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 

Andrew J. Cutler, MD, SUNY Upstate Medical University

Despite being the most common primary glomerulonephritis worldwide, 

 and end-stage kidney disease. Despite advances in understanding its pathophysiology, treatment options have historically been limited to supportive care, including renin-angiotensin system inhibitors, blood pressure control, and corticosteroids for high-risk patients.

Recently, a growing understanding of the immunopathogenesis of IgAN has led to the emergence of novel therapeutic strategies, including the inhibition of A proliferation-inducing ligand (APRIL), a key driver of IgA production. By reducing pathogenic IgA1 production at its source, APRIL inhibition has the potential to alter the course of the disease. Accordingly, several anti-APRIL drug candidates, including sibeprenlimab, atacicept, telitacicept, and zigakibart, are in clinical development for IgAN.

For more on APRIL inhibition and the current IgAN treatment landscape, the editorial team of 

 spoke with Edgar Lerma, MD, a clinical associate professor of medicine in the section of nephrology at the University of Illinois at Chicago.

: Can you provide an overview of the current treatment landscape for IgA nephropathy and what unmet needs exist for patients?

: One of the things that's interesting [about IgAN] is that this is considered a rare kidney disease, but it is the most common primary glomerulonephritis worldwide. In fact, there's an annual global incidence of 2.5 cases per 100,000 persons.

The disease manifests in several ways. Patients can present with asymptomatic hematuria, which means blood in the urine, or proteinuria, and that is protein in the urine, or they can present with advanced stages of kidney disease.

If you think about it, any patient who is diagnosed with what is called a rare kidney disease, it's a little bit disconcerting, right? So there's uncertainty about it, and this obviously impacts the patient's physical, mental, and emotional health. A lot of patients become anxious, and this can affect their daily activities, as well as even their daily work lives.

One of the things that's important about IgA nephropathy is that when patients are diagnosed, usually they are between 20 and 40 years of age. That's a very young population, right? So if these patients are 20 to 40 years of age, if you think about them and you think they eventually progress to kidney failure or what we call end-stage kidney disease, that means requirement of dialysis or kidney transplantation, this happens in their lifetimes.

So if they get to that point of reaching kidney failure, it's really a lifestyle change. They have to adjust to this new condition in their lives and it affects not only their personal lives, but also the lives of their families and their relatives.

: What challenges exist for developing effective pharmacologic therapies for IgA nephropathy?

: Let me put this in perspective. For many years, for many decades, whenever we diagnosed a patient with IgA nephropathy, and by the way, the only way to diagnose a patient with IgAN is through a kidney biopsy. Whenever a patient is diagnosed with IgAN, we explain to them that this is how the disease happens, this is what to expect, and so on and so forth.

For many years, the only thing we had to offer patients was treatment and medications to manage their symptoms and maybe slow down the progression of the kidney disease.

For blood pressure control, we use certain antihypertensive agents called renin-angiotensin system blockers. And of course, along with that, it's lifestyle – dietary salt restriction, aerobic exercise on most days, weight loss if necessary, cessation of smoking, so on and so forth.

And then the only other treatment that we offer is, whenever they don't respond to the ones I mentioned earlier, the next step would be to consider immunosuppressive therapies.However, the therapies that we had available back then had significant side effects and long-term toxicity.

So when you mention novel agents, over the past few years, we have had a deluge of novel therapeutic agents for IgAN. We now have a better understanding of the pathophysiology of how it can develop, and by understanding this mechanism, several phase 2 and phase 3 clinical trials have been published and have influenced the way we manage the disease. There are now different options for treatment that target the different pathophysiologic steps that lead to eventual kidney failure.

: There has recently been an increased focus on targeting APRIL. Can you tell me a little bit about that?

: So when we say APRIL, it stands for A proliferation-inducing ligand. This is actually a cytokine in the tumor necrosis factor family, and APRIL is integral to the development and progression of IgAN.

When we say cytokine, it is a substance secreted by certain cells of the immune system, and these cytokines have an effect on the other cells.

APRIL actually promotes the survival and the class switch, switching up B cells to produce IgA, particularly what we call the pathogenic galactose deficient IgA1. The abbreviation is Gd-IgA1, which actually forms immune complexes in the kidneys.

So these complexes are deposited in the glomeruli, which later on triggers inflammation, and as you trigger this inflammation, it leads to kidney damage. One way of thinking about this is you think of APRIL as a toggle within the immune system. So if you think of an electrical grid, APRIL powers specific circuits, and when you activate it, you turn it on, it helps promote the production of these pathogenic Gd-IgA1 and immune complexes formation and this leads to kidney damage and injury.

If you target APRIL, you turn it off, it is like pushing the toggle, turning it off and then this reduces the production of those harmful molecules that I mentioned. If you reduce the production of those molecules, then you prevent that damage and the injury that follows.

So, targeting APRIL represents a potential therapeutic strategy that disrupts this pathogenic sequence. If you inhibit APRIL, you can decrease the production of those harmful molecules, those Gd-IgA1, and eventual immune complex formation deposition into the kidneys, which eventually leads to end-stage kidney disease and the need for dialysis or transplantation.

: There are some promising agents in clinical development progressing through phase 2 and phase 3 trials. Is there anything that you think holds the most therapeutic potential for improving IgAN care?

: Right now we are actually looking at the guidelines for sort of directing how these agents will be used in the future, so it's exciting for us as nephrologists because now we have so many options. Before, we only had symptom management and blood pressure control.

For more information about IgAN and the role of APRIL, there's actually a website, 

, that has a lot of new insights and news about IgAN.

Editors’ note: Lerma has relevant disclosures with Travere Therapeutics, Akebia/Otsuka, Astra Zeneca, Bayer, Glaxo Smith Kline, Otsuka, Vifor, and Bayer.

Mathur M, Chan TM, Oh KH, et al. A PRoliferation-Inducing Ligand (APRIL) in the Pathogenesis of Immunoglobulin A Nephropathy: A Review of the Evidence. 

IgA nephropathy (IgAN) is a prevalent primary glomerulonephritis and a significant cause of chronic and end-stage kidney disease. Traditional treatments have been limited to supportive care, but recent insights into IgAN's immunopathogenesis have led to novel therapies targeting APRIL, a cytokine involved in IgA production. Inhibiting APRIL could alter disease progression by reducing pathogenic IgA1 production. Several anti-APRIL drugs, such as sibeprenlimab and atacicept, are in clinical trials, offering hope for improved management of IgAN and addressing unmet therapeutic needs.

Lerma discusses the current treatment landscape for IgA nephropathy and what role APRIL inhibition may play in treating IgAN.

The Therapeutic Potential of APRIL Inhibition in IgAN, with Edgar Lerma, MD

Edgar Lerma, MD

To watch the video series component of this episode, click here.

1:35 Importance of early diagnosis of Alzheimer’s disease

05:48 The pathophysiology of Alzheimer’s disease

09:32 Screening for Alzheimer’s disease

21:37 Utility and practicality of PET scans

In this episode of MEDcast, expert geriatric psychiatrists explore the urgent need for effective diagnostic methods that can detect Alzheimer’s disease at an early stage. We will discuss blood-based biomarkers and other advancements that can help screen Alzheimer’s disease non-invasively and early in the disease course.

Screening for Alzheimer’s Disease: Facilitating an Early Diagnosis for Prompt Intervention

Elaine Peskind, MD

 I have 1 last question for all 3 of you. I’ll start with David. What advice do you have for ophthalmologists and other health care professionals taking care of our patients with geographic atrophy [GA] or the earlier stages of age-related macular degeneration?

 The take-home message is that the times are changing. It’s no longer the mantra of, “We can’t do anything for dry age-related macular degeneration. We can’t do anything for geographic atrophy. We play no role in altering the course of that disease.” Hopefully, it’s a new day and a new time for our patients and our communities, so don’t hesitate to send us any patient you suspect may have signs of [age-related] macular degeneration. We’re happy to evaluate them and determine whether they qualify for the therapy and follow up with you about what we found.

 We’re fortunate to be retina specialists. I love what we do—we all love what we do—and this is a very exciting time. We finally have treatment for something we never had treatment for, and breakthroughs like this shouldn’t be taken for granted in medicine. For our colleagues out there, it’s important for them to know that we have options and that there are things we can do. As Dave said, get these patients in to see us so we can start stratifying them, because it’s going to come in a rush. We’re going from no treatment at all to 1 option and then potentially another option. It’s a very exciting time, and it’s a privilege to be here.

 I don’t want our colleagues to be underwhelmed by the 20% slowing of the growth rate of GA lesions, give or take some percentage points. This is the first treatment that alters the course of this neurodegenerative disease. I hope everyone will look at the FDA label once we get an approval and have a discussion with patients. Try to avoid a paternalistic approach to patient care, where we don’t think they’ll benefit. It’s hard for us to quantify and understand the disease burden caused by GA. We can’t hang our hats on visual acuity, and we may not be good communicators with our patients. Patients will select themselves. I encourage my colleagues to have a discussion with every patient who meets the label so that they understand the value proposition and to see if they want to proceed with this course of treatment.

 Well said. Before we conclude, I’d like to get brief final thoughts from each of you. David?

 This has been an excellent discussion. I learned a lot. It’s been a pleasure to hear all your voices. I’ve learned a lot listening to you guys. Thank you for having me.

 I agree 100%. This is where the magic happens. I love these discussions. I always learn a lot. Hopefully the audience learned a lot. Thank you for having us, Nora.

 I learned that in my injection clinics I’m going to have to monitor patients for safety, so thank you for that pearl.

 I couldn’t agree more. I’d like to thank you all for the very rich and informative discussion. I’d like to thank the audience. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming 

 and other great content right in your in-box. Thank you.

Drs Eleonora M. Lad, David R. Lally, Jaynath R. Sridhar, and Nancy M. Holekamp share takeaways for health care professionals taking care of patients with geographic atrophy and earlier stages of age-related macular degeneration.

Advice to Physicians Treating Geographic Atrophy 

Eleonoroa M. Lad, MD, PhD

Final Insights

Video content above is prompted by the following:

Are there any final insights you’d like to share regarding LDL-C and Lp(a) screening and management of high-risk cardiovascular patients?

Pediatric lipid screening is crucial for early detection and management of dyslipidemia, which can prevent cardiovascular diseases later in life. Current guidelines recommend universal lipid screening for children between ages 9-11 and 17-21, with selective screening for those with risk factors. However, implementation remains inconsistent due to barriers such as lack of awareness and time constraints in clinical practice. To improve uptake, strategies include integrating screening into routine pediatric visits, utilizing electronic health records for reminders, and educating healthcare providers and families about the importance and benefits of early lipid screening.

Panelists discuss how effective cardiovascular risk management requires comprehensive screening for both LDL-C and Lp(a), along with aggressive treatment strategies for high-risk patients.

Erin D. Michos, MD, MHS

Top Line Results of VICTORION-INCEPTION

The conversation highlights the critical importance of early low-density lipoprotein (LDL) reduction following acute coronary syndrome (ACS), emphasizing inclisiran’s unique role in achieving and maintaining low LDL levels. Unlike daily or biweekly treatments, inclisiran offers sustained LDL reduction with biannual dosing, improving patient adherence and clinical outcomes. The VICTORION-INCEPTION study demonstrates how upstream use of inclisiran, in conjunction with standard lipid-lowering therapies, can effectively target high-risk patients shortly after ACS, helping prevent recurrent cardiovascular events through long-term LDL control.

Key results from the study showed that patients treated with inclisiran achieved an approximately 50% reduction in LDL levels, with nearly two-thirds reaching guideline-recommended targets of less than 70 mg/dL, and many achieving even lower thresholds under the 2025 post–ACS event guidelines. The study also confirmed that inclisiran use did not lead to a decrease in statin adherence, alleviating concerns that the injectable might replace rather than complement statins. Clinically, this dual-therapy approach significantly increased the percentage of patients achieving optimal LDL levels compared with usual care alone, which showed minimal LDL reduction.

From a health systems perspective, inclisiran addresses long-standing adherence challenges by being administered in the clinic, ensuring patients receive their dose when they show up for appointments. This real-world practicality offers a transformative model for lipid management in value-based care environments, especially where health care systems are accountable for outcomes. The study underscores the importance of combining statins with PCSK9 inhibitors like inclisiran for maximal benefit, correcting misconceptions that injectable therapies alone are sufficient. Overall, the VICTORION-INCEPTION study provides compelling, actionable evidence supporting earlier and more aggressive LDL management to reduce cardiovascular risk.

Panelists discuss how inclisiran’s biannual dosing and early use after ACS events, as demonstrated in the VICTORION-INCEPTION study, offer a practical and effective strategy for sustained LDL reduction, improved adherence, and enhanced cardiovascular outcomes when combined with statin therapy.

Kirk U. Knowlton MD

Michelle Rodrigues, MBBS, is a dermatologist in Australia.

Michelle Rodrigues, MBBS

Milind Desai, MD: Real-World Data Supports Mavacamten’s Safety for oHCM

Real-world results from the Risk Evaluation and Mitigation Strategy (REMS) program confirmed mavacamten, a cardiac myosin inhibitor for 

obstructive hypertrophic cardiomyopathy (oHCM)

, maintained a favorable safety profile in more than 6,000 real-world patients.

American Heart Association (AHA) Scientific Sessions 2024

, data collected between April 2022 and February 2024 revealed that temporary treatment interruption due to reduced left ventricular ejection fraction (LVEF <50%) was rare, occurring in only 4.6% of patients, while HF requiring hospitalization (HFH) was even less frequent (1.3%).

“Overall, all the REMS objectives with regards to the mavacamten program were achieved based on the current report,” presenting investigator Milind Y. Desai, MD, MBA, a professor of medicine at the Cleveland Clinic Lerner College of Medicine, told 

. “Of course, REMS is not a clinical trial, we don’t have extensive data, but that is not what this program was designed [to do]. Every patient in the United States is represented here."

Among the 1,929 patients treated with mavacamten for at least 1 year, 4.04% experienced LVEF reductions to <50% and 0.21% had concurrent HFH, often linked to confounders like atrial fibrillation. Across 29,111 health status forms submitted during the study, LVEF <50% was reported in 0.9% of cases, and HFH occurred in only 0.3%. Additionally, drug interaction monitoring—part of the REMS protocol—led to dose adjustments in 0.25% of cases and discontinuation of interacting medications in 0.32%.

Overall, these findings reinforce mavacamten’s safety and tolerability for patients with symptomatic NYHA class II-III oHCM, even with prolonged use. Clinicians can be reassured by these real-world outcomes, demonstrating effective risk management under the REMS program. Further dosing analyses are expected to provide additional insights into optimizing long-term treatment strategies.

“The next programs will inevitably require a REMS program and they have a playbook they can adapt off of the mavacamten experience,” Desai told HCPLive. “I would imagine the future set of cardiologists or practicing clinicians who may have to deal with the REMS program, we have a huge contemporary lesson to learn from."

Disclosures: Desai reports relevant disclosures with Bristol Myers Squibb, Cytokinetics, Edgewise, and others.

Desai MY, Seto D, Cheung M, Coiro M, et al. Mavacamten: Real-World Experience from 22 Months of the Risk Evaluation and Mitigation Strategy (REMS) Program. Presented at the American Heart Association (AHA) Scientific Sessions 2024. Chicago, Illinois. November 16-18, 2024.

Mavacamten, a cardiac myosin inhibitor for obstructive hypertrophic cardiomyopathy, demonstrated a favorable safety profile in over 6,000 patients under the REMS program. Data from April 2022 to February 2024 showed low incidences of reduced left ventricular ejection fraction and heart failure requiring hospitalization. Among patients treated for at least a year, LVEF reductions and HFH were rare. Drug interaction monitoring led to minimal dose adjustments and medication discontinuations. These findings support mavacamten's safety and tolerability, providing a model for future REMS programs in cardiology.

Milind Desai, MD describes favorable real-world safety outcomes from mavacamten use over 22 months of the Risk Evaluation and Mitigation Strategy (REMS) program.

Authors