The following is an excerpt from our latest podcast on off-label therapies with Adam Friedman, MD, a professor of dermatology and interim chair of the department of dermatology at George Washington Medical School in Washington, DC.
What other barriers are there for using therapies off‑label?
I think there’s two general issues that can come up. One is the patient! You’re suggesting the patient use a systemic medication for something it wasn’t meant for. I’ve had plenty of patients say “I don’t want to be experimented on” or “how do you know it’s safe for someone like me?” Certainly, pharmacists can contribute to the problem.
A great example, I mentioned pruritus before, for chronic pruritus, utilizing antidepressants, antipsychotics, [or] anti‑seizure medications. For chronic pruritus, I use a lot of gabapentinoids in my practice, [or selective serotonin reuptake inhibitors] … if I don’t prepare them, the patient will go to the pharmacy. The pharmacist will start counseling them on their antidepressant or antipsychotic.
You get a very angry call. “You think I’m crazy? Why are you putting me on this?” Of course, we’re not putting them on the medication because we think they’re crazy or have a psychiatric illness, [though] they may have that, too, but that’s irrelevant. We’re using this because of how it works on the central nervous system to impact itch.
Preparing the patient, explaining why you’re using the medication for the intended reasons, how it works, at least as much as we know, so that when they go and pick it up, they’re not surprised. Those surprises really are what cause a lot of headaches.
The second part, of course, in terms of dermatologists being uncomfortable, is that these off‑labels uses, for many there’s limited data. If you’re not a gunslinger or a risk‑taker, certainly you may be a little more hesitant. That’s why I think the ones I selected for my lecture were my “go‑tos” because these are drugs that have been around for quite some time.
Dapsone has been around since the first half of the 20th century. I believe it was first synthesized in 1908. We know a lot about the safety. We can get a lot of good guidance, whether you’re using it for dermatitis herpetiformis, bullous lupus, or even non‑neutrophilic diseases, granuloma annulare. For example, urticaria. We have really good guidance of what labs you take before starting. How do you have to counsel a patient? What do you need to follow? At what doses do we see efficacy? Often, 100 and 200 mgs a day is what you need for a lot of the neutrophilic dermatosis, but not always for urticarial syndromes or urticaria. I just used it as one example. Some of the older ones and also cheaper ones may make those more comfortable. Talking about them and sharing that data could get those who aren’t so familiar on board.
Certainly, the same is true for all the other ones. I said these are pretty longstanding, old medications. Hydroxychloroquine, even older. It was first described in the late 1800s for the utilization in systemic lupus. We know what to expect. It has been around for so long that there are papers with the title stating why all lupus patients should be on hydroxychloroquine or anti‑malarial. I think it’s a little easier.
Sometimes, it’s more for when you have the newer medications, we get our hands on them for one particular indication, and then the gears start turning up there. I go, “What else can I use this for?”
I very much think like that, but that’s more of an exception than the rule. That’s where, of course, getting case series/case reports out there in literature is so unbelievably important and discussing at meetings like [ODAC Dermatology, Aesthetic and Surgical Conference] 2020. It’s so important to get people comfortable with using even newer therapies. n