Expert dermatologists review the use of dupilumab for the treatment of AD, focusing on the once-monthly shot as a factor in selection.
Jonathan I. Silverberg, MD, PhD, MPH: [Dupilumab] is an important option. There’s something for everyone. You’ve got to know your patients. Not everyone is going to be adherent to all the topicals. Not everyone can put it on large surface areas, and then you’re going to be forced to step up sooner.
Elizabeth Swanson, MD: For 6-year-olds—yes, it’s a shot and they’re young—the dupilumab dosing is just once a month. When I’m talking to patients and their families about it as a choice, I say I know it’s a shot and an “ouchie,” but it turns the eczema into something that the patient has to think about only once a month rather than every day or multiple times a day with topicals. Sometimes that’s very appealing to patients and their parents.
Andrew Blauvelt, MD, MBA: I have a little more of a cynical answer than you guys because at a trial center, the most typical patients coming in for atopic dermatitis trials are the ones who’ve been offered only topical steroids their entire lives. Clearly, you’re using all the things in the armamentarium, which more dermatologists should do. It’s a highly select population. Patients who are being managed well by the dermatology community aren’t coming in for clinical trials. But 1 of the typical complaints is the patient has been offered only triamcinolone their entire life. They go to dermatologists, and that’s the only offer. They want to try a clinical trial because it’s something different, or they want to try a systemic agent because it’s never been offered by their dermatologist. There are patients like that, perhaps not in your practices, who are desperate for something other than topical steroids, but they’re not always being offered other options.
Jonathan I. Silverberg, MD, PhD, MPH: I share your cynicism. It’s reasonable to start with a topical steroid, but I often say jokingly to the residents, “You’ve got about 3 days to prove you’re not as dumb as the last 15 dermatologists you’ve have seen.” If they’re coming in with that suitcase full of topicals and they have mometasone and triamcinolone, maybe they didn’t put it on as much. I’ll talk to them about how to optimize, but I’ll tell them straight out: in a case this severe, the topicals are going to help, but realistically, they’re not going to be enough. Let’s have that conversation. If you have a risk-averse parent and they say they’re not ready, I tell them to think it over. That way, if we reach the point when the topicals fail, they’re emotionally prepared and have an idea of which therapy works best for them. You have to approach that conversation early, even though there might be a chance the topicals hold them over, but it’s a slim chance you have to be realistic about that.
Elizabeth Swanson, MD: It’s also nice to plant the seed of systemic therapy. I have a lot of families who, at first, feel things aren’t that bad. There’s an expression that you can boil to death in a slowly heating bathtub. For a lot of patients and their families, eczema is that slowly heating bathtub. Slowly but surely, it’s having this impact on your life, but it’s happening so slowly over time that you’re not fully aware of the grasp it has on you. Knowing that option is available, the next time they have a sleepless night, there’s blood on the sheets, or they have to cancel an event because of their child’s eczema, they think back to that conversation. They realize maybe it’s that bad. Maybe they’re ready for this.
Brad Glick, DO, MPH, FAOCD: I may be off the mark, but in this era there’s a greater understanding of the need and use of injectables subcutaneously. It’s not that we just started them a year or 2 ago. This is a more than 20-year wait. Parents see it, and they know adults are getting it. Now it’s approved in children, and you have a discussion that it’s approved down to age 6. Of course, we’re talking about dupilumab. It’s a little easier than it was 10 years ago, particularly with parents.
Elizabeth Swanson, MD: Every other commercial is for a shot that does something.
Jonathan I. Silverberg, MD, PhD, MPH: It’s true. That’s an excellent point. Some parents, though, assume all the injectables are the same. They’ll hear about some biologic for psoriasis or rheumatoid arthritis, but then there’s the scary fine print in the commercials. I tell them, even though it’s injectable, it’s a different therapy, a different mechanism, a different disease—different everything. Then we go through the safety profile and provide reassurance.
Brad Glick, DO, MPH, FAOCD: Sometimes, maybe not in this case, you’re running out of straws and there’s not much left. Ten years ago, we didn’t have anything, and now we do.
Andrew Blauvelt, MD, MBA: Lisa, I liked your comment about the slow death. When we start recording the itch in the trials, and we give them instructions on how to do it, they’re scoring 7, 8, and 9. That’s a lot. But they think that’s normal, so they’ve adapted to having a 7 of 10 itch every day or on average over a week. I have to tell them that it’s not normal.
Elizabeth Swanson, MD: They don’t have to live that way.
Andrew Blauvelt, MD, MBA: What’s normal is a 0 every day. They might not complain as much, but you can clearly see the impact because of the adaptation that goes on, for not only patients but also families. They just adapt to the disease, and don’t realize what harm it’s causing.
Jonathan I. Silverberg, MD, PhD, MPH: I often say jokingly but quite seriously: patients with atopic dermatitis are tougher than Marines because they’re so used to taking it, but they don’t have to be. We can get them better, and they don’t have to suffer in silence. It’s important. Give them permission to get better.
Brad Glick, DO, MPH, FAOCD: I want to comment about the Numeric Rating Scale for itch. It sounds like a clinical trial thing, but from a practical standpoint…there couldn’t be a better example of the Numeric Rating Scale for itch. We can do it easily right in our electronic medical record. It takes a matter of seconds to ask someone, what’s your itch like? Zero is no itch, and 10 is the most unimaginable itch. You get those numbers. It translates nicely from clinical trials to our clinical practices. It’s really important and it gets our parents, like in this case, to understand the significance, particularly those who may be hiding it, have been hiding it, or have gotten so used to it.
Transcript edited for clarity