Personalizing Treatment Selection in Atopic Dermatitis - Episode 8
Experts discuss long-term efficacy data for topical medications for the treatment of AD.
Raj Chovatiya, MD, PhD: I want to take a deeper dive into efficacy and speed across multiple treatments in the class. Maybe we’ll start with efficacy first. I know Dr Hebert, given sometimes the limitations of pediatric patients, you’ve had a chance to use many of these topicals for a long time, and have participated in many of these trial development programs as well. So could you, with your clinical expertise and knowledge of the data, orient us with the overall differences, let’s say, in efficacy from whether it be phase 3, long term, or real-world studies. When we think about topical steroids vs a calcineurin inhibitor vs a PDE4 [phosphodiesterase 4] inhibitor vs a JAK inhibitor, how are you stacking those up based on the data?
Adelaide A. Hebert, MD: Certainly we do see some differences, but I have to agree with my colleagues in that the rapid onset of action without the fear of the steroids has been a huge advantage, certainly when we use ruxolitinib. I think the oral JAK inhibitors have been very dramatic. Many of us, because we’ve all been in practice a while, we saw nothing like this for a long time. Certainly, the biologics, both dupilumab and tralokinumab, also gave us unbelievable results. The other thing, I think because with the injectables they only have to do intermittent therapy, if you will, those medicines lend themselves very well to the patient who is perhaps less compliant with topicals, not that I don’t think many of them need topicals as well. But the fact that they only have to give these injections let’s say, once a month, for the smaller children if they’re using dupilumab, and a bit shorter intervals if they’re on the twice a month dosing. I think these patients are being compliant because they don’t have to do as much work yet achieve outcomes that previously I think for many of us were unachievable when we only had topical steroids, topical calcineurin inhibitors.
Everyone wants the quick fix. Everyone wants to get better today or tomorrow. That’s unrealistic, and I know my colleagues have alluded to that. We have to educate our patients and parents that it is going to take time. And I agree completely about the acute management, the long-term management, we have to offer different strategies for different portions of care. All these medicines do work. Getting the patients to be fully compliant, making sure they pick up the prescriptions from the pharmacy, or have a pharmacy that mails the prescription to them, all these things play key factors.
We do know that when our patients change insurance, let’s say at the beginning of the year, and they don’t inform us, and then we have to start all over with paperwork, we see what happens when they go off these medicines. Suddenly they realize how important these medicines were because they really helped keep them under control. We have to individualize the therapy and consider, are they going to use a topical? Are they going to be better served with a pill? Do they do better with a biologic that they need to inject? I think all these are factors.
Sometimes we also use combinations of these because we do want to optimize that outcome, and we know it can benefit the patient tremendously. So, I think each of us use our own formulation to come up with the best strategy. Ideally, we would make everyone better tomorrow. And realistically, we can’t simply make that happen as we wish we could.
Raj Chovatiya, MD, PhD: I love this emphasis on individualized care because I think this is an area in dermatology where we all need to step up our game when it comes to trying to walk our patients through what might be the best treatment approach for them. I think they really appreciate that you’re giving them unique consideration, beyond just fact dumping about how well it works, but what is cost going to be like for you? What is intolerability going to be like for you? Is this something that is going to be an albatross around your neck every single day, or is this going to be something that is quite simple to enter into your day-to-day life? It’s that pillar that we almost never talk about when it comes to treatment.
Matthew Zirwas, MD: The difference I have seen when I put people on topical ruxolitinib that I didn’t really get when the drug first came out, because it’s a real change in the demeanor of the patients, is it for the first time gives people a meaningful sense of control over their eczema. In the past, because we had nonsteroidals that were not that fast and not that effective, or we had topical steroids that were pretty fast and pretty effective but they didn’t want to use them. So there was this constant sense from the patient’s perspective, even whenever they were better, “Oh my gosh, the next time my eczema flares up, am I going to have to use that steroid again? I really don’t want to use that. And which one am I supposed to use again? If it’s on my face, do I use the clobetasol, is that what they told me?” Or “Oh, if my eczema flares up again, then I’m going to have to put that ointment on and it’s going to take a week before it starts getting better, I’m going to be miserable, and oh, geez.” And now they feel like, “I’ve got something that if my eczema starts to come back on Tuesday morning, if I’m like, ooh I’m a little itchy, I’m going to put something on Tuesday, I’m going to wake up Wednesday morning, my itching is going to be better. And it’s not going to be a drug that I’m afraid to use.” It has given patients a sense of control over their mild-to-moderate relapsing atopic dermatitis. I didn’t know to expect that. The sense of control that it gives people has really been surprising. Once I saw it and thought about it, I was like, yes, that make sense. You didn’t have a good option.
I always think about things in terms of headaches. Like if we all had bad headaches, and once a week we would randomly get a bad headache. And we said, “Well, you’ve got 2 medications you can use; 1 that’ll work fast but you’re really scared of it, and 1 that you have to take for 4 days before your headache would get better.” I’d be dreading the next headache. But then if you told me, “Hey we’ve got a medication that whenever you get a headache, you take it, and your headache will be gone right away, and it’s very safe.” Then my headaches would immediately go from being something I dreaded to being something like, “If I get one, I know what to do, so it’s not a big deal.” It is such a dramatic change for our patients.
Raj Chovatiya, MD, PhD: The power being back to the people, so to speak, is a really nice way to visualize it because I think that’s what every patient with atopic dermatitis is searching for. There’s such unpredictability with flares and the disease course, and everyone’s long-term atopic dermatitis looks so different, there’s only so much anticipatory guidance we can give them. Particularly for that patient with stubborn-to-treat sites, once we make some headway there, we really hate to lose it and have them go back to where they were. Those are the places where people often have the biggest quality of life impairment.
Transcript edited for clarity