Announcer:
You’re listening to DermConsult on ReachMD, and this episode is sponsored by LEO Pharma Inc. Here’s your host, Dr. Raj Chovatiya.
Dr. Chovatiya:
Welcome to DermConsult on ReachMD. I'm Dr. Raj Chovatiya, Associate Professor at the Rosalind Franklin University Chicago Medical School and Founder and Director of the Center for Medical Dermatology and Immunology Research in Chicago. Joining me today to share strategies for implementing the latest atopic dermatitis treatment guidelines is none other than Dr. Christopher Bunick. Dr. Bunick is an Associate Professor of Dermatology at the Yale School of Medicine and a close friend. Dr. Bunick, it's great to have you here today.
Dr. Bunick:
Thank you, Raj. It's a real pleasure to be here with you.
Dr. Chovatiya:
So for a little bit of background for the listeners out there, the American Academy of Dermatology recently updated their guidelines to include the latest systemic therapies. They include our targeted advanced therapeutics like biologics and JAK inhibitors. Specifically, they recommended biologics, like dupilumab and tralokinumab, for adults with moderate-to-severe atopic dermatitis. This is considered a strong recommendation and has moderate certainty evidence. So to start us off, Dr. Bunick, can you explain what this means and the key efficacy and safety data behind these biologics?
Dr. Bunick:
Yeah. Thank you, Raj. So the first thing to understand is that this atopic dermatitis guidelines from the AAD is an update from 2014. It had been 10 years since the last update. And so the guidelines as a whole have 11 evidence-based recommendations, but 5 of them are strong recommendations for medicines: biologics—dupilumab and tralokinumab—and three JAK inhibitors—upadacitinib, abrocitinib, and baricitinib. Here in the United States, the FDA has not approved baricitinib for atopic dermatitis, so I won’t really focus on the baricitinib.
But with regard to the biologics dupilumab and tralokinumab, what these guidelines say is that these biologics are strongly recommended because they are both first-line medications to be able to use in our atopic dermatitis patients with moderate-to-severe disease. The real-world and clinical trial data of these medications is very strong, and what I mean by strong is that patients that have significant skin lesions, we see in these trials and in the real-world data that the EASI score, or body surface area of active disease, is significantly reduced on these medicines. They're highly efficacious, that's ultimately what it means. But beyond skin lesions, Raj, they're also reducing itch. And so when you think of the efficacy of these medicines, they're strongly recommended. They’re first-line medicines because they work really well at reducing the skin burden of atopic dermatitis. Now it also turns out the safety of dupilumab and tralokinumab is very high and one of the reasons that we see these strong recommendations for the use of these biologics.
Dr. Chovatiya:
And so in terms of JAK inhibitors, speaking about some of the other highly approved therapies, the guidelines recommend both upadacitinib and abrocitinib for adults who have failed other systemic therapies or when use of those therapies isn't advisable. Now these are also considered strong recommendations with moderate certainty evidence, though perhaps a little bit different positioning about where they sit in terms of our treatment algorithm. What are the key efficacy and safety and practical considerations with these therapies?
Dr. Bunick:
So, Raj, I want to start off by saying I was ecstatic to see that these guidelines positioned JAK inhibitors as strong recommendations for their use. Why do I say that? Because a couple of years ago, when upadacitinib and abrocitinib were first launched, as I think a lot of the community of dermatologists knows, there was concern over the safety. No one really challenges the efficacy of the JAK inhibitors. They work very well at treating both the skin burden of atopic dermatitis, whether you measure that by EASI or body surface area, and they are really good at reducing the itch symptoms, right? There's been a lot of concern around the safety because these medicines have a boxed warning. But one of the things that I'm really glad these guidelines did is they took into account the long-term safety data that is mounting. Yes, there's some things you have to watch for. The most common adverse event that's usually seen in the JAK inhibitors is actually herpes zoster, at least from the clinical trial data, and a lot of these patients didn't have a shingles vaccine. When you look at these adverse events of serious interest, one of the things that we know from this long-term safety data is that the rates are sometimes even lower than the baseline population or the baseline population of AD patients that are not getting therapy.
Dr. Chovatiya:
These guidelines are highlighting, I think, one of the main reasons why we need to be incorporating these therapies because the actual data and evidence, hard cold facts, suggest that these indeed should be there. But I want to really ask you as one of the experts in the field, when and why should we be incorporating these systemic therapies into clinical practice?
Dr. Bunick:
Yeah, that's a really good question. So let me start with the why. The why to incorporate these four strongly recommended systemic agents into your practice is because they're what's best for the patient. When to use them? My motto is early and often.
Dr. Chovatiya:
For those of you just tuning in, you're listening to DermConsult on ReachMD. I'm Dr. Raj Chovatiya, and I'm speaking with Dr. Christopher Bunick about implementing the latest atopic dermatitis treatment guidelines into practice.
So now that we know more about the latest guidelines, Chris, I'm going to ask you a multi-part question here because I really want to understand how you use these guidelines to select a treatment. Are there other factors that you consider, and then how do you balance this with your patient’s goals and priorities when it comes to a holistic plan of care?
Dr. Bunick:
Sure. So let me give some simple points here. Number one, what I love about these guidelines is they conditionally recommend against the use of systemic corticosteroids. So number one, I don't use systemic corticosteroids in my atopic dermatitis patients unless it is an incredibly exceedingly rare circumstance. They should not be used, and the guidelines support that.
Number two, as I mentioned, the JAK inhibitors are appropriately positioned in these guidelines ahead of traditional immunosuppressant medications and antimetabolites, so cyclosporin, mycophenolate, and methotrexate. JAK inhibitors and the biologics should be before you ever consider any of those medicines based on efficacy, safety, and the certainty of evidence. All of that points to that all of those medicines we used to use in our residency before this era of innovation of advanced systemic therapies, guess what? They're third rate, third tier, so treat them as such.
Number three, don’t be afraid to use the JAK inhibitors because the safety and efficacy data is there; they're strongly recommended by the AAD atopic dermatitis guidelines, as I said. So tell your patients, these are strongly recommended medicines by the American Academy of Dermatology. That is a perfectly valid thing to do in shared decision-making process.
How do you incorporate other aspects? So patients may have comorbidities, Raj, right? So if you have a patient that has asthma, your selection process may be well, if they have atopic derm and asthma, well, we know topiramate is approved in that area as well, so why not use dupilumab there? If you have a patient that is concerned about eye adverse events like conjunctivitis or if you have a patient who has a history of arthralgia or maybe had arthralgia on dupilumab, well then tralokinumab is going to be a phenomenal option for you, even though both are first-line biologics.
And then you have patient preferences, as you mentioned. What are the goals and priorities of the patient? Some patients want oral medicine; they say, I don't want injectables. Some are very happy with the injectables and don't want the oral. And then you have patients, Raj, and I think you alluded to this, the patients that come in are like, “I want rapid itch relief now.” And we know that the small molecule JAK inhibitors provide the fastest relief of itch. Now all of them relieve itch, and they all do it very well in my opinion, but the JAK inhibitors, in terms of the rapidity and depth of the itch response, clearly, in the head-to-head trials and in the indirect network analyses, do a very good job of that. So all of these things, Raj, I take into consideration in choosing the right medicine. But I want to encourage all of the colleagues out there listening, if you don’t know what to start, one of the really good things is these medicines are so good that if you had to pick one of these four out of a hat blindly, you're probably going to do your patient really well.
Dr. Chovatiya:
We have just about a minute left here, Chris, and so I'd really love to just pick your brain one last time. Do you have any other tips, advice, or last-minute pearls about implementing the latest treatment guidelines of therapies into practice?
Dr. Bunick:
I'm glad you asked this, Raj, because I'd like to leave with one really important point, and that is that it's been estimated that 20 to 40 percent of dermatologists, dermatology nurse practitioners, and physician assistants do not write for biologics or JAK inhibitors. That's a substantial amount of dermatology providers that are not necessarily treating atopic dermatitis patients with these new standards of care. And so I want to speak directly to those providers that are not writing for biologics or JAK inhibitors. The safety data, the efficacy data, and the guideline recommendations all say that these are the new standards of care. It is important for your patient to get these standards of care.
Dr. Chovatiya:
I could not agree with you more. And with those final thoughts in mind, I want to sincerely thank my guest, Dr. Christopher Bunick, for sharing how we can apply the latest in atopic dermatitis treatment guidelines. Dr. Bunick, it was wonderful having you on the program.
Dr. Bunick:
Thank you, Raj, for having me.
Announcer:
This episode of DermConsult was sponsored by LEO Pharma Inc. To access this and other episodes in our series, visit DermConsult on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening.
