Despite recommendations to limit the use of oral antibiotics, dermatologists continue to prescribe them in high numbers, according to results of a large, retrospective analysis of U.S. prescribing trends from 2004 to 2013.
However, spironolactone prescriptions increased nearly four-fold over that same time period, which is a good sign that alternatives may be gaining traction, according to authors, who described their results in the September issue of Journal of the American Academy of Dermatology.
“Given concerns about antibiotic resistance and other complications associated with oral antibiotic use, it is encouraging to observe an increase in the use of alternative agents such as spironolactone for the treatment of acne in female patients,” wrote lead author John S. Barbieri, M.D., and colleagues from the University of Pennsylvania Perelman School of Medicine in Philadelphia.
The number of spironolactone prescriptions marched steadily upward over time in the analysis, which was based on review of claims data representing 12-14 million annual covered lives.
Dermatologists prescribed 2.08 courses of spironolactone per 100 acne patients in 2004, increased to 4.10 courses per 100 patients in 2010 and 8.13 courses in 2013.
However, oral antibiotic usage remained much higher over the entire study period. Dermatologists prescribed 26.24 courses of antibiotics per 100 acne patients in 2004. That number appeared to dip slightly to 22.90 courses per 100 patients in 2010, but returned to 27.08 courses in 2013.
“Whereas we initially observed a slight decrease in oral antibiotic use, this trend has reversed in recent years,” the authors commented on these results.
It’s uncertain why oral antibiotic use seemed to decrease but then increase again, though authors noted that the shift upward followed the “dramatic decrease” in use of drospirenone-containing combined oral contraceptive pills starting in 2009.
“It is possible that because of concerns about the safety of drospirenone-containing combined oral contraceptive pills, clinicians shifted their prescribing behavior toward the use of more oral antibiotics,” they speculated.
Use of combined oral contraceptive pills dominated the group of systemic oral agents in this claims dataset, from 34.31 courses per 100 acne patients in 2004, which declined somewhat to approximately 30 courses per 100 patients in 2010 and 2013.
The analysis included a total of 594,776 courses of oral antibiotic treatment, 527,288 courses of combined oral contraceptives, 61,042 courses of spironolactone, and 108,664 courses of isotretinoin. The report by Dr. Barbieri and colleagues describes prescribing patterns in more detail, and includes prescribing data for non-dermatologists as well.
The authors suggest that dermatologists identify patients who might benefit most from alternatives to oral antibiotics, including spironolactone, isotretinoin, or oral contraceptives.
Oral antibiotics are among the most commonly prescribed treatments for acne that cannot be managed with topical therapies. In fact, dermatologists are the highest prescribers per capita of antibiotics compared to any other medical specialty.
Excessive use of antibiotics persists throughout medicine despite ongoing concerns about excessive use of antibiotics due to emerging antibiotic resistance, as well as adverse effects that include pharyngitis and inflammatory bowel disease, Dr. Barbieri and colleagues said.
Guidelines from the American Academy of Dermatology (AAD) and others recommend oral antibiotic treatment duration be limited to 3 to 6 months, although they recognize that a subset of patients may require longer treatment.
Duration of oral antibiotic therapy in the analysis by Dr. Barbieri and colleagues was indeed a median of 126 days for patients receiving care from dermatologists, and 129 days for those treated by non-dermatologists.
However, the sheer numbers of prescriptions were a cause of concern for the authors, who called for “judicious use” and “stewardship” of antibiotics.
“Like the authors of prior studies, we observe that prescribing behavior for oral antibiotics and the use of concomitant topical retinoids are not well aligned with current guidelines, although additional research is needed to understand the optimal duration of therapy with oral antibiotics,” the said.
Despite concerns over current levels of antibiotic use, Dr. Barbieri were hopeful that use of antibiotic alternatives will “continue to grow,” particularly following recent data suggesting that routine potassium monitoring may be unnecessary for healthy women taking spironolactone for acne.
“Increasing the use of concomitant topical retinoids, and additional work to identify those patients who would benefit most from alternative agents such as spironolactone, combined oral contraceptive pills, or isotretinoin represent potential opportunities to improve the care of patients with acne,” they said.
1. Barbieri JS, James WD, Margolis DJ. Trends in prescribing behavior of systemic agents used in the treatment of acne among dermatologists and nondermatologists: A retrospective analysis, 2004-2013. J Am Acad Dermatol. 2017;77(3):456-463.e4. doi:10.1016/j.jaad.2017.04.016.
2. Centers for Disease Control and Prevention. Outpatient antibiotic Prescriptions--United States. Annual report 2013.
3. Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016;74(5):945-973.e33. doi:10.1016/j.jaad.2015.12.037.
4. Plovanich M, Weng QY, Mostaghimi A. Low Usefulness of Potassium Monitoring Among Healthy Young Women Taking Spironolactone for Acne. JAMA Dermatol. 2015;151(9):941-944. doi:10.1001/jamadermatol.2015.34.