Advances in the Management of Prurigo Nodularis - Episode 13

Challenges in Using Dupilumab in PN

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Raj Chovatiya, MD, PhD; Shawn Kwatra, MD; and Sarina B. Elmariah, MD, PhD, discuss potential challenges to the adoption of dupilumab in the treatment of PN.

Raj Chovatiya, MD, PhD: Dupilumab has been used off label in a lot of other circumstances, and Sarina was getting to this point a little bit. Do you foresee any challenges in terms of its adoption for the treatment of PN [prurigo nodularis]? Do you think it’s all going to be smooth sailing, or that perhaps there’s still going to be some hurdles even though we have this official indication? I’ll start with you, Shawn.

Shawn Kwatra, MD: There’s going to be a little bit of difficulty in terms of educating folks; we still have so much work to do in terms of disease state awareness. And when I speak about prurigo nodularis, the fact that it does have this neuroimmune basis and needs directed targeted therapy is still a concept that needs to be overcome. I think we’re way behind, in psoriasis and atopic dermatitis, so I am concerned that there won’t be as much writing because there’s still less awareness of the disease. There are so many different thoughts about the pathogenesis and what it may be really due to. And so, I think that that’s one of the hurdles that we’re all trying together to bring down. And I think with more publications, more highlighting, a lot of the recent advances honestly, with these trials, we’re learning so much about disease states. I’m hopeful that that will help turn the tide as well. But during residency training for future generations now, they’re going to hopefully be exposed to a lot of the new pathogenic elements that we know about prurigo nodularis and I’m hoping that’ll help.

Raj Chovatiya, MD, PhD: How about you Sarina?

Sarina B. Elmariah, MD, PhD: I think certainly dermatologists who are familiar with the disease and are comfortable managing it and, quite frankly, comfortable using any type of systemic medications, there will be very few hurdles. I think Shawn highlights the most important aspect, which is really spreading the word and educating people, just to even consider the pathogenesis and really this new understanding and evolving understanding of the pathophysiology of PN. So that will be helpful for our field, in our community of dermatologists. But just building awareness at other practices and working with primary care doctors, nephrologists, and other physicians who may encounter PN patients. It’s important to recognize the disorder and the fact that there are treatments approved or soon-to-be approved for it, so I think that’s a big issue.

I mentioned the wonderful aspect of having a 60% success rate or so with managing PN patients, but that also means that 40% of patients are still not necessarily being completely controlled. And again, this isn’t an issue with dupilumab, it’s an issue with all…the management of PN. So, when I use neuromodulatory drugs or other immunosuppressive or immunomodulatory drugs, I may be getting a 60% to 70% success rate, but often, there’s this population with more recalcitrant disease, and we need to focus broadly on improving their health or quality of life, their sleep, addressing their depression and anxiety. That poses an additional hurdle that we all have to have as physicians and advocates for these patients. Really, all our patients, but certainly with PN patients because they’ve struggled for so long.

Shawn Kwatra, MD: Now with the FDA, we have a four-point drop as our barometer for getting a drug approval, but that’s not good enough. If someone’s going from an itch or worse itch in the last 24 hours of a 10 out of 10 to a 6 out of 10 or a 5 out of 10, that’s not complete therapeutic success to me. It’s an amazing achievement, but that’s a little bit different. It may be misleading to say 60% of patients are completely controlled. We don’t know that, and I think the way the field is going now is that you see from the eczema trials where you have an easy 50%, 75%, 90%. Same thing with paucity. Now, we’re doing paucity at 100%. We want a relatively itch-free state. Itched less than 2 hours in the last 24 hours. A lot of these metrics are going to be how many of these therapies are going to be compared to one another in addition to safety and other metrics.

Transcript edited for clarity