Efficacy and Treatment Satisfaction of Different Systemic Therapies in Children and Adolescents with Moderate-to-Severe Atopic Dermatitis: A Real-World Study

Early itch relief with upadacitinib predicts later skin clearance in Atopic dermatitis

BACKGROUND

Though Janus kinase inhibitors such as upadacitinib rapidly relieve itch in atopic dermatitis (AD) patients, how early itch relief impacts later skin clearance is not examined.

OBJECTIVES

This study aims to determine if early itch relief by upadacitinib could predict complete skin clearance in later phases.

METHODS

This retrospective study involved 105 patients with moderate-to-severe AD treated with upadacitinib 15 mg/day. Eczema area and severity index (EASI), atopic dermatitis control tool, and achievement rate of EASI 100 were evaluated at weeks 4, 12, and 24. The threshold of early peak pruritus-numerical rating scale (PP-NRS) predicting later skin clearance was assessed by area under the receiver-operating characteristic curve, and predictors for EASI 100 achievement were determined by logistic regression analysis.

RESULTS

The rate of achieving EASI 100 at week 24 was extremely higher in patients who achieved week 2 PP-NRS ≤ 1 (42.9%) than in non-achievers (1.4%). The logistic regression analysis showed that the achievement of week 2 PP-NRS ≤ 1 and low body mass index were associated with achievement of EASI 100 at weeks 12 and 24.

CONCLUSIONS

The achievement of week 2 PP-NRS ≤ 1 may predict later skin clearance in upadacitinib treatment.

Efficacy, Safety, and Early Relapse After Cessation of Upadacitinib Versus Dupilumab in Adolescents with Moderate-to-Severe Atopic Dermatitis®: A Real-World Study in China

Background: The efficacy and safety of upadacitinib and dupilumab for atopic Dermatitis® (AD) in adolescent patients have been proven in clinical trials. However, few daily practice studies comparing agents have been conducted in this patient population. Objectives: This single-center retrospective cohort study aimed to investigate the efficacy, safety, and early relapse after cessation of upadacitinib and dupilumab for moderate-to-severe AD in Chinese adolescents. Methods: A retrospective study collected data on a cohort of 83 adolescent patients receiving upadacitinib or dupilumab from October 2021 to October 2023. This study comprised two main emphases. The first main emphasis involved the treatment phase, where the efficacy and safety of the two treatments were evaluated. Primary endpoints included the proportion of patients achieving an improvement of ≥50%, ≥75%, and ≥90% in Eczema Area and Severity Index (EASI) from baseline (EASI-50, EASI-75, EASI-90) and the proportion of patients achieving Validated Investigator Global Assessment (vIGA) 0/1 at week 4 and week 40. In the second main emphasis, AD recurrence after treatment discontinuation was assessed in the two treatment groups. The median time to relapse was calculated. Results: A total of 83 patients were enrolled. At week 4, the proportion of patients achieving the primary endpoints, including EASI-75 and EASI-90, was substantially higher with upadacitinib than with dupilumab (51.5% vs 14.0% [P < 0.001], 18.2% vs 2.0% [P < 0.05]). However, at week 40, higher proportion of patients on dupilumab were reaching EASI-50 and EASI-75 and vIGA 0/1. After the discontinuation of dupilumab or upadacitinib therapy, the Kaplan-Meier survival curve showed that the median time to relapse was 270 days in the dupilumab group and 18 days in the upadacitinib group. Conclusions: This study demonstrated that upadacitinib has superior short-term efficacy over dupilumab in adolescents with moderate-to-severe AD, whereas dupilumab trends toward better long-term remission over upadacitinib under the condition of treatment discontinuation in some patients.

An updated reappraisal of dupilumab in children and adolescents with moderate-severe atopic dermatitis

Atopic dermatitis (AD) is still a demanding challenge in clinical practice. Type 2 inflammation is the most common inflammatory pathway in children and adolescents with AD. Anti-inflammatory drugs, mainly corticosteroids (CS) and immunomodulant agents are the primary therapeutic approach to dampening type 2 inflammation. However, AD patients may require long-term high CS doses or drug combinations with possibly significant adverse effects to achieve and maintain disease control. In this regard, the advent of biologics constituted a breakthrough in managing this condition. Dupilumab is a monoclonal antibody directed against the IL-4 receptor α-subunit (IL-4Rα), antagonizing both IL-4 and IL-13 and is approved for pediatric severe AD. This review presents and discusses the most recent published studies on dupilumab in children and adolescents with AD. There is convincing evidence that dupilumab is safe and effective in managing AD. It can reduce skin lesions and associated itching, reduce the need for additional medications, and improve disease control and quality of life. However, a thorough diagnostic pathway is mandatory, especially considering the different AD phenotypes. The ideal eligible candidate is a child or adolescent with AD requiring systemic treatment because of severe clinical manifestations and impaired quality of life.

Real-world outcomes of children treated with dupilumab for moderate-to-severe atopic dermatitis: a single-centre retrospective observational UK study

BACKGROUND

Dupilumab is licensed for the treatment of moderate-to-severe atopic dermatitis (AD) in patients aged ≥ 6 months.

OBJECTIVES

The aim of this study was to examine real-world outcomes and safety of dupilumab in British children with moderate-to-severe AD attending a tertiary referral paediatric centre.

METHODS

Skin and quality of life scores, adverse events and discontinuation rates were assessed. Patients aged ≤ 18 years with moderate-to-severe AD were included if they had skin scores recorded at baseline and at least one follow-up visit. Efficacy and safety were assessed using descriptive statistics.

RESULTS

In this retrospective observational survey, 72 children/teenagers, with a median age of 14 years (range 7-18) were included. Oral systemic immunosuppressants had failed to control AD in 88% of children recruited. All patients commenced on dupilumab had pretreatment eczema skin scores consistent with moderate-to-severe disease, with a median Eczema Area and Severity Index (EASI) score of 25 [interquartile range (IQR) 20-31]. EASI scores decreased by a median of 94% (IQR 82-100) and remained consistently low over 10-52 months of the study, with a median EASI score at final follow-up of 2 (IQR 0-6). Of the 72 children, 8 (11%) were able to discontinue dupilumab as they were in remission. Nineteen (26%) experienced adverse events, most commonly conjunctivitis (12 patients; 17%). Eight (11%) discontinued dupilumab (six with ongoing inflammatory skin flares, one with severe allergic conjunctivitis, one with intercurrent Wilson disease).

CONCLUSIONS

Dupilumab was highly effective in treating most children with moderate-to-severe AD with good safety outcomes in the real world. However, 10% of children may need alternative therapy because of drug ineffectiveness or side-effects.

The Disruptive Force of Real-World Evidence

Evidence-based medicine was in the past primarily based on the (meta-)analysis of randomized clinical trials (RCTs) [...].