I spoke to a patient, a 63-year-old woman who immigrated to the United States from Central America in 1978, about her experience living with liver disease. She is now an 

 NAFLD patient advocate who was diagnosed with autoimmune hepatitis and NAFLD in 2005. After experiencing the devastation of her diagnosis, she has managed to learn to live with the disease and wants to help others achieve better quality of life.

Our patient had been diagnosed with autoimmune hepatitis for several years and doing well. She developed pain in her upper right abdomen and saw three specialists. They assumed she was an alcoholic even though she told them she didn’t drink. She talked to her primary care physician who sent her to a liver specialist. 

The doctor spent 90 minutes talking to her and, based on blood work every three months and ultrasounds every six months, determined that her autoimmune hepatitis medication- prednisone, was causing fatty liver. It took three liver biopsies to confirm the diagnosis of NAFLD on top of autoimmune hepatitis.

Helpful Tips About Healthy Diet and Finding Support

This woman has made huge changes to her lifestyle. Sheexercises regularly, meditates, drinks plenty of water and has changedher eating habits by following a healthy diet and avoiding sugary drinks, such as soda and concentrated juice drinks. She prepares her own food and only takes medicine prescribed by a physician, who do so with caution because she has been at the last stage of liver cirrhosis for the last three years.

Though difficult, she has learned to avoid greasy foods found in fast food restaurants, eats abundant greens, incorporates fruit into her breakfast and vegetables for lunch. She’s learned to prepare food in different ways by sautéing, baking or grilling her food using olive oil. She does not fry her food, which she may have done previously. She avoids additives and salt, relying instead on herbs and spices.

Before trying new foods, she and her caregivers research its possible impact on the liver. When she buys groceries, she avoids red meat, high fructose corn syrup and anything with more than five ingredients. She also practices portion control and learned that the palm of your hand is the amount of meat you should eat, which for her is mostly fish, chicken and occasionally lobster.

She advises people tofollow their doctors’ orders and, once diagnosed, find a support group to learn and share information with others living with the same disease. People can find information online from organizations, such as the 

, and Facebook groups, such as Living with Cirrhosis, Living with Fatty Liver/NASH.

She is a true reflection of what it is to live with chronic liver diseases and how changing in your lifestyle can improve liver health and overall health.

This article is the final installment of four articles exploring the epidemic of liver disease called nonalcoholic fatty liver disease and its more severe form, nonalcoholic steatohepatitis.

The Multiple, Complex Challenges of Living with and Managing Liver Disease

Amreen Dinani, MD

Healthcare is in a state of flux. As extraordinary measures are taken to stem the spread of the coronavirus, regular medical care—from routine checkups and screenings to in-office treatments and procedures—has been subject to significant disruptions and challenges. Social distancing requirements of the 

 pandemic have created new limitations on in-person physician visits. 

Office closures and safety concerns have resulted in the delay or cancelation of medical appointments for some patients. Compounding matters is the dynamic and uncertain nature of the pandemic. The issues that patients and physicians are confronting today have evolved since the COVID-19 shutdowns began in March—and further change is undoubtedly on the horizon.

 patients and their eye care professionals, the pandemic has led to an array of stressors, given the progressive but indolent nature of a disease that can lead to blindness and requires close ongoing monitoring and treatment. The current health environment is particularly worrisome for elderly patients because they are most at risk for vision loss from glaucoma and are also among the highest risk groups for COVID-19 mortality.

To better understand the concerns and experiences of glaucoma patients during the pandemic, the Glaucoma Research Foundation (GRF) commissioned an online survey in May 2020. The aim was to gain valuable, real-time patient input that can help eye care professionals better address patients’ emotional needs as they adapt to the new, and continually changing, care requirements of COVID-19. 

The GRF survey, which was supported by Aerie Pharmaceuticals, assessed patients’ confidence in their disease management during the pandemic; specific disease management concerns; patients’ experience with telemedicine; and patients’ comfort in returning to eye professionals’ offices. The survey drew a national response, with 1051 adult glaucoma patients from 49 states participating in the questionnaire.

The survey findings bring to light several key considerations for ophthalmology practices evolving glaucoma care in the COVID-19 environment.

Notably, the survey found that more than half of respondents (53%) had to delay and/or cancel an eye care appointment during the first months of the pandemic. These disruptions seem to have significantly impacted patients’ confidence in their disease management, with approximately one-third (36%) of glaucoma patients surveyed saying they were not confident that their disease was well-managed. Those who had the lowest confidence levels in their glaucoma management were 30% more likely to have had an eye care appointment delayed or canceled.

This feedback highlights the central role of communication in enhancing glaucoma care and the importance of nurturing the physician-patient relationship during the pandemic. With physician offices open again, personal and direct doctor-patient communication is paramount to helping patients understand their unique level of risk and rebuild confidence in their disease management. 

Without scaring patients, it’s important that they understand the consequences of delaying an office visit and the real risk it may have for further, even permanent, vision loss.

At my practice in San Francisco, we went through every patient record that had an appointment during the early phase of the pandemic and conducted a risk assessment. We then communicated with each patient to make them aware of their particular situation and the risk of not coming in to be evaluated when our office reopened.

The first step was to speak with our staff about our responsibility to be safe, not just in the office, but also outside of work, with specifics about how to minimize risk. I sought their input and we developed together an action plan with new office protocols.

We also invested in an expansion of our office team. With this increased staff, we are able to directly answer more patient calls and engage in longer, in-depth conversations. In addition, we have placed a greeter at our main entrance who screens patients, which includes basic health questions, a temperature check, and a check for an appropriate mask. 

After completing these safety protocols, the greeter asks patients to use hand sanitizer prior to entering the clinic. These new measures have played a valuable role in boosting our patients’ confidence in their disease management during the pandemic.

The “COVID-19 Office” and Telemedicine

The survey also reveals that glaucoma patients place high value on being able to see their physician in person. Six in 10 (63%) respondents said they are comfortable returning to their eye doctors’ offices as long as social distancing measures, such as face masks and less crowded waiting rooms, are implemented. This preference for in-person physician visits, coupled with technology challenges, make patients largely uninterested in telemedicine. A vast majority (87%) of glaucoma patients surveyed said they would rather wait six weeks for an in-person office visit than have a telemedicine visit in two weeks.

While telemedicine has been a valuable tool in other medical specialties during the pandemic, it has significant limitations for standard diagnostic procedures in glaucoma care. Since intraocular pressure (IOP) checks, visual field evaluation, and other tests cannot be easily conducted virtually, practitioners may lose considerable clinical information by trying to manage glaucoma via telemedicine.

During these unprecedented times, the safety and well-being of patients is the principal concern of all eye care professionals. It is also important to consider the needs of your staff as well. At my center, we have modified several standard procedures that not only have enhanced patient safety during COVID-19 but have also made us operate more efficiently and safely as an eye care practice. 

I have found that when members of my office team feel safe at work, their calmness and confidence extend to the patient-provider relationship, helping patients feel more comfortable about the visit. By fostering a caring and professional approach to glaucoma care in the midst of uncertainty, we can all navigate the COVID-19 pandemic while continuing to protect the vision of our patients.

Andrew Iwach, MD, is Executive Director of the Glaucoma Center of San Francisco, Associate Clinical Professor of Ophthalmology at the University of California, San Francisco, and a faculty instructor at the California Pacific Medical Center Department of Ophthalmology. 

The article reflects the views of the author, not necessarily those of the publication.

A new survey assessed patients’ confidence in their disease management during the pandemic, specific disease management concerns, and experiences with telemedicine.

Managing Glaucoma During COVID-19: Patients Point the Way to Improved Care

Andrew Iwach, MD

 What’s really important—and we’re not here to give advice to the manufacturer of inclisiran—is the reputation a drug develops when it’s brought to the marketplace. It sticks. To Dean’s point, if you look at data published by Seth Baum and others, they found that the utilization of PCSK9 was somewhere about 0.3% of those who were eligible.

What happened was you had the insurance payers creating these incredible speed bumps. It didn’t really matter. The manufacturers of PCSK9 inhibitors cut their price in half. As Dean, Manesh, and Linda have said, the access to the PCSK9 inhibitors has certainly become easier. But the doctors just aren’t interested in prescribing. As far as they’re concerned, it’s a drug that’s very difficult for patients to access. It’s an “expensive” drug. I urge the manufacturer of inclisiran to think the process through, so that when this drug finally comes to market, it is accessible. 

Otherwise, you’re going to have the same issues that we face with PCSK9 inhibitors. Perhaps we need to inject some artificial intelligence into value-based care instead of what seems to be artificial insanity. We need to be able to count on really good algorithms to determine appropriate use for these compounds.

I still have heterozygotes being turned down for PCSK9 inhibitors. It’s insanity out there. What we really need is really good artificial intelligence, not artificial insanity, in terms of making sure these drugs are being used in the appropriate patient at the appropriate time.

 Norman, that was a wonderful take-home message. In fact, I’m going to start with Dean, Manesh, and Linda; you’ll be last. Give me a similar take-home message, something you think our audience needs to hear from you. Dean?

 In secondary prevention, the LDL [low-density lipoprotein] goal is less than 70 mg/dL and probably lower for all our patients. That’s going to require combination therapy, the best statin dose you can get them on, and then other drugs.

If the cost of the medicine is too expensive, then use ezetimibe. For primary prevention, family history, pay attention to risk-enhancing factors in the guidelines and calcium scoring. That’s how we can get these patients treated earlier, so we’re not in the situation where they’ve already had events and you’ve got to be that much more intensive with regard to their treatment.

 We’re at the age where we have an explosion of possible therapies for our patients, which is great. The take-home message for me is this isn’t about cardiology or specialty care; it’s about primary care. This is about getting the message and the care pattern and the access to the primary care. That’s how we’re going to affect the population health, by getting these therapies—statin, inclisiran if it comes on the market, PCSK9 as we’ve just heard—into the hands of our primary care doctors and getting them comfortable with having the conversation with patients to get the therapies to them.

 That’s a great comment. Linda, you have the last take-home.

I just want to reemphasize lifestyle. Diet is absolutely critical. You can have somebody who is not at goal and they’re eating a terrible diet, and they can have really good results from changing that diet. Using our licensed nutrition folks and getting these people to improve their diet is very much a part of the picture.

 Thank you very much. I’m Dr Keith Ferdinand for HCPLive®. We’ve had a rich and informative discussion. Linda, Dean, Norm, and Manesh have given us a wealth of ideas and information, reviewed data, and given some opinions on where we are now with the intent of lowering risk in patients who are high risk, including the FH [familial hypercholesterolemia] patients, patients with ASCVD [atherosclerotic cardiovascular disease].

If you enjoyed watching this HCPLive® Peer Exchange, if you enjoyed the content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your in-box. Thank you very much for listening to this program.

Final thoughts from expert KOLs regarding treatment decisions and how they relate to patient accessibility when manage dyslipidemia. 

Treatment Decisions and its Relation to Patient Accessibility  

Dean Karalis, MD

 The other term that I heard is long-term monitoring. What is it? When is it indicated for hypoglycemia? Jay, can you help us out on that?

Jay Shubrook, DO, FACOFP, FAAFP, BC-ADM: 

Sure; I think you should be having a regular conversation with your patients and their families: “Do you have lows? What do they feel like?” Not everyone has the same type of symptoms and even different types of hypoglycemia have different symptoms. Then, “What do you do about it?” I think, quite honestly, this is the basis of prevention. If you can identify and they can identify the symptoms, that is going to help them be active to prevent an episode. I think, often, it is the family that knows it before the person who has the hypoglycemic episode. Making sure the family also is clued in is really important. I would also say, from the provider side, I put hypoglycemia as one of my codes because it then reminds me that is something I need to circle back to with my patient. They also see, when they see the chart, that I care not only about their glucose but I also care about hypoglycemia. I think it is a matter of awareness, regular conversation, and talking about it just like we would talk about high blood glucose at every visit.

 What about the Hypoglycemia Patient Questionnaire? That is a buzz phrase that is coming to more prominence lately. What is it? Where does that fit? Are we using it in this country?

 I think we may have our own methods by which we screen. I do not particularly use that questionnaire, but it does raise some important factors: “Are you feeling low? What do you do? What do you feel?” I have my own set of questionnaires that I use, but I do like the concept of a standardized questionnaire that could be used in the waiting room or while the patient is waiting for the provider, so that piece of information is not lost in the conversation. That is, to me, the main value, even though I do not use that questionnaire.

I think the issue is more about making sure the questions are asked. If you have a questionnaire that makes you ask those questions; if you have diabetes, every time you go to see your health care provider, those questions need to be asked. “Are you having hypoglycemia? Does your family member think you are having hypoglycemia? What time of day do you have hypoglycemia? Do you check your blood sugar? Are you wearing a CGM [continuous glucose monitor]? What happens when you have more physical activity?” I saw someone this morning who said, “I don’t have any hypoglycemia,” and I was doing a video visit, and the next thing I know his wife was behind him and said, “That’s not true!” I said, “OK, tell me when he is having hypoglycemia.” She said, “Well, any time he goes to do more activity.” This tells me that for this man, when he was having it, I needed to look at his basal rates because I asked the questions about his activity and we could adjust them. Whenever he moved around, he was having low blood sugar issues. I think, during every visit, we have to ask those questions.

Why was he denying it? Was he insensitive to it, or was he simply in denial.

 I think he was used to it—too used to it.

 This is what we were talking about before.

Right, and it became part of his life. He said, “Well, usually I am OK.” Well, he went out and worked in the garden and became hypoglycemic. I think he assumes that is how he has to live; he does not seem to grasp that we have ways we can handle it. We made a fix, and we will look again in 2 weeks as to whether that fix works to prevent it. There is no reason he should not be able to go, on a whim, work out in the yard. He could come work in mine, I told him, and I would watch for his hypoglycemia. I think that we have to ask those questions, and I do think they become very much part and parcel of their life, and they do not remember to tell you about it if you do not ask poignant questions.

 It sounds to me as if he thought, “Well, this way that I feel when I get low is simply part of my diabetes. It’s normal, and it’s what I have.”

Yes. I have heard that, too. I have a couple of diabetes educators in my group who have type 1 diabetes. And you must be sensitive to not interfere with the way they manage their diabetes and say things like, “Do you want me to get you some juice, or do you want me to get you some glucose tablets?” You must be very sensitive to that. Often what I hear them say is, “Some hypoglycemia is expected with diabetes, if I’m going to get to my treatment goal.”

 I want to thank all of you at home for watching this 

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Panelists consider the importance of long-term approaches to monitoring hypoglycemic episodes and discuss the role of education and awareness, patient questionnaires, and effective communication with physicians. 

Long-Term Monitoring for Hypoglycemic Episodes  

Elaine Apperson, MD, University of South Carolina School of Medicine  

University of Rhode Island College of Pharmacy

 In the little time that we have left, I want to go around and get some final thoughts from each one of you. I would like you to address the whole issue of using naloxone. How do you address this with patients? How do you address this with clinicians, and what is your view about going forward? How is this going to change the landscape of opioid use in the United States? Why don’t we start with Jeremy, and we will keep going from there? Take 30 seconds, and we will just keep going.

 I think we have covered a lot of ground today. We know, and have known for a long time, that opioids have certain risks. They pose risks to patients, and they pose risks in the community when they are taken unsupervised or misused. From a safety measure perspective, there are things we can do. We can do a better job identifying the patients at risk or when identifying those patients who should or should not receive opioids. At the same time, I think we need more community awareness, and we can do this by using the naloxone program or some of the other programs discussed today. Rhode Island sounds amazing, and I am interested to learn more about what is happening out there. The tools we have today can enhance the safety of what we are doing on the medical side and help out there in the community with the substance misuse and illicit side. That is outside of the reach for some of us who do not work in settings where one can reach out to the community, but I think that these types of tools are underutilized. If these tools are utilized on a more frequent basis, and in a more normalized way, we have the potential to reverse what we have seen here with opioids and the subsequent harm caused by them.

 While acknowledging that opioids are still commonly used as part of a multidisciplinary approach to pain management and that opiates are still being misused illicitly, we need to have strategies that emphasize the availability of naloxone so that people can be as safe as possible. As Dr Adler said, this must be normalized, and we need to realize, when we think about this, it is going to take more years than we would like before it will become normalized, but we need to step it up and work toward that.

 I cannot agree more with my colleagues. I think that, when it comes to normalizing naloxone, we need to take the lessons we have learned from what successfully normalizes this method of treatment. Whether it is enacting policy interventions, having naloxone everywhere, putting up billboards, or getting that access. What we are doing is studying people, saying what makes you dispense naloxone, to pharmacists? Saying what makes you dispense it, to primary care physicians? What makes you want to give it, to a caregiver? What are those barriers? How do we break them down? I look forward to the day of over-the-counter naloxone that is still covered by insurance so we do not have financial barriers. There is a lot that we know, areas where we have been successful, and I think that yes, it is going to be around a long time. We have seen how COVID-19 has created these divisions. I think, by solving those divisions during COVID-19, we will solve some of the divisions in access to care for people with opioid use disorder or people who use opioids.

I see naloxone as one part of the puzzle here, one part of the comprehensive approach that we try to take in the emergency department [ED], and that is decreasing the barriers that patients need to overcome to get naloxone. This is improving their access to naloxone not only in the ED but also in other areas of life where they have access to health care, and in their daily lives. Having it available works, whether it is having a naloxone box sitting next to an AED [automated external defibrillator] box somewhere or offering it to patients proactively and not requiring them to have to ask for it.

Additionally, I think that, as science for medication-assisted treatment continues to be redefined every day—how effective that is for treatment—it is our responsibility to not only make sure that our patients are safe as they go out and use this, or that their community is safer because naloxone is out there. But we also need to provide multiple opportunities for patients to get linked to treatment, to be linked to peers, and to have access to medication-assisted treatment. I think this is equally important and should be offered as routinely as possible.

Theresa, some people hate to be the last one to speak when all the good stuff is taken.

Theresa Mallick-Searle, MS, RN-BC, ANP-BC:

heresa Mallick-Searle, MS, RN-BC, ANP-BC: 

As the token nurse on the platform here, I am really big into listening to my patients. It is not that my colleagues are not, but I want to hear what is important to the patient. I want to be able to have them partner with me in their health care. I want to be able to encourage my peers to look at the bigger community and be in it for the long term, to decrease the amount of fear out there. As a health care provider, for anything that we do, we are trying to do the best we can to take care of our patients.

Thank you all very much. I want to thank you at home as well for watching this HCPLive® Peer Exchange. If you enjoyed this content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your inbox.

I am Dr Peter Salgo, and I will see you again next time.

The multidisciplinary panel of experts share final thoughts on strategies to normalize naloxone and decrease barriers to its obtainment and utilization. 

Final Thoughts on the Opioid Crisis and Normalizing Naloxone

Jeffrey Bratberg, PharmD, FAPhA, University of Rhode Island College of Pharmacy 

Jeremy Adler, DMSc, PA-C, DFAAPA, Pacific Pain Medicine Consultants 

 What prompts you to step up? Where do you pull the trigger when you see somebody who’s not doing so well? What do you focus on for step-up treatment?

 I focus on a couple of things. If I see a patient who’s already on a medium-dose ICS [inhaled corticosteroid], plus or minus a LABA [long-acting beta-agonist] or a LAMA [long-acting muscarinic antagonist], and they’re still uncontrolled, I look at asthma control. I look at exacerbations. I also want to make sure, before stepping up, that the patient is using their inhaler correctly. The other day, I had a patient who I wanted to step up, but then I went back. I work in a county hospital where I can go and look at the prescription refills. The patient hasn’t refilled her controller for 3 months. When I asked her, in a nice way—patients don’t like it when you confront them—it seemed like she hadn’t, and there was no reason because at a county hospital, they’re paid for.

There are lots of reasons why adherence may be a big issue, so I urge my colleagues—and we’re all doing it—before stepping up, ask: Is the patient taking their inhaler? Because we know, even for inhaled steroids, there is a plateau effect. It’s not like the higher, the better all the time. This is definitely a benefit in some patients of doubling the inhaled steroid. At some point, you reach a plateau and you have to ask: What else can I do? By increasing the dose, you may also increase risk of topical adverse effects and systemic effects. To answer your question, I look at asthma control, asthma exacerbation, and adherence. I want to make sure all the comorbidities are taken care of—especially the nose—and then I step up, and I have to bring them back to see how they do. Of course, we can’t just step up and leave them on a high-dose ICS forever.

I certainly embrace that approach quite well. I’m sure Sid and Geoff have similar aspects. But I’d highlight that when we take that and understand control, we can use objective measures like the Asthma Control Test [ACT] and filter that into our EMR [electronic medical record] so that we longitudinally track the ACT score, which gives us some objective measures. Sid, in that last section, we really drilled down into high T2 and low T2, more in a global physiological or pathophysiological approach. How do you take those learnings and practically implement them in therapeutic approach? What’s your approach, Sid?

 I’m glad this question came up on the heels of our last comments when we were talking about stepping down. Indeed, many asthmatics, it’s been shown, just don’t respond to those steroids, and they are predominantly in that T2/non-T2 category. One of the things we need to be brave enough to do is step down. Often, they’re on oral corticosteroids. It’s not doing any good. The other thing is, very often, that T2 pathways can be masked by the corticosteroid. For example, eosinophils are very sensitive to the steroids, and they may be high in a patient put on larger doses of oral corticosteroid. For example, you check: Is this a T2 patient? No, eosinophils are low, and FeNO [exhaled nitric oxide] is low. This is another area where you may want to consider that step down. That’s the approach I would take. As we know, we have a really limited armamentarium against the non-T2. When patients, as Nic was saying, are following their Asthma Control Tests and exacerbation rates, you get to the point where you’re looking at a patient saying, “This isn’t working. You’re on high-dose corticosteroids. We need to go to the next step.”

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Nicola Hanania, MD, MS, and Sidney Braman, MD, discuss step-up treatment and when it’s best to practically implement TH2-high and TH2-low into a therapeutic approach.  

Step-Up Treatment for Severe Asthma 

Nicola Hanania, MD, MS, Baylor College of Medicine 

COVID-19 has obviously presented significant challenges in our clinical work, particularly in the evaluation, diagnosis, and treatment of patients with ADHD [attention-deficit/hyperactivity disorder] of all ages. What we’ve all done, of course, is acclimate to this, largely through the use of telemedicine, telepsychiatry for a lot of our patients. Although more recently, I’ve gone back to more of a hybrid model where I am seeing some patients live and some via telepsychiatry. 

There are significant challenges. Some of those challenges include the fact that it’s a little more difficult to do an evaluation and to collect all the nonverbal information that you might get from being in the room with a person. Part of the problem is you may be seeing only a portion of the patient’s body. You may not be seeing the lower half of the body if you’re on a virtual call. You might not see some of the fidgeting or hyperactivity, for instance.

Also, what I find is patients either do really well with virtual telepsychiatry or don’t. They have trouble focusing. They get distracted. It’s really important to try to individualize care for our patients. Some people try to do in-person meetings. Ideally, this may be helpful for the initial evaluation so we can collect as much information as possible. When you’re dealing with children, you’d like to have collateral information, so you’d like to have parents and caregivers involved. That can be a little harder too, although it can be done virtually.

As far as prescribing medications, that can present a challenge. Although now, states are going to e-prescribing. In Florida, we now have to e-prescribe all controlled substances. That makes it easier, not having to handwrite a prescription and somehow get it to the patient in a COVID-19 environment.

The other thing I find is that sometimes children do a little better in this virtual environment, but many with ADHD struggle more. There’s a lot more stress and difficulty in school. Obviously, there’s more isolation, so fewer social relationships, fewer extracurricular activities, and maybe less access to exercise, which has been shown to be very beneficial for ADHD. These are some of the challenges that we’re trying to negotiate in the era of COVID-19.

Tele-prescribing of stimulants presents some unique challenges in the era of COVID-19. Part of the challenge is making sure you can e-prescribe appropriately. Most of us have figured out how to do that. Also, you want to make sure the pharmacy is available and shows up on your e-prescribing software. It is required, when we prescribe stimulants, that we monitor certain things. This can be more challenging in this environment, particularly when assessing vital signs, height, and weight. Blood pressure, heart rate, height, and weight can be a challenge in the virtual environment. This is when I may sometimes have the patient come to the office, just for the vital signs and height and weight checks. Or the patient can get 1 of the home monitoring devices, which you can get at many pharmacies. These devices can monitor blood pressure and heart rate. Your patients can check those periodically and report the results to you. Or you can certainly have them email that to you or communicate electronically.

As far as monitoring for abuse and possibility of diversion, this is something we also need to keep our eyes on. We can do this in various ways, including by checking prescribing databases, which can certainly be done online.

As far as monitoring for other issues and problems, such as the emergence of psychotic or manic symptoms or the possibility of vasoconstriction or cardiovascular issues, this is where taking a very careful history and evaluation and trying to look at the patient and evaluate them as best you can on camera really seems to help.

It’s important to understand that when evaluating and treating ADHD, comorbidity is the rule. Three-quarters of patients with ADHD will have a least 1 other comorbid condition. This is important because sometimes our core treatments for ADHD can help alleviate these other conditions. For instance, secondary anxiety or secondary depression. Sometimes, however, we do have to institute specific treatment in addition to the ADHD treatment to address a comorbid condition.

Rakesh Jain, MD, MPH: When parents and their children first come to see me for an evaluation for ADHD, there’s often a lot of confusion. We have a lot of myths in our heads. “Is this bad parenting?” “Was this just because one of us got divorced?” Is it because I had too many Diet Cokes when I was pregnant?” 

My first job is to offer parents and children a combination of sympathy and encouragement. I offer sympathy for the suffering they have gone through and encouragement that, if we do the right thing, we can make a pretty significant difference in all the challenges your child is having and you’re having as parents and caregivers. I have found that injection of enthusiasm, support, and knowledge to be as useful as anything I do.

The second step is really a pretty quick but accurate increase in knowledge base about the disease. Most people are quite surprised to know that it is a neurobiologically active condition. It is an inherited condition. It is a brain-based condition. Even though behavior is what they might see, the child is not being a “bad” child. 

Finally, we need to give an explanation of why interventions work or why a combination of nonpharmacological and pharmacological interventions is best explained in the context of neurobiology. 

When I offer that whole package of information, from sympathy to increasing their enthusiasm and encouragement to disease-state knowledge and then finally medication and nonmedication knowledge, you can see the parents and the child breathe a sigh of relief. “I’ve got a direction. There’s something I can do. I feel empowered.” That is precious. As a clinician, once I see that, I know I have established a solid therapeutic relationship that will lead to good outcomes.

Optimizing care and managing challenges for patients with ADHD during the COVID-19 pandemic and advice for clinicians educating patients and families on disease management. 

Optimizing Care for ADHD During COVID-19 

Rakesh Jain, MD, MPH, Texas Tech University School of Medicine

One of the issues has been that there does appear to be a therapeutic ceiling with all our agents. We’re seeing about 40% to 60% clinical remissions along those lines, depending on where these drugs are positioned. Both of us have been very aggressive about trying to get these drugs earlier in the course to prevent complications. If you look in the clinical trials with ustekinumab or vedolizumab, the average duration of Crohn disease is 10 years. Patients with 10 years of disease are already developing the problems that we’re trying to prevent. One of the things that I would like to focus on in the future is earlier intervention with these highly effective therapies that we’ve been discussing. What other unmet needs do you see in the pediatric and adult populations for IBD [inflammatory bowel disease]?

 I also have a very keen interest in preconception and fertility in the management of women’s reproductive health, which does tie in to everything we’re talking about. The message to all our female patients is that it’s all about safety and being able to have your disease under control. It is paramount that having anti-inflammatories onboard is what is most important. We know the risk benefit profiles associated with therapies and how to use these therapies in pregnancy, particularly the biologics. We need to be focused on teaching the right thing to our physician partners and patients, that it’s all about controlled inflammation. 

Chronic pelvic inflammation can never end well. That is something I’m vocal about within my preconception clinic, and I counsel women appropriately. But it does have to do with some of these small molecules. We’ll add a layer of complexity when we are looking at bringing these therapies to the clinic. With some therapies, such as the small molecules, we don’t have a lot of real-world experience on the impact in the first trimester because they cross the placenta. That is the question that we need to get more data on. For example, with ozanimod, it will be in the label to stop 3 months before conception. With JAKs you need to stop it. It does add a layer of complexity—we’ve become ob-gyns in terms of figuring out how to use these therapies. An unmet need is also understanding the safety of these therapies in women of reproductive age.

 Did that also apply to pediatric patients? Are there other unmet needs besides improving the efficacy and maintaining a good safety profile in kids?

Marla Dubinsky, MD: It’s a similar concept once you get beyond the VEO [very early onset] IBD. We have the same principles. Similar to what you talked about, whether those extraintestinal manifestations were activity linked or not, the same applies to growth. For all our therapies, just because you heal the intestine, does not equate to growth improvement. We don’t know. We need more data. Does gut-specific therapy have the same impact as systemic therapies? These are things that we need to see from our clinical trials.

There are a couple of unmet needs that you made me think about. I do believe, as I noted before, the future is combination therapy. It could be diet plus biologic. It could be small molecule plus biologic. It could be fecal restorative therapy. It doesn’t matter. The concept of combination means that 1 therapy alone is not going to be the answer. I was addressing your plateau. This is the way I’m thinking about it. Also, sequence will be a hugely important topic to address, meaning understanding the sequence over the long lifetime of a patient who has an evolving immune system based on the therapies we’re using.

I have to plug something that both you and I believe strongly. The plateau may also be the fact that we are not addressing the emotional or behavioral well-being of our patients in clinical trials or the real world, so we can understand how social determinants of behavior, mental health, and comorbidities impact outcomes. We may see a different percentage of remission at week 52. That is an important unmet need that we need to focus on.

I want to amplify your recognition of the social determinants. Certainly in 2021, we’ve seen social determinants of COVID-19 infections and increasingly recognize the disparities of health care in treating chronic illnesses such as ulcerative colitis, Crohn disease, inflammatory bowel disease. We really need to address these disparities and try to improve, whether it’s with psychology, social workers, diet, and education. All these combinations—as your group and our group have shown—really impact patients. They keep them out of the emergency department. Keep them out of the hospital. We need our systems to help us address these disparities. As practitioners, it’s challenging for us and our staff to address this full spectrum of the patients’ needs, from diet to psychological or behavioral support. Economically, 1 of the biggest issues we all have is access to these highly effective therapies. We’re dealing with different insurance programs that may not allow us to use these drugs in the most effective manner that we think we could.

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Current treatment limitations in inflammatory bowel disease and the rationale for earlier initiation and use of newer therapies to manage pediatric and adult patients.

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