Achieving Superior Treatment Durability and Outcomes in Neovascular AMD and DME

0:56 Need for durable treatments in nAMD and DME

7:14 Highlights from clinical trials for faricimab

10:33 Post hoc analyses of faricimab clinical trials

16:24 Factors affecting retreatment decision

29:06 Choosing between faricimab and high-dose aflibercept

Expert retina specialists discuss the latest therapies that could reduce the treatment burden and provide superior clinical outcomes in retinal diseases.

Achieving Superior Treatment Durability and Outcomes In Neovascular AMD and DME

Aleksandra Rachitskaya, MD, FASRS

Before we sign off, I’d love to hear from everyone any advice or practice pearls for other APPs [advanced practice providers] that are either new or established in the management of plaque psoriasis. Darren, let’s start with you.

Try your best to get your office to get you a good biologic coordinator, because no matter how much we know and can prescribe these medications, having a team effort in the access of these medications is very important. I know recently they had a biologic coordinator day. We’re getting more and more recognition in this, but you have to have somebody you can work with. Advanced practice providers seem to be the default providers who see psoriasis anyway, so we really want to make it streamlined as much as possible. Our patients deserve the best. We take the most time with them, it seems. I’m always spending as much time as I can with them until I’m forced out of the room. I love these medications. These are incredible.

Our toolbox is definitely full, and to Doug’s point, the quiver is full. There are so many different weapons we can use now. It is incredible. We just have to feel safe and comfortable with a lot of these. We’ve had a lot of years of using biologics and small molecules now. And there are different medications and newer creams are coming out, and you just have to use them. That’s going to be the biggest thing we can do—have a whole team that works with this. I know the companies are helping us a little with some of this access to medications, but we want to make sure everyone has access to it. And being a team player with someone in your office, like a biologic coordinator, is my biggest help. Otherwise, it’s daunting. It’s just too much work.

What’s kind of amazing is pharmaceutical companies are now sponsoring biologic coordinators to be speakers for their company to help other biologic coordinators get medication approved. I love that so much. Because there’s only so much that we know and so much we can help our biologic coordinators with and vice versa. It’s just like us talking with our peers and colleagues. It’s the same thing, and I love that that community is blowing up.

Absolutely, and they deal with all the patients. They’re the ones talking. They’re making the phones calls. They’re behind the scenes. We know the medications, we prescribe them, and it’s great, but they really do a lot of the background work and all the hard work in some cases.

There’s a biologic coordinator council and society now. They have a journal and a publication. Last month, I received the first publication of biologic coordinator council, so it’s really neat to see all that happen.

For APPs who potentially want to expand their knowledge of psoriasis and the toolbox and things we use—I know sometimes I hear that it’s a little daunting just because we have so many tools now. When you look at clinical data, I would encourage to look at not only your primary end points but also a little further out. Look out to week 52 or week 60. It kind of gives an understanding or a general feel of the trajectory of medication. Then also looking at data out a couple years down the road that maybe some companies will have. Some companies publish that as that comes out for you to understand what you may see in your clinical practice, and each medication is going to work a little differently. So its not just primary end point but some of these longer end points, too.

There are certain nuances, like with deucravacitinib. Just because they monitor for certain things doesn’t necessarily mean there’s a high incidence of safety events. Clinical monitoring is not always 100% correlated with clinical incidence. That’s something that is the other nuance, too, with medications. With some medications, clinical incidence is more frequent, which is why we justify monitoring for certain safety signals. It’s kind of just teasing out those nuances. It does get overwhelming sometimes. And like what Darren was saying with bio coordinators and them understanding the insurance part and helping us through that guidance, that is a super useful tool for us as clinicians, for the paperwork and getting medications to our patients.

The labor of love for us as clinicians is understanding the products we’re using. At least now the products and medications we’re using have delivery of really high outcomes in a tolerable vehicle for our patients. It’s kind of just grouping your medications and trying to decipher which way you go and almost having a playbook for your psoriasis treatment on how you stratify your topicals, how you stratify your systemics, and then templating it. A lot of times, having a system may help you through this process, too. It’s kind of our own flavor of what system works best for us as individual clinicians.

Awesome. Jayme, what pearls do you have, whether they’re educational or clinical? Is there anything you would give advice on for other practitioners?

I think we have a responsibility. We need to be that beacon of hope for these patients. They have such a physical and emotional burden for their disease. It’s very hard. We also have a responsibility to support one another. I feel very lucky to say I know the panelists here today, and I have a great deal of respect for them. It’s really nice to be able to reach out to somebody. Even if somebody I don’t even know were to reach out, I would be more than willing to help them just like I help the other colleagues in my office.

We always need to make sure our patients get what they need. Sometimes it’s just making sure we know all our resources. Like Darren said, it is just an invaluable resource to have a biologic coordinator. It’s very difficult. We need to know all these programs. We need to know how we can get access for our patients. To do that, we need to continue reaching out to one another. We need to continue to support one another, we need to educate one another, and we need to educate our patients. We need to always let patients know that when they leave, they are supported, we do care, and we are going to help them. That’s our commitment to dermatology, and that’s why we have been entrusted as PAs [physician assistant] and NPs [nurse practitioner] to go ahead and take on this dynamic role to help patients with psoriasis.

Douglas, do you have any advice or any practice pearls for other APPs, whether new or established, in managing plaque psoriasis?

I can only echo what my great colleagues have already said. There’s obviously a theme here: get to know the medications, take the time to understand these medications, and practice presenting them to patients. Maybe you practice by pulling your nursing assistants together and say, “Let’s talk about these medications.” Maybe you meet with colleagues that are in your office. Maybe you reach out to someone you met at a conference, or reach out to any of us. I know we’re all willing to talk to people. There’s a great supportive network in the NP and PA community, as well as with our physician supervisors.

We want to do what’s best for our patients, so the takeaway pearl is to realize the power you have at your disposal. This is not power that’s meant to lift you up. It’s power to be transferred to your patients to change their lives. What an awesome opportunity it is to do that. My pearl is to take a little bit of time. If you got into medicine and you don’t consider yourself a lifetime learner, then you may be in the wrong place. Because if you’re not a person who’s willing to get up sometimes on a Saturday morning or stay up a little bit later—I’m just a believer that what you do from 9 am to 5 pm is not as important as what you do between 5 pm and 9 am. It takes a little bit of some buy-in to be someone [who’s] going to be on the cutting edge, that’s going to be evidence based, and that’s going to be empathetic. That empathy is shown by giving patients the best options we have. Your patients deserve it, they love it, and we’re all capable of doing that. It makes it fun. That’s my encouragement to you—be a prescriber of hope. Tell patients we’ve got great things- there are great things available to them. Speak that positivity into their life when you first see them, because that begins to change things right off the bat that I’ve seen at least in my practice.

Darren, I think I cut you off before. Was there anything else you wanted to add?

We have an obligation to treat our patients, and I think we do a disservice to our patients when they walk through the door, take the time to come in and see us, and we just give them a cream and turn them loose. We need to understand these medications. We need to understand how well they work. We need to give our patients hope. I think that’s why they come and see us. I think the advantage of us being in this industry today is that we have so many tools to work with. We have the advantage on our side, and we can change lives forever. It’s incredible. I’m glad we’re a part of it these days. The companies that have put a lot of effort and work into getting these drugs to market, and the research and development we see today, is incredible. We need to all work together. We don’t have all these amazing drugs just to sit on the shelf. We need to be bold enough to try them out. We need to be not fearful in prescribing these and just jump off that ledge and do it and see how it works.

I’m not saying this, but I’ve heard others say this—others that are much more influential and are in this space. They feel like we’re getting to a point, very close in time, that not offering a patient who has severe disease a systemic agent—I’ll keep it in the category of severe—may be considered malpractice in the near future. Because we know, with severe disease, the chance of them creating a destructive joint, having a heart disease, and all the other problems we’ve mentioned—not addressing that is something that is such a disservice. I’ve heard others who are far more influential than me make those bold statements from the podium. I’m not sure I’m willing to make that bold of a statement from a podium yet, but I sit there and shake my head and agree. We’ve got these tools and we’ve got to put them to work.

Think about deciding to not treat an uncontrolled diabetic. We have to get into that mindset of the systemic condition, and I think that is changing. Psoriasis is no longer a skin condition. We just talked about all the comorbidities, all these things that come along with it, and we have to continue to relay that message to each other and our patients. I think we can always continue to learn, like Douglas said.

Thanks to all of you for this rich and informative discussion. Thank you for watching this 

 discussion. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming peer exchanges and other great content right in your inbox.

Experts in dermatology share practice pearls to advanced practice providers and community dermatologists for the management of plaque psoriasis.

Clinical Pearls and Educational Needs in Plaque Psoriasis

Alexa Hetzel, MS, PA-C

Joseph, do you have any final thoughts about, or takeaways from, this discussion?

Education is important for everybody. Many health care providers, including myself, always had this feeling about FMT [fecal microbiota transplant]. Is it dangerous? Will patients wind up getting sick? Where does the stool come from? Is it a mix of donors or a single donor? How much will it cost? And the whole idea of a colonoscopy with bowel prep and propofol, which I mentioned before, seems like a lot. We need to change the way we think about the natural course of 

 infection [CDI]. Hopefully, people will and explore all treatment options that are available at this point.

As far as education with the practitioners, it is about educating the patients as well. If they happen to be frequent fliers for, let’s say, as you mentioned, UTIs [urinary tract infections]. Or they go to their physician, and they say, “I have a cold,” and they’re given an antibiotic. You have to explain to patients as you’re seeing them come into your practice that it’s not important to get an antibiotic every time you go to your physician’s office. And to educate them and not to try to doctor-shop and get an antibiotic if they don’t get the right answer from their primary care physician [PCP] or whomever. It’s important not only for practitioners, but for patients or potential patients for 

 Certainly, we’re going to continue to need patient education, and I appreciate that comment. Andrew?

I am cautiously optimistic now, at this point, as to where we’re headed with CDI treatment, as we have the first FDA-approved FMT product at this point right now with seemingly more on the way. We’ve got the first one through the door, and it’s going to be a matter of seeing where things go from here. As you mentioned earlier, maybe hopefully in the next 10 years we’ll have narrowed it down to which key microorganisms are essential for restoring the microbiota. And if we see these improvements, then hopefully the treatments will continue to become more effective into the future as well.

Appreciate that. I have to say that I’ve considered myself in the past a drug pusher, if you will, in the good sense of the term. But I am excited the fact that there is now an FDA-approved fecal microbiota replacement and that’s a nice, good step forward with assurance that it’s screened and safe, for the most part. And that’s a major step for managing patients with recurrent 

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Experts provide practice pearls for educating patients on and using FMTs for the management of CDI.

Key Takeaways on FMTs in the Treatment of CDI

Andrew Skinner, MD

Experts conclude this series highlighting what is on the horizon of retinal disease care. 

Perspectives on the Future of Retinal Disease Management

In this final segment, the participants share their excitement for the future of retina care this year and beyond. Across the panel, experts express enthusiasm for the constant evolution of therapies, techniques, and technologies in the field of retina. They touch on the ongoing trials and current research, acknowledging the challenges and complexities of developing new drugs but remains optimistic about potential breakthroughs. Experts circle back to gene therapy, emphasizing the potential for game-changing developments once challenges like inflammation are addressed. The physicians across the panel are excited at the prospect of higher durability agents to continue improving patient quality of life.

This summary was AI-generated and edited for clarity.

Diana Do, MD

Inflammatory back pain (IBP) is a key clinical feature that can help diagnose 

. Importantly, IBP can also be caused by infections, drugs (such as isotretinoin), and various malignancies. Commonly known infections that may mimic IBP include Brucella and tuberculosis infection. Hematologic malignancies and solid tumors can also cause IBP through paraneoplastic mechanisms or via metastasis. Thus, a recent study by Albayrak et al sought to present characteristics of patients presenting with IBP in the past 10 years with a final diagnosis of malignancy.

This retrospective, multicenter study was performed in Turkey at multiple tertiary care rheumatology centers. They enrolled patients who presented with IBP in the previous 10 years who were ultimately diagnosed with malignancy as the final diagnosis. Thirty six patients with AxSpA, with similar age/sex ratio of 1:1 from each center, were included as the control group.IBP was defined according to Calin criteria. They collected demographic data as well as disease activity measures (Bath ankylosing spondylitis disease activity index or BASDAI) and laboratory testing (ESR, CRP, CBC, LDH, calcium). All patients had pelvic and lumbar radiographs, with sacroiliac MRI obtained in necessary cases.

Ultimately, 34 patients were included in the malignancy group (mean age 42.6) compared to 36 patients in the control group (mean age 43.6). There were statistically significant differences in the time interval between IBP and diagnosis (21 months in the control vs 4 months in the malignancy group) and in the BASDAI scores (6.1 in malignancy group vs 5.1 in the control group). Of the malignancy group, there were 16 hematologic malignancies (multiple myeloma, acute leukemia, lymphoma) and 18 solid tumors (including breast, lung cancer, bone tumors, prostate, colon). Pain due to metastasis was seen in 27 of the malignancies, and 7 cases of IBP were due to a paraneoplastic condition. Compared to the control group, patients with IBP due to malignancy had higher inflammatory markers (ESR, CRP), higher LDH values, and lower hemoglobin levels.

The authors believe this is the largest case series of IBP with a final diagnosis of malignancy in the literature. They note some unique features of malignancy-related IBP include short interval between symptom onset and diagnosis, with much higher acute phase reactants and LDH levels, and lower hemoglobin values compared to AxSpA.Imaging can also help differentiate AxSpA from malignancy: IBP due to malignancy is often associated with lytic lesions, collapse fractures and infiltrations, compared to bone marrow edema or new bone formation in AxSpA.The authors did not have HLA B27 results in the malignancy cases, which may be a risk factor for IBP in malignancy. Rheumatologists should consider mimics of inflammatory axial spondyloarthritis when evaluating patients with inflammatory back pain.

Albayrak F, Kısacık B, Gündüz İ et al. Inflammatory low back pain-associated malignancies mimicking spondylarthritis. Clinical Rheumatology, September 2024.

Malignancy-related IBP has distinct features: shorter diagnosis time, higher ESR/CRP/LDH, lower hemoglobin, and often involves metastasis or paraneoplastic causes.

Inflammatory Back Pain in Malignancy Mimics Spondyloarthritis

Mithu Maheswaranathan, MD

Nanette Silverberg, MD, serves as the chief of pediatric dermatology for the Mount Sinai Health System in the Kimberly and Eric J. Waldman Department of Dermatology.

Discussing Treatments, Anticipatory Guidance for Molluscum Contagiosum, with Nanette Silverberg, MD

In another segment of her interview with the 

 team, Nanette Silverberg, MD, spoke about the takeaways from her conference talk ‘What's New in Molluscum Contagiosum? Advances in Understanding and Treating Molluscipoxvirus,’ presented at the 

2025 American Academy of Dermatology (AAD) Annual Meeting

Silverberg, who serves as the chief of pediatric dermatology for the Mount Sinai Health System in the Kimberly and Eric J. Waldman Department of Dermatology, was asked in this segment of her AAD interview about identifying molluscum in children.

“We always talk about syphilis being the great imitator in dermatology, but molluscum is a great imitator in kids,” Silverberg explained. “You know, we hope kids don't get syphilis. Obviously, there have been some recent cases of congenital syphilis because of the background rise in the population, but in general, molluscum is the great imitator in childhood. It can look like acne. It can look like eczema because it can be hidden by the eczema and can trigger severe eczema. It can get so large that it looks like a cyst or an abscess. So it really can be hard to diagnose at the beginning.”

Silverberg added that clinicians have to maintain a high level of suspicion, noting that they can do so by magnifying lesions.

“If you see severe eczema, and it's always in the same location on the leg, and parents have such a hard time clearing it, you need to magnify and look for molluscum,” she explained. “It's often there. We have lots of in-office tools to diagnose, such as dermoscopy and Tzanck preparation, so certainly these can help us make the diagnosis in the office.”

Silverberg also spoke to the potential options among patients with molluscum contagiosum and their caregivers as far as therapeutics.

“We have a rich therapeutic armamentarium that's coming out now with topical berdazimer, which was FDA-approved but not yet released,” Silverberg said. “The new in-office cantharidin that we can use [as well]. All of these add to our ability to holistically treat molluscum, and they came at just the right time because we have so many cases. It's gotten more extensive over time, and it's wonderful to be able to offer patients therapeutic options.”

To learn more about these takeaways from Silverberg’s presentation on molluscum, view her full interview posted above. For more coverage of interviews with presenters and trial investigators at AAD, view our 

The quotes contained in the interview summary above were edited for clarity.

In this segment of Silverberg’s interview, she highlights providing anticipatory guidance for parents of children with molluscum as well as treatment options.

Nanette Silverberg, MD

 What I’m hearing from you guys is that it’s important to educate your patients, to provide informed tools for them to make an informed decision based on their specific scenario. For our last question, I’m going to ask all of you: sickle cell disease has been around for over 100 years, and we’re still dealing with organ damage, acute exacerbations, quality-of-life issues, fatigue, difficulty finding a mate, difficulty finding work. What are your concerns around health equity and access to care that are persistent? What would be the 1 thing that if you could fix about sickle cell disease if you had a magic wand or a genie bottle? I’m going to have Dr Desai start, then Dr Shah and Dr Smith.

 I’m going to make the first wish. It’s to get every patient connected to some care—having somebody who will care and talk about these things, to say “I don’t know” sometimes and walk through life with them. We’ve talked about how complicated it is; they can’t do it by themselves. Everybody needs that advocate, they need the person that understands the disease. Even if they don’t understand, they’re willing to take that extra step. I wish everybody had a place that they could be connected to care.

 Excellent. Dr Shah, what’s your 1 wish from the genie bottle or magic wand?

 For wish No. 2, I have a 2A and 2B; they’re connected. The 2A is a big shift in mindset about therapies, from being reactive to prophylactic. We have drugs that are reactive because they’re anemic or because they have pain. But why do they have to be anemic or in pain? Why can’t we move more toward prophylactic? But because therapies are expensive, there’s so much out there, and not all patients are in centers that can give you those therapies, when we get to those therapies being prophylactic, they must be accessible, easy to take, and cost-effective. Not a drug that’s so expensive that a payer isn’t going to want to support that across the country. We have patients who aren’t plugged in to care, don’t have access to health care, and don’t have insurance. Why aren’t they getting the same therapy as another patient in an area that has a comprehensive sickle cell center? So there are 2 arms: better prophylactic medications with access to as many patients as possible.

 Public health. We don’t know how many patients have sickle cell disease in the United States, but Brazil does. Brazil is supposed to be an emerging nation. That’s a travesty. If we knew how many patients had sickle cell disease in every state in the United States, then we could more appropriately advocate for resources to do everything you just heard. We can know just by having somebody snap their finger and make each state share their newborn screening registry with each other; we could do that. Eleven states are already doing it, according to the CDC [Centers for Disease Control and Prevention]. My 1 wish is to get all 50 states to do that so we can talk intelligently about how many patients have the disease. We can then make health care allocation decisions for not just doctors but community health workers, hospitals with drugs, and community-based organizations and resources to help these patients.

 Thank you so much. My 1 wish is that all 3 of your wishes—or 3½ to 4 wishes—come true. If we get there, then each individual with sickle cell disease should be able to live to be 99 years old, get to lose all their teeth, and use a walker. Having a quality of life and a quantity of life that equals that of their peers is the ultimate goal.

I want to thank you, Dr Desai, Dr Shah, and Dr Smith. Thank you for this very informative session, for all your knowledge, and for sharing your experiences. This is a transformational period in sickle cell disease care. I look forward to more drugs being approved, I look forward to a lot more research, and I look forward to the 50 states being connected and for every patient to have access to the right type of care. Thank you very much, everyone.

Concluding their discussion on sickle cell disease management, expert panelists share key unmet needs and hopes for the future.

Sickle Cell Disease: Unmet Needs and Future Directions in Care

Nirmish Ramesh Shah, MD, Duke University

 Before we conclude, I’d like to get some final thoughts from each of you, if you have any. Let’s start with you, Dr Nordberg.

 From my perspective, treatment-resistant depression and other complex mental health challenges are systems challenges as much as they are clinical challenges. We haven’t moved the needle in treatment effectiveness in about 50 years, and in no small respect that may be because we haven’t changed our systems that provide care. I’m a big fan of looking at developing systems where we’re doing a lot more precision referral work, and to Martin’s earlier point, identifying different providers, clinics, and centers of strength, and referring to strengths. The only way to do that is to collect the data.

There are challenges around collecting the data. It creates vulnerability and a lot of visibility where there hasn’t been historically. One of the things that we’re working on at Reliant Medical Group is trying to be more precise about how and who we refer. A lot of that involves understanding the patient that we’re being presented with, and also understanding how that person matches up with what we believe is the most likely treatment to be effective for them based on data.

I’m pretty confident that if we can do that work in naturalistic settings, we’ll get past the archaic requirement of failing 2 bonafide medication interventions and get more rapidly to something that’s going to allow a care delivery organization to say, “This is a patient with treatment-resistant depression,” and a payer to say “No problem,” and then allows that care delivery organization to connect that patient with a reimbursed intervention that has a likely shot of helping them. That’s a lot of work to be done, but it starts with measurement and having the confidence to integrate that measurement into your clinical routine.

 Well said. To your original point, we haven’t moved the needle much in these past 50 years. You’re calling for improved systems, better measurement, and moving toward precision care. Hopefully that will be supported by the validation of some biomarkers that can lead to more precise and predictive treatments. Would you also agree that part of this as well is that we haven’t had very many new tools in the past 50 years, and potentially having some effective new tools in the toolbox may also help move that needle?

 It may. We also know that there’s a lot of variability between different providers and that there are different kinds of treatments that appeal more to different kinds of patients. The biomarker research is sexy and exciting because of that possibility of carving nature at its joints and being precise. It’s also a long way off. RDoC [Research Domain Criteria] didn’t deliver the promise of precision opportunities for understanding and deep learning about what drives mental health on a physiological level.

We still have a lot of opportunities with the systems and treatments that are already out there. This system still has a lot of room for optimization. It starts with having the courage to collect more data and letting those data start to tell us what kind of a patient this is and the best place for the patient to go based on what we’ve already learned about similar patients. That’s where my focus is, less so on developing novel interventions. It’s important to figure out where the patients that we’ve been discussing fit in that overall model, but we’re not going to be able to figure that out if we’re not collecting the right data.

 For those of us who deal with the fun stuff, the insurance and billing portion of things, like I’ve been saying this whole time, it’s important to make sure that you understand your payers and their guidelines and policies. You have to play that middleman role between the insurance carriers, providers, and patients. We need to make sure that we’re educating our providers so that they know if there are any changes to these policies so that they can find the right fit for patients.

It’s also important to educate the patients in regard to what qualifies them as having treatment-resistant depression and what’s available out there. Be an advocate for the patient with the payer and keep them involved in the process so that they’re not at home wondering, “What’s going on with my prior authorization? When is my treatment going to start?” Let them know everything along the way and be there for them.

 The theme that I’d leave with is the idea of “better together.” If you think about it, there are 3 participants in the goal here. Front and foremost is the patient because they want to get better. They’re suffering. There’s the provider who’s trying their best to figure out the appropriate care. There’s also the payer who wants to make sure that the patient gets access to the benefit that they deserve and that they’re able to go on and live a healthier and happier life. You have to see that triad.

There’s a likelihood that you can blame the insurer or blame someone else, but at the end of the day, it’s about figuring out how to work better together, that triad, because we have a common interest in improving the life of that patient. That’s the part that I like to focus on. What are we doing this for? Who matters the most? The other stuff can be worked out.

 Thank you. Last but not least, Dr Ares-Romero.

 I love that. I love how you ended with that. Because as somebody who treats treatment-resistant depression regularly, I’m very passionate about having my patients improve their lives. Their quality of life is what’s important, and that they get passion and fulfillment from their lives. It’s beautiful to hear that, that we can work together. That’s key, getting the payer together with a provider. It’s not about you or me. It’s about the patient and how can we come together to work together. I love that.

Despite the hurdles and challenges and everything we’ve talked about, it’s an exciting time in psychiatry. This is a time when we have new modalities, new things, all the data collection, all the systems, and the artificial intelligence that we have now that we haven’t explored. There are so many wonderful things coming that I’m excited. I’m excited for our patients. I’m excited for everything that we’re doing.

 Thank you all again. To our viewing audience, we hope you found this 

® panel discussion to be useful and informative.

An expert panel shares insight on the future treatment landscape for treatment-resistant depression. 

Optimizing the Management of TRD

Patricia Ares-Romero, MD, FASAM

Practical Considerations for Managing Atopic Dermatitis With Biologics

Video content above is prompted by the following:

When you start a patient on a biologic, how often are you monitoring the patient’s treatment regimen for effectiveness?

When do you consider a patient a nonresponder to their current treatment?

If a patient is not responding to their current biologic or discontinues it for any reason, what would be your next approach to treatment?

Do you have any practice pearls for adherence for potential nonresponders?

What impact would switching to another systemic therapy with a different mechanism of action have on the patient?

How would you decide whether to switch to another biologic or switch to an oral JAK inhibitor?

What closing thoughts do you have on the use of biologics in moderate to severe atopic dermatitis?

Panelists discuss how biologic therapy management requires strategic monitoring with initial assessment at 4 to 12 weeks, defining nonresponse at 12 to 16 weeks, addressing adherence before considering alternatives such as switching biologics with different mechanisms or transitioning to JAK inhibitors based on comorbidities, coverage, administration preferences, and safety considerations—emphasizing that the expanding therapeutic landscape enables personalized approaches that have transformed expectations for moderate to severe atopic dermatitis.

TJ Chao, MPAS, PA-C

Gastroesophageal reflux disease (GERD) remains among the leading diagnoses given to patients, especially in an ever growing obesity epidemic. 

Our understanding of the different presentations of GERD, its diagnosis and treatment, as well as side effects of GERD-directed therapy, have been changing. An updated American College of Gastroenterology (ACG) Clinical Guideline for the Diagnosis and Management of GERD effectively summarizes the current advances in GERD.

Compared to the previous clinical guidelines, much remains the same in the diagnosis and treatment of typical GERD. 

An 8-week empiric trial of proton pump inhibitors (PPI) is recommended for patients who do not have alarm symptoms. Diagnostic endoscopy is recommended to be done off of PPI therapy for patients who do not respond to PPI, hose with red flag symptoms, and those at risk of Barrett’s esophagus. Ambulatory reflux testing is indicated in patients without objective evidence of GERD on endoscopy prior to establishing a diagnosis of GERD.

When indicated, PPIs are recommended to be continued at the lowest effective dose. This change stems from pressures of research suggesting an association of many side-effects to PPI use. 

However, it is emphasized that the evidence for these associations are based on observational studies, not designed to prove causality. 

The only randomized controlled trial has not shown evidence of causation for many of these side effects, with the exception of increased risk of enteric infections. Therefore, continued use of PPIs is still recommended for those with indications such as erosive esophagitis and Barrett’s esophagus.

The dietary and lifestyle recommendations for GERD have not changed. Optimization of PPI therapy is still the first line of management in patients with refractory GERD. 

Most PPIs (with the exception of dexlansoprazole) are recommended to be taken 30 minutes before a meal, not at bed time. Although all PPIs are effective at healing esophagitis, they have differences in their potency of acid-suppression. 

Ranked in potency from least to highest, are pantoprazole, lansoprazole, omeprazole, esomeprazole, and rabeprazole. Therefore, switching to another PPI in patients with incomplete response can be considered. In line with previous recommendations, PPIs are recommended over H2-receptor antagonists (HR2As) for their superiority at healing esophagitis. 

While H2RAs can be used on an as-needed basis, they have been shown to lose effectiveness if continuously used for >1 month.

Prior to consideration of invasive therapies for reflux, a solid diagnosis of GERD and a clear association to symptoms, should be established either by pH monitoring, or endoscopy (i.e. for large hiatal hernias and erosive esophagitis). High resolution manometry is indicated preoperatively to rule out major disorders of esophageal motility such as achalasia or absent contractility. The new addition to these recommendations, is that provocative testing for contractile reserve via multiple rapid swallows should be done to assess for risk of post-fundoplication dysphagia. 

For the carefully selected patient with indications for anti-reflux surgery, the guidelines recommend surgical fundoplication or Roux-en-Y gastric bypass. Newer, less invasive alternatives to consider include magnetic sphincter augmentation and trans-oral incisionless fundoplication (in the absence of hiatal hernias > 2 cm, and erosive esophagitis).

With the advances of ambulatory pH and impedance monitoring, the diagnosis of extraesophageal symptoms of GERD is another new focus of the updated guidelines. 

For patients who do not have heartburn or regurgitation, but have atypical GERD symptoms such as cough, throat clearing, hoarseness, globus, asthma, laryngitis, it is recommended that ambulatory reflux testing be done prior to a trial of PPI. 

For those who have both typical symptoms of GERD, as well as extraesophageal GERD symptoms, a trial of PPI can be considered. It is important to note that endoscopic evidence of GERD does not prove causality for GERD as the driver of extraesophageal symptoms. 

Therefore, ambulatory pH and impedance testing has more of a role in the evaluation of patients with extraesophageal GERD symptoms than endoscopy alone.

Not much has changed in the management of extraesophageal GERD symptoms, but the guidelines have summarized the efficacy of different treatment modalities. 

PPIs have shown varying results in the treatment of asthma and chronic cough. Antireflux surgery seems to be inferior in the treatment of patients with extraesophageal GERD symptoms, compared to those with typical GERD symptoms. 

Predictors of a positive response to surgery include the presence of typical GERD symptoms, abnormal acid exposure time on pH monitoring, and positive response to PPI. Therefore, patients with only extraesophageal GERD symptoms who do not respond to PPIs, should be advised against invasive therapies for reflux.

Overall, the 2022 ACG guidelines serve as an excellent refresher on everything GERD-related, as well as a comprehensive summary on newer developments in the diagnosis and management of GERD. With the current rate of evolution in the field of GERD research (i.e, esophageal function testing, alternatives to PPIs, and endoscopic therapies for GERD), much more remains to be anticipated from the next update on GERD.

Katz PO, Dunbar KB, Schnoll-Sussman FH, Greer KB, Yadlapati R, Spechler SJ. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. 

. 2022;117(1):27-56. doi:10.14309/ajg.0000000000001538

A review of changes to clinical, dietary and screening strategies for patients with GERD.

Authors