Optimizing Biologic Treatment Decisions in Moderate-to-Severe Atopic Dermatitis

Raj Chovatiya, MD, PhD, emphasized individualized biologic selection, shared decision-making, and adequate treatment optimization before switching therapies in patients with moderate-to-severe atopic dermatitis.

Transcript

Hi there. My name is Dr Raj Chovatiya. I’m an associate professor at Rosalind Franklin University Chicago Medical School and founder and director of the Center for Medical Dermatology and Immunology Research in Chicago.

What patient- and disease-specific factors have the greatest influence on your treatment decision when choosing among biologic therapies for moderate-to-severe AD?

Dr Chovatiya: When I’m thinking about biologic treatments for my patients with atopic dermatitis, it’s truly a holistic decision-making process, meaning that there probably isn’t one singular parameter I’m going to be leaning on. Once you’ve made the decision that a patient is appropriate for systemic therapy and they’re on board with that, there are a few things that I’m usually looking at to try to help parse through some of the data when it comes to choosing an agent.

First and foremost, efficacy is important, as is overall safety. But even within that, have there been dedicated trials looking at elements of interest in relation to the patient’s disease state? For instance, how old are they? Where do they have their AD? Is it the head and neck region? Is it the hands? Is it something else? Has there been a totality of data in combination or monotherapy based on how the patient is going to be approaching their treatment overall?

What is my expectation in terms of longitudinal treatment? What about the frequency of injections versus less frequent injections or the ability to withdraw treatment as well? It’s these types of factors that play a really important role in that shared decision-making process when we’re trying to match the right treatment to the right patient.

Ultimately, one day this may change a bit, as perhaps we may have more molecular- or biomarker-related ways to match treatment to the patient. But in today’s day and age, it’s truly some of those clinical factors that we’re thinking about when trying to find the optimal treatment.

How do treatment goals and priorities differ among patients with moderate-to-severe AD, and how can clinicians incorporate these preferences when selecting a biologic?

Dr Chovatiya: If you were to take a dozen of my patients and ask them what was most important to them when thinking about the goals they have if I were going to start a biologic therapy, you probably would get a dozen different answers. That’s one of the cool things about atopic dermatitis. It’s truly a heterogeneous disease, not only in terms of the clinical manifestations but also in terms of the goals that our patients have.

For some folks, getting their skin as clear as possible might be the most important thing. For others, it might all be about itch, and if they can have their itch rapidly improved and sustained and be nearly 0 out of 10, they’re extremely happy with that as well. For others, it’s more about, “Can this be a very, very low burden in my life? What is the least frequently I need to use this medication for me to feel like I’m able to go about my day-to-day business?”

Others might say it’s the opportunity for me to potentially get off treatment as well, no matter what exactly you’re telling me about efficacy and safety. So, truly, you have to ask your patient what matters to them when making that decision about what type of treatment you might be selecting.

We’ve seen this thought process play out in some of our newer guidelines that are really trying to help us decide how we come up with treatment options as well as pathways forward with our patients. My best recommendation to those out there who might be having the same consideration in clinic is to try to understand and ask your patient what’s important to them, then share with them what’s important to you, and try to take a little bit from column A and column B when thinking about choosing and monitoring treatment response.

For patients who have an inadequate response to their current biologic therapy, how do you determine whether to continue treatment, optimize the management approach, or switch therapies?

Dr Chovatiya: A common question that I get is, “My patient tried one biologic, and maybe they didn’t get to the goal they’re looking for. So, what might be the next thing that I do if my patient is still interested in thinking about biologic therapy?”

It’s worth taking a step back and understanding what we mean when we talk about treatment failure or inadequate response, as that’s a moving target based on the clinician you talk with. The bottom line with my patients is that I really like to try to go for a good 4- to 6-month stretch on any treatment, optimizing along the way, whether that means combining with topicals or something else, to see if they’re able to achieve their treatment goals.

Treatment goals are often some combination of skin improvement and itch control, among other things. If my patient is not where they want to be—and again, I caution all of you against making a snap decision only a couple of months into treatment—it really does take some time to get biologics going.

If they decide that they want to change treatments, then I try to think about how our treatments differ from one another. At the moment, we have dupilumab, an IL-4 and IL-13 blocker. We have tralokinumab and lebrikizumab, our IL-13 blockers, and we have nemolizumab, an IL-31 receptor blocker. So, these all work slightly differently.

Some of them have overlapping features, but from the data to date, we can see that we are able to switch patients from one treatment to another and still manage to capture a response when we haven’t been able to before. I know logically that might seem a little strange, considering that we’re moving from one drug to another that might have a similar mechanism, but that highlights how little we actually truly understand about some of these switching parameters and what’s happening on a molecular level.

I think it comes down to having the same initial discussion you had with your patient about some of the parameters of their treatment choices and ultimately making that choice together.

Using data is also another important piece, and I would ask all the clinicians out there to really try to understand what data do exist. Of all of the treatment options to date, we definitely have real-world data that show switching. From a clinical trials perspective, we do actually have a phase 3b study, particularly for lebrikizumab, that has looked at patients who have had dupilumab exposure previously and then switched to another therapy. I am assuming that essentially that type of data set is going to be coming for many of our treatments as we have more and more switching throughout.