Shared Decision-making Approach with Biologics

Dr. Peter Lio (00:07):

Hi, I am Dr. Peter Lio. I'm a Clinical Assistant Professor of Dermatology and Pediatrics at Northwestern University, Feinberg School of Medicine here in Chicago, Illinois.

(00:15):

We now have an incredible number of therapies, even in the systemic domain. Just a few years ago, we had essentially zero, and now we have four biologics. We have dupilumab, tralokinumab, lebrikizumab, neihulizumab and then we have two oral JAK inhibitors, upadacitinib and abrocitinib. This is incredible for us because again, just a few years ago, every single thing we had was off-label and was a conventional immunosuppressant.

(00:37):

So how do we parse this? How do we think about this? I would like to say I have an easy flowchart or some simple algorithm, I don't. Honestly, I think we tend to start with our biologics because we have to measure for each drug when we're talking to a patient, and this has to be done in a personal level. This is really a patient-shared decision-making process where we understand what are their goals, what is their comfort level, what are things that they're worried about in particular? What do they know about things?

(01:01):

So sometimes it's very easy. A patient comes in and says, "I have a cousin who's on abrocitinib, and can I do that?" And if they're appropriate, that might be a really nice entrée into saying, "Yes, we can do this for you. Let me talk to you about the risks and benefits. Let me explain it to you."

(01:14):

On the other hand, you have a patient who comes in and says, "I don't want any shots. I'm afraid of them." That's going to also shape our discussion. So we're looking at an individual. And I break it down into kind of four different areas. I abbreviate it as EAST, efficacy, accessibility, safety, and tolerability. We're thinking about those different pieces. And I explain it to the patient, work with them, and we come to a decision together. Typically, we're going to start with a biologic because the safety profile in general is more agreeable. It's a little bit more compact.

(01:41):

Now, the absolute safety in the real world is a little trickier because we know, for example, on our oral JAK inhibitors, the boxed warning is ultimately very theoretical. It's based on a different drug in a different disease state. So we have to be a little bit careful. But the perception of safety is really important, especially from a patient perspective.

(01:57):

So we're talking about these pieces and we tend to start with a biologic for most, but there are patients for whom we have to skip over those and go right to an oral JAK inhibitor. And then we're really trying to fine tune. What have they been on before? What are their risk tolerances? And sometimes it ends up being something that is age-related. Because if, for example, all the things we talked about are for 12 and up, but if we're under 12 years of age, then at this moment while we're filming here, we only have one option. And that's dupilumab for those patients.