Improving Quality of Life for Patients With Atopic Dermatitis

By following FDA treatment guidelines, care for patients with atopic dermatitis (AD) is not typically affected by step therapy, quantity limits, or prior authorization, explained Jerry Bagel, MD, director of the Eczema Treatment Center of New Jersey. However, patient quality of life is affected by side effects of the condition such as loss of sleep or depression.

In the second half of his interview with The American Journal of Managed Care® (AJMC®), Bagel discussed his research with RNA analysis, utilization management strategies, and what patient factors to consider when choosing treatments.

In the first part of his interview, Bagel discussed follow-up care and mitigating risk factors for AD.

AJMC^®: What patient specific factors should we take into consideration when choosing a treatment for AD?

Bagel: Well, how extensive is the AD? Is it more than 10% or less? How inflamed? How long have they had it for? And then, age: I can get people on Dupixent down to the age of 6 years, but I can't put them on other drugs. Rinvoq, down to the age of 12 years. With biologic agents, there are hardly any risks. Those 2 drugs are so safe that there's not much to be concerned with. With Dupixent, some people do get conjunctivitis. I haven't seen much of it, but they say they can get it. Some get red face. I saw that today. With Adbry, I don't see that much of that at all.

You have body surface area, itching, age, and then you start thinking about people that are really bad—with the Janus kinase (JAK) inhibitors, there's still some risk. So, let's say a 24-year-old girl comes in, she has really bad eczema, and I might want to put her on Rinvoq, but she smokes and she's on birth control pills. It ain't going to happen. I'm not putting her on Rinvoq, because there's an increased risk of blood clots and that's going to increase it even more.

AJMC^®: How do utilization management strategies, such as prior authorization, step therapy, or quantity limits affect the care of patients with AD?
Bagel: I have a full-time biologic coordinator in this office just getting drugs approved for my patients with AD, psoriasis, and hidradenitis. Step therapy really hasn't been that much of an issue. It had been for a while, like, "Oh, you have to use Protopic before you go on Dupixent. Here's a tube of Protopic, we'll get the Dupixent approved, and we'll deal with it that way.” But it hasn't been that much lately.

Quantity limits—you use it FDA approved. Dupixent is every other week, 1 shot. Adbry, 2 shots every other week until week 16, then if you're doing well, 2 shots every fourth week. If you go with the basic FDA-approved regulations on how to use it, the insurance companies usually don't give you a problem. It's more of an issue if you want to increase the frequency. Having said that, people want to extend the duration? No, you take the drug the way it was prescribed, and you don't change it. You don't go less. You don't go more. You use it the way it's supposed to be used, because the half-lives are based upon that.

In general, I would say that managed care is different throughout the whole country. In New Jersey, the Princeton area where I am, we have mostly really good insurance. If I want to write Advry and they say, “No, you have to have Dupixent,” and it's someone who's never had Dupixent, I don't fight that. What am I going to fight? It's not worth fighting. They're about equal. Some people say Dupixent is a little better, but I'm not going to fight that, so I'm going to go with what the insurance company allows as long as I think the drug is commensurate with the amount that I need to treat the individual.

AJMC^®:What are some of the biggest quality-of-life issues your patients with AD experience?

Bagel: Loss of sleep, and when I talk about loss of sleep, I'm talking about people that go to work tired, because they have to make their money, and there's presenteeism, and they're not functioning as well. Or, worse, absenteeism: they don't go to work at all because they're too tired. Children get more attention-deficit/hyperactivity disorder, because they're itching. They can't stay still. Some people have eczema so bad it can be malodorous, because it's bacteria on the surface. They're scratching. Their skin is lichenified. It's really thickened. They no longer want to go out. They don't want to date. They don't want to meet people. They become isolated. There's an increase in depression.

AJMC^®: What are you working on in AD that you're excited to share?

Bagel: We're doing some things like, if Dupixent doesn't work, would Adbry work, or will lebrikizumab work? We're doing some things where people who are on Dupixent, we stop them, and we see how well they do and then if they start flaring a little bit, we put them on Opzelura, and we see how long they can stay clear for.

We're doing a Dupixent narrowband ultraviolet B (UVB)study where people come in, we put them on Dupixent and narrowband UVB 3 times a week to see how they're doing. Also, we're doing RNA analysis on people who go on biologics or systemic therapy to correlate who will respond to what based upon their RNA sequencing. We'll know in the beginning, ultimately, how to get a higher percentage yield on those people by knowing what drug they're going to respond to.

AJMC^®: Did you want to add anything else?

About 4 years ago, right before the COVID-19 pandemic, I recognized that in our clinical trials, which were heavily invested in psoriasis, that the psoriasis research was going to decrease, and the AD was going to increase. I didn't really see a lot of adults with AD, but we invested a quarter of a million dollars of our own money into marketing, and all of the sudden, we started seeing as many severe, adult, atopic dermatitis patients as psoriasis patients. So, they're out there. I'm surprised that they were, but they are out there, and they're suffering.

In many ways, as much as my life has been involved in treating people with psoriasis, I have a lot of empathy for the people that have eczema, because they're scratching, they're itching, they're uncomfortable. You feel like, I've just got to get them better.