Addressing Unmet Needs in Patients With Type 2 Inflammatory Conditions

Peter Lio, MD, FAAD, clinical assistant professor of dermatology & pediatrics, Northwestern University Feinberg School of Medicine, and founding director, Chicago Integrative Eczema Center, discusses the common challenges associated with treating type 2 inflammation, what factors play a role in determining the correct therapy, and offers insight into what payers should understand when covering this patient population.

Welcome back to Pop Health Perspectives, a conversation with the Population Health Learning Network where we combine expert commentary and exclusive insight into key issues in population health management and more. Today, we are joined by Dr Peter Lio who discusses the common challenges associated with treating type 2 inflammation. What factors played a role in determining the correct therapy and offers insight into what payers should understand when covering this patient population? Dr Lio?

My name is Dr Peter Lio. I'm a clinical assistant professor of dermatology and pediatrics at Northwestern University, Feinberg School of Medicine in Chicago, Illinois. I'm also the founding director of the Chicago Integrative Eczema Center.

Great. Thank you, Dr Lio. Moving on to our first question, can you describe some of the common challenges associated with treating type 2 inflammation?

Yes, so increasingly in the modern world, we're seeing more and more patients that are suffering from type 2 inflammatory conditions, and this really—broadly speaking, includes the allergic type of inflammatory conditions. One of the biggest ones and the one that I've devoted most of my career towards is atopic dermatitis. Atopic dermatitis is a chronic, very itchy, very uncomfortable type 2 inflammatory skin disorder, but we know that it actually is more than skin deep. The entire immune system is involved. There really is a systemic component to this disease. That is why, we think, particularly, for those with more widespread disease, sometimes, just treating the skin is not going to cut it.

They have itch, they have pain, some of the patients actually, in the last few years, we've really started to ask about pain or discomfort like that, many patients have it. They have sleep problems. Many patients actually have trouble falling asleep or they get up multiple times during the night, and of course, all this leads to a whole host of other comorbidities related to the underlying type 2 inflammation.

Recent data show that certain biologics have proven beneficial at reducing type 2 inflammation. In turn have multiple FDA-approved indications like asthma, atopic dermatitis, like you said, what factors play a role in choosing the best treatment option for a patient, and does having multiple indications provide any benefits?

Yes, a lot of times in medicine, we have to make a difficult trade-off. More powerful medicines often bring with them more significant side effects, and so I often say, "The sword cuts both ways," but with the biologic agents, we've found a way around this, at least to some degree, mother nature can solve this problem better than we can in a lab by synthesizing a small molecule, at least so far, and by being very, very specifically targeted, we can get the best of both worlds with many biologics.

Now, the trade-off is that a biologic agent directed against type 2 inflammation really is only going to work against type 2 information, so that can be a good thing and that is maybe not going to suppress the rest to the immune system, it's not going to make you more susceptible to viral infections or bacterial infections. On the other hand, it does mean that it's a narrower potential indication range for a drug. However, we already seen with one of the ones that's already out, dupilumab, it seems to work in a number of different conditions. It has an indication for atopic dermatitis. Now, down to 6 years of age. It also has an indication for asthma and for chronic rhinosinusitis with nasal polyps.

So really neat to see one drug being able to be used across a couple of different important diseases, and we understand that the common thread is that they are type 2 inflammatory processes. Now, this wouldn't necessarily work like, for example, prednisone or steroids across many other conditions. That, I think, we understand now, it's because there really are different sub-components of the immune system.

What should payers understand about therapies like dupilumab to improve care for their members?

I think the most important thing is to realize that there is a huge amount of suffering in atopic dermatitis. Sometimes, it's really in the face of people dismissing it as just a skin thing. "Oh, it's just like a little rash, put some steroid cream on it." It's a, "Wait a minute." Yes, for some patients, they're lucky and it's pretty mild and that's all one might need, but as it gets more serious, it has a gigantic impact on the quality of life, not just on the patient but the whole family. It really stresses everybody out.

I come into a room, sometimes, and everybody looks exhausted. They have bags under their eyes. People are crying. It's a nightmare, and they really have been through a terrible, terrible time. I think it's not for everybody. I do fully understand that we have to try the basics first and we must. Our job is to start with that therapeutic ladder, make sure we're doing good education, all the good proper skincare, but for a lot of patients, that truly is not going to be enough.

The biologic agents can come to the rescue and help not only with the itch, the inflammation, the skin barrier damage, but also, hopefully, with some of these other type 2 allergic comorbidities. We're really still just learning about that. One of the things we think is possible is that if we get this under control really well from the very beginning, we think it may be possible to modify the disease outcome. It's not that crazy because we know it's a disease of vicious cycles.

The more the inflammation rages, the more scratching happens of the skin and the barriers damage. You don't have to be a rocket scientist to say, "Yes, that's clearly going to make things worse." It follows then if we stop it early, get really good healing, get sleep restored, take out the itch and the pain, that it's going to go the opposite direction and maybe some of these other comorbidities, both atopic ones, but also, maybe even the non-allergic type of comorbidities will be decreased. That would be hugely important for the patient but also, ultimately, for the payers. Good care really should pay good dividends.

Great. Thank you, Dr Lio. That's the majority of my questions, but is there anything that I haven't asked you about or anything that you'd like to add?

Maybe one thing we could just jump into is: are there any unmet needs? Why do we have any needs now? Doesn't this solve everything? Well, as good as the medicine as dupilumab is, and it is a pretty good one. All things considered, it has a pretty favorable risk-benefit ratio. The accessibility of the medicine has actually been pretty darn good. I hear from some colleagues, they have some trouble, but in general, I feel like I'm able to get it for the patients who need it especially if I'm willing to push, I definitely am.

It doesn't help everybody. It's not for everybody. It has some side effects. It has some potential patients where it's not enough. We still need more options. The fact that it's an injection, also, can be a real point of departure for some patients. They're going to say, "I don't want a shot." I think we're looking for more opportunities in oral medicines. We're also thinking about other topical agents that could be transformative. I think this is the beginning of an incredible time for atopic dermatitis, but is by no means the end. This is truly just the first step.

Thank you, Dr Lio for taking the time out of your day to speak to me and our listeners, our readers. I really appreciate it.

It's my pleasure. Thank you so much for having me.

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