Pharmacy Times interviewed Stephanie Pilat, PharmD, clinical pharmacy specialist, dermatology, University of Rochester Specialty Pharmacy, and Monica Dougherty, PharmD, BCACP, clinical pharmacy specialist, dermatology and asthma, University of Rochester, on plaque psoriasis and atopic dermatitis. In this discussion, Pilat—who specializes in plaque psoriasis—and Dougherty—who specializes in atopic dermatitis—highlight available treatment options for patients with plaque psoriasis and atopic dermatitis, as well as how treatments may vary across age groups. Pilat and Dougherty also share potential updates and what is coming in the near future.
Key Takeaways:
- Treatment Landscape Overview: Topical therapies are the starting point for mild to moderate cases of atopic dermatitis and plaque psoriasis, with systemic options such as biologics and oral medications being utilized for moderate to severe cases. Differences exist in the specific medications utilized due to factors such as comorbidities, patient and payer preference, and insurance coverage.
- Biologic Advances: The advent of biologic therapies, including TNF inhibitors, IL-12/IL-23 inhibitors, IL-17A inhibitors, and IL-23 inhibitors, has revolutionized the management of plaque psoriasis, with recent approvals like bimekizumab offering hope for patients who have failed other treatments, while for atopic dermatitis, the introduction of dupilumab and JAK inhibitors including abrocitinib and upadacitinib have significantly expanded therapeutic options.
- Considerations For Pediatric Patients and Future Options: Treatment approaches for atopic dermatitis in pediatric patients largely mirror those for adults, with dupilumab emerging as a pivotal therapy because of its approval for patients as young as 6 months. Ongoing clinical trials and the development of new therapies such as nemolizumab and lebrikizumab hold promise for further enhancing the treatment landscape, with hopes for expanded use of combined topical JAK inhibitors and biologics pending additional safety and efficacy data.
Pharmacy Times: What treatments are available for atopic dermatitis and plaque psoriasis, and can the same treatments be used for both conditions?
Stephanie Pilat: Yeah, so I can start off in terms of psoriasis. Generally, for mild to moderate disease for either condition—psoriasis, or atopic dermatitis—we're seeing like a lot of topicals being used, which is mainly where the crossover between the 2 occurs. But where we kind of get into the differences are with the systemic treatments, so I can kind of walk through each of those, but treatment decisions overall are driven mostly by severity of the condition, comorbidities—especially in psoriasis—and payer and patient preference as well.
So again, for mild to moderate disease with psoriasis that typically presents as like more localized plaques, and it can be treated with a lot of the topical corticosteroids and topical calcineurin inhibitors for those more sensitive areas. It's often combined with phototherapy if it's feasible for the patient, so oftentimes, this presents financial barriers, location barriers too if the patient is far away from the office, and [it] can take a lot of time out of their day, to come multiple times a week to the office to have their phototherapy session, and then feasibility in terms of home phototherapy units is also a whole other discussion as well.
Topicals can also be used in combination with our systemic medications as well, so even after we're starting systemic medications, we're encouraging patients to use those topical creams and ointments for breakthrough symptoms during an acute flare. I had mentioned a lot of the exacerbating factors, so if they are noticing flaring in between their doses of the systemic medication—if that's like an injectable biologic—they can kind of use topicals to bridge those symptoms. Then also, when bridging two systemic treatments. I often say as the medication starts to take effect, you might notice that you don't need as much or as frequent use of these topicals, but [it’s important to] continue to use those as needed and keep them on hand if [patients] do experience a flare.
As far as moderate to severe disease, that's really when we're getting into the systemic treatments. It's commonly treated with systemic medications, including methotrexate and cyclosporine, which have really fallen out of favor due to some of the [adverse effects (AEs)] that we can run into with them, and then some other considerations. For example, methotrexate is contraindicated in patients with alcoholism or other liver diseases, and [with] cyclosporine, we have to be cautious in patients with uncontrolled hypertension, and overall, it just has a lot of drug interactions. Just being mindful of the other medications that patients are taking, can come into play when thinking about those options.
My area of expertise—as well as Monica [Dougherty]—does fall in line with the biologic options. There's a few different classes of biologics that we use in psoriasis. The first would be the TNF inhibitors, which include adalimumab (Humira; AbbVie), etanercept (Enbrel; Immunex Corp.), infliximab (Remicade; Janssen Biotech, Inc.), certolizumab pegol (Cimzia; Union Chimique Belge), but we have to be mindful of the comorbidities that patients have within this class of medication. So, if patients have a history of malignancy, this is a class that we would absolutely avoid, and then [it’s important we are] being cautious and patients with either [multiple sclerosis] or heart failure within this class as well. [Adalimumab] I see very commonly, infliximab as an infusion—so not typically falling under my area in the specialty pharmacy—and then [certolizumab] is commonly used for patients that are planning to become pregnant or that are pregnant because we have more data in terms of the placenta and how it crosses that barrier.
The next class of medications would be the interleukin (IL)-12 and IL-23 inhibitors, so this includes ustekinumab (Stelara; Janssen Biotech, Inc.), and this can be used as a medication in certain [gastrointestinal] conditions as well, so again, [we should be] thinking about some comorbidities that patients might have.
The next one would be the IL-17a inhibitors so this includes secukinumab (Cosentyx; Novartis), and ixekizumab (Taltz; Eli Lilly and Company). These are not recommended in patients with a history of [inflammatory bowel disease], so you can kind of see again, how a lot of the comorbidities are really going to separate which options we might consider in certain patients.
Bimekizumab-bkzx (Bimzelx; Union Chimique Belge) is a recently approved medication that came out at the end of 2023…and we're starting to see more and market entry recently, so this is an IL-17A and IL-17F inhibitor [that] has shown very promising results in clinical trials, especially for patients that have tried and failed to some other biologics in the past. So, it's definitely 1 that we're excited about.
And then the last class of the biologics is the IL-23 inhibitors, so, Tremfya (Janssen Biotech, Inc.) and risankizumab-rzaa (Skyrizi; AbbVie) fall into this category. Generally, the decision on which biologic medication to select is really driven by those comorbidities, and then also insurance preferences, so, insurances will frequently require patients to try and fail those topical and other systemic options before moving to a biologic, and then once they have met that criteria, there's different preferred biologics on each formulary as well. Thinking about not only insurance preference but patient preference, the biologics have different dosing schedules, most with a loading dose, meaning there's a higher dose or an increased frequency in injections at the very beginning of the schedule compared to the maintenance or long-term schedule. An example of that might be [risankizumab], we use a 150-mg injection [on] the first day, 4 weeks later, we'll use the second injection and then it gets phased out to every 12 weeks. So, roughly every 3 months or so, which is great for patients, they enjoy only having to use 4 doses a year basically.
And then [biologics] all require baseline labs as well, so we're typically tracking a [comprehensive metabolic panel], [complete blood count], hepatitis panel, tuberculosis (TB), and HIV test at baseline, and then we're routinely monitoring for TB annually. So, the risk is if a patient does have a history of hepatitis or TB, we're typically thinking about antiviral therapy before starting a biologic if they have a history of hepatitis, and for TB, if they have latent TB, we're thinking about potentially treating that before starting a biologic because the risk of reactivation exists with either of those.
And then the only other class that I would want to go over for psoriasis particularly, we actually just have a few different oral medications, 2 different classes—1 of them being apremilast (Otezla; Amgen Inc.), which is a PDE4 inhibitor, and then Tky2 which is part of the family of the JAK inhibitors. So again, this can kind of come into play with patient preference, if they're concerned about self-injections, the oral options might present another potential option for them.
Monica Dougherty: In addition to topicals, [for atopic dermatitis] we've got topical corticosteroids—which are really first-line treatment—and then topical calcineurin inhibitors. Beyond those and a few other topical medications, once patients have moderate to severe atopic dermatitis, really our treatment options open up.
Dupilumab (Dupixent; Regeneron Pharmaceuticals, Sanofi Genzyme) is probably the most commonly used medication, that's an anti-IL4 and anti-IL13 inhibitor. So, and that is an injectable medication, it's a biologic, it does not have as much monitoring as the biologics for psoriasis—actually, there's no lab monitoring, which is great—but it is an injectable medicine, so that might be a barrier for some patients.
And then we also have tralokinumab-ldrm (Adbry; LEO Pharma), which is [an] anti-IL13 but we don't tend to use that one as often. we have a few patients on that, but the evidence doesn't seem to be as robust dupilumab. Dupilumab is actually approved down to 6 months of age, so it's really an option for pediatric patients and adult patients, which is great.
Then we also have a few JAK inhibitors, so we have abrocitinib (Cibinqo; Pfizer) and a upadacitinib (Rinvoq; AbbVie), which are 2 oral JAK inhibitors. They're also extremely effective. There is some lab monitoring which can be a barrier for patients as we're kind of seeing more real-world use. Our patients don't tend to go to the lab as often as they should, so that that kind of limits the use sometimes, and they do have possibly more [AEs], and they carry those black box warnings, so they do tend to be used a little bit less but [they] create a great option for some patients that have either failed other biologic therapies or just really cannot bear the thought of injecting themselves, that might be a great option for them.
And then we also have a topical JAK inhibitor ruxolitinib (Opzelura; Incyte), and that's also very effective for moderate atopic dermatitis and can basically be used as needed for flares. It works really great because it is that JAK inhibitor mechanism of action but [instead it is] used topically, so that's another great option for patients.
Pharmacy Times: Are there differences in symptoms and does treatment vary between adult and pediatric patients?
Dougherty: As I mentioned, dupilumab is approved for [patients] 6 months and older, so really, [atopic dermatitis] treatment doesn't differ too, too much. Typically, for younger kids, we're still using topical therapies as first-line, the only difference versus adults is the strength of that topical therapy [which] might be obviously different than in adults. But once patients fail those, the clinical evidence as they qualify for something like dupilumab, so we are using that in very, very young children. We have [patients a year of age] on the medication, and we’ve got patients [aged 95 years] on the medication, so it's kind of similar there. Of course, the dosing is different for pediatrics, it's based on their age and weight. And then children sometimes just offer more unique challenges, since the medicine is injectable, so that might be a barrier for parents, they might not want to inject their child, of course, understandably. We do work with a great nursing team luckily and we have patients do the injections in the office. For patients that live far away, or for other pharmacists out there that might not have that resource, sometimes we do work with pediatrician offices as well. We'll kind of call them and see if they feel comfortable having the parent and the child come in once a month—it usually ends up being—for the injection, and we'll train the nurses over the phone just to increase that access to a very effective medication.
The JAK inhibitors, of course are not used for young patients. [Upadacitinib] is approved for 12 years [of age] and older, so those pediatric patients can qualify but otherwise typically dupilumab is the medicine that will span age ranges.
Pharmacy Times: Is there anything coming up in this field (eg, clinical trials, treatments) that you are looking forward to or want to highlight?
Dougherty: Yeah, so I think in general it's an exciting time for dermatology. [There have been] decades of no new medications or no options for patients, but now we have so many new medications that are really changing the game for patients and getting to the root cause of the disease. Based on the current pipeline—at least for atopic dermatitis—we might have over a dozen new therapies in the next coming years so that'll just really increase options for patients. We do have 2 new medications that will likely be approved in the next year or 2, nemolizumab, which is anti-IL31 and lebrikizumab, an anti-IL13. [Those will] give more options for patients, [we’re currently] not really sure if it's going to have any advantage over dupilumab, but at least we'll just have more options for [patients].
And then something that I look forward to in the future or hope for is that payers [will] allow for the combined use of topical JAK inhibitors with a biologic. So right now, we've been able to do that for some patients that have used dupilumab or a different biologic and it's been quite effective, but they just have a few areas that are just not budging at all, despite continued use of topicals. We've been utilizing samples of topical ruxolitinib with great results, but right now payers aren't allowing for that just because there's no [safety] evidence out there for it…but mechanistically it's just such a wise treatment regimen, so hopefully in the next coming years, we'll have more case reports, maybe more clinical trials that we can present to payers and that would be a really, really great game changer for those patients that are just about there but might just have a little bit more to go and don't really want to switch their main treatment.
Pilat: The things that are potentially coming up within the psoriasis space, the biggest hot topic for us right now is the biosimilars, so [there will be] more to come on those soon. There's been several that have been approved at this point, which really have the potential to change the landscape for treatment in psoriasis. We haven't seen very many payers list any preferences in their formularies as far as biosimilars go yet, but I'm sure that will probably become outdated within the next few months…but the newest medication that we have is bimekizumab, which I had previously mentioned. I'm excited to see how those patients do, especially because we're starting it and those that have tried and failed multiple other options.
