Experts in dermatology discuss the use of biologic agents in the first-line treatment of atopic dermatitis and share their approaches.
Peter A. Lio, MD: Now that we’ve seen the array of different treatments from our topical agents to our conventional immunosuppressants to our new biologic agent, which has been out since 2017, do you believe that biologics should become the first-line treatment for moderate-to-severe atopic dermatitis? How has that changed over the past few years that we’ve had it? Linda, could you tell us what you think about them in terms of your treatment regimens?
Linda Stein Gold, MD: Yes. For a lot of patients, I start with a topical agent because I’ve been surprised by how many people I can get under control with topical therapy, especially if they’re experiencing a flare. For patients who have extensive disease or those who have disease for a significant portion of the year, I feel that systemic therapy is appropriate, and a biologic agent would be my first-line choice for several reasons.
First of all, it has proven efficacy, which is huge, but it also has proven safety. I want something that I know I can put the patient on; I want something that I would be comfortable treating a member of my own family with. I’m comfortable with the long-term data. I’m comfortable with the fact that there is no increased risk of infection. I’m comfortable with the fact that we have 76-week data. At this point, it’s been published and studied for years and years. I’d like something that’s FDA approved that has gone through the rigors of having to prove the safety and efficacy.
Absolutely: if it’s me with moderate to severe disease, I want the FDA-proven biologic agent.
Peter A. Lio, MD: Emma, have you found that your practice has changed as well, especially as it keeps getting these lower age indications?
Emma Guttman, MD, PhD: Yes, absolutely. When I talk to patients, I tell them, for example, when they think about treating their disease, they need to think beyond their skin because if they have asthma, seasonal allergies, or eosinophilic esophagitis, they need to think about what drug may target more than 1 disease. It has definitely changed. I also have discussions with my allergy colleagues who sometimes want to give additional biologics for asthma. I tell them, “Why should we do that if 1 drug may treat several things?” There are certain considerations that we need to think about and discuss with our patients about their treatment.
Peter A. Lio, MD: I find that having lower age indications allows me to doubly reassure adults. I can say, “A couple of years ago, it got approved in adolescents, and this year, it got approved in the kids.” People like that. In addition to what you said, Linda, we have more than a year’s worth of data published now. Even when it launched, some of my patients in the first few weeks said, “Am I a guinea pig?” I said, “No, absolutely not. These are 52-week data. We had the KRONOS study that showed us how patients have done.”
Plus, as a category or class of medicines, this might be unwarranted to some degree. Of course, any medicine can have issues and be powerful, but the biologics as a class seem to be a bit gentler than our conventional immunosuppressants, at least in other conditions that we see it: psoriasis and a lot of rheumatology issues as well. Biologics seem to be answering the call for targeted approaches to inflammation without some of the adverse effects and metabolic issues that we often see. The fact that we’re not having to draw monitoring laboratory tests is another point that patients like to hear.