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Expert touts ivermectin 1% cream as treatment of choice for rosacea

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No surprise that ivermectin bests metronidazole

To say that ivermectin should be the treatment of choice because it outperformed metronidazole cream .75% seems a bit overzealous. The reality is, and I believe most of my colleagues agree, metronidazole .75% cream is not very effective. We give it because it is what insurances force us to give, or we gave it because we had nothing else to give. Fortunately this has changed over the years with the advent of azelaic gel and now ivermectin 1% cream.

I do agree, however, that it is rare to see a company structure a superiority head-to-head study, so I will give credit where it is due. However, my guess here is that it was anticipated that ivermectin would at the very least prove noninferior, if not superior, given the poor success rate of this long-standing workhorse. This should not distract from the fact that a) the studies were thorough and well structured and b) held for a good time frame. The data are certainly compelling, so I don’t want that to be overshadowed by the heavy focus on comparing to metronidazole twice a day. To me, that’s a red herring; had they only compared to placebo, we wouldn’t be having this discussion.

The data herein presented are more than supportive of its addition to our limited armamentarium, but to say first line is premature at this early stage. The once-daily dosing and limited adverse events are supportive features as patient compliance is always an issue. Probably more important, and only time will tell, is will insurance companies cover it? Or, will they reject our prescriptions and continue the current trend of recommending medications that bear no similarity to mechanism of action or efficacy. I am suddenly reminded of the all too frequent notice sent, stating that I should give an acne patient benzoyl peroxide, instead of the retinoid I initially selected.

Kudos to Galderma for keeping innovation alive and bringing a new topical drug forward – curious to see if I can actually prescribe it.

Dr. Adam Friedman is associate professor of dermatology and director of translational research in the department of dermatology at George Washington University, Washington, D.C.


 

EXPERT ANALYSIS FROM WCD 2015

References

One of these underappreciated findings concerned safety. The rate of treatment-related dermatologic adverse events during the double-blind first 3 months of the study was 2.5% in the ivermectin group compared with 6.3% in vehicle-treated controls.

“That’s pretty impressive. That the active treatment arm of the study had less treatment-related dermatologic adverse events than placebo has never been seen before in any other topical study. It tells you something: The assumption here is that the potent inherent anti-inflammatory activity of ivermectin is overwhelming,” the dermatologist said.

The other particularly noteworthy finding came in the long-term, 40-week extension study that followed the initial 12-week, double-blind stage. What was impressive here was the way the proportion of patients who were IGA clear/almost clear rose steadily throughout, he noted. At the end of the initial 3-month phase of the two studies, 38%-40% of ivermectin-treated patients were clear/almost clear. At 12 months, nearly 70% were.

“In most studies, efficacy sort of plateaus at some point. Here it keeps going up through 12 months. So if somebody comes to your office after 3 months using ivermectin and says, ‘Eh, I’m okay, but I’m not clear or almost clear,’ there’s no reason to switch to another medication, because if they continue you know there’s a high chance they will become clear/almost clear,” Dr. Kircik said.

On the other hand, study participants who were still IGA ‘severe’ after 3 months remained severe after 12 months on the drug. So the message here is if a patient still has severe rosacea after 3 months on ivermectin it’s time to change drugs, he added.

bjancin@frontlinemedcom.com

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