Improving Access to Appropriate Therapies in Atopic Dermatitis - Episode 4

Prescribing AD Therapy: What to Consider

Dr Bhatia concludes our discussion by outlining what factors physicians should be cognizant of when prescribing therapies to patients with AD.

Neal Bhatia, MD: The needs of the individual patients with atopic dermatitis come basically from the fundamentals. We talk a lot about their living situation, if they’re in a house or apartment, and what potential irritants they’re around, such as pets. Do they have a water softener? Do they have any exposures to other pollutants or irritants? Then we get into daily moisturizing and cleansing, their showering habits. We want to remind them to shower for less than 5 minutes a day with lukewarm water, not hot water. We try to watch for if they’re swimmers or anything else.

Then we’ll ask about foods. There are still very few correlations between foods and food allergies, but we still send them to an allergist if they want to get some testing done. Then you get into some of the other nuances, like scratching. When are they scratching the worst? Is it around bedtime or some other time of day? Are they putting anything on their fingertips to help numb up the skin? Even more so, it’s the experience of what they’ve been on before. Have they been on a lot of antihistamines? Have they used topicals? Have they had many courses of steroids, for example? All of that fits into the determinants of what we’re moving forward with.

Then it gets into some of the essentials, like patients’ age. Obviously, the color of their skin is going to have a lot to do with how much following because we’re going to make sure we’re not still dealing with violaceous erythema that could still be active in darker skin. Then we want to get into kids being helped by their parents. All of that comes into play. A lot of factors come into the discussion topics, as well as what the best options are for the patients.

With JAK [Janus kinase] inhibitors, we were fortunate to be investigators in the trials as they’ve been slowly reaching the market. Abrocitinib [Cibinqo] is for 18 years [old] and up. Upadacitinib [Rinvoq] is for 12 years [old] and up. But abrocitinib is dedicated to atopic dermatitis. It’s a dermatology drug, if you look at it that way. Upadacitinib has a lot of experience in the field in other specialties. They both come with a lot of upside.

The key to the dermatologist for adopting these into practice is the expectation of how fast things will get better, but also when you want to get laboratory tests. You want to check things at baseline, at 4 weeks, then with any dosing change, and also consider some blood tests like lipid check at about 12 weeks. Even more so is the understanding of what can we do top down. We can use steroids. We can use anti-itch lotions. The only thing that seems to be a contraindication is using biologics and JAK inhibitors together. But maybe we’ll learn more about that another day, especially with a topical version. Right now, the incorporation has to be getting past the access issues. Let’s get past the phobias. Let’s get patients better because that’s what’s missing in the market.

Anyone prescribing JAK inhibitors for atopic dermatitis should be aware of some of the potential issues that go along with what has been experienced in the rheumatology world where these indications came from. A lot of them were seen in patients aged 50 and up who were on other immunosuppressants or steroids. The black box warnings were brought to the dermatology space for that. But from what we saw on the trials, most of these medications are very safe. Unfortunately, there were some cases of deep vein thrombosis. There were a few patients with major cardiovascular events. One or 2 had a malignancy develop. More so, the laboratory monitoring of leukopenia and thrombocytopenia are things to watch for, as well as CPK [creatine phosphokinase] elevations, which could manifest as muscle aches. These are things that should be followed and monitored.

With serious adverse events, you obviously want to stop the drug right away. In patients who are of childbearing age, you want to discuss their timeline for having children and stop the drug then. With any serious infection, you want to make sure that the drug is stopped, and the infection is managed. Another issue that comes up is tuberculosis [TB], especially in areas that are endemic to TB or if a patient has a history of latent TB. You want to get those issues covered first. Then make sure to avoid any live vaccines with any of these drugs.

The real-world access is always a problem. It’s a struggle that we all have to deal with, whether you’re in dermatology or another specialty. The key is going to be defending the rationale for therapy, the safety of steroids and immunosuppressants, working off label, and any potential failures from biologics or topicals. The patient profile of someone who’s a good candidate for a topical JAK inhibitor is someone who has areas around the eyelids, intertriginous areas, and surface area that lends itself to being treated. The fatigue of steroids, the opportunity of steroids in some of those places, and the lack of efficacy should be good talking points to get topical JAK inhibitors coming. More so, it’s a matter of painting the picture in terms of who’s a good topical JAK inhibitor candidate.

This transcript has been edited for clarity.