Journal Club: Biologics for Young Children

Dr. Larry Eichenfield:
Hi, I am Dr. Larry Eichenfield from the University of California, San Diego and Rady Children's Hospital.

Dr. Dawn Eichenfield:
Hi, I am Dawn Eichenfield. I am also from the University of California, San Diego and Rady Children's Hospital.

Dr. Larry Eichenfield:
And we were asked to discuss an interesting article on biologic therapies in atopic dermatitis children less than six years of age. This was an article from Russo et al, an expert opinion in drug safety, really raising a lot of issues of some of the changing practices in atopic dermatitis with systemic therapy in young children.

Dr. Dawn Eichenfield:
So what has been your experience, Dr. Eichenfield?

Dr. Larry Eichenfield:
Well, so for me, I'd say that it's been a breakthrough in therapy to have dupilumab approved down to age six months of age. And we're still in this time period where we're learning about the impact of biologicals in early therapy and taking very severe children who we didn't use systemic therapy before and using dupilumab on them with tremendous successes.

Dr. Dawn Eichenfield:
And definitely with these younger children, there are different considerations that we have. For example, younger kids probably don't want as many shots as older kids. Well, no one wants shots, but younger kids, even less so. Younger kids, we have to worry about their immunization schedule, for example.

Dr. Larry Eichenfield:
Yeah. So I think that we're both pediatric dermatologists in practice. So that issue of is it an appropriate therapy for children in the first few years of life really depends upon the severity of disease, the clinical experience we have with how they responded to our topical therapies, and then it becomes a discussion with the family about what the trade-offs would be, especially the injections which kids don't like in that age group. But boy, it's remarkable to see sometimes the very rapid responses we get with the dupilumab in these individuals.

Dr. Dawn Eichenfield:
No, I completely agree. I mean, some patients, they get the shot and they tell us, "As we're driving home, we feel less itchy."

Dr. Larry Eichenfield:
Yeah, yeah, we get what I call the one-shot or two-shot wonders where they come back, and in the younger children they have standard monthly injections, so it's not that frequent. Do you want to discuss how you handle the first injection or two? How do you get families through that?

Dr. Dawn Eichenfield:
So I probably started youth council about... Are you in the systemic bucket or the topical bucket? I think I talk about things a little bit similarly. I'm like, "Okay, your atopic dermatitis is medium." Sometimes I'll tell kids like, "It's medium. You could maybe, it's very possible that we do topicals really, really well. We can get you to mild and we can keep you on topicals. But if your atopic dermatitis kind of keeps on crazy, then we're going to need to think about systemic medications." And then the one I talk about, of course, is dupilumab and then we go over how there's different ways that we can get you through the shot. It's going to be two shots at one sometimes, or one shot, and then sometimes you'll be in every two-weeker or every four-weeker. I find that some kids in that thinking about how they never have to be itchy or their life is going to be so changed by doing the medication, they're okay with getting the shots, but then there are patients who are still very fixated all on the shots.

Dr. Larry Eichenfield:
Yeah, well, certainly under six, it's going to be rare that they love the shots.

Dr. Dawn Eichenfield:
No.

Dr. Larry Eichenfield:
But the changes in family life are incredible and the families come back because many times, especially in the first two years of life, with severe atopic dermatitis, the whole family's life has been disrupted. And it's actually easier in a way with the injections. Those highly responsive patients are really quite interesting. And we bring them in generally to get the first injection done by our nurse and teaching the family right away how to do it. Sometimes they come back for the second one to make sure the family's comfortable in doing it. Let's discuss what we don't know. I mean, how important is it for us to get data on long-term effects with dupilumab in young kids and the impacts on comorbidities?

Dr. Dawn Eichenfield:
So I think it's, of course very, very important to get that data. I think everyone in the audience probably agrees. I think some of that data's starting to trickle in. There was the article on JAD. There was another article in Allergy where they were looking at the comorbidities like allergies, allergic rhinitis, food allergies, and how dupilumab affected that long term. And then, of course, in the the Allergy literature, there was another study where they were looking-

Dr. Larry Eichenfield:
Yeah, so basically there's been a set of studies which was dupy compared to placebo showing decreased development of asthma and allergic rhinitis on the dupy patients. And then a set of patients from registry studies and then some big database studies all with the same signal that early therapy seems to obviate or decrease the development of asthma, allergic rhinitis. We clinically see families report less pet allergy in those who had pet allergy before. So it's very interesting to see the modification with our therapies, but we also don't know how long a course of therapy we need to further keep those comorbidities from developing and coming. And I think we just don't have enough experience in the very young children.

Dr. Dawn Eichenfield:
So how does this data, having these new articles, change when you start your patients on dupilumab and when and how you time your discontinuation of dupilumab?

Dr. Larry Eichenfield:
I mean, I'm more liberal now than I was six months ago or a year ago in terms of early treatment in the first six year of life with systemic therapy with dupilumab. Just the experience leads us there. I also tell them that I'm not sure how long we should treat for. And that standardly I treat for a year, we might consider treating at nine months and stopping sooner, or we could go longer. And that we'll be telling them as we go what data points we get because we're collecting data around the world, which will inform our clinical practice.

Dr. Dawn Eichenfield:
I completely agree. Thank you everyone for joining us for Atopic Dermatitis Journal Club. I'm Dr. Dawn Eichenfield.

Dr. Larry Eichenfield:
And Larry Eichenfield. Pleasure to be part of it.