Factors Guiding Treatment Selection in AD

Raj Chovatiya, MD, PhD: I want to pivot slightly and think about that heterogeneity of the patient and the disease characteristics that have play the biggest role in selecting treatment. Dr Hebert, can I get your thoughts? What are you thinking about as a clinician and from the patient perspective—whether it’s for an itch, how they’re feeling, quality-of-life issues—during that visit when you’re making a therapeutic decision?

Adelaide A. Hebert, MD: I probably see more pediatric patients than some of the colleagues on this call, so I’ll focus on those patients. Certainly, atopic dermatitis is a disrupter within the family. The children don’t sleep because they scratch all night. The parents don’t sleep. There are many things going on in the home that relate to this disease state. I try to focus on a total approach. I want to get that child’s disease under control so the family can have a better quality of life.

We also have the issue of steroid phobia and shot fear in the pediatric population, so I’m often constrained by some of the things the child or the family simply won’t do. I try to focus on what we can do. I want to bring up something that nobody has mentioned before. Very recently, our colleagues in allergy had a landmark article published. Peter Lio participated in that article, where they put aside this construct that food allergy is 1 of the mainstays that we need to focus on in the management of atopic dermatitis [AD]. It’s not that I’m completely dismissing the concept that some children with eczema have food allergies. That’s real, but eliminating foods isn’t the magic bullet that we’ve all sought. That article was so well-constructed. It gave guidance. We don’t want these families focusing on what they can’t do or shouldn’t do with their children. We want them to focus on what they can do.

Some of these new medicines have opened the door to allow not only better therapy but also less fear of the therapy. Some of the treatments, of course, have adverse effects. We have to monitor those. But especially in the pediatric population, the risk for the children seems to be less for older patients, particularly patients older than 65 years old if we’re talking about JAK inhibitors. My focus is on what we can do. Some of these new medicines allow us to do that, especially many that are steroid-free.

Raj Chovatiya, MD, PhD: I love that. In many ways, it’s a glass-half-full approach. We’re not trying to make life more miserable for patients who already have a certain degree of misery with their disease. We’re trying to make that burden a little less. That’s 1 of the keys about atopic dermatitis care that’s unique compared with other diseases. I’ll throw things over to you, Dr Zirwas, as we transition from kids to those who are in the adult range. What are you looking at, talking about, asking about to help you make that decision when it comes to helping a patient select the right therapy?

Matthew Zirwas, MD: I have yet to see anything that tells me there’s a particular drug that’s going to be more effective in a particular patient. Maybe I’m a little less likely to go to dupilumab if somebody has significant face and neck involvement. Other than that, I want the patient to make the decision. It’s as if I’m trying to set the patient up on a date with the drug that’s going to be best for them. If somebody came to me and said, “Do you know anybody you can set me up with?” I’m not going to say, “Here’s who I think you should date.” I’m going to say, “What are you looking for?”

I try to give patients 2 options at a time: A vs B. I give them succinct descriptions of the 2 options. I start a discussion with, “We’ve got 2 options. We could do pills that are going to work fast—in a couple of days—but they slightly weaken your immune system. Or we could do shots. It takes them a bit longer—maybe a week or 2 to start working—but they don’t weaken your immune system at all. With pills, there are no shots, it’s really fast, and it slightly weakens your immune system. With shots, it’s still fast but not as fast, but it doesn’t weaken your immune system at all. What do you think?” Typically, patients will have a strong preference. Maybe they say, “I can’t imagine giving myself a shot.” Or maybe they say, “I don’t want to do anything that will affect my immune system.” Then they make that initial decision.

In terms of data, I don’t think there’s much of a difference between upadacitinib and abrocitinib. I’ve prescribed both drugs a lot, and I don’t think I can tell who’s on which 1. Safety-wise and efficacy-wise, all the data show them to be similar. When we look at biologics, I make the decision about JAK inhibitors based on access, insurance coverage, and those things. With the biologics, I give people the option: “We’ve got 2 different medications. One has been around longer, so we know a little more about it. It’s going to be a shot every 2 weeks, and it works a little faster than the other 1. The second option has not been around as long. It doesn’t work as fast, but once you get better, there’s a chance we can switch you to taking injections once a month instead of once every 2 weeks. What do you think?” I give people that summary in the A vs B.

This is going to get a lot harder over the next several years. Instead of 4 drugs to choose from, by the end of next year we should have 6. A year after that we’ll probably have 8 or 10. It’s going to keep multiplying. For now, it’s pretty simple to do this A-vs-B deciding. With topicals, we have pretty good data showing that topical steroids used in the long term increase the risk of osteoporosis, fractures, and type 2 diabetes. We have good data from European studies showing those things. Although they aren’t the things we talk about with patients, if we’re not trying to get our patients on nonsteroidals and they’re using topical steroids chronically, we’re doing them a disservice.

Raj Chovatiya, MD, PhD: I’m glad you mentioned that. Oftentimes what gets lost with therapeutic innovation and systemic therapies is the backbone and mainstay of what we’re doing for most patients in the case of topicals.

Transcript edited for clarity