Transcript
Dr. Mesinkovska:So now that we have treatments out there, Dr. Kindred and Dr. Senna, everybody's asking what to pick first, what to pick second, another thing. So what are some of the factors, Dr. Kindred, that you find that your patients care about now that there's options? What are some of the characteristics of a medication that you have when you discuss with them and decide to choose a medication to proceed with?
Dr. Kindred:So the two main questions I get is how long before I see hair grow? So how quickly it grows makes a difference. And then two, is it safe? And that's where we have to lean on the clinical trials and our current experience on that safety profile. So they want to get their hair back, and they want to get it back safely.
Dr. Mesinkovska:So how do you guide them through that? What kind of a timeline do you usually give them or what are some of the pointers you try to hit home when you discuss this, Dr. Kindred?
Dr. Kindred:Yeah, so I call it my song because each patient gets the same spiel just about. So everyone is just told a year. It might take a year for you to see significant hair growth, but at the six-month mark, I'm looking to see something. I'm looking to see some hint that this is working. And I try to level set them like, "This isn't like your eczema. This isn't like your acne." This isn't like whatever it is else I'm treating for them so that in their brain, they can have a comparison. So sometimes I'll use a holiday. "So by next Juneteenth, next Memorial Day weekend, we should be talking about blah, blah, blah," is how I said it.
And then for safety, I say that ... I talk about how there's another medication in the same class that we were worried about quite a few scary side effects, heart attacks, death, cancers, hospitalizations. And I really do say these things because I don't want them to look it up later and they weren't on the same page as me. I say, "However, we have years of patients with AA on these medications, and the numbers are actually really low." And then, again, to help the patient, I'll say, "For example, compared to your ... Whatever other medication you're taking," and I'll give them an example of that risk level.
And that helps the patient to really understand where this medication fits because they're going to Google it, and I don't persuade patients to take the medication. I just lay out the information and then they pick. But then internally, I do look at the patient's medical history and decide based on the side effect profile of the medication and the patient's medical history, how to match it up. I will admit I'm an outlier. Based on the data, I'm not overly concerned about clots. Now, hopefully one of you on here disagree. We could have both opinions in here, but the data isn't overwhelming that this is causing clots in all these patients. I'll tell the patient-
Dr. Mesinkovska:Wait, wait. Wait, wait, wait. Yeah. But you know what? We're talking, but we didn't even mention what it is. We didn't mention what the medications are.
Dr. Kindred:Oh, good point.
Dr. Mesinkovska:Yeah.
Dr. Kindred:Deuruxolitinib, ritlecitinib, baricitinib. We have some more coming up.
Dr. Mesinkovska:JAK inhibitors, right?
Dr. Kindred:Yeah. Exactly right.
Dr. Mesinkovska:The era of JAK inhibitor. Dr. Senna, so the JAK inhibitors, as Dr. Kindred nicely put us into the field, where do they fit for you in treatment of alopecia areata severity wise, algorithm that exists, doesn't exist wise? Tell us.
Dr. Senna:Yeah. So if someone's coming to me and they have 30% scalp hair loss and they don't have comorbidities that would make them in my mind not a good candidate for a JAK inhibitor, they're getting a JAK inhibitor. Why? Because the likelihood of a patient like that ... And usually by the time they come to people like us they've tried other things or they've had it for a little bit. But even if not, the likelihood of someone with 30% scalp hair loss or 25% scalp hair loss and eyebrows or something regrowing on our conventional treatments to a place that's meaningful and sustainable is very low.
And what are the other treatments we're going to offer them? Scalp injections? Eyebrow injections? We know topicals don't work. We know that other medications that we've had to try in the past, like our conventional medications like methotrexate, cyclosporine, the efficacy there far outweighs any of those, and it's the obvious choice. And again, we're learning treating early is important. We don't want to wait till they get to this very severe place. They grow hair back faster. They grow more robustly, more fully, and they get their lives back on track sooner too.
Dr. Kindred:And that's the whole point. That's the whole point.
Dr. Mesinkovska:So I'm just going to ask you, Dr. Senna, what are the things that you will recommend somebody that is about to prescribe a JAK inhibitor to document in their chart? Because everybody's favorite, nobody's favorite, prior auths. So we can say all this here, but you both have been in the arena for a while. We've had to deal with every insurance company, I bet, and with every medication that's out on the market. So pointers, Dr. Senna, and maybe, Dr. Kindred, you can add as well, for things that document or things that consistently over and over deliver results with coverage?
Dr. Senna:So I really try to shy away from anxiety or depression unless a patient already has it documented in their record because I've seen it affect patients' insurance policies and things like that if it's the first time it's mentioned and it's not a documented thing. If it's a documented thing and the patient has automatic ... I'll put that if it's related. But what I do put is the patient is ... On a scale of zero to 10, with 10 being absolutely the worst negatively affected they could be by this, today the patient reports that their alopecia areata is affecting them and I put a number.
And so you don't have to put anxiety or depression, you just put a number, and that has been very helpful. Obviously a SALT score, because they want the SALT score, even if you estimate it. I'll put ... If it's an adolescent, I'll write if they're staying home from school, if they're not wanting to participate in their sports. Like a narrative of whatever the parents are telling me. Same thing with adults. "I'm a lawyer, and I can't do my job. I don't want to go in to court." I'll put that in the note, and I'll take excerpts from my note for prior auths. And then-
Dr. Mesinkovska:Do you do eyebrow, eyelashes?
Dr. Senna:Yeah, absolutely. Eyelashes, nails, body hair.
Dr. Mesinkovska:Did you ever have to submit photos for any patients? Do you think-
Dr. Senna:I have. It's rare, but I have. I mean, I can think of at least a handful where I did because they just kept denying unnecessarily. Yeah.
Dr. Mesinkovska:Dr. Kindred, do you have to list any of the prior things that have failed? Do you still … despite this not having an algorithm, anything else?
Dr. Kindred:Absolutely. So the three are severity. Sometimes I'll do mild, moderate, severe with AAS, or sometimes I'll do a SALT. For SALT, honestly, I just eyeball it and list what they failed. And then three, I'll write out how it's affecting them psychosocially. Mine tend to be self-esteem, less social, not participating in activities they did, like sports or hobbies or something like that. And those are the three that I include, and then my staff would put that in the prior auth template.
Dr. Mesinkovska:OK. So when you had to deal with appeals, anything else? Do you attach that article with the severity?
Dr. Senna:Oh, I have references.
Dr. Mesinkovska:Yeah.
Dr. Senna:I have all the references. I cite the literature in my letter if I write a letter. I also encourage my patients, if they're rejecting it and I'm writing an appeal and I think it's going to be a battle, I have the patients call or write a letter too.
Dr. Mesinkovska:Oh, that's a good one too. Patients are calling.
Dr. Kindred:That's really powerful actually. Sometimes that works better than what we're doing.
Dr. Mesinkovska:It's also a shared burden. Unfortunately, we don't want it to be a burden for anybody. But as I just got off a phone with somebody today, I'm like, "I don't know what to do anymore." And this was for something else, but I'm just saying, it's getting challenging.
