Personalizing Treatment Selection in Atopic Dermatitis - Episode 14
Omar Noor, MD, and Adelaide A. Hebert, MD, discuss monitoring requirements for various classes of treatments in atopic dermatitis, including topical vs systemic.
Raj Chovatiya, MD, PhD: Dr Noor, when you’re thinking about the extra baggage that comes into any treatment, depending on the atopic dermatitis or the systemic issues, that will require you to see your patient more or less. Some require some lab work when you’re starting or ongoing lab work; others don’t. Can you tell me a little about some of the differences across the treatment types we’ve mentioned today? What extra monitoring requirements fall on the clinician or the patient?
Omar Noor, MD: None of our topical options require any initial lab monitoring for the patient or monitoring over time. That’s definitely a nice option for our mild to moderate patients who don’t necessarily have to go to a systemic option. The first biologic that has come to the market for atopic dermatitis, dupilumab, does not require any blood monitoring, whether it’s initial or ongoing lab monitoring. This makes it a great option for starting patients right away. With the oral JAK inhibitors that have come to the market, and even with the topical, the onset is very quick. With dupilumab, the onset might be a little slower. We’re treating that speed of onset for more of a maintenance over time. In regard to a different type of safety profile that doesn’t require blood monitoring, we can start the patient with a loading dose right in the office, so we can get beyond needle phobia or apprehension and move toward our newer options, which are oral JAK inhibitors.
What I talk to my patients about is that I want to make sure they’re healthy prior to starting the medication. We know that there are certain parameters that we want to make sure are met. Patients have a hemoglobin greater than 8 g/dL, a neutrophil count greater than 1000 per mm3, and a lymphocyte greater than 500 per μL. These are baseline characteristics that I don’t want to overlook. There are other unique situations that I’ll keep an eye out for. I’ll look at someone’s cholesterol, especially if, at baseline, they look like they might be obese or overweight, or if they mentioned that they’re on a cholesterol-lowering agent like a statin. Let’s make sure their cholesterol isn’t too high, because with JAK inhibition, the way the molecule works is that there’s a risk for an elevation of cholesterol over time.
We also want to check with a QuantiFERON-TB Gold because there’s a theoretical risk of TB [tuberculosis] reactivation. To be honest, for access to the medications, a lot of times insurance companies will ask for that QuantiFERON-TB Gold test prior to starting the medication. For checking blood work, there’s no reason to not throw that on as well. This happens very rarely, but there’s a transient increased risk of creatine phosphokinase [CPK]. If I have a patient who’s getting ready to run a marathon or to do solid core or some other exercise regimen to get ready I may check a CPK at baseline. I might mention to that individual, “If you’re having any of the ordinary muscle pain, call me and let me know.” I’ll check these parameters in 4 or 12 weeks, depending on which oral JAK inhibitor I start them on.
Raj Chovatiya, MD, PhD: Thanks for that overview. Obviously, you don’t necessarily have options to all these therapies, but you do have your adolescent group, 12 years and up. Of course, access to biologics are much longer. Historically, with methotrexate and others there was always a lot of monitoring. What does that discussion look like for you and your patients? How do you handle the aspect of a longitudinal monitoring?
Adelaide A. Hebert, MD: Many patients are pretty desperate for additional therapy because they’ve failed everything else that I’ve tried, and we’ve been using methotrexate and cyclosporine for years. I feel strongly that the new JAK inhibitors are safer in the long run, and we have better evidence-based medicine in terms of using those medications. Ironically, insurance companies often make us use 1 or 2 non-FDA approved medicines to get the best medicine. Sometimes, that’s the harder conversation: “Your insurance company requires me to use 2 non-FDA medicines.” Patients have a hard time getting their head around that, as do parents, but we have the conversation and say, “That’s the lay of the land.”
We talk about the lab work we need. If the patient is an older teenager or immunocompromised, we talk about getting a shingles vaccine. We certainly do that with our adults who are going on some of these JAK inhibitors. First, it’s very good basic medical care. All of us have treated patients with shingles who we wish had had that vaccine and reduced their risk of having shingles, especially when it’s a very bad case. That’s another discussion that I have.
I also talk about drug interactions because we know JAK inhibitors can’t be used in concert with certain medicines. They must pay extra attention. We often have that conversation about cyclosporine, about not mixing it with grapefruit. That’s the state fruit of Texas, so that’s an imperative in my state. For methotrexate, we can’t use Bactrim and other agents in concert with that medicine. We’ve all had these conversations. It’s a little more challenging with pediatric patients because adverse effects and safety become critical.
My colleagues in general pediatrics don’t use cyclosporine, methotrexate, biologics, or JAK inhibitors. They’re totally unfamiliar with this realm. Fortunately, I trained most of the pediatricians, so they know I’m not going to give their patients something unsafe. But it’s a harder discussion because when they go back to the pediatrician, the pediatrician has never heard of this therapy, or is a little concerned. It’s a unique orientation, for the patient and the parent, to this new arena. It’s exciting, and they sense my excitement when we have an opportunity to bring their severe atopic dermatitis under control.
Raj Chovatiya, MD, PhD: That’s a nice overview of the considerations in your population. No matter what age we’re seeing, there are many shared principles in this discussion. The desperation and need of our patients, particularly with uncontrolled disease, ends up guiding a lot of what we do. Frankly, it gets buy-in from patients, especially those who’ve seen many other physicians and not been able to get control of their disease.
Transcript edited for clarity