Welcome to ReachMD. This medical industry feature titled, “Shared Decision-Making in Atopic Dermatitis: Communicating Benefits & Risks”, is sponsored by AbbVie US Medical Affairs.
The US Medical Affairs department of AbbVie Incorporated is the sole author and copyright owner of this presentation and has paid ReachMD to host this presentation. AbbVie is solely responsible for all written content within this presentation. Copyright 2022 AbbVie Incorporated. All rights reserved.
Personal opinions and thoughts are Drs. Shi’s, Bunick’s and Golant’s own. All experts serve as paid consultants for AbbVie.
Shared decision making allows for clinicians and their patients to make health care decisions that are informed by the best available evidence about therapeutic options, including potential side effects, and that consider patient preferences. All medications come with risks, but communicating these risks and benefits is central to all shared decision-making conversations.1
Coming to you from Little Rock, Arkansas, I’m Dr. Vivian Shi.
Joining me from the ReachMD Studios in Fort Washington, Pennsylvania to share about treatment risks and strategies for refractory moderate-to-severe atopic dermatitis are Dr. Christopher Bunick and Dr. Alexandra Golant. Dr. Bunick is an Associate Professor of Dermatology at Yale School of Medicine.
Dr. Bunick, thanks for joining us!
Thank you for the opportunity to be here and talk with you today.
Dr. Golant is an Assistant Professor of Dermatology at Ichan School of Medicine at Mt. Sinai. Dr. Golant, thanks for being here today!
Wonderful to be here with you.
Let’s begin with a clinical scenario.
Let’s say our patient is an adult male with refractory moderate-to-severe atopic dermatitis and with no comorbidities. He has been on various topical and oral systemic immunosuppressive agents, including a short course of oral prednisone, but couldn’t maintain an adequate response. Dr. Golant, starting with you, how would you approach this case?
In cases where a patient is refractory to topical therapies, systemic steroids, or other traditional systemic therapies, I document disease severity, previous therapies tried, and the impact on the patient’s skin symptoms and quality of life (such as loss of sleep, productivity, and social engagements) to further guide treatment modification.
I like to discuss impact of the disease with patients to learn about how this is impacting them, which usually includes a discussion around what the patient’s treatment goals are. I find that this step is very helpful so that treatment decisions can be tailored to the patient’s priorities.
I then present the patient with all available treatment options, and share what I think are the expected clinical benefits and potential adverse events associated with each option. I like to then engage the patient in the shared decision-making process as we decide together what the best treatment option will be.
Dr. Bunick, how would you go about discussing treatment options with your patient?
I’d begin by reviewing all treatment options, making the patient aware of all of his or her choices. In this case of refractory disease, I would switch the patient to an advanced systemic therapy now that we have several FDA-approved agents: oral and injectable medicines.
I would discuss the oral Janus Kinase inhibitors, also known as JAK inhibitors, and share their benefits and risks and required lab monitoring. I would discuss their most common adverse reactions and the potential serious adverse reactions. They have the ability to achieve symptomatic responses quickly and have gone through rigorous safety analysis. The dose can be increased from the starting dose in appropriate patients according to the disease activity.
I would also discuss available injectable biologics, which are effective as well and have gone through rigorous safety analysis. I would discuss their most common adverse reactions and the potential serious adverse reactions. If this patient decided to go with an injectable biologic, injections are needed every two to four weeks.
Let’s focus on the boxed warning for JAK inhibitors for a moment. Dr. Bunick, how would you explain these to your patients?
The first thing to tell our patients is that a boxed warning doesn’t mean “do not use the medicine,” it’s a call-out to serious risks and a reminder to use the medicine with proper monitoring and counseling. Dermatologists routinely use medicines with boxed warnings, and in fact, many of our commonly used medicines, such as methotrexate and cyclosporin and some biologics, carry such warnings. Because of that, we have experience using other products with serious risks.
I have found that the best approach when communicating these issues to patients is to start with a larger overview of boxed warnings before diving into more of the specifics. Risks of serious infections, mortality, malignancy, major adverse cardiovascular events, and thrombosis were reported in clinical trials for oral JAK inhibitors. Patients should understand that these are risks but that, fortunately, they do not occur in the majority of patients. The benefits may outweigh the risks, depending on the patient. But patients and clinicians can make informed decisions about whether these medications are right for the patient, considering disease severity, quality of life, patient preferences, other medical problems, age, and other treatment options that may be available.
Beyond everything I’ve mentioned, there are two key things I like to communicate with my patients: one, if you were my family member and had refractory moderate to severe atopic dermatitis, I would consider using these advanced therapies, such as oral JAK inhibitors, after weighing the benefits and risks; and two, if you do experience any side effects, please always pick up the phone and call my office.
Going back to you, Dr. Golant, how do you contextualize the boxed warning for your patients?
Selecting a treatment is an important decision. While these adverse events were generally seen in certain high risk patient profiles (those with pre-existing risk factors or co-morbidities), they are very important to discuss alongside efficacy, other safety information and patient preference when helping your patient with atopic dermatitis select the most appropriate therapy. I like to give context surrounding the magnitude of these risks, and explain that they were not commonly seen in the atopic dermatitis trials.
Labels that contain a boxed warning will typically include recommendations for lab monitoring and patient counseling.
Appropriate patient selection and monitoring can help minimize risks to patients when prescribing agents with boxed warnings. I find it helpful to take a detailed history and then communicate to patients why I feel a particular therapy is safe, given their unique medical history.
Also, many of our patients are still not aware of advanced therapies for atopic dermatitis, and this represents a nice opportunity to introduce those treatments to our patients through the shared decision-making process.
I want to thank my guests Dr. Christopher Bunick and Dr. Alexandra Golant for sharing their insights on shared decision making in atopic dermatitis. Dr. Golant, Dr. Bunick, it was great speaking with you both today.
It was wonderful talking with you.
Great to be here, thank you.
In the next section we will discuss practical considerations when using advanced therapies for atopic dermatitis.
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