American College Of Emergency Physicians (ACEP)

Novel oral anticoagulants (NOACs) are increasingly being prescribed, but until a few months ago there wasn’t a specific reversal agent for Factor Xa inhibitors. ACEP was a good opportunity to gauge the enthusiasm for – and uptake of – Portola Pharmaceuticals’ Andexxa. Emergency department physicians said they would like to have Andexxa in their pharmacy, but they are concerned about the cost. On average, doctors predicted they would use Andexxa 2-3 times a month – if it were available. Two new technologies were getting attention at ACEP: Butterfly Network’s iPhone-connected ultrasound, and Genetesis’ CardioFlux, a non-invasive magnetic imaging device to evaluate coronary stenosis in the ED.

Plastic Surgery The Meeting

There wasn’t a lot of late-breaking news at the annual meeting of the American Society of Plastic Surgeons, but it was a good opportunity to get a snapshot of developments in breast implants as well as adoption of a therapy for hyperhidrosis, Sientra’s miraDry. Plastic surgeons said their breast implant volume over the last year has been flat to slightly up, and that trend is expected to continue over the next year. Johnson & Johnson/Mentor and Allergan remain the dominant implant providers, but Sientra is gradually regaining market share, and Ideal Implant is starting to get some attention. There is increasing concern about the safety of textured implants, which may make it difficult for Establishment Labs’ Motiva to get traction in the U.S.

North American Spine Society (NASS)

Robotics is catching on in spine, but slowly. Medtronic hopes to give that a push with the purchase of Mazor Robotics and some aggressive marketing. Stryker, Zimmer Biomet, and Johnson & Johnson also all have spine robots in development. Surface materials was a hot topic at NASS, and many companies offer a 3D-printed porous titanium implant, but there may be important differences. This was highlighted with reports of troublesome breakage with Stryker’s devices. Expandable cages are catching on but not taking over.

NYC Neuromodulation Conference and the North American Neuromodulation Society (NANS) Summer Series

The market for SCS is growing, raising all boats (manufacturers), and so is the number of players, but pricing is holding steady. With four established companies, it is hard for new entrants to gain traction. SCS explants are not a big concern, and reports of an excess of explants with Nevro are viewed as overblown or counter-marketing. What is a big concern is whether a device is MRI compatible. Neurostimulation is being explored in a long list of conditions – such a long list that it dilutes the messages. The hot area in treatment-resistant depression is TMS, which is dampening enthusiasm for invasive therapies like LivaNova’s VNS. Reimbursement for TMS is good, though the cost to insured patients is pretty hefty, and MagVenture’s MagVita, which is faster and cheaper, could lead to a cut in reimbursement overall. In VNS, there is growing interest in non-invasive systems (tVNS) for headache, particularly electroCore’s gammaCore.

Bulletin: SITC Guidelines for Lung Cancer Immunotherapy

The Society for Immunotherapy of Cancer (SITC) hosted a webcast on Cancer Immunotherapy Guidelines for Non-Small Cell Lung Cancer (NSCLC) on September 13, 2018, with at least 84 people participating. It was a torough review and timely given the number of checkpoint inhibitors that have been approved by the FDA since 2015.

PAINWeek

This was the 12th PAINWeek meeting, and it was an opportunity to hear about the opioid abuse situation from a physician standpoint, as well as hear about new migraine drugs. The bottom line: Opioid abuse is a problem, but clinicians at the meeting see fentanyl and heroin as the bigger problem today. It has become a dangerous environment for physicians prescribing opioids, which is discouraging prescribing. Development and use of abuse-deterrent opioids has been slow, but insurance coverage is starting to improve, which may encourage more use in the future. Treatment of opioid use disorder with medication-assisted treatment is increasing, but many of the doctors at the meeting refer these patients to addictionologists. When opioid-use disorder is treated, most commonly it is with buprenorphine, usually Indivior’s Suboxone. There is little use of naltrexone or methadone for medically-assisted treatment among these clinicians. New CGRP inhibitors for migraine prevention were getting a lot of attention, but it is early, and uptake is still almost non-existent among these clinicians.

Alzheimer's Association International Conference (AAIC)

From the busy schedule and the attendance at this meeting (a record >5,800, with more than half women), you might think there were major advances or treatment breakthroughs taking place in Alzheimer’s disease (AD). However, the news was mostly risk reduction approaches – i.e., lifestyle factors and changes (e.g., diet, pregnancy), better diagnostics, and non-cognitive symptoms of AD. There were no therapeutic breakthroughs reported at the meeting, with Biogen and Eisai’s BAN-2401 antibody the only somewhat exciting therapeutic with new data, though experts were skeptical of the data that were presented. However, there were updates on a number of other agents.

American Diabetes Association (ADA)

Insulin pumps and continuous glucose monitors are under-used, but increases are likely to be incremental. Dexcom’s G5 and G6 remain the favorite CGM of doctors, but patients really like the simplicity and lower cost of Abbott’s FreeStyle Libre, which doesn’t require fingersticks. Senseonics’ Eversense got attention at the meeting but is not expected to really catch on until fingersticks are eliminated. n A number of new closed-loop systems are being investigated that are more user-friendly. n On the drug front, AstraZeneca’s MEDI-0382 looked interesting but there wasn’t a lot of enthusiasm for it. Evidence is building that SGLT2 inhibitors can be used in combination with insulin in Type 1 diabetics, and an oral GLP-1 is on the horizon. n Doctors were reassured that the two new basal insulins – Sanofi’s Toujeo and Novo Nordisk’s Tresiba – looked very similar in the BRIGHT trial. n Islet cell transplants are still extremely limited, and cell therapy is considered far off.

American Academy Of Neurology (AAN)

The AAN meeting lasts longer than many major medical conferences, but it covers a broad array of neurological conditions. The key news this year was in migraine, Parkinson’s disease, and spinal muscular atrophy. In addition, this report covers developments in treatments for Alzheimer’s disease, Dravet and Lennox-Gastaut syndrome, Huntington’s disease, and multiple sclerosis. There are also some shorter notes at the end on Duchenne muscular dystrophy (DMD), dyskinesia, epileptic seizures, and myasthenia gravis (MG).

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