Jeffrey D. Dunn, PharmD, MBA: [Let’s talk about] interleukin vs JAK [inhibitors]. What are their pros and cons? How are you going to decide where you go?

David Rosmarin, MD: It’s going to depend on what the data show. We don’t have any data on anti–IL-15 [interleukin-15] therapy in vitiligo, but in general, I find that there’s a place for all treatments. We just have to [decide] where it’s placed based on the patient’s own goals and interests. Maybe the anti–IL-15 will remit patients but not repigment quite as well, so that may be advantageous to a patient. Or we may end up using a combination of treatments, repigmenting somebody first with phototherapy or a JAK inhibitor and then give the anti–IL-15.

David Epstein, MD, MBA: That’s going to push the payers to be more skeptical and get very strict in terms of access.

David Rosmarin, MD: As I said, we still have to see the data. Once we see the results from that Immune Tolerance Network trial, we’ll have a much better sense of where the anti–IL-15 treatment may fit in. For now, we at least have data on the topical and oral JAKs, which are certainly promising. It’s a start. These offer a lot of promise and hope to many patients, and hopefully we’ll be able to give the appropriate patients access to them. But even after this, there’s still going to be a need to improve patients. It doesn’t work for everybody.

Jeffrey D. Dunn, PharmD, MBA: The trump card is still the efficacy. Let me play payer advocate for a second. Let’s say we don’t have clear definitive clinical differentiation. Is it OK to make decisions based on cost?

Brett King, MD, PhD: It’s undeniable that in a world that costs a lot of money and where there isn’t endless money, cost is going to be a part of the decision tree. We all do this when we decide what car to buy, where we want to buy our home, and where we want to go to dinner. I very much like the idea of this being less of a first question when it comes to health, but I understand it.

Jeffrey D. Dunn, PharmD, MBA: What would you say to a payer now that you have the opportunity? Dr Epstein, you’re going to follow up regarding what you want to see from the provider. Dr King, do you mind starting?

Brett King, MD, PhD: Sure. It’s what I heard Dr Rosmarin say earlier. I want access to treatment. I love a world where my decision reigns supreme, but fundamentally, I want to get treatment at some point. I don’t want to have to do absurd things or things that put my patients at risk to try to get to the [therapy] that I’d love to ask for first, but I also don’t mind. I meant it sincerely earlier about data-driven step therapy, as long as I’m not having to step through some punishing course of therapy. [I’m happy with] a sensible algorithm of treatments where I can maybe get my first choice but I have to do it systematically. That’s OK.

Jeffrey D. Dunn, PharmD, MBA: Hopefully conversations like this will help.

Brett King, MD, PhD: Yes.

Jeffrey D. Dunn, PharmD, MBA: Dr Rosmarin?

David Rosmarin, MD: I certainly agree that we live in a world with limited resources, and we aren’t going to be able to get unlimited treatments whenever we want them for our patients. But it’s important to be data driven. For instance, if we have good data that topical calcineurin inhibitors work well for the face, I’m OK using that as a first-line treatment before I get access to a topical JAK inhibitor. But if a patient has an adverse effect from the medicine or has a lack of efficacy, then I’d like to get access to that other treatment that works. That’s reasonable, and patients will understand that too.

However, the key for us is what Dr King said. We don’t want these absurd treatments or it to be onerous that we have to step through treatments that lack data behind them that we’re confident aren’t going to help the patients in order to get later-line treatments. Having that conversation with payers that we have a reasonable plan in place that satisfies all parties is important, along with bringing everybody to the table—patient advocates, providers, payers, and pharmaceutical companies—to come up with the best outcome. We all have to be at the table for those conversations.

Jeffrey D. Dunn, PharmD, MBA: I love it. Dr Epstein?

David Epstein, MD, MBA: I’m encouraged to have heard our esteemed colleagues’ answers, because that’s exactly the direction that I wanted to see when I got into managed care 30 years ago. I wanted the doctors to realize that just because something is out there doesn’t mean I’m going to use it. An example is when I first got into the business in the late 1980s, and all of a sudden patients with breast cancer were being given bone marrow transplants. There was no clinical evidence. The plans initially denied it and then wound up caving and covering it. About a year and a half later, the specialty community said, “These aren’t effective. We aren’t doing it anymore.”

We’ve moved forward 30 years, and the 2 last comments are very responsible approaches to trying to find the right drug for the right patient at the right time. To have that willingness and recognition from the provider community is a critical step forward in trying to be able to get our arms around this crazy world we’re living in. I very much respect what I heard, and I’d support and welcome that approach very much.

Transcript edited for clarity.