Special Report: Overcoming Therapeutic Inertia and Communicating Safety of JAK Inhibitors

Therapeutic inertia is a recurrent challenge in the management of moderate to severe atopic dermatitis.

Mona Shahriari, MD, suggests that inertia often stems from clinician comfort with “good enough,” time pressures, and residual uncertainty about newer therapeutic classes such as JAK inhibitors. She notes that until 2017 there were no targeted agents combining high levels of skin clearance with long-term safety suitable for chronic use, which shaped expectations for what was considered acceptable control. Now, with advanced biologics and JAK inhibitors available, she argues that continuing to prioritize convenience over optimal outcomes can inadvertently shortchange patients whose lives might be transformed by deeper disease control.

In this video, part of a 6-part Special Report series on switching therapeutic classes in atopic dermatitis, both Shahriari and expert guest Andrew Mastro, MS, PA-C, emphasize the critical role of communication in mitigating therapeutic inertia. Mastro describes reframing safety conversations so that they are proactive, structured, and time-efficient, rather than a barrier to prescribing. Shahriari shares a concise script she uses when discussing JAK inhibitors: she acknowledges that pursuing greater efficacy and speed of response may involve additional risk, explains her plan for baseline laboratory evaluation, and contextualizes boxed warnings by clarifying that they derive from a different drug in a different disease population with additional immunosuppressive therapies. She reassures patients that, based on their individual medical history, she does not anticipate a heightened risk but invites them to contact her if anything feels concerning once treatment starts.

Mastro complements this with his “three Ps” framework—emphasizing that the situation in which the boxed warning arose is not the same person, problem, or prescription as the atopic dermatitis patient and agent under consideration. He briefly reviews the surveillance study that generated the warning, highlights differences in population and indication, and then explicitly explains why he believes those data do not directly translate to the current atopic dermatitis scenario. Both clinicians stress that these conversations can be conducted in 1 to 2 minutes yet have a profound impact on patient trust, adherence, and willingness to switch.

Relevant disclosures for Shahriari include AbbVie, Apogee, Arcutis, Bristol Myers Squibb, Dermavant, Galderma, Incyte, Johnson & Johnson, LEO, Lilly USA, Novartis, Regeneron, Sanofi-Genzyme, Takeda, UCB, Pfizer, and others. Mastro has no relevant disclosures to report.

References:

Silverberg JI, Gooderham M, Katoh N, et al. Combining treat-to-target principles and shared decision-making: International expert consensus-based recommendations with a novel concept for minimal disease activity criteria in atopic dermatitis. J Eur Acad Dermatol Venereol. 2024;38(11):2139-2148. doi: 10.1111/jdv.20229

Silverberg JI, Bunick CG, Hong HC, et al. Efficacy and safety of upadacitinib versus dupilumab in adults and adolescents with moderate-to-severe atopic dermatitis: week 16 results of an open-label randomized efficacy assessor-blinded head-to-head phase IIIb/IV study (Level Up). Br J Dermatol. 2024;192(1):36-45. doi: 10.1093/bjd/ljae404