MedPage Today brought together three expert leaders for a virtual roundtable discussion on atopic dermatitis: Moderator Peter Lio, MD, of Northwestern University Feinberg School of Medicine in Chicago, is joined by Linda Stein Gold, MD, of the Henry Ford Health System in Detroit, and Alexandra Golant, MD, of the Icahn School of Medicine at Mount Sinai in New York City.
This second of four exclusive episodes explores how they decide when to introduce systemic treatments to their atopic dermatitis (AD) patients, along with considerations when switching agents. Click here to watch other videos from this roundtable series.
Following is a transcript of their discussion:
Lio: Now that we have new tools in our toolbox, we need to figure out when is the appropriate time to actually break them out for a patient. And maybe, Dr. Stein Gold, I can start with you by saying: you have a patient who is on, maybe they’re on sort of that liminal aspect, they’re on the border of needing a systemic or not. What kinds of things go into your thought process about, OK, now it’s time to ramp up to a systemic therapy? And when might you say, look, we’re going to double down with topicals.
Stein Gold: I think it’s important to really treat the patients. And when we see them in our office, it’s just a short snapshot. So I want to get a little bit of understanding of what their journey has been like. The first thing I ask my patients is, When was the last time you were clear?
Now for some patients, they don’t even understand what I’m talking about, because they’ve never been clear. That’s important for me, because you might be coming in on just a bad day. I want to know, What does your journey look like? I also ask them, How often do you think about your atopic dermatitis? And if they think about it every day, multiple times a day, we’re not where we need to be, even if they look good today. So I have a very low bar for going to a systemic agent. My goal is: ideally I want you to be clear, I want you to be itch free, and I don’t want you to think about your atopic dermatitis. I want you to live your life [as] somebody who happens to have atopic dermatitis, but you don’t live your life around atopic dermatitis.
Lio: I like that a lot. And I think one of the questions that comes up a bunch too, and you really speak to this, is the burden that it’s having on the patient. I often say that before I go up, I do need to make sure that it really is atopic dermatitis and that they have made sure we’ve maximized their topicals.
Dr. Golant, when you’re making that shared decision-making discussion with your patients, how do you verify that it’s AD? How do you make sure they’re really have used the topicals as you’ve said, and how do you make sure that all the boxes are checked before you move up?
Golant: Interesting points. When you look at the AAD [American Academy of Dermatology] diagnostic criteria for atopic dermatitis, which was simplified in its last rendition several years ago, there’s really not many required criteria to make a diagnosis of AD. So I find that I spent a lot of time actually teaching my residents and our students that once you fill those — the itch, the skin lesions (the eczematic skin lesions), and the chronicity — you go ahead and kind of assume AD and treat it as such. The times that I take a pause is if I’m using a therapy that I think should have gotten a patient to a certain level of efficacy and it has not, or in unusual presentations — always a guiding light in dermatology is considering your differential diagnosis.
Those are usually my pause points. But the patients that I find that are kind of strung along the longest are patients that maybe don’t have a childhood onset or maybe don’t fit neatly into the box of what we assumed was requirements for the diagnosis in the past.
I agree with you that I require patients to do topicals my way. Usually a combination of a steroid and a non-steroid, but not in that hamster wheel that we used to continue. Patients used to come into the office, see a provider leave with a topical steroid of a different name, come back 2 months later, leave with a different topical steroid, and then come back to us with these two gallons of Ziploc bags. So once they’ve kind of done my experiment, which is usually about 4 to 6 weeks of my routine, and I’m very strict with the kind of quantities of these things that I give, I’m having a conversation about what’s coming next if they’re not well controlled.
And I think to Linda’s point, something I love that she mentioned was that emphasis on quality of life. You’ll almost never miss a severe patient, but if you’re not asking about quality of life, you will often miss a moderate. “What can’t you do that you’d otherwise like to do if you didn’t have AD?” Those types of questions I think really have helped me better identify who perhaps would benefit from an escalation of therapy.
Lio: I love that. And Dr. Stein Gold, would you agree that because we’ve gotten more comfortable with some of the new systemics, that your threshold for starting them has actually come down a little bit? Maybe 10 years ago because our systemics weren’t so great, you would be less likely to use them, but now do you feel like you’re more eager to use them?
Stein Gold: I absolutely do. I think we have this wealth of resources now. We have so many fabulous options. We have biologic options, we have oral options, we have great topical options. So I think that we should really advise our patients: demand more. Demand more from your dermatologist, demand more from yourself. We need to get to a place of better control, and I think we were given the tools to get there.
Lio: I love that. For me, one of the biggest questions that ADCT, that Atopic Dermatitis Control Tool, has brought up is that maybe the question we should be asking, and this is I think what you’re both getting at beautifully, is control. And getting the patients under that point where we really feel that they’re actually able to live their lives and get back to normal as opposed to just getting some element of their disease process clear, especially on a daily basis.
I mean, that’s what we always say. The real aspect that I think falls short with an EASI [Eczema Area and Severity Index] score or an IGA [Investigator Global Assessment] score is it’s just that moment in time. So if a patient is, for better or for worse, luck or unlucky that day, they look good. That doesn’t tell us what’s been going on in the last 3 months. So as you say, the journey is so important, and that’s why I think this concept of control is really, really key.
Alright, now the next question is a tough one. The biologics I think are a relatively easy sell, right? Because the risk-benefit ratio is pretty favorable. They do a very nice job. There’s no lab monitoring. There really are very few issues that we have to think about. They’re not perfectly safe by any stretch, but they’re relatively safe. There’s no known drug-drug interactions, but they don’t work for everybody. And of course, the more specialized I’ve become, the more I get patients who have failed the biologics and now it’s like the next step tends to be our JAK [Janus kinase] inhibitors. So my question, Dr. Golant, for you would be, when you’re going up to a JAK inhibitor, or if that’s a question, what kinds of things are you considering for a patient who may or may not be a candidate for a JAK inhibitor? What might make you jump right on it? What might make you shy away from it? I know that is a hard question.
Golant: That is a tricky question, and I think that that answer is different for every single dermatologist who uses these agents. I think it ends up being an end product of the patient’s risk tolerance and oftentimes how the message is delivered. I say especially to audiences that have not used the JAK inhibitors as much, that the success of the conversation in the exam room is going to succeed or fail based on your delivery and your explanation of where some of these warnings came from. So sitting with the safety data, not just pie-in-the-sky looking at a boxed label, but looking at the safety data of the events that occurred in our clinical trials for our JAK inhibitors approved for atopic dermatitis in an atopic dermatitis population, as well as getting comfortable with the boxed warning and knowing how to counsel a patient through that is really important.
One thing that has, I think, helped me succeed is knowing the origin story of where the boxed warning came from — it being a higher-risk population, it being a much more immunosuppressive JAK inhibitor — and being comfortable myself with having that conversation with patients to identify their own risk factors, if they exist. And explaining to patients my personal comfort level with initiating this class of drugs for their disease.
Lio: I love it. Dr. Stein Gold, anything to add, contraindications that might make you pause for a patient who is a candidate for a JAK inhibitor?
Stein Gold: Yep. First of all, I think sometimes the biologic can be a tough sell as well, because patients often think if I’m getting a shot, that’s a hardcore medication. So I do take some time to explain it. And the biologics are my first step generally, because a lot of patients really can be controlled with a good biologic for atopic dermatitis. So given the safety profile, I will often start there. But as you mentioned, that’s not always enough. And I just had a patient in my office yesterday who was on a biologic agent, young guy, early 20s, but he wasn’t doing well enough. And so this was the time when I had a conversation with him that I think it’s time that we demand more. And you’re doing well, but you’re not doing well enough, and you’re still, again, thinking about your skin every single day. And I really look at the risk-benefit profile.
And we know with our experience with JAK inhibitors at this point and the more safety data that we gather, we understand that there are certain populations that are going to be at higher risk. Those patients 65 and over are at higher risk for potential side effects. So that’s a population where I’m going to think twice and really have that safety conversation and maybe monitor a little bit more closely. Whereas for instance, this young gentleman — 23, 24, no risk factors — I might feel much more comfortable with this particular patient population. When they’re younger, they’re healthier, they don’t have a lot of comorbidities, where I’m perfectly comfortable with it, even though I’ll still monitor.
Lio: I love it.