Counseling Points for Patients Concerned About Long-term Immune Modulation

Dr. Peter Lio (00:07):

Hi. I am Dr. Peter Lio. I'm a clinical assistant professor of dermatology and pediatrics at Northwestern University, Feinberg School of Medicine here in Chicago, Illinois.

(00:15):

Whenever we have newer medications, and some are newer than others of course, there can be this concern about what happens in five years, 10 years, 20 years, what happens to the next generation? And I think the truth is we don't know. We don't know. You literally cannot always foresee the future for these things. But of course, we're continuously learning, we're continuously following these patients up. And I think we do have some sense of the pathways and we have enough experience with similar medications that we can often make a good educated guess. Again, imperfect. Fully, fully open about that idea.

(00:46):

However, what we've seen so far, especially with some of these neuroimmune modulators that we have, is that not only do patients seem to get better very rapidly but they also seem to be able to maintain that on less medication. We see this with some of the agents. For example, tralokinumab, lebrikizumab, and nemolizumab all have a dosing schedule that after we can achieve that improvement, they can actually space out, they can lengthen the interval. That is meaningful to me because that tells me already the patient is better in a way that's different than just a clinical improvement. Now, they're better but they also are needing less medication.

(01:21):

The next step is that I actually have patients who are able to completely come off of these medications, not everybody and maybe not even the majority. But there is a group of patients that have been stable for a long enough period that they say, "I'm going to take a break." And we can debate whether or not that's a good idea, I think that we have to be cautious about this. But I now can tell you that I have a number of patients on the order of several dozen patients who have been able to stop their systemic agents completely and maintain pretty darn clear for sometimes years afterwards. I'm not calling this a cure but I would call this a form of disease modification and I think we see that.

(01:53):

I think we even saw that in the older days when we would use things like cyclosporine, I think you can modify the disease. This is a disease of vicious cycles, if you break that cycle long enough, the skin barrier strengthens, the microbiome normalizes, the immune system settles down, even the nerve endings undergo some changes. And of course, the mind-body piece, the behavioral piece settles, people sleep better. We already have evidence that treating some of these patients with biologics like dupilumab, that actually can help their growth in kids, they grow more, things like their vertical height. This is powerful stuff and I think this fits into a narrative that we realize not treating and under-treating really does have serious bad effects and is dangerous for patients too.

(02:29):

It's not just saying nothing versus a drug. It's saying untreated atopic dermatitis, again, by definition, moderate and severe for the patients that we're describing, versus nothing versus a drug. These are the three different groups we're looking at. And when you put it that way, I think things become much clearer for patients, families, and everybody as a whole.