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Building Out Treatment Formularies for Atopic Dermatitis


Variables considered when developing and referring to treatment formularies for atopic dermatitis.

Bhavesh Shah, RPh, BCOP: We’re looking at the effectiveness and safety of therapies. The cost is the most important driver of how that product is going to be positioned to the formulary. We know that mild to moderate patients may be controlled by creams, topical emollients, and topical corticosteroids. There are higher strength topical corticosteroids. There are topical calcineurin inhibitors. Then there are PDE4 topical agents. All those agents have some efficacy in these patients. If you can control someone’s disease with a low-cost therapy, then that would definitely be the choice. If you look at most of the payers, they have this pyramid that starts with the topical emollients, topical corticosteroids, and topical calcineurin inhibitors. Then you move toward the PDE4 inhibitors and to systemic therapy. For some payers, systemic therapy is cyclosporin, thiopurine, or methotrexate—some of the drugs that could be required for a patient to go on to biologic therapy. We know that there’s a significant cost for biological therapies, so if we can control the disease with some lower-cost options, then that’s how a formulary is positioned.

Sometimes even if we prefer a more aggressive treatment approach, we’re limited depending on the type of service line you have. If you have a primarily Medicaid service line, you’re going to be tied to a PDL [prescription drug list], which is going to dictate what you can prefer and what you can’t. A lot of that is driven by contracts, formularies, and rebates, unfortunately. Of course, we know that there are patients who will eventually fail these therapies and will require these more effective therapies.

Managing utilization for a class like this, there’s a significant amount of patients who are going to qualify for a drug that’s approved for moderate to severe atopic dermatitis. Cost plays a huge factor in deciding how that utilization gets to that biologic. We’re looking at the baseline characteristics required for a patient to receive treatment in the first place, which is pretty straightforward. You have a differentiating factor of low, moderate, and severe disease that these patients will have. We know that topical treatments often have limited efficacy in moderate to severe disease. Of course, they don’t always address the systemic inflammation or allergic comorbidities that patients have, like allergic rhinitis. If you have some of those factors already on board, like if a patient has allergic rhinitis and atopic dermatitis, or atopic dermatitis and asthma, then they require a biologic. That also changes the utilization management of the patient. Comorbidities are factored into utilization management. But we also have to have a hierarchy of starting with the basic agents, where there’s some efficacy, and then move to the more costly agents or more of the systemic therapies for patients who require more aggressive treatment or dual-indication management.

Transcript edited for clarity.

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