Tag: Harvard Health Publishing

An ad for a new eczema drug leaves some questions unanswered.

Dry, itchy, reddened skin is the hallmark of eczema. If you have eczema and have seen this ad, you may be wondering about Dupixent (dupilumab). Does this new medicine work as well as it seems to in the ad? Where does the ad hit the mark, and where could it do better?

The medicine only treats one type of eczema

While the ad uses “eczema” and “atopic dermatitis” interchangeably, these conditions aren’t exactly the same. Eczema is an umbrella term that includes:

• atopic dermatitis, which develops in people prone to asthma and environmental allergies, such as hay fever
• contact dermatitis, which is an allergic reaction to a substance touching the skin, such as soaps, scented products, or poison ivy
• skin inflammation that accompanies leg swelling.

Atopic dermatitis is the only skin condition for which Dupixent is approved.

The pitch

Every ad is a sales pitch, whether it uses real people or paid actors. Here we see real people banging on drums in a band, playing piano or trombone, and baking in the kitchen. A voiceover says “With less eczema, you can show more skin. So, roll up those sleeves and help heal your skin from within with Dupixent.” The pitch? People with eczema may be embarrassed by it and try to hide it — and effective treatment means you need not keep your skin covered.

We next hear this is “the first treatment of its kind that continuously treats moderate to severe eczema, or atopic dermatitis, even between flare-ups.” The viewer sees an outstretched arm with a red rash that clears up over a second or two. Of course, that’s not what happens in real life; it can take weeks to see improvement.

More perplexingly, the voiceover tells us that the drug “…is a biologic, and not a cream or steroid.” Perhaps you’re wondering what a “biologic” medicine is. Hold that question for further explanation below. “Many people taking Dupixent saw clear or almost clear skin and had significantly less itch. That’s a difference you can feel.“

Side effects, warnings, and a tagline

The warnings may raise eyebrows. “Don’t use if you’re allergic to Dupixent. Serious allergic reactions can occur, including anaphylaxis, which is severe. Tell your doctor about new or worsening eye problems such as eye pain or vision changes, or parasitic infection. If you take asthma medicines, don’t change or stop them without talking to your doctor.“

Quickly, though, the ad moves on to a glowing tagline: “So help heal your skin from within” and recommends talking to “your eczema specialist” about Dupixent. That may be difficult: most people with eczema see their primary care physician for it, not a dermatologist.

What the ad gets right

It’s true that people with eczema may try to hide it and that effective therapy may be liberating, allowing them to worry less about others seeing their skin. Dupixent is, indeed, neither a cream nor a steroid, which are older, common treatments for eczema. And, yes, Dupixent is the first treatment of its kind for eczema. It blocks a chemical called interleukin 4 (IL-4), which is thought to play an important role in this skin disease.

What else should you consider if you have atopic dermatitis?

• How is it usually treated? Mild cases of atopic dermatitis may respond to skin moisturizers or medicated creams, gels, or ointments, some of which contain steroids. But this may not be effective for more severe eczema.
• What’s a biologic? These medicines are made in a living system such as a microorganism, human or animal cells, or plant cells. They are often antibodies that block a substance in the body thought to cause or contribute to a disease. Because biologics are usually large molecules that would be destroyed during digestion if taken in pill form, they are generally available only by injection. Dupixent is injected every two weeks.
• Why are eye problems, parasites, and asthma mentioned in the warnings? Eye inflammation was a side effect of the medicine in studies leading to approval. IL-4 is considered a key part of our immune defense against parasitic infections, and a few study participants developed parasitic infections. As for asthma, Dupixent is an approved asthma treatment when combined with other medicines. So, if you had asthma and it improved while you treated your atopic dermatitis, you might be tempted to cut back on your other medicines — but that’s not safe without medical supervision.
• What about cost? Biologics are expensive. This yearly price tag for this medicine is about $40,000 a year. Even when covered by health insurance, copays and deductibles can make it a costly treatment.
• Does it work? Text appearing on the screen says 37% of adults and 24% of teenagers saw major improvement after four months of treatment, compared with less than 10% of people not taking Dupixent. That may seem great if you’re in the minority of people who dramatically improved. Or it might seem like modest success for a systemic treatment with significant risk of side effects and a large price tag.

The bottom line

Drug ads exist to sell a product. They should never be your primary source of health and treatment information. For that, look to your own health care providers and other reliable sources of information like the FDA or NIH. Their primary interest is providing accurate information and promoting public health and medication safety, not convincing you to use a particular drug.

Busy people may find it hard to take heart-healthy steps. These simple swaps can help.

Busy days make it hard to put heart health on the front burner. It just feels like you don’t have time for habits that keep the ticker in top shape — like exercising regularly, getting enough sleep, and eating a healthy diet. So maybe you take the stairs when you can, or you park farther away from a store to rack up a few extra steps each day. But what else can you do? Here are three things that might fit in your schedule.

Swap electronic communication for an in-person meeting

It’s fine if texting, emailing, social media, or Zoom calls are your primary means of communicating with others. But it’s not okay if those methods leave you feeling lonely or isolated — two problems linked to higher risks for heart disease, heart attack, or stroke, according to a scientific statement from the American Heart Association in the Journal of the American Heart Association.

To combat loneliness and isolation, try to replace some of your electronic back-and-forth with people with in-person meetings. Maybe you can find room in your schedule for a quick walk, cup of coffee, or brief lunch with a friend or colleague.

“Time spent face-to-face helps connect you to others and may make you feel less isolated,” explains Matthew Lee, a sociologist and research associate at Harvard University’s Human Flourishing Program. “Being physically co-present can help you feel more engaged with others, more valued, and more likely to feel a sense of shared identity — all things that may help ease loneliness. This is why some doctors are starting to engage in ‘social prescribing,’ including suggesting that people get involved in volunteering and other activities that build in-person social relationships.”

A recent study published in the International Journal of Public Health by Lee and a team of Harvard-led researchers suggests that better social connectedness may reduce the risk of being diagnosed with depression or anxiety. Both are associated with heart disease or making existing heart conditions worse.

Swap an unhealthy breakfast for a healthier one

Is your typical breakfast something quick and full of refined (not whole) grains, processed meat, saturated fat, or added sugar? Eating that kind of food regularly may drive up calories, weight, blood sugar, or cholesterol levels — and that’s not good for your heart.

Instead, chose breakfast foods rich in fiber, a type of carbohydrate that either passes through the body undigested (insoluble fiber) or dissolves into a gel (soluble fiber) that coats the gut.

Not only does fiber help digestion, it also

• traps, mops up, and lowers bad [LDL] cholesterol that can lead to clogged arteries
• controls blood sugar and lowers the risk for diabetes, which is strongly associated with heart attacks and strokes
• may help fight chronic inflammation, which plays a role in clogging arteries and causing heart attacks.

Fruits, nuts, seeds, whole grains (oats, barley, quinoa) and many other foods are rich in fiber. Try these fiber-rich breakfast ideas:

• microwaved oatmeal (heat a 1/2 cup of oatmeal with almost a cup of low-fat milk for about two minutes)
• a serving of cooked quinoa (cold, if you have it in your fridge) with a dollop of nonfat Greek yogurt, berries, and granola
• whole-grain cereal with milk (go for cereals with the highest amounts of whole grains and lowest amounts of added sugars)
• a slice of whole-grain toast with two tablespoons of nut butter (like almond or peanut butter)
• one or two handfuls of homemade trail mix (use your favorite unsalted nuts, sunflower seeds, and dried fruit such as raisins or apricots).

Swap a few minutes of scroll time for meditation time

If you ever take a break from your busy day to scroll through news on your phone or computer, chances are you can also find a little time to meditate, which is important for heart health. Research indicates that people who meditate have lower rates of high cholesterol, diabetes, high blood pressure, stroke, and coronary artery disease compared with people who don’t meditate.

What’s the connection? Meditating triggers the body’s relaxation response, a well-studied physiological change that appears to help lower your blood pressure, heart rate, breathing rate, oxygen consumption, adrenaline levels, and levels of the stress hormone cortisol.

The great news: it doesn’t take much time to reap the heart-healthy benefits of meditating — just about 10 to 20 minutes per day.

Ideas for quick ways to meditate in a busy day include sitting quietly, closing your eyes, and

• focusing on your breathing, without judging sounds you hear or thoughts that pop into your head
• listening to a guided meditation, which uses mental images to help you relax
• listening to a recording of calming sounds such as waves, a bubbling brook, or gentle rain.

Just try to calm your brain for a few minutes a day. Soon, you may find you’ve become better at meditating and better at practicing other heart-healthy habits, no matter how busy you are.

Burnout is causing physicians to leave the profession.

Reading the book The Doctor Stories by William Carlos Williams seared into my mind the ways in which a primary care physician (PCP) can transform the lives of patients with a nuanced blend of careful listening, emotional connection, and medical skill. This book inspired me to become a PCP.

According to a 2021 report by the National Academy of Sciences, Engineering, and Medicine, an increased supply of PCPs is associated with better population health and more equitable outcomes. With our country’s fraying healthcare system, it is essential to have a PCP who knows you, because it is almost impossible to access any type of coherent medical care without the coordination of a PCP.

The most common question I get asked as a doctor — by friends, acquaintances, relatives, families of patients, colleagues — is “Can you help me find a PCP?” I can’t. None of us can. Why is it so difficult to find a PCP nowadays?

Unfavorable demographics and PCPs leaving the profession

While the COVID pandemic certainly pushed a large subset of already burned-out PCPs over the brink into semi- or full retirement, or into less stressful jobs, the current primary care crisis has been brewing for much longer. The US is expected to face a shortage of primary care physicians ranging from 21,000 to 55,000 by the year 2033.

Both patients and doctors are getting older. As patients age, they tend to need more care from their PCPs to address the proliferation of medical problems and medications that inevitably comes with aging. At the same time, the Association of American Medical Colleges reports more than 40% of active physicians in the United States will be 65 or older within the next decade. The American Medical Association notes that 29% of physicians retire between the ages of 60 and 65, and 12% retire before the age of 60.

These numbers have daunting implications for the future supply of seasoned doctors. Further, one-fifth of doctors say they will likely leave their current practice within the next two years, and one-third of doctors are intending to reduce their work hours within the next 12 months.

PCPs have higher burnout and lower pay than many specialties

Primary care is getting hit harder than most specialties, due to having lower salaries, higher ratings of burnout, and a growing feeling that their job is generally impossible and thankless on all fronts. According to a 2019 physician survey, the burnout scores among PCPs were up to 79%. Many hospitals are happy to replace PCPs with even lower-paid NPs and PAs, who do a good job with routine care but aren’t trained in subtleties and complexities, which come into play if you develop a challenging or rare medical condition, or if you have multiple medical comorbidities.

Multiple causes of primary care dissatisfaction

Many PCPs are facing requirements by their hospitals to see a greater number of patients, who get sicker and whose care gets more complicated every year, in the face of significant salary and benefit cuts and with dwindling administrative and clinical support. PCPs have more to do at each visit, as new requirements and treatments come up, but none of the work aimed toward preventive health seems to disappear, such as managing blood pressure and cholesterol, as well as discussing and providing hospital scheduling requests for health screenings like mammograms and colonoscopies.

Further, when patients are finally able to get in to see us in person, they have many more unaddressed problems and concerns because they often haven’t seen us for a year or two. This creates a vicious feedback cycle, with PCPs having ever-growing issues to address under a time pressure and patients having increasingly unmet medical symptoms and needs.

Time devoted to electronic medical records is further impacting burnout

It is estimated that for each hour a PCP spends with a patient, up to two hours of work are generated, which includes writing summary notes and treatment plans in a patient’s electronic medical record (EMR) and communicating test results or other important information to patients and their caregivers. Many PCPs that I know go home at the end of crushingly stressful days, spend an hour or two with their families, and then stay up late to finish all the computerized documentation that their day in clinic has generated. Many also have second jobs or side gigs to pay off their medical school debts.

What we are managing in today’s clinics is increasingly complicated and out of our control. As our entire health care system struggles, it is more difficult to get patients into the emergency department, into the hospital, and scheduled to see medical specialists. PCPs are left managing many things in the absence of the support that we are ordinarily used to.

We are also managing greater mental health needs and dealing with the brunt of our patients’ problems, such as lack of housing and employment, unaffordable medications, and widespread financial problems. The fact that we are unable to care for our patients nearly as well as we previously could is considered to be a “moral injury” that many of us are suffering. And there is research that when your doctor is struggling like this, the quality of your health care can suffer.

What can patients do to find a PCP?

If your current PCP quits or retires, ask the practice to assign you to someone new. In theory, practices aren’t supposed to leave patients stranded and abandoned, even if they, like many places, don’t truly have enough experienced physicians to take adequate care of patients. If that doesn’t work, or if you don’t feel that your new doctor is a good match for you, you can call your health insurance and see which doctors are accepting new primary care patients.

If you happen to have a friend who is a doctor or a nurse, perhaps they can advocate for you by asking a colleague to accept you into their practice. Our system shouldn’t work this way, but it often does. Most practices have waiting lists, so if you are without a PCP, put your name down, as late is better than never.

What might reverse the primary care crisis?

We need to train and financially support more PCPs by encouraging trainees to go into primary care, and to eliminate the pay gap between PCPs and specialists. We need to buttress those doctors who are currently trying to stick it out as primary care doctors, so they don’t cut down hours or quit. These doctors urgently need emotional, financial, logistical, and psychological support.

Finally, we need to cultivate in new doctors the magic of primary care, so eloquently spelled out by William Carlos Williams, so that people can, in fact, access the care that will enable them to live and enjoy the long and healthy lives they deserve.