Peter Lio, MD, discusses patient factors to consider before deciding on a treatment strategy for atopic dermatitis.
Peter Lio, MD: Let’s move on to the available standard of care for atopic dermatitis. This is an important question because we know that there are a lot of different factors that go into picking a treatment. It’s not just how good it is, right? We can look at clinical trials all day long, and we can say, OK, these look to be the best, this is the most effective, but it is far more complex than that in real life. When we think about medications and selecting a therapy, we have to run them through sort of a matrix. I like to think about 5 different aspects whenever I’m thinking about a medicine for a patient. I like to talk about it with the patient directly because I believe in this concept of shared decision-making, that we’re going to go into this together, we’re going to talk about the risks and benefits and try to find the optimal treatment approach for that given patient at that time. Of course, we’re open to the fact that things can change. Sometimes we make a decision, and we try it, and it doesn’t work out for many reasons.
The 5 things that I’m thinking about in general, first of all, the efficacy onset, how fast does it work? If somebody is really miserable and in the office and they’re all open, oozing, not sleeping, and exhausted, it is a very tough sell to tell someone, “You might have to wait a few months for this to kick in,” for example, with phototherapy. That’s not a very good explanation or a choice for that patient at that given moment. The next one is efficacy maximum effect, how well are we going to get them under control likely with this kind of a medicine? Again, some things are better than others. Topical medicines often plateau out for those more mild to moderate patients, and those who are more severe might need something at the next level. We want to bring that into our calculation.
The next one is the accessibility, and this is huge. This is much more complex than just the cost of the medication. How much it costs on paper, that doesn’t have that much meaning to clinicians, patients, or to pharmacists really. We think about it, but if an insurance company covers something fully, it could be [extremely expensive] and it’s fine, and if it doesn’t cover it at all, sometimes $29 is too much for the patient. They say, “I can’t afford it.” So much of it is that access. Can they get it? Is it affordable to that patient given all the different aspects?
The last 2 are safety and tolerability. Many times, we’ve lumped these together, but it’s quite important to separate them, both from an informed consent perspective and also when we think about the use of medicines in real life. The safety includes those key issues that can have an impact on their health. We have to make sure we go over those, and there are many complex profiles for different medicines that we talk about, from skin thinning and atrophy, to the risk of infection, to causing folliculitis, all of those different pieces. Tolerability is also important from a patient perspective. Is it going to cause nausea? Are they going to get photosensitivity? Are there going to be issues with even the cosmetic acceptability of a preparation, especially things we’re putting on the skin? I have many patients say, “I hated it, it felt so greasy, I didn’t want to use it.” Other patients say, “I put this on, it stung and burned, I couldn’t use it, doctor.”
We only have usually about 15 minutes if we’re lucky to go through that entire matrix with the patient and think about that. Those all contribute to the ability of giving the right patients the right medicines. Secondarily, when we’re going to recommend change in therapy, this is often really tough. People say, well, they failed it. That’s a big chapter. What do you mean they failed it? It didn’t work, it caused a bad adverse effect, they couldn’t even get it in the first place, they got it but didn’t even use it. All of those things go into play, and we want to make sure we flesh that out during the visit. As a health care team, we have to communicate with each other. I’m going to communicate to the pharmacist, “Hey, this didn’t work because of X, Y, and Z.” Hopefully we can both communicate to the insurance company that the reason we’re going to this level is become these things didn’t work, especially in the situations where we have step therapy requirements, which can be kind of exhausting. We’re saying, “Gosh, this is an inappropriate step for this patient because of these reasons.” Sometimes we have to work together on that.
This transcript has been edited for clarity.