Raj Chovatiya, MD, PhD, and Lisa Swanson, MD, FAAD, review the challenges of identifying the right regimens for patients and the many factors that influence treatment selection.
Raj Chovatiya, MD, PhD: For a JAK [Janus kinase inhibitor] inhibitor, whether it be a topical or whether it be an oral, a big question exists about patient identification and patient selection. What’s the right type of patient for topical ruxolitinib? What’s the right type of patient for oral abrocitinib or upadacitinib? Any pearls of wisdom there, Lisa?
Lisa Swanson, MD, FAAD: For topical ruxolitinib—I think that’s the easiest—it’s a patient that’s 12 or older. It’s a patient with less than 20% BSA [body surface area] affected. I do go over that with my patients. After I tell them about Kendall Jenner, I tell them about 20% body surface area and the size of your hand, and you can use it up to 20 hands. I go through that with them so that they know what appropriate use is. I would say those are the 2 things with topical ruxolitinib, less than 20% BSA and their age.
For the oral JAK inhibitors, that’s a little bit more detailed. You want to determine the age of the patient. Of course, upadactinib is age 12 and up, abrocitinib is 18 and up. Also, as the patient’s age increases, some of your concern for potential adverse effects would increase as well. So that’s an important factor to consider, especially if it’s the first patient you’re putting on an oral JAK inhibitor, if you’re getting yourself comfortable with it and embracing the black box warning and offering this treatment to your patients. Perhaps a younger patient would be a good patient to start with. Their past medical history—I think as dermatologists we aren’t as focused on past medical history as some other medical practitioners—medicines like this certainly make us pay attention to that more crucially. Also look at other medications that they’re on because both of the oral medications can have some interactions with other medicines. So you do a little bit more of being a doctor and diving into all of that past medical history, medication stuff and making sure you really understand where the patient has been health-wise. And then having those discussions about family planning with females of childbearing potential, and asking about smoking history, which I didn’t often ask about before. It’s just increasing our “doctor-ness” and our interactions with our patients to determine eligibility and good candidates.
Raj Chovatiya, MD, PhD: What a great perspective. I think the one thing that¼you and I would really like to get across is that when you really understand the data, just take a look at the patients that were studied. You’ll realize that they’re pretty normal people that you see on a day-to-day basis. They have a history of a lot of medical things. They aren’t super-selected 20-year-olds that are all in great shape without any risk factors. That should really feed into how you contextualize anything that you might be worried about in terms of safety as it relates to the box warning or anything else you might be thinking of, for the topical agent and for the oral agents as well.¼Expand and broaden your mind and realize that when it comes to box warnings, these are really not yes or no questions, but everything is one big gray area when it comes to medicine. You should really be thinking about all the treatment options in your patients and seeing if they fit the criteria you’re looking for for mild, moderate, severe and body surface area and those parameters.
Shared decision-making is the buzzword that’s used a lot of times, but it’s just a fancy way of saying that you’re working with the patient to come up with something that is going to fit with what they want for treatment and not what you think the textbook or the label tells you that you need to tell someone to do. I think that’s what it all comes down to.
For somebody with mild or mild to moderate disease, topical ruxolitinib should be in your conversation, especially based on its indication that typically it’s for somebody who may not have had an adequate response to a previous topical therapy of any kind, let’s say a topical steroid. It’s pretty easy to find a patient like that. In the case of somebody for abrocitinib or upadacitinib, someone with moderate to severe disease is what you’re looking at¼somebody who may have had experience with a systemic agent of any kind, not just a biologic, not another JAK inhibitor, not an oral immunosuppressant, steroids, you name it. If they’ve had experience with something, then that is a candidate for them, so that opens up to a lot of people potentially as well. I think it’s important to really lay your options on the table; in many ways it’s a bit of a choose your own adventure kind of game where you really want to follow the path that’s going to resonate the most with the patient in front of you.
Lisa Swanson, MD, FAAD: I often tell my patients: I’m the navigator, you’re the captain. It’s my job to tell you which ways we can go. It’s your job to choose the route that we take. I literally in clinic will write down all the options that are appropriate for them, and have a good discussion about all of them and see what they think.
Raj Chovatiya, MD, PhD: I love that nautical analogy. Our job in many ways, once we confirm the diagnosis and understand the patient, is really to shepherd them around in the way that they see best fits them in terms of the options that might work.
Transcript edited for clarity