Atopic Dermatitis Journal Club: AD Guidelines May Represent a ‘Paradigm Shift’ in Care

Peter Lio, MD:
Hello and welcome to our Atopic Dermatitis Journal Club from Practical Dermatology. We'll be discussing all aspects of atopic dermatitis from pediatric eczema to drug pipeline issues to safety. I'm Dr. Peter Lio, I'm a clinical assistant professor of dermatology and pediatrics at Northwestern University; Feinberg School of Medicine, and a fellow of the American Academy of Dermatology, as well as a practical dermatology board member.

Today's topic is about the new atopic dermatitis guidelines released by the American Academy of Asthma, Allergy and Immunology's Joint Task Force. I'm joined by Dr. Derek Chu, a key contributor to the new AD guidelines, which I believe are reshaping our approach to atopic dermatitis care and understanding. Dr. Chu and I will delve into the heart of these new guidelines, which represent a paradigm shift in managing atopic dermatitis across all severities. The new guidelines really move beyond the old standards, incorporating cultural considerations, quality of life, and combating misinformation.

In our conversation today, I want to discuss some of the considerations and decision-making processes behind the new guidelines and how they're expected to influence the practice and management of atopic dermatitis. I'd like to jump right in. Dr. Chu, could you introduce yourself as well, please?

Derek Chu, MD:
Thanks so much, Peter. I'm Dr. Chu. I am an assistant professor on Allergy Immunology at McMaster University up here in Canada, and I'm also the methods chair for our recently released atopic dermatitis care guidelines by the Joint Task Force, and really excited to be here today.

Peter Lio, MD:
Well, me too. I'm so glad we get to do this together. I'd love to just start because you really have been the point person, the driving force, the tip of the spear for these guidelines. If I could ask you the question, what do you think is the most important piece in this set of guidelines and this release? What is most exciting to you or what really stands out as different and novel?

Derek Chu, MD:
To me, this guideline really represents an evolution or revolution in the way that we bring together all aspects of atopic dermatitis care. All relevant people that have an interest in the condition and incorporate the best available evidence, trustworthy guideline standards in terms of following institute medicine principles and the great approach to translating rigorously appraised evidence to trustworthy recommendations, to incorporating that patient voice from the very start and having them central to shared decision making.

Peter Lio, MD:
I love that too, the number of stakeholders. It really is a very modern guideline. There's patients, there's all these different viewpoints that are put together. I think one of the most exciting parts for me very specifically was that we put such an emphasis on the proactive aspect of AD care. This is something I think we've known about for a long time, but I've not seen it so prominently featured in a guidance document to say, "Listen, it's really good for patients to do something proactively preventative." I think to me is really a big sea change for a lot of clinicians who maybe haven't really done this as much in the past.

Derek Chu, MD:
Fully agree. There's been a lot of very common thought and misconception about purely being reactive that I treat a lesion, it goes away, but then so often we come back and patients ask, "Why do I keep getting this?" It's actually, let's take a step back, and that's why we start with that first good practice theme and in the guideline that says, before doing anything or even intensifying anything, number one, make sure you got the diagnosis right. Make sure you support your patient with education, that you address triggers that they can adhere properly, and that they've got that fundamentals of moisturizer, and that we also backed that up with a strong recommendation for proactive therapy. Absolutely. Fully agree.

Peter Lio, MD:
What were some of the biggest challenges in integrating patient and other caregiver perspectives into the guidance document process, and how did you overcome them?

Derek Chu, MD:
We started off using a number of different approaches. It was challenging because in some respects it hasn't been done before. We did the first ever systematic review of patient values and preferences specifically for treatment, what influences their decision-making and also what are the practical considerations that they think about when choosing treatments. We were able to synthesize that and publish that together in General Dermatology to understand and contextualize all the recommendations that we were going to make.

And beyond that, we were then able to not only have that best available evidence, but bring in patients directly to the guideline panel and discuss those evidence above patient values and preferences along with does this align with patients that are afflicted with the disease right now in front of us? Discuss not only that scientific evidence, the patient values and preferences evidence, and then how does that feed into how well any one treatment works or harms in making our recommendation.

I think we were able to do some innovative things and also intercome some of those hurdles into a very nice way of presenting those recommendations with a very explicit theme each time. This is what our patients told us for each recommendation.

Peter Lio, MD:
I think actually it's pretty revolutionary. I've read a lot of guideline documents and I am sure others have incorporated the patient voice or the patient view, but never, at least in my experience, I've never seen it quite like this. One place where that really came out was discussing the JAK inhibitors. The JAK inhibitors I think are a very powerful and super important new tool in our toolbox. I use them a lot, I rely on them, but it was neat to see how there was a little bit of a disconnect.

I think the patient's perception of their potential safety concerns really shaped our guidance, and I think that's important. I don't think it's appropriate to push back against that, although I've heard some colleagues say, "Well, boy, if the patients are worried about it, maybe we have to educate better." But I think it's important still to hear their point of view. Could you talk about that? Because I think that stood out as something a little bit different or even controversial in a way, in our guidance document.

Derek Chu, MD:
Absolutely. I think one thing that we tried to be very different in how we did this time around was we put that patient voice front and center to make it much more explicit than it has been done previous to go beyond what people have done previously. For the JAK inhibitors, it's a great point that you make. We ā priōrī set with our, not only the guideline panel, but also the patients. What are the outcomes that are important? What are the things that you worry about? And then when it came to deciding about JAK inhibitors, yes, very clear evidence that they could be among the best in terms of clearing the skin. But at the same time, the patients very clearly articulated not only in our guideline panel, but also all that other systemically reviewed evidence about values and preferences for treatment that they are afraid of harm.

And so as you mentioned, we have the choice of either ignoring their perspective and just saying, "Hey, look, we're going to be prescriptive and this is what you need to do and you don't need to worry about that." Or we have the choice of engaging with them into a shared decision. We may face patients that ultimately will say, "You know what, doc, you're completely right. I completely agree with your assessment. I'm not worried about those risks." But I'm sure you've run into patients where they say, "You know what? My relative or my uncle or my parent, they've had cancer, and I don't want to see anything like that. I don't want to even take the shred of a risk possible." And then you say, "Okay, well it's important to understand your perspective. Let's see what else in the toolbox we can find that works best." Really a partnership in finding the best optimal route for their care is something that's been central to what we've been trying to thread throughout this new guide.

Peter Lio, MD:
And I applaud you for it. I think it's a brilliant way to do it because the truth is, I think we are living in a time where there is more medical mistrust. Patients are worried, and I think it's really refreshing to see a guidance document that says, "Look, these have good evidence, but there are some concerns and we're going to respect that." And when I have a patient, an individual patient whose has anxiety around it, I respect that and I say, "Listen, take your time. Maybe for you, I think still this is the best route, but you do it on your terms." And a lot of times after a period of thinking and discussion, they'll say, "Okay, I'm ready to do it."

But I like that idea. I'm not going to pressure them. Our job is not to say, to be paternalistic and say, "This is what you need to do." Our job is to say, "Listen, this is an option. These are the potential risks." And also being very transparent. We don't know all the risks. We have a sense of what we've seen in these studies. We have a sense, but these are relatively new medicines, so we're still learning.

Well, that really segues nicely into the next question, which is one of the hardest parts of atopic dermatitis right now is just this rapid change. We're learning so much more about the disease. We're getting so many new treatments, and I call it the virtuous cycle of drug development. We learn more, we get better treatments, that in turn teaches us more about the disease and we get better treatments still. We find that guidance documents seem to be out of date the moment they drop. Heck, as we're working on them, new papers are coming out.

So how do you feel we could balance, and how did this guidance document balance the evolving landscape of emerging therapies with the need for robust evidence in using some of these and these recommendations?

Derek Chu, MD:
It's such a fast-moving field, and that's why, and not everything is published right on time, like these guideline documents. We had to go through three separate rounds of peer review, like a month each, and even then, every day we're waiting, we're thinking, "Oh my goodness, I want to make sure there's nothing game changing that comes out." But what we're fortunate with is that the joint task force has really prioritized this to be a high priority document, one that's going to become a living guideline.

That means even coming into the recommendations we made, we kept on searching for new information, anything that would actually critically change what we said. Each of the big summary tables, the systematic review and network meta-analysis of talkable treatments, as well as the systematic review and meta-analysis of systemic treatments, including phototherapy, were each updated almost down to the wire, until October 2023, right before we submitted. That literature is still ongoing, that screening is still ongoing as part of the joint task force commitment to a living guideline.

Not only will we be able to update and revise if there is practice changing evidence, but also we'll also be able to incorporate potentially new questions, questions that maybe we do have to revisit some old medicines or practices that are heavily ingrained in our current clinical care, but maybe they need a very focused appraisal or maybe there'll be a new drug.