Switching From a Biologic to Upadacitinib in Atopic Dermatitis: Key Learnings From the Level Up Study

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The Level Up study provided crucial real-world evidence for switching from dupilumab to upadacitinib in patients with inadequate biologic response. In the head-to-head comparison, upadacitinib demonstrated superior efficacy in achieving the primary end point of simultaneous EASI-90 and an itch score of 0 to 1 at week 16. Most significantly, patients who didn’t achieve EASI-75 on dupilumab (averaging only 50% improvement) were switched to upadacitinib 15 mg without a washout period.

The switch population showed remarkable improvement, with two-thirds achieving EASI-75 and one-third achieving EASI-90 within just 4 weeks of switching. By week 16 post switch, 80% achieved EASI-75 and 60% achieved EASI-90, with nearly 30% reaching minimal disease activity (simultaneous EASI-90 and itch 0-1). Importantly, most of the patients-maintained response on the lower 15-mg dose, though dose escalation to 30 mg was available for nonresponders at week 4.

The study’s design reflects real-world clinical practice with immediate switching without washout periods, avoiding unnecessary disease flare during transition. These results demonstrate that patients with poor biologic response can achieve substantial improvement with Janus kinase inhibitors, often experiencing deeper skin clearance and more robust itch reduction than previously achieved. The durability of response extends beyond 140 weeks based on published data, providing sustained disease control without neutralizing antibody concerns associated with biologic therapies.