelings of helplessness and dependency, social isolation, or difficulty communicating with significant others can lead to anxiety or depression, he said at a meeting on the medical management of HIV and AIDS sponsored by the University of California, San Francisco.

Biologic factors such as metabolic or endocrine abnormalities and side effects from antiretroviral therapy can also cause psychiatric disorders in patients with HIV. When anti-HIV drugs may be causing the mood disorder, consider possibly subtracting a drug, he said. (See box.)

Approximately 36% of patients with HIV had major depression and 16% had generalized anxiety disorder, one study found (Arch. Gen. Psychiatry 2001;58:721–8). Mood disorders may impair compliance with antiretroviral therapy.

In a survey of psychiatrists with AIDS expertise, the top choices for first-line treatment of depression in patients with HIV who had not yet started antiretrovirals were desipramine, amitriptyline, fluvoxamine, or a monoamine oxidase inhibitor, Dr. Daroff said. For patients already on highly active antiretroviral therapy with a ritonavir-boosted protease inhibitor, the top choices for an antidepressant were citalopram or escitalopram, and Dr. Daroff would put sertraline among these top choices if efficacy, acceptability, and cost are all considered.

Few psychiatric drugs are contraindicated in patients on antiretrovirals. Patients taking protease inhibitors should avoid pimozide, midazolam, triazolam, and St. John's wort. Patients taking non-nucleoside reductase inhibitors should avoid alprazolam, midazolam, triazolam, and St. John's wort.

If a patient may have bipolar depression, avoid tricyclic antidepressants and dual-acting medications such as venlafaxine or duloxetine. Quetiapine or lamotrigine may be better than an antidepressant in these patients. Treatment for anxiety disorders most often involves SSRIs, venlafaxine, benzodiazepines, or buspirone. he said.

Psychotherapy should be considered, he said. “I think we're underprescribing psychotherapy in HIV.”

The kind of psychotherapy seems to be less important than the quality of the relationship between the therapist and the patient, “which suggests that there is great power in the relationship you build with your patients,” he added.

Dr. Daroff reported having no relevant disclosures.

Few psychiatric drugs are contraindicated in patients on antiretrovirals.

Source DR. DAROFF

Side Effects of Antiretrovirals

Didanosine: Nervousness, anxiety, confusion, insomnia.

Lamivudine: Insomnia, mania.

Stavudine: Confusion, depression, anxiety, mania, insomnia.

Zidovudine (AZT): Mania, depression, anxiety, insomnia, confusion.

Raltegravir: May worsen preexisting depression.

Efavirenz: Stepped-up dosing reduces neuropsychiatric side effects seen in clinical trials.

Source: Dr. Daroff

SAN FRANCISCO — Substance abuse is such a common cause of anxiety or depression in HIV-infected patients that Dr. Robert B. Daroff advises getting a toxicology screen in every patient with HIV and a mood disorder.

“It's the only objective measure I have in psychiatry. I might as well use it,” said Dr. Daroff, director of the HIV Psychiatry Program at the San Francisco VA Medical Center.

Social factors also may cause or contribute to mood disorders. Feelings of helplessness and dependency, social isolation, or difficulty communicating with significant others can lead to anxiety or depression, he said at a meeting on the medical management of HIV and AIDS sponsored by the University of California, San Francisco.

Biologic factors such as metabolic or endocrine abnormalities and side effects from antiretroviral therapy can also cause psychiatric disorders in patients with HIV. When anti-HIV drugs may be causing the mood disorder, consider possibly subtracting a drug, he said. (See box.)

Approximately 36% of patients with HIV had major depression and 16% had generalized anxiety disorder, one study found (Arch. Gen. Psychiatry 2001;58:721–8). Mood disorders may impair compliance with antiretroviral therapy.

In a survey of psychiatrists with AIDS expertise, the top choices for first-line treatment of depression in patients with HIV who had not yet started antiretrovirals were desipramine, amitriptyline, fluvoxamine, or a monoamine oxidase inhibitor, Dr. Daroff said. For patients already on highly active antiretroviral therapy with a ritonavir-boosted protease inhibitor, the top choices for an antidepressant were citalopram or escitalopram, and Dr. Daroff would put sertraline among these top choices if efficacy, acceptability, and cost are all considered.

Few psychiatric drugs are contraindicated in patients on antiretrovirals. Patients taking protease inhibitors should avoid pimozide, midazolam, triazolam, and St. John's wort. Patients taking non-nucleoside reductase inhibitors should avoid alprazolam, midazolam, triazolam, and St. John's wort.

If a patient may have bipolar depression, avoid tricyclic antidepressants and dual-acting medications such as venlafaxine or duloxetine. Quetiapine or lamotrigine may be better than an antidepressant in these patients. Treatment for anxiety disorders most often involves SSRIs, venlafaxine, benzodiazepines, or buspirone. he said.

Psychotherapy should be considered, he said. “I think we're underprescribing psychotherapy in HIV.”

The kind of psychotherapy seems to be less important than the quality of the relationship between the therapist and the patient, “which suggests that there is great power in the relationship you build with your patients,” he added.

Dr. Daroff reported having no relevant disclosures.

Few psychiatric drugs are contraindicated in patients on antiretrovirals.

Source DR. DAROFF

Side Effects of Antiretrovirals

Didanosine: Nervousness, anxiety, confusion, insomnia.

Lamivudine: Insomnia, mania.

Stavudine: Confusion, depression, anxiety, mania, insomnia.

Zidovudine (AZT): Mania, depression, anxiety, insomnia, confusion.

Raltegravir: May worsen preexisting depression.

Efavirenz: Stepped-up dosing reduces neuropsychiatric side effects seen in clinical trials.

Source: Dr. Daroff

SAN FRANCISCO – The “medical” use of marijuana, which is common among patients diagnosed with illnesses such as HIV or cancer, might lead to depression or anxiety disorders. However, data suggesting that marijuana use is a risk factor for throat and neck cancers are weak, two experts say.

Evidence that marijuana use might play an etiological role in the development of psychotic disorders and schizophrenia has been mounting (Eur. Arch. Psychiatry Clin. Neurosci. 2009;259:413–31, Am. J. Psychiatr. 2009;166:1251–7). The relationship between marijuana (or “pot”) and anxiety or mood disorders, however, is less clear, Dr. Robert B. Daroff Jr., director of the HIV Psychiatry Program at the San Francisco VA Medical Center, said at a meeting on the medical management of HIV sponsored by the University of California, San Francisco.

Patients with HIV often contend that they are self-medicating to symptoms and that the most common “diagnosis” associated with medical marijuana use is “stress,” he said.

“I usually advise–and this doesn't always go smoothly–that depressed or anxious patients take a trial off of pot before I treat their depression or their anxiety,” he said. If patients are willing to try interrupting marijuana use, often they will find that the drug was a major contributing factor to their psychiatric symptoms.

“At least for patients who have treatment-resistant depression and anxiety, we ought to be pushing harder for them to give a trial off of pot to see if that's related” to their psychiatric problem, he said.

Deborah Greenspan, D.Sc., professor and chair of orofacial sciences and distinguished professor of dentistry at the university, said anecdotal reports that the practice of using marijuana contributes to the development of oral squamous cell carcinoma (SCC) prompted her to review studies related to this topic.

A large, population-based case-control study with 407 subjects found no association between marijuana use and SCC either in the cohort as a whole or in any subgroup based on age, cigarette smoking status, or alcohol consumption (Cancer Research 2004;64:4,049–54).

An analysis of five case-control studies with 4,029 cases of head and neck cancer, and 5,015 control patients found no significant association between cancer and marijuana use in patients who did not smoke cigarettes (Cancer Epidemiol. Biomarkers Prev. 2009;18:1544–51).

“There may have been some dual activity going on” from cigarette use by marijuana smokers that contributed to suggestions that marijuana increased cancer risk in some earlier small studies, Dr. Greenspan said.

Dr. Daroff and Dr. Greenspan reported having no relevant disclosures.

SAN FRANCISCO – The “medical” use of marijuana, which is common among patients diagnosed with illnesses such as HIV or cancer, might lead to depression or anxiety disorders. However, data suggesting that marijuana use is a risk factor for throat and neck cancers are weak, two experts say.

Evidence that marijuana use might play an etiological role in the development of psychotic disorders and schizophrenia has been mounting (Eur. Arch. Psychiatry Clin. Neurosci. 2009;259:413–31, Am. J. Psychiatr. 2009;166:1251–7). The relationship between marijuana (or “pot”) and anxiety or mood disorders, however, is less clear, Dr. Robert B. Daroff Jr., director of the HIV Psychiatry Program at the San Francisco VA Medical Center, said at a meeting on the medical management of HIV sponsored by the University of California, San Francisco.

Patients with HIV often contend that they are self-medicating to symptoms and that the most common “diagnosis” associated with medical marijuana use is “stress,” he said.

“I usually advise–and this doesn't always go smoothly–that depressed or anxious patients take a trial off of pot before I treat their depression or their anxiety,” he said. If patients are willing to try interrupting marijuana use, often they will find that the drug was a major contributing factor to their psychiatric symptoms.

“At least for patients who have treatment-resistant depression and anxiety, we ought to be pushing harder for them to give a trial off of pot to see if that's related” to their psychiatric problem, he said.

Deborah Greenspan, D.Sc., professor and chair of orofacial sciences and distinguished professor of dentistry at the university, said anecdotal reports that the practice of using marijuana contributes to the development of oral squamous cell carcinoma (SCC) prompted her to review studies related to this topic.

A large, population-based case-control study with 407 subjects found no association between marijuana use and SCC either in the cohort as a whole or in any subgroup based on age, cigarette smoking status, or alcohol consumption (Cancer Research 2004;64:4,049–54).

An analysis of five case-control studies with 4,029 cases of head and neck cancer, and 5,015 control patients found no significant association between cancer and marijuana use in patients who did not smoke cigarettes (Cancer Epidemiol. Biomarkers Prev. 2009;18:1544–51).

“There may have been some dual activity going on” from cigarette use by marijuana smokers that contributed to suggestions that marijuana increased cancer risk in some earlier small studies, Dr. Greenspan said.

Dr. Daroff and Dr. Greenspan reported having no relevant disclosures.

SAN FRANCISCO – The “medical” use of marijuana, which is common among patients diagnosed with illnesses such as HIV or cancer, might lead to depression or anxiety disorders. However, data suggesting that marijuana use is a risk factor for throat and neck cancers are weak, two experts say.

Evidence that marijuana use might play an etiological role in the development of psychotic disorders and schizophrenia has been mounting (Eur. Arch. Psychiatry Clin. Neurosci. 2009;259:413–31, Am. J. Psychiatr. 2009;166:1251–7). The relationship between marijuana (or “pot”) and anxiety or mood disorders, however, is less clear, Dr. Robert B. Daroff Jr., director of the HIV Psychiatry Program at the San Francisco VA Medical Center, said at a meeting on the medical management of HIV sponsored by the University of California, San Francisco.

Patients with HIV often contend that they are self-medicating to symptoms and that the most common “diagnosis” associated with medical marijuana use is “stress,” he said.

“I usually advise–and this doesn't always go smoothly–that depressed or anxious patients take a trial off of pot before I treat their depression or their anxiety,” he said. If patients are willing to try interrupting marijuana use, often they will find that the drug was a major contributing factor to their psychiatric symptoms.

“At least for patients who have treatment-resistant depression and anxiety, we ought to be pushing harder for them to give a trial off of pot to see if that's related” to their psychiatric problem, he said.

Deborah Greenspan, D.Sc., professor and chair of orofacial sciences and distinguished professor of dentistry at the university, said anecdotal reports that the practice of using marijuana contributes to the development of oral squamous cell carcinoma (SCC) prompted her to review studies related to this topic.

A large, population-based case-control study with 407 subjects found no association between marijuana use and SCC either in the cohort as a whole or in any subgroup based on age, cigarette smoking status, or alcohol consumption (Cancer Research 2004;64:4,049–54).

An analysis of five case-control studies with 4,029 cases of head and neck cancer, and 5,015 control patients found no significant association between cancer and marijuana use in patients who did not smoke cigarettes (Cancer Epidemiol. Biomarkers Prev. 2009;18:1544–51).

“There may have been some dual activity going on” from cigarette use by marijuana smokers that contributed to suggestions that marijuana increased cancer risk in some earlier small studies, Dr. Greenspan said.

Dr. Daroff and Dr. Greenspan reported having no relevant disclosures.

SAN FRANCISCO – Substance abuse is such a common cause of anxiety or depression in HIV-infected patients that Dr. Robert B. Daroff Jr. advises getting a toxicology screen in every patient with HIV and a mood disorder.

“It's one of the only objective measures I have in psychiatry. I might as well use it,” said Dr. Daroff, director of the HIV Psychiatry Program at the San Francisco VA Medical Center. Social factors also may cause or contribute to mood disorders. Feelings of helplessness and dependency, social isolation, or difficulty communicating with significant others can lead to anxiety or depression, he said at a meeting on the medical management of HIV and AIDS sponsored by the University of California, San Francisco.

Biologic factors such as metabolic or endocrine abnormalities and side effects from antiretroviral therapy can also cause psychiatric disorders in patients with HIV. When anti-HIV drugs may be causing the mood disorder, consider possibly subtracting a drug instead of adding one, he said. (See box.)

Approximately 36% of patients with HIV had major depression and 16% had generalized anxiety disorder, one study found (Arch. Gen. Psychiatry 2001;58:721–8). Mood disorders may impair compliance with antiretroviral therapy in patients with HIV.

In a survey of psychiatrists with AIDS expertise, the top choices for first-line treatment of depression in patients with HIV who had not yet started antiretrovirals were escitalopram, citalopram, sertraline, and mirtazapine, Dr. Daroff said. For patients already on highly active antiretroviral therapy with a ritonavir-boosted protease inhibitor, the top choices for an antidepressant were unchanged, but Dr. Daroff would not generally initiate treatment with escitalopram because the other agents were available in generic form.

Few psychiatric drugs are contraindicated in patients on antiretrovirals. Patients taking protease inhibitors should avoid pimozide, midazolam, triazolam, and St. John's wort. Patients taking non-nucleoside reductase reverse transcriptase inhibitors should avoid alprazolam, midazolam, triazolam, and St. John's wort.

If a patient may have bipolar depression, avoid tricyclic antidepressants and dual-acting medications such as venlafaxine or duloxetine to decrease the risk of switching to mania. Quetiapine or lamotrigine may be a better choice than an antidepressant in these patients, he said.

Treatment for anxiety disorders most often involves SSRIs, venlafaxine, benzodiazepines, or buspirone. Start at a quarter to half of normal dosing and increase the dose slowly because patients with HIV and anxiety are often “exquisitely sensitive to side effects,” he advised.

Psychotherapy should be part of the therapeutic approach, he said. “I think we're underprescribing psychotherapy in HIV.”

Psychotherapy was associated with decreased HIV levels and improved CD4 counts in 7 of 14 randomized, controlled trials in patients with HIV, a review found.

The review (Psychosom. Med. 2008;70:575–84) and other studies suggest that psychotherapy reduces mental distress associated with HIV, and that different forms of psychotherapy may be equally effective in these patients, Dr. Daroff said.

The kind of psychotherapy seems to be less important than the quality of the relationship between the therapist and the patient, “which suggests that there is great power in the relationship you build with your patients,” added Dr. Daroff.

He reported having no relevant disclosures.

Psychotherapy is underprescribed in HIV patients and should be considered a part of the overall therapeutic approach, Dr. Robert B. Daroff Jr. says.

Source Courtesy Patricia Reed

Side Effects of Antiretrovirals

Didanosine: Nervousness, anxiety, confusion, insomnia.

Lamivudine: Insomnia, mania.

Stavudine: Confusion, depression, anxiety, mania, insomnia.

Zidovudine (AZT): Mania, depression, anxiety, insomnia, confusion.

Raltegravir: May worsen preexisting depression.

Efavirenz: Stepped-up dosing reduces neuropsychiatric side effects seen in clinical trials.

Source: Dr. Daroff

SAN FRANCISCO – Substance abuse is such a common cause of anxiety or depression in HIV-infected patients that Dr. Robert B. Daroff Jr. advises getting a toxicology screen in every patient with HIV and a mood disorder.

“It's one of the only objective measures I have in psychiatry. I might as well use it,” said Dr. Daroff, director of the HIV Psychiatry Program at the San Francisco VA Medical Center. Social factors also may cause or contribute to mood disorders. Feelings of helplessness and dependency, social isolation, or difficulty communicating with significant others can lead to anxiety or depression, he said at a meeting on the medical management of HIV and AIDS sponsored by the University of California, San Francisco.

Biologic factors such as metabolic or endocrine abnormalities and side effects from antiretroviral therapy can also cause psychiatric disorders in patients with HIV. When anti-HIV drugs may be causing the mood disorder, consider possibly subtracting a drug instead of adding one, he said. (See box.)

Approximately 36% of patients with HIV had major depression and 16% had generalized anxiety disorder, one study found (Arch. Gen. Psychiatry 2001;58:721–8). Mood disorders may impair compliance with antiretroviral therapy in patients with HIV.

In a survey of psychiatrists with AIDS expertise, the top choices for first-line treatment of depression in patients with HIV who had not yet started antiretrovirals were escitalopram, citalopram, sertraline, and mirtazapine, Dr. Daroff said. For patients already on highly active antiretroviral therapy with a ritonavir-boosted protease inhibitor, the top choices for an antidepressant were unchanged, but Dr. Daroff would not generally initiate treatment with escitalopram because the other agents were available in generic form.

Few psychiatric drugs are contraindicated in patients on antiretrovirals. Patients taking protease inhibitors should avoid pimozide, midazolam, triazolam, and St. John's wort. Patients taking non-nucleoside reductase reverse transcriptase inhibitors should avoid alprazolam, midazolam, triazolam, and St. John's wort.

If a patient may have bipolar depression, avoid tricyclic antidepressants and dual-acting medications such as venlafaxine or duloxetine to decrease the risk of switching to mania. Quetiapine or lamotrigine may be a better choice than an antidepressant in these patients, he said.

Treatment for anxiety disorders most often involves SSRIs, venlafaxine, benzodiazepines, or buspirone. Start at a quarter to half of normal dosing and increase the dose slowly because patients with HIV and anxiety are often “exquisitely sensitive to side effects,” he advised.

Psychotherapy should be part of the therapeutic approach, he said. “I think we're underprescribing psychotherapy in HIV.”

Psychotherapy was associated with decreased HIV levels and improved CD4 counts in 7 of 14 randomized, controlled trials in patients with HIV, a review found.

The review (Psychosom. Med. 2008;70:575–84) and other studies suggest that psychotherapy reduces mental distress associated with HIV, and that different forms of psychotherapy may be equally effective in these patients, Dr. Daroff said.

The kind of psychotherapy seems to be less important than the quality of the relationship between the therapist and the patient, “which suggests that there is great power in the relationship you build with your patients,” added Dr. Daroff.

He reported having no relevant disclosures.

Psychotherapy is underprescribed in HIV patients and should be considered a part of the overall therapeutic approach, Dr. Robert B. Daroff Jr. says.

Source Courtesy Patricia Reed

Side Effects of Antiretrovirals

Didanosine: Nervousness, anxiety, confusion, insomnia.

Lamivudine: Insomnia, mania.

Stavudine: Confusion, depression, anxiety, mania, insomnia.

Zidovudine (AZT): Mania, depression, anxiety, insomnia, confusion.

Raltegravir: May worsen preexisting depression.

Efavirenz: Stepped-up dosing reduces neuropsychiatric side effects seen in clinical trials.

Source: Dr. Daroff

SAN FRANCISCO – Substance abuse is such a common cause of anxiety or depression in HIV-infected patients that Dr. Robert B. Daroff Jr. advises getting a toxicology screen in every patient with HIV and a mood disorder.

“It's one of the only objective measures I have in psychiatry. I might as well use it,” said Dr. Daroff, director of the HIV Psychiatry Program at the San Francisco VA Medical Center. Social factors also may cause or contribute to mood disorders. Feelings of helplessness and dependency, social isolation, or difficulty communicating with significant others can lead to anxiety or depression, he said at a meeting on the medical management of HIV and AIDS sponsored by the University of California, San Francisco.

Biologic factors such as metabolic or endocrine abnormalities and side effects from antiretroviral therapy can also cause psychiatric disorders in patients with HIV. When anti-HIV drugs may be causing the mood disorder, consider possibly subtracting a drug instead of adding one, he said. (See box.)

Approximately 36% of patients with HIV had major depression and 16% had generalized anxiety disorder, one study found (Arch. Gen. Psychiatry 2001;58:721–8). Mood disorders may impair compliance with antiretroviral therapy in patients with HIV.

In a survey of psychiatrists with AIDS expertise, the top choices for first-line treatment of depression in patients with HIV who had not yet started antiretrovirals were escitalopram, citalopram, sertraline, and mirtazapine, Dr. Daroff said. For patients already on highly active antiretroviral therapy with a ritonavir-boosted protease inhibitor, the top choices for an antidepressant were unchanged, but Dr. Daroff would not generally initiate treatment with escitalopram because the other agents were available in generic form.

Few psychiatric drugs are contraindicated in patients on antiretrovirals. Patients taking protease inhibitors should avoid pimozide, midazolam, triazolam, and St. John's wort. Patients taking non-nucleoside reductase reverse transcriptase inhibitors should avoid alprazolam, midazolam, triazolam, and St. John's wort.

If a patient may have bipolar depression, avoid tricyclic antidepressants and dual-acting medications such as venlafaxine or duloxetine to decrease the risk of switching to mania. Quetiapine or lamotrigine may be a better choice than an antidepressant in these patients, he said.

Treatment for anxiety disorders most often involves SSRIs, venlafaxine, benzodiazepines, or buspirone. Start at a quarter to half of normal dosing and increase the dose slowly because patients with HIV and anxiety are often “exquisitely sensitive to side effects,” he advised.

Psychotherapy should be part of the therapeutic approach, he said. “I think we're underprescribing psychotherapy in HIV.”

Psychotherapy was associated with decreased HIV levels and improved CD4 counts in 7 of 14 randomized, controlled trials in patients with HIV, a review found.

The review (Psychosom. Med. 2008;70:575–84) and other studies suggest that psychotherapy reduces mental distress associated with HIV, and that different forms of psychotherapy may be equally effective in these patients, Dr. Daroff said.

The kind of psychotherapy seems to be less important than the quality of the relationship between the therapist and the patient, “which suggests that there is great power in the relationship you build with your patients,” added Dr. Daroff.

He reported having no relevant disclosures.

Psychotherapy is underprescribed in HIV patients and should be considered a part of the overall therapeutic approach, Dr. Robert B. Daroff Jr. says.

Source Courtesy Patricia Reed

Side Effects of Antiretrovirals

Didanosine: Nervousness, anxiety, confusion, insomnia.

Lamivudine: Insomnia, mania.

Stavudine: Confusion, depression, anxiety, mania, insomnia.

Zidovudine (AZT): Mania, depression, anxiety, insomnia, confusion.

Raltegravir: May worsen preexisting depression.

Efavirenz: Stepped-up dosing reduces neuropsychiatric side effects seen in clinical trials.

Source: Dr. Daroff

Major Finding: When opioids were used long-term for noncancer pain, 6%-23% of patients stopped taking them due to inefficacy or side effects and 0.3% developed signs of addiction.

Data Source: Cochrane Collaboration review of 26 clinical studies with 4,893 participants.

Disclosures: None.

One of the first systematic reviews of data on long-term use of opioids found weak evidence to support the idea that adults who can take chronic opioids get chronic pain relief, though effects on function or quality of life are unclear.

In a Cochrane Collaboration review of 26 prospective studies with 4,893 participants, 6%-23% of patients dropped out of the clinical trials (depending on the route of drug administration) due to inefficacy or side effects, but those who finished the studies maintained clinically significant reductions in pain during up to 48 months of opioid use, Meredith Noble and her associates reported.

The review also suggested that opioid abuse or addiction were rare, but acknowledged that the findings are compromised by the limited quantity and poor quality of the studies. Only 7 (0.3%) of 2,613 patients developed signs of addiction or took their medicine inappropriately in the studies that reported those outcomes (Cochrane Database Syst. Rev. 2010 [doi: 10.1002/ 14651858.CD006605]).

Most of the studies excluded patients with risk factors for abuse. The low rate of addiction may be generalizable only to patients with no history of abuse or addiction, wrote Ms. Noble, a senior research analyst at the Economic Cycle Research Institute, one of 14 evidence-based practice centers under the U.S. Agency for Healthcare Research and Quality. A previous study suggested that addiction or abuse may develop in 3% of patients in all studies of opioid use for chronic pain and in 0.2% of patients in studies that screened out participants with a history of abuse or addiction (Pain Med. 2008;9:444–59).

The evidence of long-term relief of noncancer pain with chronic opioid use was too sparse in the current review to draw firm conclusions about the treatment's effectiveness, including any quantification of mean level of relief from noncancer pain, the investigators concluded. All of the studies had low internal validity, making it highly likely that future studies could overturn their findings.

Among 3,040 patients treated with oral opioids, 23% discontinued treatment due to adverse effects and 10% dropped out of the trials because of insufficient pain relief. Among 1,628 on transdermal opioids, 12% stopped due to adverse effects and 6% stopped due to insufficient pain relief. Intrathecal pumps delivered opioids in 231 patients who could not find pain relief any other way; of these, 9% stopped due to adverse effects and 8% dropped out due to insufficient pain relief.

One of the studies in the review was a randomized trial comparing two opioids; the other 25 studies were case series or uncontrolled continuations of short-term trials of opioids for noncancer pain. None of the studies included comparisons with placebo or nonopioid therapies.

The only other systematic review of long-term opioid use for chronic noncancer pain was a 2008 study by the same investigators that used somewhat different methodology.

All of the patients had been taking opioids for at least 6 months after failing previous nonopioid therapy for noncancer pain of at least 3 months duration, mainly chronic back pain, severe osteoarthritis, or pain related to nerve damage.

Solid estimates are lacking for the number of people with chronic noncancer pain who are taking opioids long-term and what they are taking. Two U.S. studies suggest that 0.65% of people with medical insurance use opioids chronically and that 10% of people who claimed insurance coverage for opioids had at least a 3-month supply.

The Cochrane Collaboration is an international nonprofit, independent organization focused on systematic reviews of health care interventions.

However, three pain experts said in interviews that they fear clinicians might read too much into the review's limited findings.

The report is “very encouraging, but it's far from the whole story,” said Dr. Perry Fine said. A literature review doesn't necessarily reflect concerns in real-life practices. Because there are no good substitutes for opioids on the horizon, physicians need to find ways to make long-term opioid use more effective and safe, he said.

Dr. Fine, president of the American Academy of Pain Medicine (AAPM) and professor of anesthesiology at the University of Utah, Salt Lake City, compared current use of long-term opioids for noncancer pain with the use of surgical anesthesia 20–30 years ago when it was associated with significant morbidity and mortality.

“That didn't stop us from doing surgical procedures when necessary,” but it did motivate research and improvements in patient selection, monitoring, and dosing that led to the very low rates of morbidity and mortality with anesthesia today.

Dr. Adrian Bartoli, a pain specialist practicing in San Francisco, said he was disappointed that the authors of the review implied that patients who have had a prior problem with addiction should be excluded from opioid therapy for chronic noncancer pain. “There's nothing in this analysis that would suggest that. That was their opinion,” he said.

He also felt that the review muddled concepts of pain and addiction, referring to addiction in terms of tolerance and dependence, which are very different concepts.

“I got the sense that they felt that patients could be imbued with addiction by taking a medicine like a narcotic,” Dr. Bartoli said. “It's a genetically predisposed condition.”

On the other hand, he worried that the report of a very low rate of addiction may lead primary care physicians, in particular, to put patients with chronic noncancer pain on long-term opioids without sufficiently considering other remedies or medications.

“The pharmaceutical industry over the past 10 years has been incredibly strong in trying to move these narcotics onto the market and to put the primary care physicians at ease that they are not prescribing something that has a risk of addiction or abuse,” he said. “This review probably is going to reinforce that. Ultimately, there are pros and cons to that occurring.”

Primary care internist Dr. Roger Chou agreed, saying that the 0.3% rate of addiction reported is “a little misleading, because it's based on pretty crummy data.” The review's findings on addiction, pain relief, and adverse events apply to very select groups of patients, not the more complicated cases that raise concerns for physicians considering long-term opioids.

Mainly, the review shows how little is known about prescribing long-term opioids, suggested Dr. Chou, of Oregon Health and Science University, Portland, and lead author of clinical guidelines on chronic opioids for noncancer pain by the American Pain Society and the AAPM.

“We really don't have good quality, long-term data on this, which is scary because we're prescribing these medications so much,” Dr. Chou said. Over the past 2 decades, “we have been prescribing more, but we're also prescribing higher doses and more Schedule II drugs,” which have a higher potential for abuse.

None of these commentators were associated with the Cochrane review. Dr. Bartoli and Dr. Chou reported no potential conflicts of interest. Dr. Fine has been a speaker for Wyeth and an adviser and consultant for many pharmaceutical companies that manufacture opioids.

The 0.3% rate of addiction reported is 'a little misleading, because it's based on pretty crummy data.'

Source DR. CHOUwww.nejm.org

Major Finding: When opioids were used long-term for noncancer pain, 6%-23% of patients stopped taking them due to inefficacy or side effects and 0.3% developed signs of addiction.

Data Source: Cochrane Collaboration review of 26 clinical studies with 4,893 participants.

Disclosures: None.

One of the first systematic reviews of data on long-term use of opioids found weak evidence to support the idea that adults who can take chronic opioids get chronic pain relief, though effects on function or quality of life are unclear.

In a Cochrane Collaboration review of 26 prospective studies with 4,893 participants, 6%-23% of patients dropped out of the clinical trials (depending on the route of drug administration) due to inefficacy or side effects, but those who finished the studies maintained clinically significant reductions in pain during up to 48 months of opioid use, Meredith Noble and her associates reported.

The review also suggested that opioid abuse or addiction were rare, but acknowledged that the findings are compromised by the limited quantity and poor quality of the studies. Only 7 (0.3%) of 2,613 patients developed signs of addiction or took their medicine inappropriately in the studies that reported those outcomes (Cochrane Database Syst. Rev. 2010 [doi: 10.1002/ 14651858.CD006605]).

Most of the studies excluded patients with risk factors for abuse. The low rate of addiction may be generalizable only to patients with no history of abuse or addiction, wrote Ms. Noble, a senior research analyst at the Economic Cycle Research Institute, one of 14 evidence-based practice centers under the U.S. Agency for Healthcare Research and Quality. A previous study suggested that addiction or abuse may develop in 3% of patients in all studies of opioid use for chronic pain and in 0.2% of patients in studies that screened out participants with a history of abuse or addiction (Pain Med. 2008;9:444–59).

The evidence of long-term relief of noncancer pain with chronic opioid use was too sparse in the current review to draw firm conclusions about the treatment's effectiveness, including any quantification of mean level of relief from noncancer pain, the investigators concluded. All of the studies had low internal validity, making it highly likely that future studies could overturn their findings.

Among 3,040 patients treated with oral opioids, 23% discontinued treatment due to adverse effects and 10% dropped out of the trials because of insufficient pain relief. Among 1,628 on transdermal opioids, 12% stopped due to adverse effects and 6% stopped due to insufficient pain relief. Intrathecal pumps delivered opioids in 231 patients who could not find pain relief any other way; of these, 9% stopped due to adverse effects and 8% dropped out due to insufficient pain relief.

One of the studies in the review was a randomized trial comparing two opioids; the other 25 studies were case series or uncontrolled continuations of short-term trials of opioids for noncancer pain. None of the studies included comparisons with placebo or nonopioid therapies.

The only other systematic review of long-term opioid use for chronic noncancer pain was a 2008 study by the same investigators that used somewhat different methodology.

All of the patients had been taking opioids for at least 6 months after failing previous nonopioid therapy for noncancer pain of at least 3 months duration, mainly chronic back pain, severe osteoarthritis, or pain related to nerve damage.

Solid estimates are lacking for the number of people with chronic noncancer pain who are taking opioids long-term and what they are taking. Two U.S. studies suggest that 0.65% of people with medical insurance use opioids chronically and that 10% of people who claimed insurance coverage for opioids had at least a 3-month supply.

The Cochrane Collaboration is an international nonprofit, independent organization focused on systematic reviews of health care interventions.

However, three pain experts said in interviews that they fear clinicians might read too much into the review's limited findings.

The report is “very encouraging, but it's far from the whole story,” said Dr. Perry Fine said. A literature review doesn't necessarily reflect concerns in real-life practices. Because there are no good substitutes for opioids on the horizon, physicians need to find ways to make long-term opioid use more effective and safe, he said.

Dr. Fine, president of the American Academy of Pain Medicine (AAPM) and professor of anesthesiology at the University of Utah, Salt Lake City, compared current use of long-term opioids for noncancer pain with the use of surgical anesthesia 20–30 years ago when it was associated with significant morbidity and mortality.

“That didn't stop us from doing surgical procedures when necessary,” but it did motivate research and improvements in patient selection, monitoring, and dosing that led to the very low rates of morbidity and mortality with anesthesia today.

Dr. Adrian Bartoli, a pain specialist practicing in San Francisco, said he was disappointed that the authors of the review implied that patients who have had a prior problem with addiction should be excluded from opioid therapy for chronic noncancer pain. “There's nothing in this analysis that would suggest that. That was their opinion,” he said.

He also felt that the review muddled concepts of pain and addiction, referring to addiction in terms of tolerance and dependence, which are very different concepts.

“I got the sense that they felt that patients could be imbued with addiction by taking a medicine like a narcotic,” Dr. Bartoli said. “It's a genetically predisposed condition.”

On the other hand, he worried that the report of a very low rate of addiction may lead primary care physicians, in particular, to put patients with chronic noncancer pain on long-term opioids without sufficiently considering other remedies or medications.

“The pharmaceutical industry over the past 10 years has been incredibly strong in trying to move these narcotics onto the market and to put the primary care physicians at ease that they are not prescribing something that has a risk of addiction or abuse,” he said. “This review probably is going to reinforce that. Ultimately, there are pros and cons to that occurring.”

Primary care internist Dr. Roger Chou agreed, saying that the 0.3% rate of addiction reported is “a little misleading, because it's based on pretty crummy data.” The review's findings on addiction, pain relief, and adverse events apply to very select groups of patients, not the more complicated cases that raise concerns for physicians considering long-term opioids.

Mainly, the review shows how little is known about prescribing long-term opioids, suggested Dr. Chou, of Oregon Health and Science University, Portland, and lead author of clinical guidelines on chronic opioids for noncancer pain by the American Pain Society and the AAPM.

“We really don't have good quality, long-term data on this, which is scary because we're prescribing these medications so much,” Dr. Chou said. Over the past 2 decades, “we have been prescribing more, but we're also prescribing higher doses and more Schedule II drugs,” which have a higher potential for abuse.

None of these commentators were associated with the Cochrane review. Dr. Bartoli and Dr. Chou reported no potential conflicts of interest. Dr. Fine has been a speaker for Wyeth and an adviser and consultant for many pharmaceutical companies that manufacture opioids.

The 0.3% rate of addiction reported is 'a little misleading, because it's based on pretty crummy data.'

Source DR. CHOUwww.nejm.org

Major Finding: When opioids were used long-term for noncancer pain, 6%-23% of patients stopped taking them due to inefficacy or side effects and 0.3% developed signs of addiction.

Data Source: Cochrane Collaboration review of 26 clinical studies with 4,893 participants.

Disclosures: None.

One of the first systematic reviews of data on long-term use of opioids found weak evidence to support the idea that adults who can take chronic opioids get chronic pain relief, though effects on function or quality of life are unclear.

In a Cochrane Collaboration review of 26 prospective studies with 4,893 participants, 6%-23% of patients dropped out of the clinical trials (depending on the route of drug administration) due to inefficacy or side effects, but those who finished the studies maintained clinically significant reductions in pain during up to 48 months of opioid use, Meredith Noble and her associates reported.

The review also suggested that opioid abuse or addiction were rare, but acknowledged that the findings are compromised by the limited quantity and poor quality of the studies. Only 7 (0.3%) of 2,613 patients developed signs of addiction or took their medicine inappropriately in the studies that reported those outcomes (Cochrane Database Syst. Rev. 2010 [doi: 10.1002/ 14651858.CD006605]).

Most of the studies excluded patients with risk factors for abuse. The low rate of addiction may be generalizable only to patients with no history of abuse or addiction, wrote Ms. Noble, a senior research analyst at the Economic Cycle Research Institute, one of 14 evidence-based practice centers under the U.S. Agency for Healthcare Research and Quality. A previous study suggested that addiction or abuse may develop in 3% of patients in all studies of opioid use for chronic pain and in 0.2% of patients in studies that screened out participants with a history of abuse or addiction (Pain Med. 2008;9:444–59).

The evidence of long-term relief of noncancer pain with chronic opioid use was too sparse in the current review to draw firm conclusions about the treatment's effectiveness, including any quantification of mean level of relief from noncancer pain, the investigators concluded. All of the studies had low internal validity, making it highly likely that future studies could overturn their findings.

Among 3,040 patients treated with oral opioids, 23% discontinued treatment due to adverse effects and 10% dropped out of the trials because of insufficient pain relief. Among 1,628 on transdermal opioids, 12% stopped due to adverse effects and 6% stopped due to insufficient pain relief. Intrathecal pumps delivered opioids in 231 patients who could not find pain relief any other way; of these, 9% stopped due to adverse effects and 8% dropped out due to insufficient pain relief.

One of the studies in the review was a randomized trial comparing two opioids; the other 25 studies were case series or uncontrolled continuations of short-term trials of opioids for noncancer pain. None of the studies included comparisons with placebo or nonopioid therapies.

The only other systematic review of long-term opioid use for chronic noncancer pain was a 2008 study by the same investigators that used somewhat different methodology.

All of the patients had been taking opioids for at least 6 months after failing previous nonopioid therapy for noncancer pain of at least 3 months duration, mainly chronic back pain, severe osteoarthritis, or pain related to nerve damage.

Solid estimates are lacking for the number of people with chronic noncancer pain who are taking opioids long-term and what they are taking. Two U.S. studies suggest that 0.65% of people with medical insurance use opioids chronically and that 10% of people who claimed insurance coverage for opioids had at least a 3-month supply.

The Cochrane Collaboration is an international nonprofit, independent organization focused on systematic reviews of health care interventions.

However, three pain experts said in interviews that they fear clinicians might read too much into the review's limited findings.

The report is “very encouraging, but it's far from the whole story,” said Dr. Perry Fine said. A literature review doesn't necessarily reflect concerns in real-life practices. Because there are no good substitutes for opioids on the horizon, physicians need to find ways to make long-term opioid use more effective and safe, he said.

Dr. Fine, president of the American Academy of Pain Medicine (AAPM) and professor of anesthesiology at the University of Utah, Salt Lake City, compared current use of long-term opioids for noncancer pain with the use of surgical anesthesia 20–30 years ago when it was associated with significant morbidity and mortality.

“That didn't stop us from doing surgical procedures when necessary,” but it did motivate research and improvements in patient selection, monitoring, and dosing that led to the very low rates of morbidity and mortality with anesthesia today.

Dr. Adrian Bartoli, a pain specialist practicing in San Francisco, said he was disappointed that the authors of the review implied that patients who have had a prior problem with addiction should be excluded from opioid therapy for chronic noncancer pain. “There's nothing in this analysis that would suggest that. That was their opinion,” he said.

He also felt that the review muddled concepts of pain and addiction, referring to addiction in terms of tolerance and dependence, which are very different concepts.

“I got the sense that they felt that patients could be imbued with addiction by taking a medicine like a narcotic,” Dr. Bartoli said. “It's a genetically predisposed condition.”

On the other hand, he worried that the report of a very low rate of addiction may lead primary care physicians, in particular, to put patients with chronic noncancer pain on long-term opioids without sufficiently considering other remedies or medications.

“The pharmaceutical industry over the past 10 years has been incredibly strong in trying to move these narcotics onto the market and to put the primary care physicians at ease that they are not prescribing something that has a risk of addiction or abuse,” he said. “This review probably is going to reinforce that. Ultimately, there are pros and cons to that occurring.”

Primary care internist Dr. Roger Chou agreed, saying that the 0.3% rate of addiction reported is “a little misleading, because it's based on pretty crummy data.” The review's findings on addiction, pain relief, and adverse events apply to very select groups of patients, not the more complicated cases that raise concerns for physicians considering long-term opioids.

Mainly, the review shows how little is known about prescribing long-term opioids, suggested Dr. Chou, of Oregon Health and Science University, Portland, and lead author of clinical guidelines on chronic opioids for noncancer pain by the American Pain Society and the AAPM.

“We really don't have good quality, long-term data on this, which is scary because we're prescribing these medications so much,” Dr. Chou said. Over the past 2 decades, “we have been prescribing more, but we're also prescribing higher doses and more Schedule II drugs,” which have a higher potential for abuse.

None of these commentators were associated with the Cochrane review. Dr. Bartoli and Dr. Chou reported no potential conflicts of interest. Dr. Fine has been a speaker for Wyeth and an adviser and consultant for many pharmaceutical companies that manufacture opioids.

The 0.3% rate of addiction reported is 'a little misleading, because it's based on pretty crummy data.'

Source DR. CHOUwww.nejm.org

SAN FRANCISCO – A study of female undergraduates found significant correlations among three problems: psychological aggression by an intimate partner, alcohol-related problems, and proneness to suicide.

College counseling centers should assess women who are suspected of being at risk for suicide or health-harming behaviors for partner violence victimization and alcohol-related problems, Dorian Lamis said at the annual meeting of the American Society of Suicidology.

The study of 713 women found that psychological aggression by an intimate partner was significantly correlated with alcohol-related problems, and alcohol-related problems were significantly correlated with suicide proneness. Alcohol-related problems emerged as a significant mediator between the experience of psychological abuse and subsequent suicide proneness, reported Mr. Lamis of the University of South Carolina, Columbia, and his associates.

The women volunteered for the study and received extra academic credit for completing the Revised Conflict Tactics Scales (a psychological aggression subscale), the Rutgers Alcohol Problems Index (assessing problems related to alcohol use within the previous year), and the Life Attitudes Schedule-Short Form (assessing current suicide proneness).

The findings were limited by the homogeneous sample of subjects, who were all female, 76% European American, and mostly freshmen or sophomores.

The data were self-reported and cross-sectional, which might also have limited the significance of the findings.

SAN FRANCISCO – A study of female undergraduates found significant correlations among three problems: psychological aggression by an intimate partner, alcohol-related problems, and proneness to suicide.

College counseling centers should assess women who are suspected of being at risk for suicide or health-harming behaviors for partner violence victimization and alcohol-related problems, Dorian Lamis said at the annual meeting of the American Society of Suicidology.

The study of 713 women found that psychological aggression by an intimate partner was significantly correlated with alcohol-related problems, and alcohol-related problems were significantly correlated with suicide proneness. Alcohol-related problems emerged as a significant mediator between the experience of psychological abuse and subsequent suicide proneness, reported Mr. Lamis of the University of South Carolina, Columbia, and his associates.

The women volunteered for the study and received extra academic credit for completing the Revised Conflict Tactics Scales (a psychological aggression subscale), the Rutgers Alcohol Problems Index (assessing problems related to alcohol use within the previous year), and the Life Attitudes Schedule-Short Form (assessing current suicide proneness).

The findings were limited by the homogeneous sample of subjects, who were all female, 76% European American, and mostly freshmen or sophomores.

The data were self-reported and cross-sectional, which might also have limited the significance of the findings.

SAN FRANCISCO – A study of female undergraduates found significant correlations among three problems: psychological aggression by an intimate partner, alcohol-related problems, and proneness to suicide.

College counseling centers should assess women who are suspected of being at risk for suicide or health-harming behaviors for partner violence victimization and alcohol-related problems, Dorian Lamis said at the annual meeting of the American Society of Suicidology.

The study of 713 women found that psychological aggression by an intimate partner was significantly correlated with alcohol-related problems, and alcohol-related problems were significantly correlated with suicide proneness. Alcohol-related problems emerged as a significant mediator between the experience of psychological abuse and subsequent suicide proneness, reported Mr. Lamis of the University of South Carolina, Columbia, and his associates.

The women volunteered for the study and received extra academic credit for completing the Revised Conflict Tactics Scales (a psychological aggression subscale), the Rutgers Alcohol Problems Index (assessing problems related to alcohol use within the previous year), and the Life Attitudes Schedule-Short Form (assessing current suicide proneness).

The findings were limited by the homogeneous sample of subjects, who were all female, 76% European American, and mostly freshmen or sophomores.

The data were self-reported and cross-sectional, which might also have limited the significance of the findings.

SAN FRANCISCO — A year-long pilot study found Pneumocystis carinii DNA in initial oropharyngeal wash results of 10 of 104 health care workers, and 7 more converted from negative to positive tests on subsequent gargle tests.

Among a control group of 61 other staff (administrative, financial, and janitorial staff) who reported having no direct patient-care responsibilities, none tested positive for P. carinii, Dr. Laurence Huang said at a meeting on HIV management sponsored by the University of California, San Francisco.

The implications are not clear. “Is finding Pneumocystis DNA in a gargle representative of dead or alive organisms? Are we colonized, or carriers? Are we infectious to our patients?” asked Dr. Huang, professor of medicine at the university.

He and his associates tested oropharyngeal wash specimens monthly and serum specimens quarterly and asked subjects to complete a questionnaire. The 17 health care workers (doctors, nurses, and a respiratory therapist) with P. carinii DNA in gargle results accumulated 28 positive gargle tests. Two of the health care workers each had five tests that were positive for P. carinii.

Unlike the control group, all of the health care workers with P. carinii reported on questionnaires that they had been exposed to patients with HIV and/or P. carinii pneumonia, with the most recent exposure ranging from 1 hour ago to more than a month ago.

The findings support a previous study by Dr. Huang and his associates that found significantly higher Pneumocystis antibody levels in the blood of 103 clinicians, compared with 23 nonclinical staff (Emerg. Infect. Dis. 2009;15:1590–7).

Previous studies have suggested that P. carinii pneumonia can be transmitted between people in hospitals and clinics, he added. People without P. carinii pneumonia shown to be colonized with P. carinii include some infants and children, pregnant women, people with lung disease, people with HIV, and HIV-negative immunocompromised patients.

Disclosures: Dr. Huang reported having no relevant conflicts of interest.

SAN FRANCISCO — A year-long pilot study found Pneumocystis carinii DNA in initial oropharyngeal wash results of 10 of 104 health care workers, and 7 more converted from negative to positive tests on subsequent gargle tests.

Among a control group of 61 other staff (administrative, financial, and janitorial staff) who reported having no direct patient-care responsibilities, none tested positive for P. carinii, Dr. Laurence Huang said at a meeting on HIV management sponsored by the University of California, San Francisco.

The implications are not clear. “Is finding Pneumocystis DNA in a gargle representative of dead or alive organisms? Are we colonized, or carriers? Are we infectious to our patients?” asked Dr. Huang, professor of medicine at the university.

He and his associates tested oropharyngeal wash specimens monthly and serum specimens quarterly and asked subjects to complete a questionnaire. The 17 health care workers (doctors, nurses, and a respiratory therapist) with P. carinii DNA in gargle results accumulated 28 positive gargle tests. Two of the health care workers each had five tests that were positive for P. carinii.

Unlike the control group, all of the health care workers with P. carinii reported on questionnaires that they had been exposed to patients with HIV and/or P. carinii pneumonia, with the most recent exposure ranging from 1 hour ago to more than a month ago.

The findings support a previous study by Dr. Huang and his associates that found significantly higher Pneumocystis antibody levels in the blood of 103 clinicians, compared with 23 nonclinical staff (Emerg. Infect. Dis. 2009;15:1590–7).

Previous studies have suggested that P. carinii pneumonia can be transmitted between people in hospitals and clinics, he added. People without P. carinii pneumonia shown to be colonized with P. carinii include some infants and children, pregnant women, people with lung disease, people with HIV, and HIV-negative immunocompromised patients.

Disclosures: Dr. Huang reported having no relevant conflicts of interest.

SAN FRANCISCO — A year-long pilot study found Pneumocystis carinii DNA in initial oropharyngeal wash results of 10 of 104 health care workers, and 7 more converted from negative to positive tests on subsequent gargle tests.

Among a control group of 61 other staff (administrative, financial, and janitorial staff) who reported having no direct patient-care responsibilities, none tested positive for P. carinii, Dr. Laurence Huang said at a meeting on HIV management sponsored by the University of California, San Francisco.

The implications are not clear. “Is finding Pneumocystis DNA in a gargle representative of dead or alive organisms? Are we colonized, or carriers? Are we infectious to our patients?” asked Dr. Huang, professor of medicine at the university.

He and his associates tested oropharyngeal wash specimens monthly and serum specimens quarterly and asked subjects to complete a questionnaire. The 17 health care workers (doctors, nurses, and a respiratory therapist) with P. carinii DNA in gargle results accumulated 28 positive gargle tests. Two of the health care workers each had five tests that were positive for P. carinii.

Unlike the control group, all of the health care workers with P. carinii reported on questionnaires that they had been exposed to patients with HIV and/or P. carinii pneumonia, with the most recent exposure ranging from 1 hour ago to more than a month ago.

The findings support a previous study by Dr. Huang and his associates that found significantly higher Pneumocystis antibody levels in the blood of 103 clinicians, compared with 23 nonclinical staff (Emerg. Infect. Dis. 2009;15:1590–7).

Previous studies have suggested that P. carinii pneumonia can be transmitted between people in hospitals and clinics, he added. People without P. carinii pneumonia shown to be colonized with P. carinii include some infants and children, pregnant women, people with lung disease, people with HIV, and HIV-negative immunocompromised patients.

Disclosures: Dr. Huang reported having no relevant conflicts of interest.

SAN FRANCISCO — Kaposi's sarcoma in HIV patients is turning up again—sometimes in a surprisingly deadly form and other times in an indolent, nonthreatening form—according to two experts.

Kaposi's sarcoma (KS) used to be one of the signature complications of AIDS before antiretroviral therapy, Dr. Deborah Greenspan said at a meeting on the medical management of HIV and AIDS sponsored by the University of California, San Francisco.

“We're starting to see Kaposi's sarcoma again,” presenting as oral lesions in patients who have started antiretroviral therapy for HIV but who still have low CD4 cell counts.

KS has a predilection for the palate in HIV patients, for reasons that have never been understood, said Dr. Greenspan, professor and chair of orofacial sciences and distinguished professor of dentistry at UCSF. Oral KS typically appears as a flat, plaquelike lesion on the hard or soft palate. Looking in the mouth can be a key step to diagnosing KS, she said.

“Years ago, KS seemed to disappear right off the radar screen, but it is back. We are seeing a lot of Kaposi's sarcoma,” Dr. Toby A. Maurer, an associate professor of clinical dermatology at UCSF said in a separate presentation. On the skin, early KS shows up as flat lesions. “We're all for early diagnosis, so look, look, look” for KS lesions, she urged.

She and her colleagues were surprised recently by the lethality of KS after they followed 65 of their patients being treated with antiretroviral therapy for HIV and with chemotherapy for KS. “We were shocked to find out that 25% of that cohort died of their Kaposi's sarcoma, even when they had chemotherapy,” she said.

A separate case series in Seattle found that 23% of patients who were on antiretroviral therapy for HIV and who received adequate chemotherapy for KS died of the cancer. “This is quite alarming,” Dr. Maurer said.

Clinical trials are planned to measure KS response to antiretroviral treatment and chemotherapy and to try to find new ways of identifying organ involvement in KS, she said. MRI and PET scans cannot spot internal organ involvement of KS, so “by the time you find internal involvement, it may be quite late.”

Physicians should always biopsy lesions they think might be KS, she advised. On darker-pigmented skin, it can be difficult to differentiate KS from other lesions without a biopsy. The biopsy also provides important information as to whether the patient needs chemotherapy, as many with KS do.

Most patients who have not started treatment for HIV or KS should see their KS resolve within 9 months of starting antiretrovirals. Dr. Maurer and her associates are collecting immunology and laboratory test results at baseline and after 9 months of therapy in a study to compare response in patients. “Please send us your KS patients” who have not started antiretroviral therapy. “We would be very happy to biopsy them,” she said.

A less-threatening form of KS is also starting to turn up for the first time in relatively young patients with HIV. “They develop what looks to us like 'old man's Kaposi's sarcoma'—that is, Mediterranean, classical-type KS,” Dr. Maurer said.

These are patients who develop small areas of KS, usually on the lower legs and feet, after having HIV for 17-20 years. Their HIV has been suppressed for at least 2 years (“usually much longer than that,” she noted) on antiretroviral therapy, and they have relatively healthy CD4 counts of 300-600 cells/mm

“We think that they are showing signs of immune aging,” and preliminary studies suggest this is the case, she said. In several years of follow-up, none have had exacerbations or internal involvement of KS, and none have needed chemotherapy. “This Kaposi's sarcoma seems very indolent and is not going anywhere,” Dr. Maurer said.

Disclosures: Dr. Maurer and Dr. Greenspan reported having no relevant conflicts of interest.

SAN FRANCISCO — Kaposi's sarcoma in HIV patients is turning up again—sometimes in a surprisingly deadly form and other times in an indolent, nonthreatening form—according to two experts.

Kaposi's sarcoma (KS) used to be one of the signature complications of AIDS before antiretroviral therapy, Dr. Deborah Greenspan said at a meeting on the medical management of HIV and AIDS sponsored by the University of California, San Francisco.

“We're starting to see Kaposi's sarcoma again,” presenting as oral lesions in patients who have started antiretroviral therapy for HIV but who still have low CD4 cell counts.

KS has a predilection for the palate in HIV patients, for reasons that have never been understood, said Dr. Greenspan, professor and chair of orofacial sciences and distinguished professor of dentistry at UCSF. Oral KS typically appears as a flat, plaquelike lesion on the hard or soft palate. Looking in the mouth can be a key step to diagnosing KS, she said.

“Years ago, KS seemed to disappear right off the radar screen, but it is back. We are seeing a lot of Kaposi's sarcoma,” Dr. Toby A. Maurer, an associate professor of clinical dermatology at UCSF said in a separate presentation. On the skin, early KS shows up as flat lesions. “We're all for early diagnosis, so look, look, look” for KS lesions, she urged.

She and her colleagues were surprised recently by the lethality of KS after they followed 65 of their patients being treated with antiretroviral therapy for HIV and with chemotherapy for KS. “We were shocked to find out that 25% of that cohort died of their Kaposi's sarcoma, even when they had chemotherapy,” she said.

A separate case series in Seattle found that 23% of patients who were on antiretroviral therapy for HIV and who received adequate chemotherapy for KS died of the cancer. “This is quite alarming,” Dr. Maurer said.

Clinical trials are planned to measure KS response to antiretroviral treatment and chemotherapy and to try to find new ways of identifying organ involvement in KS, she said. MRI and PET scans cannot spot internal organ involvement of KS, so “by the time you find internal involvement, it may be quite late.”

Physicians should always biopsy lesions they think might be KS, she advised. On darker-pigmented skin, it can be difficult to differentiate KS from other lesions without a biopsy. The biopsy also provides important information as to whether the patient needs chemotherapy, as many with KS do.

Most patients who have not started treatment for HIV or KS should see their KS resolve within 9 months of starting antiretrovirals. Dr. Maurer and her associates are collecting immunology and laboratory test results at baseline and after 9 months of therapy in a study to compare response in patients. “Please send us your KS patients” who have not started antiretroviral therapy. “We would be very happy to biopsy them,” she said.

A less-threatening form of KS is also starting to turn up for the first time in relatively young patients with HIV. “They develop what looks to us like 'old man's Kaposi's sarcoma'—that is, Mediterranean, classical-type KS,” Dr. Maurer said.

These are patients who develop small areas of KS, usually on the lower legs and feet, after having HIV for 17-20 years. Their HIV has been suppressed for at least 2 years (“usually much longer than that,” she noted) on antiretroviral therapy, and they have relatively healthy CD4 counts of 300-600 cells/mm

“We think that they are showing signs of immune aging,” and preliminary studies suggest this is the case, she said. In several years of follow-up, none have had exacerbations or internal involvement of KS, and none have needed chemotherapy. “This Kaposi's sarcoma seems very indolent and is not going anywhere,” Dr. Maurer said.

Disclosures: Dr. Maurer and Dr. Greenspan reported having no relevant conflicts of interest.

SAN FRANCISCO — Kaposi's sarcoma in HIV patients is turning up again—sometimes in a surprisingly deadly form and other times in an indolent, nonthreatening form—according to two experts.

Kaposi's sarcoma (KS) used to be one of the signature complications of AIDS before antiretroviral therapy, Dr. Deborah Greenspan said at a meeting on the medical management of HIV and AIDS sponsored by the University of California, San Francisco.

“We're starting to see Kaposi's sarcoma again,” presenting as oral lesions in patients who have started antiretroviral therapy for HIV but who still have low CD4 cell counts.

KS has a predilection for the palate in HIV patients, for reasons that have never been understood, said Dr. Greenspan, professor and chair of orofacial sciences and distinguished professor of dentistry at UCSF. Oral KS typically appears as a flat, plaquelike lesion on the hard or soft palate. Looking in the mouth can be a key step to diagnosing KS, she said.

“Years ago, KS seemed to disappear right off the radar screen, but it is back. We are seeing a lot of Kaposi's sarcoma,” Dr. Toby A. Maurer, an associate professor of clinical dermatology at UCSF said in a separate presentation. On the skin, early KS shows up as flat lesions. “We're all for early diagnosis, so look, look, look” for KS lesions, she urged.

She and her colleagues were surprised recently by the lethality of KS after they followed 65 of their patients being treated with antiretroviral therapy for HIV and with chemotherapy for KS. “We were shocked to find out that 25% of that cohort died of their Kaposi's sarcoma, even when they had chemotherapy,” she said.

A separate case series in Seattle found that 23% of patients who were on antiretroviral therapy for HIV and who received adequate chemotherapy for KS died of the cancer. “This is quite alarming,” Dr. Maurer said.

Clinical trials are planned to measure KS response to antiretroviral treatment and chemotherapy and to try to find new ways of identifying organ involvement in KS, she said. MRI and PET scans cannot spot internal organ involvement of KS, so “by the time you find internal involvement, it may be quite late.”

Physicians should always biopsy lesions they think might be KS, she advised. On darker-pigmented skin, it can be difficult to differentiate KS from other lesions without a biopsy. The biopsy also provides important information as to whether the patient needs chemotherapy, as many with KS do.

Most patients who have not started treatment for HIV or KS should see their KS resolve within 9 months of starting antiretrovirals. Dr. Maurer and her associates are collecting immunology and laboratory test results at baseline and after 9 months of therapy in a study to compare response in patients. “Please send us your KS patients” who have not started antiretroviral therapy. “We would be very happy to biopsy them,” she said.

A less-threatening form of KS is also starting to turn up for the first time in relatively young patients with HIV. “They develop what looks to us like 'old man's Kaposi's sarcoma'—that is, Mediterranean, classical-type KS,” Dr. Maurer said.

These are patients who develop small areas of KS, usually on the lower legs and feet, after having HIV for 17-20 years. Their HIV has been suppressed for at least 2 years (“usually much longer than that,” she noted) on antiretroviral therapy, and they have relatively healthy CD4 counts of 300-600 cells/mm

“We think that they are showing signs of immune aging,” and preliminary studies suggest this is the case, she said. In several years of follow-up, none have had exacerbations or internal involvement of KS, and none have needed chemotherapy. “This Kaposi's sarcoma seems very indolent and is not going anywhere,” Dr. Maurer said.

Disclosures: Dr. Maurer and Dr. Greenspan reported having no relevant conflicts of interest.

SAN FRANCISCO — Treating metabolic abnormalities in patients with schizophrenia may be a better way to deal with insulin resistance or dyslipidemia than switching antipsychotics, Dr. Sun H. Kim suggests.

Second-generation antipsychotics can cause weight gain, and some data suggest that these drugs may have direct effects on insulin resistance and the risk for diabetes, independent of body mass index. The psychiatric literature has focused on managing patients with schizophrenia who develop metabolic abnormalities by switching second-generation antipsychotics, because some drugs are associated with less weight gain than others.

The few studies on the topic, however, suggest that this strategy doesn't work and can psychiatrically harm patients who were stable on medication before switching, she said at the Sixth Annual World Congress on the Insulin Resistance Syndrome.

“Switching isn't likely to resolve their existing metabolic abnormalities,” said Dr. Kim of Stanford (Calif.) University. “I think there should be more focus on directly treating the abnormalities.”

A pilot study by Dr. Kim and her associates included 15 young outpatients with schizophrenia and a fasting glucose of 126 mg/dL or lower who tried to switch therapy after gaining more than 10 kg on a second-generation antipsychotic medication. They were obese (with a mean BMI of 34 mg/kg

Oral glucose tolerance tests at baseline showed that 47% had diabetes (20%) or impaired glucose tolerance (27%). The mean fasting glucose was 97 mg/dL, and the mean 2-hour glucose was 150 mg/dL. “Based on our measurements, three-quarters of them were highly insulin resistant,” Dr. Kim said. The patients had been taking quetiapine, olanzapine, risperidone, ziprasidone, or clozapine.

When they tried to switch to the antipsychotic aripiprazole, five patients (33%) could not tolerate the switch psychiatrically. After 4 months on aripiprazole, 3 of the other 10 patients had lost 6-13 kg, 1 patient had no change in weight, and 6 patients gained 1-11 kg. As a group, the mean weight did not change significantly. The weight changes “didn't have a tremendous impact on insulin resistance,” she said, and no significant changes were seen in mean BMI, waist circumference, total triglycerides, HDL or LDL cholesterol levels, plasma glucose levels, or steady state plasma glucose (J. Clin. Psychopharmacol. 2007;27:365-8).

A larger, multicenter study by other investigators of 173 patients with schizophrenia or schizoaffective disorder who were being treated with olanzapine randomized them to continue on olanzapine (85 patients) or switch to aripiprazole (88 patients). The cohort had a mean BMI of 27 kg/m

Dropout rates were high in both groups—36% on aripiprazole and 26% on olanzapine. By the end of the 16-week study, mean weight had increased by 1.4 kg in the olanzapine group and decreased by 1.8 kg in the aripiprazole group—not an impressive change, Dr. Kim said. A slight benefit in triglyceride levels was seen in the aripiprazole group (a 14% decrease), compared with the olanzapine group (a 5% increase), but there were no significant changes in fasting glucose or insulin resistance. The Clinical Global Impressions–Improvement scores were statistically better with olanzapine than with aripiprazole, she added (J. Clin. Psychiatry 2008;69:1046-56).

“You have to weigh the risks and benefits of switching someone who is stable psychiatrically on one of these medications,” and aggressively manage their metabolic abnormalities, she said.

Disclosures: Dr. Kim has received research funding from Eli Lilly & Co.

SAN FRANCISCO — Treating metabolic abnormalities in patients with schizophrenia may be a better way to deal with insulin resistance or dyslipidemia than switching antipsychotics, Dr. Sun H. Kim suggests.

Second-generation antipsychotics can cause weight gain, and some data suggest that these drugs may have direct effects on insulin resistance and the risk for diabetes, independent of body mass index. The psychiatric literature has focused on managing patients with schizophrenia who develop metabolic abnormalities by switching second-generation antipsychotics, because some drugs are associated with less weight gain than others.

The few studies on the topic, however, suggest that this strategy doesn't work and can psychiatrically harm patients who were stable on medication before switching, she said at the Sixth Annual World Congress on the Insulin Resistance Syndrome.

“Switching isn't likely to resolve their existing metabolic abnormalities,” said Dr. Kim of Stanford (Calif.) University. “I think there should be more focus on directly treating the abnormalities.”

A pilot study by Dr. Kim and her associates included 15 young outpatients with schizophrenia and a fasting glucose of 126 mg/dL or lower who tried to switch therapy after gaining more than 10 kg on a second-generation antipsychotic medication. They were obese (with a mean BMI of 34 mg/kg

Oral glucose tolerance tests at baseline showed that 47% had diabetes (20%) or impaired glucose tolerance (27%). The mean fasting glucose was 97 mg/dL, and the mean 2-hour glucose was 150 mg/dL. “Based on our measurements, three-quarters of them were highly insulin resistant,” Dr. Kim said. The patients had been taking quetiapine, olanzapine, risperidone, ziprasidone, or clozapine.

When they tried to switch to the antipsychotic aripiprazole, five patients (33%) could not tolerate the switch psychiatrically. After 4 months on aripiprazole, 3 of the other 10 patients had lost 6-13 kg, 1 patient had no change in weight, and 6 patients gained 1-11 kg. As a group, the mean weight did not change significantly. The weight changes “didn't have a tremendous impact on insulin resistance,” she said, and no significant changes were seen in mean BMI, waist circumference, total triglycerides, HDL or LDL cholesterol levels, plasma glucose levels, or steady state plasma glucose (J. Clin. Psychopharmacol. 2007;27:365-8).

A larger, multicenter study by other investigators of 173 patients with schizophrenia or schizoaffective disorder who were being treated with olanzapine randomized them to continue on olanzapine (85 patients) or switch to aripiprazole (88 patients). The cohort had a mean BMI of 27 kg/m

Dropout rates were high in both groups—36% on aripiprazole and 26% on olanzapine. By the end of the 16-week study, mean weight had increased by 1.4 kg in the olanzapine group and decreased by 1.8 kg in the aripiprazole group—not an impressive change, Dr. Kim said. A slight benefit in triglyceride levels was seen in the aripiprazole group (a 14% decrease), compared with the olanzapine group (a 5% increase), but there were no significant changes in fasting glucose or insulin resistance. The Clinical Global Impressions–Improvement scores were statistically better with olanzapine than with aripiprazole, she added (J. Clin. Psychiatry 2008;69:1046-56).

“You have to weigh the risks and benefits of switching someone who is stable psychiatrically on one of these medications,” and aggressively manage their metabolic abnormalities, she said.

Disclosures: Dr. Kim has received research funding from Eli Lilly & Co.

SAN FRANCISCO — Treating metabolic abnormalities in patients with schizophrenia may be a better way to deal with insulin resistance or dyslipidemia than switching antipsychotics, Dr. Sun H. Kim suggests.

Second-generation antipsychotics can cause weight gain, and some data suggest that these drugs may have direct effects on insulin resistance and the risk for diabetes, independent of body mass index. The psychiatric literature has focused on managing patients with schizophrenia who develop metabolic abnormalities by switching second-generation antipsychotics, because some drugs are associated with less weight gain than others.

The few studies on the topic, however, suggest that this strategy doesn't work and can psychiatrically harm patients who were stable on medication before switching, she said at the Sixth Annual World Congress on the Insulin Resistance Syndrome.

“Switching isn't likely to resolve their existing metabolic abnormalities,” said Dr. Kim of Stanford (Calif.) University. “I think there should be more focus on directly treating the abnormalities.”

A pilot study by Dr. Kim and her associates included 15 young outpatients with schizophrenia and a fasting glucose of 126 mg/dL or lower who tried to switch therapy after gaining more than 10 kg on a second-generation antipsychotic medication. They were obese (with a mean BMI of 34 mg/kg

Oral glucose tolerance tests at baseline showed that 47% had diabetes (20%) or impaired glucose tolerance (27%). The mean fasting glucose was 97 mg/dL, and the mean 2-hour glucose was 150 mg/dL. “Based on our measurements, three-quarters of them were highly insulin resistant,” Dr. Kim said. The patients had been taking quetiapine, olanzapine, risperidone, ziprasidone, or clozapine.

When they tried to switch to the antipsychotic aripiprazole, five patients (33%) could not tolerate the switch psychiatrically. After 4 months on aripiprazole, 3 of the other 10 patients had lost 6-13 kg, 1 patient had no change in weight, and 6 patients gained 1-11 kg. As a group, the mean weight did not change significantly. The weight changes “didn't have a tremendous impact on insulin resistance,” she said, and no significant changes were seen in mean BMI, waist circumference, total triglycerides, HDL or LDL cholesterol levels, plasma glucose levels, or steady state plasma glucose (J. Clin. Psychopharmacol. 2007;27:365-8).

A larger, multicenter study by other investigators of 173 patients with schizophrenia or schizoaffective disorder who were being treated with olanzapine randomized them to continue on olanzapine (85 patients) or switch to aripiprazole (88 patients). The cohort had a mean BMI of 27 kg/m

Dropout rates were high in both groups—36% on aripiprazole and 26% on olanzapine. By the end of the 16-week study, mean weight had increased by 1.4 kg in the olanzapine group and decreased by 1.8 kg in the aripiprazole group—not an impressive change, Dr. Kim said. A slight benefit in triglyceride levels was seen in the aripiprazole group (a 14% decrease), compared with the olanzapine group (a 5% increase), but there were no significant changes in fasting glucose or insulin resistance. The Clinical Global Impressions–Improvement scores were statistically better with olanzapine than with aripiprazole, she added (J. Clin. Psychiatry 2008;69:1046-56).

“You have to weigh the risks and benefits of switching someone who is stable psychiatrically on one of these medications,” and aggressively manage their metabolic abnormalities, she said.

Disclosures: Dr. Kim has received research funding from Eli Lilly & Co.