Shared Decision-Making to Atopic Dermatitis Care

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 coming to you from Chicago, Illinois, and joining me to share their perspectives on how we can utilize shared decision-making when treating patients with atopic dermatitis are Dr. Matthew Zirwas and Mr. Douglas DiRuggiero. Dr. Zirwas founded Bexley Dermatology Research Clinic in Columbus, Ohio where he specializes in adult eczema. Dr. Zirwas, thank you so much for joining us today.

Dr. Zirwas:
Thanks, Raj. Excited to be here. Love talking about atopic dermatitis.

Dr. Chovatiya:
And Mr. DiRuggiero is a certified physician assistant at the Skin Cancer and Cosmetic Dermatology Center in Rome, Georgia. Mr. DiRuggiero, it’s great to have you with us.

Mr. DiRuggiero:
Yes, thank you so much. Honored to be included in this group.

Dr. Chovatiya:
So, let’s just jump right into it because I’d love to pick your guys’ brain when it comes to thinking about treatment and shared decision-making. Maybe, Matt, we can start it off with you. Just a little background – you’ve been treating eczema for a long time. Can you kind of give us the quick rundown of what the current treatment approach is for atopic dermatitis? I know a very packed question, but just a general overview.

Dr. Zirwas:
So the first thing that you’re thinking about is what’s the severity and body surface area of the disease that we’re addressing. Is it reasonable to treat it topically? Is it intermittent disease that they do very well most of the time but then they flare occasionally? In which case we might be looking for something that’s more of as-needed therapy. So we’ve got some really good topicals now. We still have our traditional nonsteroidal topicals and topical steroids that I think we’re all very comfortable with using, and then we now have systemic agents that are really, really good systemic agents, and at the moment, we’ve got two classes to choose from. We’ve got the biologics, which have a really good safety profile and are very easy to talk about with patients; they work very well. There are some significant differences between the agents we have available, right? So we’ve got an IL-4 and 13 inhibitor that’s approved for multiple atopic conditions, and then we’ve got IL-13-only inhibitor that’s approved only for atopic dermatitis, and then we’ve got the systemic JAK inhibitors. And then, of course, we still have our traditional treatments: oral drugs like methotrexate, cyclosporine, and mycophenolate. We’ve got phototherapy and those kinds of things, but that’s kind of the overview of our treatment landscape at the moment.

Dr. Chovatiya:
That’s really, really helpful, and it’s amazing to think that that discussion would’ve been totally different if I’d asked you that same question a few years ago, and it’s interesting to think that we have all these tools now, but perhaps the biggest question is how we think about sort of changing patients’ one therapy to another and deciding what to put them on, and that’s where I want to pick your brain a little bit, Doug. What signs indicate a patient hasn’t achieved an adequate response to therapy? And how often would you say this actually occurs?

Mr. DiRuggiero:
Well, that’s a great question, and it’s a great question because it is so real world. We deal with this every day when we see eczema patients. I think the key is making sure that as a prescriber, as a clinician, that you’re not just letting your eyes guide the decision-making process; you have to lead with questions because we may look at body surface area and EASI score and those types of subjective measures in order to make a decision in our own mind that the patient needs to be on a certain therapy, but really we need to ask or we may see that they have very little skin involvement. So you’ve got to ask them, "How are you sleeping at night? How much do you itch during the day? Is the child missing school? Have you had any skin infections recently? How often are you using your creams? You look pretty good. Are you looking good because you’re using the creams three times a day or the steroid three times a day? Or have you been off of it for a few weeks and you’re looking this good?” So it really is an issue of leading with questions and not just leading with what you see.

Now with that said, when someone is not being adequately controlled, they either say, “I want better control, I want better quality of life, or I want to look better.” When those things are being agreed upon then it's time to move off of topicals and off of just good bathing and good moisturizing and into something that’s systemic, the question’s when do you do that? In 2017, in October in JAAD, the International Eczema Council put out official recommendations, and part of those recommendations are when do you switch from topicals to systemics, and basically, in short, they said systemic therapy is warranted for any individual where it’s age-appropriate, FDA-approved, and it is when topicals have failed. And that’s a pretty broad statement, and so that leaves you to sit there with the patient in this shared decision-making process and say, “It seems to me based on what you’re telling me and what I’m seeing that these creams are not doing the job that we want them to do, so if I could talk to you about doing something that’s systemic because this is a systemic disease, would you be interested in that?” And that’s how I lead into that next decision-making process.

Dr. Chovatiya:
That’s excellent. I feel like very much in line with what my practice, too, and I love this interplay between sort of a visible burden and almost the invisible burden of disease where if you don’t ask about it, you don’t really know about it, and this kind of leads me to a question I have for you, Dr. Zirwas, in terms of some of those counseling strategies that you use to really kind of get at a patient’s goals and needs, something that is not going to be visible on their skin if you just take a quick glance at them.

Dr. Zirwas:
The single question or the one question that I really like is just, ”Can you remember any nights where you had trouble sleeping because of your itch?” Because what I have found is that a lot of patients, if their last flare was two months ago, a month ago, or even several weeks ago, when I’m saying, “Well, how you doing? How’s your eczema doing?” a lot of times they’re like, “I’m doing great!” and it’s like they forget that they had this flare because they’ve been doing good for a few weeks or a few months. But that’s a very concrete question to say, “Since the last time you were here,” or if it’s the first time I’m seeing them, "Do you remember any nights when you could not sleep?” And if there was even a single night where someone was unable to sleep because of their itch and atopic dermatitis, that really makes me think that we need to do better in therapy.

Dr. Chovatiya:
And maybe I can kind of quickly follow up with that, Dr. Zirwas. How do you balance what the patient wants versus perhaps what you want?

Dr. Zirwas:
The simple answer for me when I’m treating eczema or psoriasis is that what I want doesn’t matter. We’re not treating something that if left untreated leads to an unacceptable risk of some horrible health outcome. It’s not like we’re talking about high blood pressure, and somebody’s 180 over 110, and I’m saying we really need to treat your blood pressure – “Well, I don’t think I want to take a medication,” – and I’m really trying to talk them into, “We need to control this or you’re going to have a long-term complication.” For atopic dermatitis, psoriasis, and most derm diseases, it really is up to the patient how much therapeutic intervention they want to take, and so what I want doesn’t really matter.

Now on the other hand, the patient wants to know what I think, and so I frequently will, either before or after I give them the options of the things that I think are reasonable possibilities for them, I will tell them, “If you were my sister or my mom or my kid or if I was in your shoes, I would probably do this.” It’s my job to try and give them the information that they need in order to make an informed decision and then to maybe help them make that decision, and some patients will say, “Just tell me what I should do,” and then I will make the decision for them in that situation, but I really try hard to just give them the relevant information. Try not to give them too much because information overload is a very real thing where if we give people too much information, then they can’t make an informed decision. It’s trying to tailor the information and the amount of information to the individual and then allow them to make the decision.

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. Matt Zirwas and Mr. Doug DiRuggiero about the role of shared decision-making in atopic dermatitis care.

So, Mr. DiRuggiero, Dr. Zirwas was just telling us all about a really real-world practical approach to therapeutic decision-making and really shared decision-making. What kind of impact does this shared decision-making have on patients when you’re thinking about the patient perspective, your perspective, and really bringing it all together?

Mr. DiRuggiero:
Well, I mean, I think at the core of shared decision-making is the fact that if a patient is participating in this, and they should be running the show as Dr. Zirwas just said, but if they’re participating, then they have higher buy-in. But I also just want to comment that sometimes some patients come in, and they’ve been put on a biologic or a JAK inhibitor, and we walk in the room and they look great. It’s easy for us to assume that because their skin looks 90 percent improved that they are where they should be. I’m thinking to myself sometimes, “Man, you look awesome! Are you happy with where you’re at? What’s going on?” And sometimes you can talk them out of being honest and say, “Yeah, I love being 75 percent clear, but is there anything we can do to make me all the way clear?” So I think even with treatment success, you still have to back away as a clinician and ask them, “My eyes tell me that you look much improved, but tell me how you feel.” Again, that same question: “Are you sleeping at night? Are you feeling like you’re really engaging in all the activities you want to engage in?” Because sometimes someone will say, “If there’s anything out there that can maybe help,” and maybe it’s adding on the right topical, whether it’s nonsteroidal or not, or shifting to a different systemic. You need to find out from that patient if 75 percent improvement is really what their expectation was because they may be hesitant. They may feel like “I don’t want to seem ungrateful; I’ve gotten 75 percent better, that is really awesome,” but you don’t want to put them into silence to not talk about the remaining 10 to 25 percent that they did not get with the therapy and whether or not you need to address that with them in certain ways.

Dr. Chovatiya:
Well, there you have it. With those comments in mind, I’m Dr. Raj Chovatiya, and I want to sincerely thank my guests, Dr. Matt Zirwas and Mr. Doug DiRuggiero, for joining me to discuss how we can better manage our patients with atopic dermatitis. Matt, Doug, it was so great having you both on the program.

Dr. Zirwas:
Thanks, Raj. This was really fun.

Mr. DiRuggiero:
Yes. Thank you very much for including me.

Announcer:
This episode of DermConsult was sponsored by LEO Pharma Inc. To access this and other episodes in this series, visit ReachMD.com/Derm Consult, where you can Be Part of the Knowledge. Thanks for listening!