Advances in the Management of Atopic Dermatitis - Episode 10
A brief evaluation of the concomitant use of JAK inhibitors, topical or systemic, in patients with atopic dermatitis.
Lawrence Eichenfield, MD: Raj and Lisa, how do you expect to use JAKs with other agents? You can include both orals and topicals. Do you think concomitant use is going to affect efficacy? How do you think we might mix and match? Or is it all going to be monotherapy, the way they usually studied?
Raj Chovatiya, MD, PhD: I’ll start with topicals, and maybe we can go to the orals next. In real-world settings, no matter what medication people look at with systemic, there’s always concomitant topical use going on, which is why we always say that trials can’t necessarily represent what a real-world population looks like. There are some data in the trial programs for the oral agents on concomitant topical steroid use. It seems with baricitinib—this was the BREEZE-AD7 trial compared with the 1 and 2—you get almost double the EASI [Eczema Area and Severity Index]–75, IGA [Investigator’s Global Assessment] 0/1, Itch NRS [Numeric Rating Scale] Score if you’re comparing across trials. It seems to boost efficacy without much of a change in the safety signal.
For the more JAK1 selective medications, abrocitinib and upadacitinib, it seemed equivocal when they looked at with and without concomitant topical steroid use. In those cases, it’s not going to change your outcome much. But when we get these in our hands, we’re eventually going to start needing to collect the real-world data to see the ways in which people are using these.
Lawrence Eichenfield, MD: Lisa, any thoughts?
Elizabeth Swanson, MD: I 100% agree. The first patients I put on an oral JAK will be the patients who haven’t done as well on dupilumab as I would have liked, had an adverse effect from dupilumab and need another systemic therapy, or have a history of alopecia areata or vitiligo. That’s going to be my first patient population who I personally start on an oral JAK. To echo everybody else’s thoughts about topical ruxolitinib, I’m excited about that and feel the same as Peter [Lio]. I hope the studies bear fruit in real life. I hope it’s as good as it looks, because that will be revolutionary topical treatment for our patients to avoid steroids.
Raj Chovatiya, MD, PhD: The interesting aspect about the oral agents is that there’s been a lot of talk that this is something that’s going to be used in place of an oral steroid, like oral cyclosporine. It has a pretty fast onset, and it’s highly potent. The safety signal seems a little better. That’s a reasonable thought. I can’t speak for every dermatologist, but I have a feeling the people who are going to be some of the early adopters might be using it in the same way that you might. Like with cyclosporine, for somebody who’s having a very strong flare for an acute period of time, maybe they’re 1 of those people who flares for only a few months a year. This might be a great choice and something that would allow you to get away with not having a lot of the baggage and extra monitoring that comes with some of those agents.
Lawrence Eichenfield, MD: I do have what I call seasonally severe patients.
Raj Chovatiya, MD, PhD: Exactly.
Lawrence Eichenfield, MD: They’re not terrible in between, but they’re definitely there, and that might be another place. There’s another funny niche for topical ruxolitinib. I have a fair number of patients on dupilumab who have persistent facial dermatitis but otherwise are happy with the drug. As I’ve been lining them up, when we have access to the drug, I’m going to be trying it on them to hopefully calm them down. That’s a pretty good overview and summary on JAK. It’s exciting as we hit our next phase.
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Transcript edited for clarity.