Clinical Rationale for Switching From Biologics to JAK Inhibitors in Atopic Dermatitis

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The decision to switch from biologics to JAK inhibitors should be based on AHEAD recommendations, specifically when patients don’t achieve simultaneous Eczema Area and Severity Index 90 (EASI-90) and itch scores of 0 to 1 within 3 to 6 months. Many patients may appear to have good skin clearance visually but continue experiencing significant itch scores of 4 to 6, resulting in persistent quality-of-life impairment, including sleep disruption and activity limitations. This scenario represents inadequate disease control despite apparent visual improvement.

Tolerability and safety concerns provide additional rationale for switching, including injection site reactions, headaches, migratory arthralgia, conjunctivitis, or head and neck dermatitis. The dupilumab prescribing information specifically recommends monitoring for arthralgia, highlighting the importance of probing questions during follow-up visits. These adverse events, although not frequent, can significantly impact patient quality of life and treatment satisfaction.

The heterogeneous nature of atopic dermatitis means that patients failing one biologic may not respond adequately to another within the same pathway (IL-4/IL-13). JAK inhibitors offer a mechanistically different approach that targets multiple inflammatory pathways simultaneously. Rather than cycling through various biologics, switching to JAK inhibitors may provide superior outcomes for patients with inadequate biologic responses, offering broader anti-inflammatory coverage for complex disease presentations.