How Increased Market Competition May Impact Patients With Atopic Dermatitis

Shawn Kwatra, MD, FAAD, director, Johns Hopkins Itch Center, describes how the atopic dermatitis treatment paradigm has been changing amid increased market competition, as well as where the future of care may be headed.

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Welcome back to PopHealth 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.

In this episode, Dr Shawn Kwatra offers insight into how increased market competition is impacting patients with atopic dermatitis.

I'm Shawn Kwatra. I'm the director of the Johns Hopkins Itch Center in Baltimore, Maryland and an associate professor of dermatology.

Given all the new drugs and ongoing innovation, how has the treatment paradigm in atopic dermatitis been changing?

The treatment paradigm is changing considerably. My personal philosophy is to try very hard to get patients clear. Patients also like to be on the least amount or maintenance dose of a medication.

Many patients are opting for a variety of different therapies. Some are going for biologics, some are going for small molecule inhibitors. All of these are very reasonable options for patients. But what we are trying to do now is get patients as quickly as possible in maintenance, and then once they're in maintenance and they're doing well for quite some time, that is where we want to be.

Atopic dermatitis is likely going to follow psoriasis, meaning less and less frequent medication. Some of the biologics are administered every three months in psoriasis. We are already seeing that in atopic dermatitis, for two to four weeks. Even the oral pills sometimes are seasonal, because atopic dermatitis is more seasonal than psoriasis.

All forms of atopic dermatitis are not the same. There are many different endotypes and a ton of heterogeneity, so we're able to tailor treatments better. I've been treating patients with a combination of things. Some folks get a biologic and a topical JAK inhibitor or other compound. Other folks are opting for a small molecule inhibitor, but they're also having a systemic agent. It’s not one or the other.

I think we're truly benefiting from these additions to our therapeutic armamentarium.

Do you anticipate any major shifts in access or reduced burden because of the increased competition in the market?

If you look at psoriasis, what we found is the greater the amount of competition, the better it is for patients.

Folks who have commercial insurance haven't had too many problems getting their drugs approved. Where we've truly struggled is with Medicare and Medicaid populations. I think that having greater competition is going to allow for better coverage. Competition is absolutely going to be good for patient access.

For the oral JAK inhibitors, there's a line in the package insert that folks may have had to try a systemic agent. That doesn't necessarily have to be a monoclonal antibody; that can be prednisone. That also opens opportunities for patients to be treated the way they'd like.

What I've grown to appreciate is I can't assume how a patient wants to be treated. That's why I think it's very important when we have so many new agents that are developing, that we do a really great job with educating dermatologists about the subtle differences between therapies. Among my colleagues in dermatology, we often see patients every 10 to 15 minutes. Sometimes there's not enough time to have such a detailed conversation, but we really do owe it to our patients to learn about and go through all these different options that patients have.

Where do you see the future of care headed as more options become available?

The future of care is very bright. I think there are few hot areas that are going to emerge. One of them is intermittent therapy. I see that that becoming more common, especially for atopic dermatitis. Remember, atopic dermatitis has less disease flares than psoriasis. It's less so chronicity of disease. It’s more, here and now you get disease flares and then for a long period of time you can be totally clear. In some cases that's going to lead to more intermittent therapy. I'm already seeing that in patients.

Also, what's very exciting is agents that can deplete memory of inflammation. There are memory T-cells that are important both in the blood and the skin that mediate inflammation. Now we're seeing the emergence of compounds that can modulate some of that memory. OX40 has been very hot. Those drugs are coming through, and there's some whispers about could there potentially be a longer-term remission with some of those agents.

I see us trying to understand just how long patients can be clear once they’re off a drug. Patients are clamoring for intermittent options. I think that all of those are going to be very important considerations moving forward.

Finally, if you have so many different options—JAK inhibitors, IL-13 inhibitors, IL-31 inhibitors, IL-13 receptor alpha one inhibitors, IL-4 receptor alpha inhibitors—there's an element of precision medicine that I think has potential to develop moving forward. Science is picking up, our understanding that there's both systemic and cutaneous inflammation. I truly believe that at some point we're going to be able to see how much of certain cytokines patients have and make judgments about who might be the best candidate for particular therapy.

That is the big divide that we're moving towards, is being able to precision medicine phenotype patients and say, "Hey, you have atopic dermatitis. Atopic dermatitis is very heterogeneous disease, but I think your disease may respond better to this therapy." To me, that is truly the future.

These patients say it themselves. I go through the options and they say, "Okay, doc, well, I have a bunch of options. How do I know which one's the right one for me?" Sometimes we don't know, too, so I think that’s the big gap we want to fill.

Thank you, Dr Kwatra. That's it for my big questions. Is there anything else you want to add?

No, thank you so much for having me.

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This transcript has been edited for clarity.