Poster Pearl: Itch Control Matters Most to Patients with Moderate-to-Severe Atopic Dermatitis

Announcer:
You’re listening to DermConsult on ReachMD, and this episode is sponsored by LEO Pharma Inc. Your host is Dr. Raj Chovatiya.

Dr. Chovatiya:
Hello, this is DermConsult on ReachMD. And I'm Dr. Raj Chovatiya, coming to you from Chicago. Joining me to share key findings from the poster he co-authored and presented at the 2023 Fall Clinical Dermatology conference that focused on patient preferences in moderate-to-severe atopic dermatitis care is Dr. Steven Feldman. He's a Professor of Dermatology, Pathology, Social Sciences, and Health Policy at the Wake Forest University School of Medicine in Winston-Salem, North Carolina. Dr. Feldman, thanks so much for joining us today.

Dr. Feldman:
Dr. Chovatiya, it's a pleasure being here.

Dr. Chovatiya
Well, this is always fun, and I'm really excited to talk about one of your latest projects, really thinking about what drives choice among patients with atopic dermatitis. What led you to conduct this really interesting research?

Dr. Feldman:
We have a much better understanding of immune pathways in atopic dermatitis that there's a host of new treatments being developed, especially for patients with moderate-to-severe disease. And so this study, which was a collaboration with LEO, was designed to get at what matters most to patients. What do they want to see treatment do for them?

Dr. Chovatiya:
Yeah, it's always interesting when you think about how we went from a period five, six years ago where we really didn't have any targeted treatments for moderate-to-severe disease, and now there's sort of multiple in that space. We often face this dilemma of discussing all these options with our patients and trying to weigh a variety of factors together. And that's kind of what goes into a discreet choice experiment. Now, the listeners may not be entirely familiar with what a DCE is, so maybe you could tell us a little bit about how you went about assessing patient preferences and what exactly goes into designing a discreet choice experiment-type project.

Dr. Feldman:
A discreet choice experiment is often done in conjunction with some vendor that has expertise at doing these. And what they'll do in the first phase of the research is they'll have interviews with patients to get at the general areas that patients report are important to them, and then for each area, they'll work to identify levels of severity in that area. For example, if you were thinking about side effects, you'd ask patients, “Well, what side effects are you worried about?” Patients would probably say “cancer,” and then you would say, “Well, okay, how big a risk of cancer are we willing to take—one in 1,000, one in a hundred?” And so the discrete choice experiment will have probably five to seven questions. They're going to ask patients about different features of a treatment response that they will get at. And then for each of those questions, there'll be maybe three or four different levels. They will administer this survey to hundreds of patients, and they'll have each patient look at a variety of scenarios. They'll take different combinations of the six attributes, and then statistically at the end, they'll determine what attributes seem to be more important than others.

Dr. Chovatiya:
And just to kind of help our audience understand a little better about some of those characteristics that came out of a lot of that qualitative work, the different aspects that were being rated against each other included sustained improvement in skin appearance, itch control, risk of respiratory infections, risk of cancer, risk of heart problems, frequency and mode of administration, and blood test frequency as well.

Now, before we kind of jump into a little bit of those data, could you maybe tell me a little bit about this population that was studied? I know it was about 300 patients. What do they look like, who they were, any interesting characteristics? What about their clinical characteristics?

Dr. Feldman:
For a study like this, what you really want is to have a representative population, and there are vendors who offer that. So this study was done using a population that was drawn from across the United States, and they're generally representative of people with moderate-to-severe atopic dermatitis. They had to have extensive disease. Many of them had involvement of the face and neck. The feet were involved in many of the patients. And one of the real highlights, I think, of this patient population was the ability to capture that representative sample. There are a lot of people from groups that historically don't participate in clinical trials who were captured in this study. So about a fourth of the patient population in this study came from such generally underrepresented groups.

Dr. Chovatiya:
I think it's important to note that there was also a really good spread of individuals in terms of their actual atopic dermatitis disease activity. So more than half of the people had experience with systemic therapy, about half started their first treatment for atopic dermatitis more than five years ago, and of the majority of people that were getting treated, many of these patients were getting treated with topical therapies, which really makes them a very good population to study about what they may choose for moderate-to-severe disease.

For those of you just tuning in, you're listening to DermConsult on ReachMD. I'm Dr. Raj Chovatiya, and I'm speaking with Dr. Steven Feldman about a poster he co-authored for the 2023 Fall Clinical Dermatology Conference.

Now, the exciting step: if we turn our attention to some of the results, Dr. Feldman, what treatment attributes did participants prefer in moderate-to-severe atopic dermatitis care?

Dr. Feldman:
The dominant finding was itch control. Patients really wanted itch control, and if you looked at the different levels of improvement, each increase in improvement in itch made a big difference in how patients valued the product. The concern about side effects too, particularly cancer—even a 1 percent cancer risk—really pushed people away from treatments. I think interestingly, the mode of administration on oral versus injectable or how much blood work you had to do didn't seem to matter much. And in my practice, it does seem like people care about oral versus injectable. A lot of people who've never been on an injection are pretty fearful of them and would rather try an oral first, certainly in my psoriasis population I see that. And I think to get them over that, I just do a little game of anchoring them on the idea of taking the injection every day. And then when I tell them the injections are only every two weeks, they're much less concerned and happy to take an injection therapy. And that probably fits with the results of this discrete choice experiment where people really cared much more about itch relief and avoiding side effects than they did about how you gave them the drug.

Dr. Chovatiya:
I too was surprised based on sort of other studies that have been done in the past that actually frequency and mode of administration and even blood test frequency was pretty low on the list as far as thinking about these relative ideals. The other point that I was a little surprised about was sustained improvement in skin appearance was actually quite low. What do you make about that with patients being more highly concerned about their itch and seemingly very, very low levels being concerned about at least sustained improvement in skin in these results?

Dr. Feldman:
Yeah, I think itch is underappreciated because itch is not just itch. Itch is you can't sleep, you can't focus, you can't do well in school, and itch is affecting your work. Itch is just such a big factor for people that perhaps is not surprising that it's driving things and not how people look.

Dr. Chovatiya:
Intriguing point, and perhaps this has a lot more to do with some of the other aspects that we can't appreciate as clinicians, but definitely are intertwined quite a bit with the patient experience. Which kind of brings me to maybe my last question in the couple minutes that we have here together. We've obviously talked about a lot about really intriguing results and ones that hopefully we’ll follow up on a bit more to see how they relate to real life.

But maybe you can kind of summarize for our audience here: what are the key points that you really think we should derive from this project, and how did it change the way that we approach our patients with atopic dermatitis?

Dr. Feldman:
The discrete choice experiment, or DCE, is a great way to get a sense of what the average desires of the group are, and I think that's quite valuable for understanding what drugs need to be developed and what aspects of the disease need to be targeted. When you're dealing with individual patients, I'm pretty sure you could ignore the results of this study. I mean, it might inform you that itch is important in general, but when you're dealing with an individual, you really want to know what specifically is driving their desires and try to meet their goals.

Dr. Chovatiya:
I think you really highlighted one of the complexities with atopic dermatitis, which is really the human element. And we know that balancing a discussion of efficacy, safety, and patient preference ultimately is going to be unique from person to person, and it's the reason why probably there never is going to be a one-size-fits-all care to this disease.

Dr. Feldman:
Well said.

Dr. Chovatiya:
And that brings us to the end of today's program. I want to thank my guest, Dr. Steven Feldman, for joining me to discuss his research on evaluating patient preferences in moderate-to-severe atopic dermatitis care. Dr. Feldman, it was great having you on the program.

Dr. Feldman:
Always a pleasure.

Announcer:
This episode of DermConsult was sponsored by LEO Pharma Inc. To access this and other episodes in our series, visit DermConsult on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening.