S K I N & A L L E R G Y N E W S • O c t o b e r 2 0 0 8
Midlevel Practitioners Help Drive Bottom Line
B Y R O B E R T F I N N
the things dermatologists should consider
mal risk before plunging in with a ful -time
when hiring a physician assistant (PA) or
S A N F R A N C I S C O — Physician assis-
tants and nurse practitioners can enhance
“This is a way to enhance profitability,”
rect staff to monitor all new-patient calls,
see once these individuals are hired is not
tice, but it is important to take a hard look
gists are about as busy as they can be, so
each day? Are prospective patients making
profitability,” Ms. McLaughlin said. “It’s
the solution is not simply to see more pa-
not all about the profit, but certainly you
where because they couldn’t get appoint-
day. Aside from the financial issues, many
ments within a reasonable period of time?
Doing this is not as straightforward as it
might seem. It’s not a matter of simply
lin, a certified health care business consul-
perhaps 2 full days or 4 half-days—can be
subtracting the practitioner’s salary and
benefits from his or her gross receipts. To
The following table summarizes the highest scores of local cutaneous signs and symptoms of irritation that wereworse than baseline:
must also subtract a realistic share of the
Metronidazole Gel, 1% Gel Vehicle For topical use only. Not for oral, ophthalmic or intravaginal use. INDICATIONS AND USAGE Sign/Symptom
METROGEL® (metronidazole gel), 1% is indicated for the topical treatment of inflammatory lesions of rosacea. 138 (25.4) 63 (34.2) CONTRAINDICATIONS METROGEL® (metronidazole gel), 1% is contraindicated in those patients with a history of hypersensitivity to metro-
nidazole or to any other ingredient in this formulation. Midlevel PRECAUTIONS General: Topical metronidazole has been reported to cause tearing of the eyes. Therefore, contact with the eyes
should be avoided. If a reaction suggesting local skin irritation occurs, patients should be directed to use the medica-
tion less often or discontinue use. Metronidazole is a nitroimidazole and should be used with care in patients with
134 (24.6) 60 (32.6)
evidence of, or history of, blood dyscrasia. should ‘never see Information for Patients: Patients using METROGEL® (metronidazole gel), 1% should receive the following informa-
1. This medication is to be used as directed. a new patient,
3. Avoid contact with the eyes. 4. Cleanse affected area(s) before applying METROGEL® (metronidazole gel), 1%. Pruritus 86 (15.8) 35 (19.0) because I think
5. This medication should not be used for any other condition than that for which it is prescribed.
6. Patients should report any adverse reaction to their physicians. the biggest Drug Interaction: Oral metronidazole has been reported to potentiate the anticoagulant effect of coumarin and war-
farin, resulting in a prolongation of prothrombin time. Drug interactions should be kept in mind when METROGEL®
(metronidazole gel), 1% is prescribed for patients who are receiving anticoagulant treatment, although they are less
danger we all
likely to occur with topical metronidazole administration because of low absorption. Stinging/burning 56 (10.3) 28 (15.2) Carcinogenesis, Mutagenesis and Impairment of Fertility: Metronidazole has shown evidence of carcinogenic activ- have is missing a
ity in a number of studies involving chronic, oral administration in mice and rats, but not in studies involving ham-
In several long-term studies in mice, oral doses of approximately 225 mg/m2/day or greater (approximately 37 times
the human topical dose on a mg/m2 basis) were associated with an increase in pulmonary tumors and lymphomas.
Several long-term oral studies in the rat have shown statistically significant increases in mammary and hepatic
tumors at doses >885 mg/m2/day (144 times the human dose). something.’
The following additional adverse experiences have been reported with the topical use of metronidazole: skin irritation,
Metronidazole has shown evidence of mutagenic activity in several in vitro bacterial assay systems. In addition, a
transient redness, metallic taste, tingling or numbness of extremities, and nausea.
dose-related increase in the frequency of micronuclei was observed in mice after intraperitoneal injections. An
OVERDOSAGE: There are no reported human experiences with overdosage of METROGEL® (metronidazole gel), 1%.
increase in chromosomal aberrations in peripheral blood lymphocytes was reported in patients with Crohn’s disease
Topically applied metronidazole can be absorbed in sufficient amount to produce systemic effects.
who were treated with 200 to1200 mg/day of metronidazole for 1 to 24 months. However, in another study, no
DOSAGE AND ADMINISTRATION: Areas to be treated should be cleansed before application of METROGEL® (metro-
increase in chromosomal aberrations in circulating lymphocytes was observed in patients with Crohn’s disease treat-
nidazole gel), 1%. Apply and rub in a thin film of METROGEL® (metronidazole gel), 1% once daily to entire affected
area(s). Patients may use cosmetics after application of METROGEL® (metronidazole gel), 1%.
In one published study, using albino hairless mice, intraperitoneal administration of metronidazole at a dose of 45
HOW SUPPLIED: METROGEL® (metronidazole gel), 1% is supplied as follows:
mg/m2/day (approximately 7 times the human topical dose on a mg/m2 basis) was associated with an increase in
60 gram tube – NDC 0299-3820-60
ultraviolet radiation-induced skin carcinogenesis. Neither dermal carcinogenicity nor photocarcinogenicity studies
60 gram tube with complimentary 4 oz Cetaphil® Gentle Skin Cleanser – NDC 0299-3820-04
have been performed with METROGEL® (metronidazole gel), 1% or any marketed metronidazole formulations.
pointed and might well leave after a short
Pregnancy: Teratogenic Effects: Pregnancy Category B. There are no adequate and well-controlled studies with the Storage Conditions: Store at controlled room temperature: 20˚ to 25˚C (68˚ to 77˚F), excursions permitted between
use of METROGEL® (metronidazole gel), 1% in pregnant women.
time if reality doesn’t match expectations.
Metronidazole crosses the placental barrier and enters the fetal circulation rapidly. No fetotoxicity was observed after
Prescribing Information as of February 2007.
oral administration of metronidazole in rats or mice at 200 and 20 times, respectively, the expected clinical dose.
However, oral metronidazole has shown carcinogenic activity in rodents. Because animal reproduction studies are
so whether switching to an incentive pro-
not always predictive of human response, METROGEL® (metronidazole gel), 1% should be used during pregnancyonly if clearly needed.
gram will work, but employees shouldn’t
Nursing Mothers: After oral administration, metronidazole is secreted in breast milk in concentrations similar to those found in the plasma. Even though blood levels taken after topical metronidazole application are significantly
be switched unless it’s clear that they will
lower than those achieved after oral metronidazole, a decision should be made whether to discontinue nursing or todiscontinue the drug, taking into account the importance of the drug to the mother and the risk to the infant. Pediatric Use: Safety and effectiveness in pediatric patients have not been established. Geriatric Use: While specific clinical trials in the geriatric population have not been conducted, sixty-six patients
aged 65 years and older treated with METROGEL® (metronidazole gel), 1% over ten weeks showed comparable safe-
ty and efficacy as compared to the general study population. ADVERSE REACTIONS
it on the practice’s gross revenues or on de-
In a controlled clinical trial, 557 patients used METROGEL® (metronidazole gel), 1% and 189 patients used the gelvehicle once daily. The following table summarizes adverse reactions that occur at a rate of ≥ 1% in the clinical trials:
System Organ Class/Preferred Term Metronidazole Gel, 1% Gel Vehicle
pressed a strong preference for using gross
Patients with at least one AE Number (%) of Patients 186 (33.4) 51 (27.0) Infections and infestations 76 (13.6) 28 (14.8)
PAs some responsibility for keeping oper-
penses that they cannot control. “You can
chase a piece of equipment and they think,
‘This is going to cut into my take, so I’m
not so interested in doing it,’ ” she said.
Manufactured by: Musculoskeletal and connective tissue disorders
tioner’s billings with patients’ medical
Baie d’Urfé, QC, H9X 3S4 CanadaMade in Canada. Neoplasms Marketed by:
practitioners are rarely trained in the art
Galderma Laboratories, L.P. Fort Worth, Texas 76177 USA
of third-party compensation, and there is
Nervous system disorders References: 1. Wolters Kluwer, PHast Database, January 2008. 2. Data Respiratory, thoracic and mediastinal disorders
on file. A multi-center clinical study of metronidazole 1% compared
to vehicle for 10 weeks (n=552). 3. Data on file. HSA-3. Galderma
Laboratories, L.P. 4. Odom RB. The subtypes of rosacea: implications for Skin and subcutaneous tissue disorders
treatment. Cutis. 2004;73:9-14.
matologist in private practice in Los An-
tation, he always compensates his midlevel
practitioners with a straight salary.
with these practitioners: “They [should]
the biggest danger we all have is missing
ARTERIAL HYPERTENSION Progression of White Coat Hypertension to Sustained Hypertension After 10 Years OLGA B. PÁEZ†, 1, PABLO A. PULEIO1, MARTA G. GOROCITO1, MIGUEL VISSER1, MIGUEL SCHIAVONE2, CLAUDIO R. MAJULMTSAC, 1, 2 ABSTRACT Background The long-term outcome of white coat hypertension (WCH) is still controversial despite the extensive information currently available. Objecti
NON-INJECTABLE MEDICATIONS THAT REQUIRE AUTHORIZATION PRIOR TO COVERAGE UNDER THE ENROLLEE’S RXPRIME BENEFIT. Brand Name Requires documentation of diagnosis of anginaRequires documentation of diagnosis of testosteronedeficiency in menRequires documentation of diagnosis of Osteoarthritis orRheumatoid Arthritis and evidence of risk of gastrointestinaladverse reaction to other NSAIDs. Requi