Recommendations for Prescribing Dupilumab

Elaine Siegfried, MD: I think the biggest impact that prescribers face in getting access to dupilumab for patients who really qualify for the drug is strictly economic and payer-based. We have developed kind of a routine system, and then we have some assistance from some pharmacies, to help us along with the really time-consuming process that is prior authorization. So hopefully it’ll be easier. The hesitation that most providers have I think has much more to do with access than it does with safety. But I think for any new drug there are factions of providers, you know? It’s just like with technology. Some people are early adopters and some people are late adopters. And that’s just much more of an emotional thing I think than it is anything that’s supported by data that we do or don’t have. But for some people, until we have very long-term data, they’re not going to feel comfortable with any new drug in children. And other people recognize the risk of the disease.

From my perspective, that is the really important issue. There’s the risk of the drug and the risk of the disease, and people tend to focus on the risk of drugs and what the adverse effects are, and they tend to not really focus on the risk of the disease. And we’ve already spoken about all the atopic and non-atopic morbidities that go with atopic dermatitis. So having a medication that can turn that off and perhaps modify the disease, that’s the risk that I focus on and that’s why I embrace a new drug like dupilumab. But for other people, it’s an individual decision.

Julie Block: I think for physicians with this new biologic on the market, there’s a lot of educating that we need to do. Physicians need to get comfortable with what the treatment is and who it’s appropriate for. The good news about this particular biologic is there is no other testing that needs to be done along with it. But again, I think it is educating the physicians, and the patients, and the caregivers about what this treatment is, how to get it, not to give up, and to continue to have hope. But we are climbing a big mountain there to ensure that all of those stakeholders involved in the care of an atopic dermatitis patient have the tools and resources they need to do their very best.

Elaine Siegfried, MD: By the time you get to be an adolescent and you still are suffering from atopic dermatitis, the approach is I think different than when you have very young children, for whom using topical treatments I think is more doable. Once you get to be an adolescent it becomes much more challenging to do daily topical treatment. So considering systemic options I think is really important.

We didn’t have a chance to talk about the standard systemic options that people use and use probably more in adolescent children than they do in younger children, like systemic corticosteroids or antihistamines, and repeated courses of antibiotics. Those were an old paradigm and people used those things, again, off-label because they didn’t have anything else. But those are treatments that may actually potentiate the long-term course of the disease. They certainly can put out the fire of flares, but they don’t give you long-term control.

So for adolescents I think it’s more important to help them with an agent that can really overcome the burden of their disease. I’ve actually seen teenagers whose parents were really attentive to their needs with topical treatments who did everything. They did everything up until the time they were ready to go off to college. And because these adolescents were so dependent on their parents taking care of them, once they got to college it was the primary reason that they couldn’t stay.

Julie Block: My recommendation for physicians caring for adolescents is ask them. Just ask them the question. “How are you? How ya doing, buddy? How’s your atopic dermatitis? How’s it affecting your life?” A simple question to show that you see that it has much more than a skin-deep impact, that you recognize that this has really changed their lives, and that you, as the physician, or nurse practitioner, or other healthcare provider care and that knowing that answer is important to the treatment plan that you’re going to have together. Ask about the itch, ask about the sleep, and ask just how they are.

Getting access to the new biologic, dupilumab, on the market is extremely burdensome. We hear both anecdotally and now we’re seeing in the literature that the prior authorization steps as well as the step edits or step therapy are delaying treatment a great deal. And much of the access is being denied. Many practitioners are shying away from prescribing this because it is an undue burden on their practice. It has many layers, so we at the National Eczema Association in particular, are working very hard to advocate for obviously appropriate treatments but also policies that are appropriate. The most important thing is that the healthcare provider, and the patient, and the family make a decision about the treatment. And we don’t want barriers and too many steps put in the way.