The Evolving Treatment Landscape of Atopic Dermatitis and Other Dermatological Conditions - Episode 5

Topical vs Systemic Treatment for AD

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Medical experts navigate the selection process for optimal atopic dermatitis treatment strategies from provider and payer perspectives.

Casey Butrus, PharmD: Dr Cameron, what factors do you consider in your decision when you’re prescribing a topical vs a systemic treatment? How are you evaluating that patient to meet them where they are in their stage of atopic dermatitis [AD]?

Michael Cameron, MD, FAAD: That’s a great question. In terms of treating AD, unfortunately, most patients still need a topical no matter what. If you look at something as efficacious, like upadacitinib, or Rinvoq, most patients are not reaching EASI [Eczema Area and Severity Index] 100. Remember, EASI 100 is a dichotomous end point. It’s only being measured at 1 point in time. If you follow a patient and check EASI 100 every day, they’re going to have a rash at some point. Most patients are going to need a cream at some point. The question in my eyes is, do they need a systemic? That’s the operative question. How do I decide if I want to do topicals only or topical plus systemic?

For me, it’s driven by the patient and how debilitating they’re finding their disease. Let’s say someone has over 10% body surface area or sensitive area involvement, like the hands or the groin or the scalp. Let’s say they’re using their topical steroids consistently, doing good skin hygiene, and taking care of their skin. If they’re not clearing their rash and it’s affecting their quality of life, then they’re an immediate candidate for these systemic therapies. Fortunately, these biologics are extremely safe, like dupilumab and Adbry [tralokinumab] and lebrikizumab. I’d argue that JAKs are very safe too. From my perspective, we need to give therapies to these patients if they’re not clearing.

Brian Keegan, MD, PhD: What’s also important is what patients say they want vs what they actually want. Both of us, and hopefully many out there, will dig into that with patients. A lot of times patients come in and say, “Can I just have another cream?” We might look through their chart or discuss the multitude of medicines they’ve used and realize they’ve tried many. Giving them another cream is probably not going to make a difference. They know that. They know they want to be better, but they sometimes hold themselves back. They’ll use language like, “It’s just my skin. It’s not a big deal.”

Ironically, some patients are often their own worst advocate when they’re in the office if they want to downplay the severity of their condition. In some offices, the path of least resistance is to give them what they want, which is another topical medicine. But what they really want is to get better.

Michael Cameron, MD, FAAD: I couldn’t agree more. I find that the atopic population has become used to their skin. They’ve been beaten down, and they think this is the way they are and that it’s the only way they can live. They don’t remember not being itchy. I have countless Dupixent patients who I persuade to go on therapy. They thank me every time. I see them every 6 or 12 months, and every time they bring it up: “You changed my life. I thought this was the only way I could live.” They get to the point where they think it’s a part of them as opposed to a patient with psoriasis, who tends not to be as symptomatic. They find it unsightly, and they don’t view those plaques as a part of them. They want to get rid of it right away. So that’s a great point.

Brian Keegan, MD, PhD: You talked about itch and how it can become overbearing in their life. You’ve probably been involved in clinical trials, as I have, where patients call back several days after experiencing new medicine when they realize they’re itch-free for the first time in their life. What a liberating feeling it can be. So how do we help the patients? Sometimes we’re helping them understand the severity of their condition and how impactful it is on their life. That may take an extra 30 seconds to dig into a couple of questions about what else it’s affecting ? How are people sleeping? For adult patients, do they sleep in separate bedrooms from their significant others? Sometimes there are a couple of questions that can be eye-opening in terms of how it affects their life.

Casey Butrus, PharmD: Some patients may not know what itch relief is like until they experience these new therapies. Something that gets payers hung up is the labeling of these drugs. Atopic dermatitis is for moderate to severe conditions when a patient has had an inadequate response to topical therapy or isn’t a candidate for topical therapy. It’s interesting. If they have sensitive skin, they may not be the best candidates for topical therapies. Especially if they have lesions that are open, then they wouldn’t want to take a corticosteroid.

Amy, I’m wondering your perspective as a biologic coordinator. When you’re reviewing prior authorizations, do you notice payers have avenues that allow for exceptions where these topical therapies may not be advisable in their step-therapy criteria?

Amy Brennan: That’s a great point. That’s a key to what we’ve been discussing in regard to asking patients those leading questions because body surface area alone isn’t everything. That’s not the whole picture of the patient. We need to have clear documentation for every patient we see, including the nuanced parts of their cases and why you feel that they need a medication over whatever formulary is in place for that payer. And it’s different for every payer.

Knowing the criteria and what the label is for coverage for the drug itself are key to advocating for the patient to the payer. Then we can say, “They’re uncontrolled, and this is how we’re showing that they’re uncontrolled. This label says that they need to be moderate to severe. These are the scales to show they’re moderate to severe. This is what we’re considering controlled on topical therapies. This is what we consider an inappropriate patient for topical therapies.” Laying out the documentation is a huge part of this process, explaining to insurance companies why we’re choosing 1 drug over another.

Brian Keegan, MD, PhD: Your point is great. Just to balance it out for the prescribers out there who are a little apprehensive, as much as it helps you with the documentation, it doesn’t have to be a ton—1 or 2 sentences are all we’re talking about. You don’t need to write paragraphs and paragraphs about what they need. Another sentence or 2 about how it’s affecting their inability to concentrate in school, or their inability to do work, or the fact that it’s keeping other people in the household awake at night, has been effective documentation in our office. It doesn’t need to be a lot more, but a little goes a long way.

Amy Brennan: Definitely.

Casey Butrus, PharmD: From the payer perspective, we’re trying to understand the scenarios and exceptions that come up, but they may be more common than rare exceptions. We’re seeing how we can build out these criteria in prior authorization. If we require a topical corticosteroid or a topical calcineurin inhibitor, which patients wouldn’t be candidates for this? How can we best accommodate them so they’re not rejected? We may have to go through the appeals process when they get overturned on appeal.

Transcript edited for clarity.