Research / Poster Presentations
The goal of the Annual Program Planning Committee is to provide educational activities of excellent quality on a wide variety of dermatology nursing related topics. Members and non-members of the Dermatology Nurses' Association are invited to submit abstracts for poster presentations at the Annual Convention.
The following research posters were presented at the 25th Annual Convention, "Embracing the Future of Dermatology Nursing," February 1-4, 2007 in Washington, D.C. To view a list of all posters presented at the meeting, click here.
A Cost Analysis of Daycare Treatment Program
Judith Gerbrandt, Elaine Stebbing, Harvey Lui, Jerry Shapiro, Youwen Zhou
Background: Long considered the benchmark treatment for chronic recalcitrant psoriasis, the daycare program has recently been relegated to the back seat by the new biological treatment modalities. While the high costs of these newer treatments are readily available, an analysis of the costs of the daycare program has not been well documented.
Objective: The goal of this study is to calculate the cost of the Psoriasis Daycare program in the Vancouver Psoriasis & Phototherapy Clinic based on the cost of topical medications and labour/manpower schedule for nurses and Medical Services Plan payments to medical staff.
Method: A two month window August/September 2005 was used to gauge the amount of topical medications used from the clinical stock inventory supplied by Annie Dufour, Pharmacist, Skin Care Centre divided by the seven patients enrolled in the Daycare program during that time. Labor costs were calculated by the measured time nurses spent with patients multiplied by their hourly wages plus MSP billings made by consulting dermatologists.
Results: The total program cost per patient is $916.20 divided by 10 days for a daily per patient rate of $91.62.
Conclusion: Using current market topical medication prices, nurse's hourly wages and physicians billing schedules, the Psoriasis Daycare treatment program proves to be a cost effective form of therapy for moderate to severe psoriasis.
Efficacy, Safety, and Patient-reported Outcomes From the UNITE Study: Narrow-band UVB Light Therapy and Etanercept for the Treatment of Psoriasis
Leon Kircik, MD
Description: Background: The combination of psoralen plus ultraviolet A (PUVA) and 25 mg twice weekly (BIW) etanercept may be an effective and well-tolerated treatment option for psoriasis.1 While narrow-band ultraviolet B (NB-UVB) is slightly less effective in patients with psoriasis than PUVA,2 it is associated with fewer safety concerns and is more convenient for patients. Our analyses explored whether combination therapy with etanercept and NB-UVB phototherapy may provide an additional treatment option for the management of the signs and symptoms of moderate to severe plaque psoriasis. Methods: Patients with moderate to severe plaque psoriasis received 50 mg BIW etanercept in combination with NB-UVB light three times weekly for 12 weeks in an open-label, single-arm study. The primary measure of effectiveness was the proportion of patients achieving e"75% improvement from baseline in the Psoriasis Area and Severity Index (PASI 75) at week 12. Other analyses included PASI 90, PASI 100, time to PASI 75, patient-reported outcomes such as the dermatology life quality index (DLQI) and the patient global assessment (PtGA) of psoriasis, and safety assessments. Exploratory endpoints included fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue [FACIT-F] questionnaire), symptoms of depression (Beck Depression Inventory [BDI]), patient satisfaction survey, and utility (EQ-5D). Safety analyses and primary efficacy analyses were based on all patients who received at least one dose of both etanercept and NB-UVB phototherapy. Effectiveness analyses were conducted using both an observed case approach and a last observation carried forward (LOCF) approach. Results: Of the 86 patients who were dosed (56% were men, mean age was 41 years, and most patients had severe disease at baseline), 83 completed the study. Using LOCF imputation, 26% of patients achieved PASI 100, 58% achieved PASI 90, and 85% achieved PASI 75 at 12 weeks. Median time to PASI 75 response was 57 days, with 70% of patients achieving PASI 75 by 8 weeks. By 12 weeks, improvements from baseline in DLQI total score and all DLQI subscales were seen, and improvements from baseline in PtGA of psoriasis were observed as early as week 4. Mean FACIT-F, BDI, patient satisfaction survey, EQ-5D, and Patient Pruritus Assessment scores all improved from baseline to week 12. Results from the as-observed approach were consistent with those from the LOCF approach. No safety concerns were apparent, and the 2 most common adverse events were UVB-induced skin injury (63%) and injection site reactions (16%). Conclusions: In this study, etanercept and NB-UVB combination therapy was effective (85% of patients achieved PASI 75 at 12 weeks) and generally well tolerated. Notably, complete psoriasis clearance, as measured by PASI 100 response, was reported as early as 8 weeks after initiating this combination therapy, with 26% of patients achieving this endpoint at 12 weeks.
References:
[1] Woodson J et al. JAAD 2005;52(suppl):P179
[2] Yones SS, Palmer RA, Garibaldinos TT, Hawk JL. Arch Dermatol 2006;142:836-42
Synopsis: Patients with moderate to severe plaque psoriasis received 50 mg BIW etanercept in combination with NB-UVB light three times weekly for 12 weeks in an open-label, single-arm study. Etanercept and NB-UVB combination therapy was effective (85% of patients achieved PASI 75 at 12 weeks) and generally well tolerated in this study.
Objective: To explore whether combination therapy with etanercept and NB-UVB phototherapy may provide an additional treatment option for the management of the signs and symptoms of moderate to severe plaque psoriasis.
Efalizumab Treatment in a Patient With Atopic Dermatitis
Lila Orr, MSN, FNP-C and Leslie R. Capin, MD, PC
Description: This presentation is a case study of the treatment of a patient with severe, recalcitrant, atopic dermatitis. The patient demographics, details of the disease, and treatment history are presented. A description of the successful treatment with efalizumab, with photos before and after treatment, will be included.
Synopsis: Here we report the case of a patient with severe atopic dermatitis affecting 90% of her body surface area and recalcitrant to conventional therapy. She initiated efalizumab 1 mg/kg/wk concomitant with cyclosporine 50 mg twice daily and experienced a dramatic response within 3 weeks; cyclosporine was discontinued after 3 months, and the patient remains on efalizumab monotherapy with 95% clearance of disease.
Objective: The objective of this case was to identify an effective therapy for management of the patient's recalcitrant atopic dermatitis.
Baseline Comorbid Conditions of Psoriasis Patients Participating in RESPONSE, an Observational Study of Long-Term Treatment with Efalizumab and Other Biologic Therapies
Marrise Phillips, BSN, Emily Elliott, RN, Linda Daus, RN, Katrina Masterson, ARNP, Winifred Werther, PhD, Peter Compton, MS and Ivor Caro, MD
The Raptiva Epidemiologic Study of Psoriasis Outcomes and Safety Events (RESPONSE) is an observational study of patients treated with biologic agents for psoriasis. The study will track a large sample of patients with psoriasis for up to 5 years, including 5000 efalizumab-treated patients and 2500 patients treated with other biologics. Efalizumab is a humanized anti-CD11a antibody that has been approved for the treatment of adult patients with chronic moderate to severe plaque psoriasis. The other current biologics include a T-cell modulator (alefacept) and tumor necrosis factor inhibitors (etanercept, infliximab, and adalimumab). As of April 2006, 13.3% (997) of the targeted patient population were enrolled, 663 in the efalizumab cohort and 334 in the comparison cohort. We have baseline data on comorbid conditions for 702 patients. Patients in the efalizumab cohort have similar observed rates of hypercholesteremia (14.0% vs. 11.4%), hypertension (19.6% vs. 18.1%), and type II diabetes (14.8% vs. 9.7%) compared with the comparison cohort at this time. Interestingly, a higher proportion of patients in the comparison cohort reported arthralgia (22.8% vs. 14.6%) at baseline compared to efalizumab-treated patients. With respect to cancer history, compared with the efalizumab cohort, more patients in the comparison cohort had been diagnosed with basal cell carcinoma (5.9% vs. 2.6%). Histories of all other cancers were similar between the cohorts. At baseline, a higher proportion of patients in the comparison cohort had been diagnosed with a pre-malignant condition under medical investigation (23.3% vs. 17.9%) compared with the efalizumab cohort.
Synopsis: Psoriasis patients present with many comorbid conditions. Among biologic-treated psoriasis patients enrolled in RESPONSE, comorbid conditions reported included hypertension, hypercholesteremia, and type II diabetes. Athralgias were more commonly reported in non-efalizumab biologic-treated patients.
Objective: To describe the comorbid conditions experienced by psoriasis patients treated with biologic therapies.
Etanercept in Psoriasis: Patient Information, Training and Nurse Advising
Marta Sanjuan-Aragon, RN, Sonia Expósito-Vizcaino, RN, Diana Gil-Castillejos, RN and Carmina Jimenez-Jimenez, RN
Psoriasis is a chronic skin that affects between 1 and 3 percent of the world population. In its most typical form, psoriasis results in plaques of thick, red skin covered with silvery scales. Psoriasis most often occurs on the elbows, knees, scalp, lower back, face, palms, and soles of the feet but it can affect any skin site and nails. People with psoriasis may suffer discomfort, including pain and itching, and emotional distress, and 15 percent have psoriatic arthritis. Patients with moderate to severe psoriasis may need systemic therapies, as etanercept.
Etanercept is a type of protein called a tumor necrosis factor (TNF) blocker. TNF is a naturally occurring cytokine that is involved in normal inflammatory and immune responses. It plays an important role in people with an immune disease, such as rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis. In addition, TNF plays a role in the inflammatory process of plaque psoriasis. Etanercept is indicated for the treatment of adult patients (18 years or older) with chronic moderate to severe plaque psoriasis who are candidates for systemic therapy. Adults can take Etanercept using an easy-to-use 25 or 50 mg/mL prefilled syringe.
In our hospital, psoriasic patients receiving etanercept are trained by a qualified nurse how to self-inject the first two doses, and after this adequate training, patient inject it at home. Etanercep is self-injected just under the skin with a small needle, using a prefilled syringe for a single use. Nurses may have an active role in the education and information of psoriasic patients. Nurses complete the information received in doctor's office, try to reduce the emotional distress associated with psoriasis, and gives information about psoriasis associations. Nurses train patients in the use of 25 or 50 mg/mL prefilled syringe, so that patient can use it appropriately at home. We review the clue points of patient's training in the adequate administration of the drug. In addition, nurse review with the patient doctor's advice about etanercep and most important side effects. The possible serious side effects of etanercept include serious infections (including tuberculosis and infections caused by bacteria or fungi), nervous system diseases, blood problems, heart failure, allergic reactions, and malignancies. Patients are instructed to contact doctor when any suspicious symptom is presented. Patients receive also information about other more common side effects with Etanercept, as local reaction at injection site, upper respiratory infections and headaches. Local reactions where the injection was given are usually mild and include redness, rash, swelling, itching, or bruising. These usually go away within 3 to 5 days. Patients are instructed to call the doctor if they have pain, redness or swelling around the injection site that doesn't go away in a few days or gets worse.
Synopsis: We review the role of nurse in the information, training, advising and counselling of the psoriasic patient receiving etanercept.
Objectives: We describe the training of psoriasic patients receiving subcutaneous etanercept in prefilled syringes. We describe the role of nursery in the complementary information and advising of the psoriasic patient.