Dupixent (dupilumab) ushered in a new era and a growing number of treatment options has brought awareness to the condition. But the panelists also discussed problems with step therapy, delays and denials of treatment and the lack of a “gold standard” test for diagnosis.
Newly approved medications. Others in the offing that are in late-stage clinical trials. Peter Lio, M.D., says clinicians and patients are now experiencing one of the brighter chapter in the history of treatment of atopic dermatitis.
“The biggest difference is just the awareness,” said Lio, a clinical assistant professor of dermatology and pediatrics at Northwestern University Feinberg School of Medicine and founding director of the Chicago Integrative Eczema Center. “That is one of those unintended consequences of (pharmaceutical) companies actually focusing on it. People are talking about it. They are preparing to get better for the first time. They are coming back to our clinic. I have met people who have said, ‘The last time I saw a dermatologist was in the ’90s.’ They just felt like there was nothing new to offer.” Lio was one of the speakers yesterday at a symposium on atopic dermatitis at AMCP 2022.
Atopic dermatitis is the most common type of eczema and can overlap with other types of eczema. Sometimes the terms atopic dermatitis and eczema are used interchangeably.
In a brief interview after his presentation, Lio also discussed problems that clinicians and patients are facing, one of the main ones being step therapy. “The idea of it (step therapy) makes sense and is reasonable. You don’t want people starting on a super-powerful medicine,” Lio said. “It is just in the details that it is incredibly challenging, and the more complex patients are, the more severe they are, the worse it is.”
He gave an as example some insurers’ requirement that treatment with Eucrisa (crisaborole), an ointment, be tried first and deemed ineffective before other treatments will be covered.
“That is not even indicated for severe patients,” said Lio. “It doesn’t make any sense.”
Another speaker at the symposium, Neil Minkoff, M.D., chief medical officer for Coeus Consulting, shared the results of a survey of patients with atopic dermatitis that showed 50% had experienced a delay or denial of prescription in the past 12 months. The survey also showed that half of the denials were due to step therapy and 60% of the delays were due to prior authorization.
Lio, who specializes in patients with severe atopic dermatitis, credited Dupixent (dupilumab), an injectable biologic approved in 2017, with ushering in a new era of atopic dermatitis treatment. “It has changed everything and allows us to really offer sustained control for a huge group of people who never had it before, in a really safe way,” he said. Lio also mentioned Rinvoq (upadacitinib) and Cibinqo (abrocitinib), oral treatments in the JAK inhibitors, as stoking optimism.
Still, Lio said, there are people for whom Dupixent is not effective or has serious side effects. He said there is a need for more treatment options. He mentioned five agents in late-stage clinical development: lebrikizumab, nemolizumab, baricitinib, delgocitinib and difamilast.
In addition to the “big guns” for severe cases, additional treatments are needed for people with milder cases of atopic dermatitis, he said: “We need better stuff on the lower level,” he said.
Another panelist at the symposium, Michael Zeglinski, senior vice president and CEO of Optum Specialty and Infusion pharmacies, shared data showing that 42% of atopic dermatitis patients have out-of-pocket expenses of $1,000 or more and 8.5% reported costs of more than $5,000. Zeglinski noted that patients cope with the cost by not starting treatment or taking breaks from treatment to spread the costs out. He said copay assistance may buffer the out-of-pocket costs but added that accumulator programs, which keep the value of the copay assistance from counting toward an insurance policy’s deductible, have complicated the situation.
Zeglinski also mentioned the lack of a “gold standard” test for diagnosing atopic dermatitis and an absence of biomarkers. Those voids make tracking patients’ response to treatment difficult.
Minkoff argued for considering how atopic dermatitis affects sleep, mood, social life and other aspects of people’s lives, using a hypothetical college student as an example. As with many chronic diseases, he said it was important to set realistic treatment goals; for example, reducing the number of flares from three a year to one rather than creating expectations of getting rid of them altogether.
Michele Guadalupe, M.P.H., associate director of advocacy and access at the National Eczema Foundation, also participated in the symposium. She described the foundation’s role in raising awareness of atopic dermatitis and its efforts to improve treatment with tools that help patients record their symptoms.