Management Optimization in Atopic Dermatitis - Episode 12
Jonathan Silverberg, MD, PhD, MPH: I think what’s tricky is even when you’re assessing itch in a lot of these things, as clinicians, we catch patients in the cross-section of time. I often have the experience where patients say, “Doctor, I look good today, but yesterday I was a mess” or “A week ago I was a disaster and had to take prednisone.” So, I think it’s hard when we pigeonhole a couple of measures where patients might fall just short, when you know if you would have gotten them a day or two earlier, they would have met criteria. I feel like if we limit to one measure only, like body surface area, there may be patients who desperately need these drugs who may not get it. And so, we could have maybe some more options that we agree upon.
Ed Pezalla, MD, MPH: I could see that there could be a combination of things as part of utilization management, as long as it doesn’t get overly complex. But we do already have utilization management and prior authorization criteria, and you probably do a lot of these for us where we’ll ask them if you have this or that or you have these other two. So, as long as we can define what each one is to some reasonable extent, then you can look at that. We might not need a hard score like a 4 or a 12-1/2 or something like that, but if we could say—for example, as you had already put it together as a small number of lesions—a large body surface area, whether it’s terrible or not terrible, it’s large. And then there are patients’ other symptoms, like pruritus. You don’t even have to ask about sleeping. If we know about itching, we probably know a lot more about that patient already.
Peter L. Salgo, MD: Let me kick this back to Jeff. I’m not going to make you speak for the entire profession, but in your view, what are the most important aspects to managing this disease? How do you overcome these challenges?
Jonathan Silverberg, MD, PhD, MPH: Well, I think we talked about a lot of this already. I think the extent of the disease, certainly we were thinking about a systemic agent, is going to be crucial. The itch is going to be super important, and I think there’s some harmony in terms of our discussion in that we’re going to already try some of the topical cheaper stuff out there first. I think in that sense, where there’s harmony, there are some of the nuances that probably need to be hashed out. I don’t like the idea of using an EASI or a SCORAD in clinical practice because I don’t think it’s something primary care doctors, and even the average dermatologists, are familiar with, let alone how to use in a reliable way. So, I think important aspects are the extent of body surface area, how itchy, how intense, and then how miserable the patient is, how much it’s affecting them.
Peter L. Salgo, MD: There’s a misery index out there somewhere?
Jonathan Silverberg, MD, PhD, MPH: Well, if the patient is going to head to the point of disability—which I have a lot of patients who are currently on disability, partial or full, because that’s how bad the disease is for them—things like that need to be taken into the equation.
Peter L. Salgo, MD: And by the way, this comes back to who’s going to pay, right? Because for the people on disability, then you’re not paying.
Jeffrey D. Dunn, PharmD, MBA: That’s what I’m talking about with these secondary measures, the functionality and things like that. They’re important, so I don’t want to discount that. But when you’re saying this improves sleep, I need to understand what that means in terms of the disease state, not just that it improves sleep. That was the point on that. From a payer perspective in response to that question, it’s exciting to have new drugs that actually treat the disease state rather than the symptoms. But the challenges here are going to be that we’ve gone from a disease state that we’re really not paying for right now—or we don’t understand how we’re paying for it because there’s generics, over-the-counter—to something that’s potentially going to be very expensive. So, the challenge is, how you pay for that and how we come to a consensus on where these drugs fit.
Cheryl Allen, BS Pharm, MBA: I was going to say I think another measure that could be taken into account with these patients is previous or current therapies that you’re using to control your atopic dermatitis. What are you using? Because that would be sleep therapies, antidepressants, things like that, along with the functionality to give a total picture of this patient. As we’re advocating on behalf of the patients to make the case for drug therapy, you have to look at that 360° view of that patient.
Peter L. Salgo, MD: If you could start to peel off some of those other therapies, is what you’re saying?
Cheryl Allen, BS Pharm, MBA: Right.
Peter L. Salgo, MD: Doesn’t that reduce the overall cost? Maybe it’s more with the new therapies, but not quite as much more.
Jeffrey D. Dunn, PharmD, MBA: I don’t disagree. I understand where you’re coming from. Let’s use asthma as an example. If the value proposition is that I can reduce one rescue med a day, a puff, and use three instead of four, great. But, again, where’s the value prop in that? If the value prop here for a, let’s just say, $25,000-a-year drug is that I’m avoiding a $4-a-month genetic antidepressant, then we need to understand where that fits. That’s not a value prop. The value prop is the disease state is changing and these things are changing and the patient is getting better. It’s not that I’m avoiding a $4-a-month generic antidepressant.
Peter L. Salgo, MD: That’s a very subtle statement, which, if I understand what you’re saying, is how the patient’s doing. Is the patient better? You’re willing to pay for something that’s going to make the patient’s life better.
Jeffrey D. Dunn, PharmD, MBA: Absolutely.
Peter L. Salgo, MD: But not for something that you can’t show makes the patient’s life better. Is that fair?
Jeffrey D. Dunn, PharmD, MBA: That’s fair.
Peter L. Salgo, MD: I like that. That’s nice. Does that make sense to you?
Cheryl Allen, BS Pharm, MBA: That makes sense.