Sequencing Therapies for Long-Term Control of Atopic Dermatitis

Christopher Bunick, MD, FAAD (00:08):

When you take current American Academy of Dermatology guidelines for the treatment of atopic dermatitis and the United States product information for the advanced systemic therapies, what we know is this: that if you have a patient with moderate to severe atopic dermatitis, right now you generally don't have trouble getting a biologic approved. Dupilumab, lebrikizumab, tralokinumab, nemolizumab, all are generally easy to get approved for atopic dermatitis, your moderate to severe patients.

(00:41):

Some of the caveat in the label language comes with the Janus kinase inhibitors, where it is not necessarily true to believe that you can only prescribe a JAK inhibitor after a patient with atopic dermatitis has failed a biologic. That's actually not true and not what the label says. The US product information for upadacitinib and abrocitinib says you can use those medicines if you have failed another systemic therapy, which may include systemic corticosteroids. We know that in dermatology, we are overusing systemic corticosteroids, according to recent studies. And I'm excited to report here that there's going to be some new guidelines coming out from an expert consensus panel on avoiding systemic corticosteroid use in atopic dermatitis.

(01:26):

But what we know is that from a label perspective, if a patient has failed systemic corticosteroids or maybe methotrexate, maybe cyclosporine, you can go directly to a JAK inhibitor if that is what you as the clinician believe is best for that patient. We also know that there's some patients where a biologic may not be indicated. The label also says if there are other therapies that are not indicated for a certain reason, that you can go to a JAK inhibitor. So, I want us as a community of dermatologists to understand, yes, from a label perspective, we can go to the biologics, but we also have the ability to go to the Janus kinase inhibitors more often than we think.

(02:07):

This is important because we want to maximize the options that our patients have available. And we have six wonderful, effective, and safe advanced systemic therapies for atopic dermatitis, and we want to make sure that we can get our patients on them as early as possible. And I think that the label language allows us to do that if we fully understand this perspective, especially about the systemic nature of corticosteroids. Every dermatologist is a little bit different in what they prefer to use for their moderate to severe atopic dermatitis patients. Keep your mind open. The toolbox is large. Keep your options open for everything in that toolbox. But also, I want you to make sure that you're thinking about, are you hitting optimal treatment targets? What we know in atopic dermatitis is the benchmark is changing because these advanced systemic therapies are so good. The AHEAD task force has recommended that we as dermatologists try to achieve optimal treatment targets for our atopic dermatitis patients within three to six months.

(03:12):

What does this mean? Well, in particular, the AHEAD recommendations strive for achieving a patient-reported outcome, particularly the most important being itch, minimizing that, so itch of zero or one, and combining that with a clinician-reported outcome, which is generally skin clearance. Therefore, an optimal treatment target for an atopic dermatitis patient is going to be the concomitant achievement of either EASI 90 or IGA 0/1, clear or almost clear skin, and simultaneous little to no itch, which is itch on the numerical rating scale of zero or one on that 10 point scale. That is what's considered the optimal treatment target, and that's also considered minimal disease activity. The benchmark for treating moderate to severe atopic dermatitis has been set by this AHEAD task force. It is our duty as dermatologists to now ask the right questions of our patients, both from a skin perspective and an itch or quality of life perspective, so that we can make sure that we're not getting trapped into a concept called therapeutic inertia, which is where we keep a patient on a medicine despite it not achieving those thresholds or benchmarks in terms of standard of care.

(04:35):

We want to strive for the highest standard of care for atopic dermatitis patients, and this means understanding and asking the right questions, both from the clinician and patient-reported outcomes perspective, and really challenging yourself as the provider to see if you can get the patient on the therapy that can achieve that optimal treatment target or minimal disease activity.