Role of Disease-Modifying Therapies for Atopic Dermatitis Treatment

Raj J. Chovatiya, MD, PhD: As Lisa told us, the last 5 years and counting have been a miraculous time for the case of atopic dermatitis, because years of research have started to pay off. Instead of treatments that are designed to do the best we can to limit inflammation, there are now more disease-modifying therapies, or particularly immunotherapies, that can work on the patients with moderate to severe disease. We heard about one of those in Taylor’s story, dupilumab, which is what we called a biologic therapy. Biologic therapies are injectable. They’re literally very specific antibodies that turn down overactive pathways in the case of inflammation. In the case of dupilumab, it’s a biologic that controls IL-4 [interleukin-4] and IL-13 [interleukin-13], which are 2 important signaling molecules in inflammation. There was another biologic that was recently approved, tralokinumab, this one’s more specific for one of those pathways, IL-13.

The advantage of these types of therapies is that they’re dosed every couple of weeks, safety is very promising, so no laboratory monitoring. There’s not immunosuppression going on, and they seem to provide longer term control to people who have bad moderate to severe disease. And so, particularly with the approval of dupilumab now 5 years ago, I can’t believe I’m saying that, it’s changed how we think about treating atopic dermatitis not only in adults but also adolescents and children. And based on some promising data, it’s approved all the way down to infancy. We’re going to have some great options there. So it’s not just me talking, Lisa can chime in, how has biologic therapy changed your practice, particularly in the case of young patients with bad atopic dermatitis?

Elizabeth A. Swanson, MD: It has entirely changed it for the positive. I will think of my career in treating people with atopic dermatitis as BD, before dupilumab, and AD, after dupilumab, because it has revolutionized the treatment paradigm and what we can achieve for our patients in a safe way. For the first biologic, first systemic agent approved in the pediatric population for the treatment of atopic dermatitis, dupilumab hits a home run right out of the gate. I feel so lucky to have it and to be able to treat patients with it. It has been a life changer for patients, their families, and their doctor. It brings me so much joy to improve people’s lives in this way. In my patient population, I’ll take before pictures, before they go on dupilumab, and I’ll take after pictures, it can help with insurance and stuff like that. But more recently, I thought to myself, I should be taking a picture of the patients every time I see them, of their face, of what they come in wearing, because the metamorphosis, the transformation that occurs in these children and teenagers going on this medicine is profound and amazing, and brings me so much joy.

The first few visits, they don’t talk to me much, they have a hoodie on and sweatpants, and it’s 100 degrees outside. Then, they get on this medicine, and visit after visit, they’re shedding layers, they’re coming in in dresses and tank tops. They’re playing sports that their parents didn’t even know they had an interest in, but they were being held captive by their atopic dermatitis. I can’t express the gratitude I have for practicing dermatology at a time where I can witness this and be a part of it. It’s been profound.

Raj J. Chovatiya, MD, PhD: Have there been difficulties that you’ve found in terms of getting access, particularly for children, when it comes to biologic therapy with something like dupilumab? Any tips or tricks that you have in that regard?

Elizabeth A. Swanson, MD: It’s all about persistence and perseverance, and fighting for your patient. I practiced for the first 10 years of my career in Colorado, where access to dupilumab was quite good. Then I moved to Idaho a year and a half ago. When I moved there, there were a couple of insurance companies that were requiring children to fail systemic immunosuppressants, methotrexate and cyclosporine, before they would cover it. My head just about exploded when I was exposed to that. And so, I fought against it. I wrote letters to the medical directors, and eventually, they changed their policies, thankfully. Because dupilumab is a wonderful medicine…I was never excited to put a patient on methotrexate or cyclosporine, I did it out of desperation. I wanted to try to help them. And now, it’s great to not have to pick among those anymore.

Raj J. Chovatiya, MD, PhD: I can bounce over to you, Taylor…. What was your experience in terms of starting dupilumab? Was it something that required a lot of waiting; did it happen quickly? What was it like getting on it from the patient perspective?

Taylor Capps: It was game changing to my life getting on the medication. I was desperate to try to find anything that worked. I was at a point where the topical steroid creams were no longer having much reaction. As you spoke about earlier, the light therapy was something that definitely worked, but it didn’t sustain my lifestyle. I was in a professional career that required me traveling almost every week. And it wasn’t something that was going to work for my life. It worked for the atopic dermatitis, but it certainly wasn’t the solution that was going to fix it for me. With dupilumab, I would say, it was effective from the first injectable. I haven’t had any reactions since.

As far as getting on to the medication, it was quite a process, because my insurance denied the initial claims several times. I remember when I finally got approved, it was like the entire dermatology office had reactions you’ve never seen, because so many people had put so much time and effort into getting me approved for the Dupixent [dupilumab]. With the MyWay patient support program, it’s free for me, even though my insurance had denied the initial claims. I would say that that was something that I’d also never experienced, having medical professionals who were willing to stand up for me and fight my insurance to get me access to a program even though they wanted me to go through these leaps and hurdles.

I remember Dr Chovatiya told me that if I wasn’t someone who could get approved for dupilumab, then there was no reason the medication should even exist because I was the perfect candidate for it. There was a struggle getting through that, but once I was able to get on the medication, it has been completely life changing. And for me, I’ve changed jobs since then. I have had to go back through the preapproval process and all of that. But I specifically call the insurance company to ask them about this medication to ensure that I’m going to get coverage and figure out which insurance policy I should pick every year, because it’s something that I don’t want to live without.

Raj J. Chovatiya, MD, PhD: You highlight some powerful points about the fact that it seems complicated from both ends, right? From the medical side, you’re jumping through these hoops, fighting, writing letters like Lisa Elizabeth is to be like, “We need somebody to get this medication.” From your standpoint, you’re like, “When am I going to get this? I’m getting a denial, I’m getting a denial.” It’s hard to stay positive and motivated from both ends. If there are any payers and larger folks out there listening, this is an area where we need a lot of work to be able to help access it for our patients.

Taylor Capps: I was going to say, I remember that I got the call from Dupixent on my birthday. And I was like, this is the greatest birthday gift anyone could give me, that I had been approved for the MyWay program. Ever since then, it’s been such a joy to be on it.

Raj J. Chovatiya, MD, PhD: From a patient perspective, you also highlight the fact that with many of these newer medications, there are mechanisms, even if there are issues with insurance, to try to help get our patients medications that they need. I applaud that effort to figure out ways that you can. Because many times, even if something is rejected, it’s a matter of being persistent as Lisa put it, in terms of fighting the battle to help get somebody the therapy they need. As we’re getting more new treatments, I hope this will be less of an issue. It’s going to be a matter of choosing between a lot of great therapies, and it remains to be seen if we’re going to have to jump through fewer hoops or not.

There have been a couple of exciting leaps in the therapeutic landscape of atopic dermatitis. We talked about biologic therapies in the last few years, but recently, there were a number of new oral therapies approved as well. I highlighted that JAK [Janus kinase] inhibitor class in the case of a topical medication, but there have been a few oral inhibitors of the JAK proteins that have come out. The data seem to suggest that these oral medications work fast, they seem to be good for people with moderate to severe disease who may have a lot of itch and a lot of lesions. The big difference perhaps between them and the injectable therapies is they do have some lab monitoring. I talked a bit about there being a boxed warning based on longer term studies in different patients with different diseases and different drugs in the same family that have to come into play when you’re having that discussion.

But I can say that for my patients at least 12 years old and up, it’s amazing to have another option in the armamentarium for control of their disease. As a class, JAK inhibitors have started to change how we think about different kinds of inflammatory disease, in addition to atopic dermatitis. And when you’re going to look toward the future, there are hundreds of trials going on in the preclinical phase 1, 2, and 3 programs for atopic dermatitis. What was once an empty tool box is going to get crowded very soon.

Transcript Edited for Clarity