Despite recommendations to limit the use of oral antibiotics, dermatologists continue to prescribe them in high numbers, according to a large, retrospective analysis of U.S. prescribing trends from 2004 to 2013.
However, spironolactone prescriptions increased nearly fourfold over that same time period, which is a good sign that alternatives may be gaining traction, the researchers said, writing in the Journal of the American Academy of Dermatology.
The number of spironolactone prescriptions marched steadily upward over time in the analysis, which was based on review of claims data representing 12 million to 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, the results showed. 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 researchers said.
It is uncertain why oral antibiotic use seemed to decrease but then increase again, although the team 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.”
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 study also includes prescribing data for non-dermatologists.
The authors suggested that dermatologists identify patients who might benefit most from alternatives to oral antibiotics, including spironolactone, isotretinoin, and oral contraceptives.
Oral antibiotics are among the most commonly prescribed treatments for acne that cannot be managed with topical therapies, the researchers noted. In fact, dermatologists are the highest prescribers per capita of antibiotics compared with any other medical specialty.
Guidelines from the American Academy of Dermatology (AAD) and others recommend that the oral antibiotic treatment duration be limited to 3 to 6 months, although a subset of patients may require longer treatment.
The duration of oral antibiotic therapy in the analysis by 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, with the authors calling 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.”
Despite concerns over current levels of antibiotic use, Barbieri et al said they 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.