New Atopic Dermatitis Algorithm Matches FDA-Approved Treatment to Patient

Oral Janus kinase inhibitors (JAK inhibitors) may be an appropriate alternative to monoclonal antibodies for treating patients with atopic dermatitis, but tailoring biologic therapies is crucial. At the 2023 Annual Meeting of the American Academy of Dermatology (AAD), held from March 17 to 21, 2023, in New Orleans, Louisiana, researchers presented an evidence-based table and algorithm for assessing which US Food and Drug Administration (FDA)-approved treatment for atopic dermatitis would most benefit patients.

They reviewed phase 3 clinical trial data as of May 2022 evaluating the efficacy of JAK inhibitors (abrocitinib, upadacitinib) and interleukin 4 (IL-4; tralokinumab) and IL-13 (dupilumab) antagonists for atopic dermatitis. They examined change in Eczema Area and Severity Index improvement >75% (EASI 75), SCORing atopic dermatitis (SCORAD), Dermatology Life Quality Index (DLQI), Pruritus Numerical Rating scale (NRS), and Investigator’s Global Assessment (IGA) scores from baseline through 16 weeks.

Compared with IL-4 and IL-13 antagonists, JAK inhibitors had greater maximum EASI 75 benefits. The researchers reported that improvement in EASI 75 varied significantly by drug: abrocitinib, 39.7% to 76.0%; upadacitinib, 60.1% to 73.4%; dupilumab, 41.5% to 68.9%; and tralokinumab, 25.0% to 64.2%.

As efficacy ranges depended on factors including patient age, comorbidities, adjunctive treatments, dosage, and immune status, the researchers developed an algorithm for evaluating the patients for each therapy.

“[W]e have proposed an evidence-based table and algorithm for screening AD patients for each approved biologic therapy based on patient profile and drug efficacy data as well as suggested drug monitoring parameters,” the researchers wrote.

They noted dermatologists should assess a patient’s history of smoking and deep vein thrombosis/pulmonary embolism, as well as use of contraceptives and tumor necrosis factor-alpha inhibitors. Moreover, the patient’s history of opportunistic infections should be obtained. The presence of comorbidities — including ulcerative colitis, psoriatic arthritis, rheumatoid arthritis, eosinophilic asthma, and chronic rhinosinusitis with nasal polyps — should be documented. Also, assessing whether a patient has a family history of cancer is essential when determining therapy.

Based on age, physicians can consider either dupilumab or upadacitinib for pediatric patients with atopic dermatitis. They recommend that dupilumab or tralokinumab be considered for patients who are pregnant, breastfeeding, or planning to become pregnant. Dupilumab or tralokinumab can be considered for patients who are at increased risk for thrombosis, cardiovascular death, or malignancy; have hepatic or renal impairment; have low lymphocyte count, hemoglobin, or absolute neutrophil count; or are on anti-platelet therapy apart from low-dose aspirin.

“There is utility of Oral JAK-inhibitors for AD treatment in lieu of monoclonal antibodies but patients need to be adequately screened,” the researchers concluded.