Dr Elaine Siegfried Discusses Using Biologics to Treat AD

In this interview clip, Elaine Siegfried, MD, of Saint Louis University School of Medicine discussed using biologics—specifically dupilumab, tralokinumab, and lebrikizumab—to treat atopic dermatitis (AD) and how they differ from other treatments.

Siegfried diagnoses and treats skin-related disorders in infants and children; her specialties include AD, psoriasis, vascular birthmarks, and other eczemas. She is interested in research that investigates AD and pediatric drug development as she participates in clinical trials for new eczema and psoriasis treatments. Siegfried is also a professor of pediatrics and dermatology in the Department of Pediatrics, Division of Dermatology, at Saint Louis University School of Medicine.

Transcript

What role do biologics play in AD treatment? How do they differ from other treatment options?

Targeted biologic therapy for this disease has been really nothing short of a miracle. Because dupilumab was the first one out of the gate...actually, if you compare it to lebrikizumab, they work slightly differently, but they have the same target; lebrikizumab and tralokinumab target IL [interleukin]-13, dupilumab targets the IL-4 and IL-13 receptor. But, again, they work through this similar mechanism where they're targeting aberrant type 2 immune dysfunction that drives a lot of atopic diseases.

Having a targeted treatment like that has changed everything. Before we had that treatment available, I only had immunosuppressants, I used a lot of methotrexate, and I still use a fair amount of methotrexate. But for children who have primary immune dysfunction—and that's a pretty big subset of that population, at least in my world—you can't put them on immunosuppressants because they get infected and sick. So, having a targeted treatment, particularly for people who are strep carriers, or who get recurrent herpes, or who have widespread molluscum, or total body dermatophyte infection, having this kind of a targeted biologic agent is really the treatment for them.

We also originally had some problems getting access to the medication, but because it was the first systemic treatment beyond the contraindicated systemic corticosteroids that were FDA-approved for this condition, at the beginning, step edits were requiring us to use medications that were not FDA-approved as first-line treatment, which is an incredible disservice to patients and it makes it very difficult to treat them. But, in the 5 years since initial approval in adults in the United States, gradually, we've made inroads into making it available to patients as first-line treatment, so that's been really important.

Now that we're going to get some other biologics approved, how do you choose between those? That's a much more difficult problem. I do think cost is important to pay attention to. I think they're all coming in about the same cost, but then there's other access programs that may or may not be available to patients, and that's based on the manufacturer. So that can play a role in medical decision-making.

The other thing that plays a big role in medical decision-making when you're comparing dupilumab with tralokinumab is that medication is formulated in a less concentrated version so that loading doses for adults on tralokinumab requires 4 injections, and routine dosing requires 2 injections every other week, as opposed to dupilumab, which is just 1 injection every other week, and really getting to even 1 injection a month for the younger children.

Because we have more long-term data [on dupilumab], now we're beginning to accumulate data about how you can taper the medication or even discontinue it in a certain percentage of patients, and we only have that data really for dupilumab. We're looking forward to that emerging data for the other drugs, but we don't have as much data on those.

For me, personally, I am much more comfortable with dupilumab. First of all, it's the only one FDA-approved in children so far. Also, even comparing it to tralokinumab, the number of injections is a real quality of life problem for some patients; needle phobia is pretty common, so doubling the amount of injections, quadrupling the amount of loading doses, is problematic for many patients.