Management of Atopic Dermatitis in Pediatric and Adult Patients - Episode 4
Drs Raj Chovatiya, George Han, and Vivian Shi review the current challenges and opportunities surrounding the utilization and availability of biologic therapies in atopic dermatitis.
Raj Chovatiya, MD, PhD: We’re going to play a little game. I’m going to put each of you on pro and con. You’re in the camp for biologic therapy vs the situation that you may not want to. I’m going to give you the con position, Vivian. What are the circumstances in which biologic therapy would not be the right decision for your younger child when you’re trying to control their atopic dermatitis? Let’s say this is an infant, a toddler, or a very young child.
Vivian Shi, MD, FAAD: The label is the biggest con. It’s not approved below age 12, so we don’t…know how to dose it. That’s 1 of the barriers. With JAK inhibitors, there’s a requirement for lab monitoring for individuals. Most children are healthy and don’t have the comorbidities that we’ve seen in some of the postmarketing studies that led to the box warning, but we need repeated needle sticks to see laboratory changes if they’re ordered too early. Most of them will return to baseline and are clinically insignificant. It can give a little high blood pressure for both the parents and the prescribing provider.
Raj Chovatiya, MD, PhD: I’m making her scrape the bottom of the barrel because we all figured out that there are mostly advantages. I’ll put you on the other side, George. In the pro column, if I’m a parent with a young child, what are the top 3 or 4 reasons why your infant with moderate to severe disease needs biologic therapy?
George Han, MD, PhD: Right off the bat, it’s that track record—hundreds of thousands of patients, multiple indications. It’s reassuring that you’re not the guinea pig. You’re not the 1 testing this out for the first time. Then they need to step back and think about how this disease is affecting other areas of their lives, like embarrassment and normal social development. These are all things that they might not be talking to their parents about, but they’re definitely experiencing. That’s part of it. The compliance is important: what a teenager can be bothered to start ointments? I’ve been surprised. For some of my patients, I start the discussion by painting a full picture of what’s out there. By the time they get to us in our academic centers, they’ve usually been through a couple of offices. They’ve seen their primary care provider. They’ve been on different things. They come in holding the bags of various antifungals, steroids…
Raj Chovatiya, MD, PhD: Antibiotics.
George Han, MD, PhD: Maybe there’s voodoo witch magic. It’s nice to set the tone and say these are all the things. I’ve been surprised by some of my patients. If I’m looking at them, I don’t think they want to go on a biologic, but then the moment I say it, they’re like, “You mean I could do an injection every 2 weeks and not have to smear these ointments all over and worry about greasing up my clothes and my sheets? Give it to me. Why am I not on it already?”
Raj Chovatiya, MD, PhD: I’ll add another pro. For dosing patients who are that young, plenty of them are going to be once every 4 weeks instead of every 2 weeks. It’s a matter of prepping for that 1 dose. I love how you highlighted this idea of adherence and compliance. We get so caught up in safety and efficacy that we forget the other part of the discussion. Is it something patients are going to want to use? More important, is it something people can get? Access is another part of it. My experience is that there’s a broad range of pluses and minuses when it comes to getting the therapy I want for my patients. I’ve been empowered. We’ve been doing many things off-label for so long. There’s no reason we shouldn’t be using medications that are approved for their indication instead of wasting time with anything else. That’s my biggest feeling. I tell my patients that I’ll go to bat for them as much as I can to make sure that this is the right therapy, and that’s what we’re going to do. It’s important to support our patients through this journey, because it’s complex when it comes to thinking about advanced treatment. We need to make sure they’re getting access to a patient-assistance program and that there’s help in terms of ambassadors or other support. It can be a lot, no matter what the age group is. Have you faced any specific challenges for your patients, Vivian? We’re all in different academic centers and places, and you and I have talked about some of your specific access challenges before.
Vivian Shi, MD, FAAD: It’s definitely academic center and state specific. I’m in Little Rock, Arkansas. My institution is the only academic center in the state. The majority of my patients are on Medicaid or Medicare. Access is not great for Medicaid in my state. I joke because the coverage for Medicaid changes if you live in a border town—you could move across the border and coverage for that biologic might change right away. I’ve had patients move 10 minutes across the state line to get access to their systemic medications. A biologic coordinator or a clinical pharmacist is so important in an academic center.They work with a specialty pharmacy. It’s true. My clinical pharmacist is the best-kept secret of my clinic. I can’t imagine running an eczema clinic without her.
You mentioned patient-assistance programs. It’s important to get in touch with the local pharmaceutical rep and continually check out the criteria for eligibility. A few years ago, we published a paper on a patient-assistance program for different pharmaceutical companies. If I looked at the next month, the criteria would change. I said don’t get beat up because it was denied initially. Keep checking.
Raj Chovatiya, MD, PhD: Get everybody enrolled no matter what, whether it’s through an online portal or a form. There’s no way you can investigate benefits and figure out if there’s anything that can help your patients unless you try. There’s billions of dollars pumped into this for assistance. It’s there, and it’s a huge untapped resource for a lot of patients who feel they can’t get therapy.
George Han, MD, PhD: It’s so important. That’s the other piece of having more medications available: there’s more competition and more pressure on companies to do better with their access programs. One clinics I work at with my wife is underserved—about half our patients are uninsured—and the joke is that it’s better because there’s no formulary to follow. We just pick the right medicine and apply it to the patient-assistance program.
Raj Chovatiya, MD, PhD: That’s an interesting way to look at it. I have different challenges than Vivian. In my population in downtown Chicago, I do have a good chunk of commercially insured patients, but I also see a lot of Medicare patients. With Medicare criteria, you often run into all sorts of things that you may end up getting approval for. But the out-of-pocket cost is so high that when you hit that not-sweet spot, it’s unaffordable. They earn a little too much to be in the assistance program. This is the bane of our existence, and it’s something I’m constantly thinking about. For anyone listening, this is 1 of the areas we need help with the most. That’s not a challenge unique to me. It’s 1 we all face.
Thank you for this rich and formative discussion to all my colleagues, George and Vivian. Thanks to the audience for tuning in. If you enjoyed the content that we were talking about, please subscribe to our e-newsletters to receive upcoming MEDcast episodes and other great content right to your inbox.
Transcript Edited for Clarity