An Expert Nurse Practitioner & Physician Assistant Exchange on the Management of Pediatric Atopic Dermatitis - Episode 9
Alexa Hetzel, MA, PA-C; Matthew Brunner, PA; and Lakshi Aldredge, MSN, ANP-BC, DCNP, share their real-world utilization experiences with dupilumab in pediatric patients with atopic dermatitis.
Melodie Young, NP: Dupilumab was approved down to six months of age recently, have either of you prescribed it for anybody under age 11 yet and how's that going? Has it been an easy thing to convince the parents to do, or has it been a challenge? Sometimes adults, when you say, ‘this is even approved in children and infants,’ they think, ’if the FDA think it's OK to use in children, then I should feel good about it.’ I personally don't much pushback about dupilumab. There are several little things people are still struggling with, “am I going to have to do this forever?” The chronic disease aspect. Have you implemented dupilumab in your pediatric population yet? Matthew?
Matthew Brunner, PA: Yeah. I have a handful of patients in the sub-12 group that I've begun more recently, which has been great, and we're excited to see them with their improvements. It's all rather new for us, so we haven't seen a lot of follow-up yet on that. How about you, Alexa?
Alexa Hetzel, MA, PA-C: I have a six-year-old who's on it right now. It was originally approved down to six which was good and then we got the extension down to six months. I had seen him for two years before I could get them up to that. He had thickened plaques, patches mostly on hands and feet, and theDad, you could just tell he was out of his wits. When he finally got to that point, I kind of primed them and was like, “listen, when he gets older, we can get to this.” They were frustrated just as much as I was at wanting to get his skin better. I didn’t feel great about using steroids constantly on a five-year-old so when he finally turned six, we were like, yes. He's been doing fantastic, he hates the shot, I'm not going to lie. I must bribe him with stickers when he comes to see me and there's some tears, but mom and dad have been great and you can tell he is much more talkative. His mood has changed and he's much more vibrant. He looks me in the eye more, even though he doesn't love that I must poke him with a needle when he comes to visit. It's been life-changing for them, and you can see the relief. I think it's amazing the medications that we have to offer support and relief, it's great.
Melodie Young, NP: I've done this long enough that I remember when we had to write double prescriptions when a child had divorced parents. They'd have one set of meds at dad's house and one set of meds at mom's house, and now to do something that you only have to do every couple of weeks it's so much easier. The needle thing, no one likes that until they see the reliefs they get.
Alexa Hetzel, MA, PA-C: They could take it out of the fridge earlier enough. It's not as thick and you can get through some of those symptoms that you've experienced. Once they see the clearance, the parents feel reinvigorated to treat their child again.
Melodie Young, NP: They understand that you're not just rubbing something on the skin, you are treating that dysregulation, which makes a big difference. Lakshi, have you had any pediatric experiences or issues with family members you want to share?
Lakshi Aldridge, MSN, ANP-BC, DCNP: As an adult nurse practitioner, I don't treat pediatric patients, but I do have anecdotal stories. First, along with Matthew, I'm also a sufferer. I talk with my adult patients who have atopic dermatitis about my experience and set that stage to say, “I wish I had this when I was young and five years old and itching and going to school with calamine lotion all over my body, flaking and white and feeling like pariah. I would've taken this in a heartbeat.” One thing that they have shared with me is that often it's the parents who may have atopic dermatitis, so they've taken the shot, and they see how revolutionary it can be for them, and they are much more likely to give it to their children. I had a colleague share with me that a patient who was a toddler came with big tears, with the first and second injection, but less tears with the third injection, and kissed the nurse and said, “thank you for making me better”. It was remarkable to see the change in that child and realize and switch to, “make-me-better-shot” or “my-cupcake-day-shot” or whatever it is, but reframing it to something that is going to help them in every aspect of their life. The other thing is to speak to the safety of this and changing it from the concept that injection therapy is somehow more severe or fraught with more adverse events. Just as we need to reframe our perspective of the efficacy of topical therapy, especially with some of the newer agents that are coming, we must reframe the family and patient conversation that because this is an injection therapy, that it is somehow linked to more severe outcomes or that this is going to be more dangerous to a patient, which we're not seeing that both in clinical and post-clinical real-world experience.
Melodie Young, NP: It's a paradigm shift for the families. They think topicals are safe, but you can do strong pain meds topically, which people are learning more about. Topical should not be equated to being safer. I try to say, “if you're taking a shot they sometimes have less side effects than the pills do” Which you've mentioned before with the other therapies. I also like what Alexa mentioned, which is that she is having patients come in to get their injections. I think that's something that clinics, medical assistants, and some of the other team from within your clinic can do because that takes it away from the family where the mom doesn't have to be the one to cause the pain. We can do the shot every couple of weeks, at least for a while until they are used to it. That's a great addition to a clinic, to be able to offer that service. Almost everybody I've spoken with has tried to do that, to be understanding about bring in and we can do that as well too, just anything you can do to reduce that caregiver burden. That's one of the things that we're taught when we got a bachelor's degree in nursing, that sometimes that's what your job is, to help take care of them and shift that burden a little bit. That's what it can do.
Alexa Hetzel, MA, PA-C: I was going to say it helps them, but it also lets us be a little selfish too, to really see how well it works and see the itching stop. Ilove seeing that so much, it's just as beneficial for me.
Melodie Young, NP: One of my first patients that I put on after he did the clinical trials with dupilumab, and I couldn't put him in the trial because he couldn't risk any sort of placebo. I had a handful of people that there wasn't an inch on their body that wasn't scratched, excoriated, and damaged. When we got it approved and his child had it, she was maybe 15 or 16 and hers was milder. When he got clear, he couldn't believe it; he could go on a vacation and not have to carrythis box of stuff with him. He could buy a shirt that he wanted, and not have to think about all the grease that he was going to wear, what he was going to do, and all these different aspects. When she started having problems it was not approved in in adolescents yet and he says, it's going to hurt her. Those conversations they have. We all know what he did. He said, “I'm going to give up my medicine. I am not going to let my child go through what I went through. I will go back to suffering because I cannot bear to see her, this beautiful girl damaged.” I was able to say, “look, it's just around the bend.” Then of course she got on it and would not be a bit surprised. She has a child that will be as well, the multi-generational piece of it. We get to see all of those folks and they become some of our best marketing about us to say“you should go see Matthew or Alexa because of what they've been able to do for me when nobody else would or could”.
Transcript Edited for Clarity