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Q&A on Atopic Dermatitis
Expert Answers to Compelling Questions About Managing Moderate to Severe Atopic Dermatitis

Released: August 16, 2024

Expiration: August 15, 2025

Victoria Garcia-Albea
Victoria Garcia-Albea, PNP, DCNP
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Key Takeaways
  • The American Academy of Dermatology recently published updated guidelines on the use of systemic therapies to manage moderate to severe atopic dermatitis in adult patients.
  • Several systemic therapies are now available for patients as young as 6 months of age to treat moderate to severe atopic dermatitis.
  • Shared decision-making and streamlining insurance coverage are important elements of individualizing and optimizing care for patients with atopic dermatitis.

In this commentary Victoria Garcia-Albea, NP, DCNP, answers frequently asked and compelling questions from a live satellite symposium on using systemic therapy for patients living with moderate to severe atopic dermatitis (AD).

Since the guideline update is specific to adult patients, do you extrapolate insights from it to your pediatric population? 
Generally speaking, the answer is yes; and to the extent that the indications by the FDA extend to the pediatric population, it's almost equivalent in my mind. Oral Janus kinase (JAK) inhibitors and tralokinumab are currently approved for patients 12 years of age and older and dupilumab is approved for use in those as young as 6 months old.

We are still evaluating data about long-term effects, which I think is a bridge that we cross down the road because right now the patient in front of you really needs symptom improvement. We have no signals from trials to date indicating these therapies will have negative effects long term, but we will need to continue analyzing. For patients younger than 12 years, this is little more unclear in the sense that these agents typically are not as well studied in these populations. However, I think that within reason, I would continue to extrapolate the guideline recommendations down to these ages within those FDA-approved age ranges. 

Is there a difference in efficacy between dupilumab and tralokinumab? 
It's very hard to really compare that, because there have been no head-to-head clinical studies. In the absence of a head-to-head study, the best we can do is consider clinical trials responses. I would say in general, at an earlier time point, dupilumab seems to have efficacy earlier in therapy. The data overall for the longer-term effects appear to be similar when evaluating their individual clinical trials.

The other thing to keep in mind is that clinical trials measure the impact on a population level while in clinical practice. We need to individualize care, including evaluating safety and efficacy, in each patient. Individual patients will respond differently to different agents, with some responding more to dupilumab while others respond more to tralokinumab. When you think about the patient in front of you, you can use real-world clinical trial evidence in addition to the randomized clinical trials to determine the likelihood of the average person responding to treatment.

But ultimately, at this point we don't have ways to accurately predict how each individual patient will respond. With that in mind, finding the right agent for the right patient may require trying one that is likely to work and be tolerable for them, and switching if needed to an alternate agent if the effects are not as desired.

This is where shared decision-making and patient–healthcare professional (HCP) rapport comes in. Keeping those lines of communication with your patient open is critical to ensuring they are on the right agent for them. These 2 options appear to be fairly similar in the trials. Insurance formulary may prefer one over the other, which tends to sway the choice of initial therapy.

How likely are insurance companies to approve JAK inhibitors prescribed by family medicine HCPs?

I think the likelihood of coverage is as good as with family medicine HCPs as with dermatology specialists. To streamline coverage approval, there are some steps you can take with your initial request. You should document the body surface area involved, discuss history with prior treatments (list these in your notes), and discuss the psychosocial impacts of the disease for the patient. Also, include contraindications to other therapies and when possible, add information about IgE levels. So, if somebody has moderate to severe AD, typically an IgE level would be around 3 or 4; adding this provides more clinical justification for the therapy being necessary.

Do the American Academy of Dermatology guidelines provide recommendations for treating AD during pregnancy and lactation?
The guidelines don't discuss pregnancy and lactation, and I think in general it is an area that is a little opaque, because the available data in those circumstances are very limited. Use of these agents during pregnancy is typically avoided, though there are certainly cases reported of dupilumab use during pregnancy. I think for the most part, phototherapy would be considered safe during pregnancy, whereas the other systemic treatments certainly don't have the data to back up the safety and the potential risks involved.

Your Thoughts?
What questions do you have regarding the latest guideline recommendations for moderate to severe AD? Leave a comment to join the discussion!

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