Reviewing Complex Cases: Disruptive AD

Lakshi Aldredge, MSN, ANP-BC, DCNP, FAANP, and Horizons attendees

In the first round of breakout sessions at the Horizons in Advanced Practice meeting in Las Vegas, Nevada, Omar Noor, MD, FAAD; Douglas DiRuggiero, DMSc, MHS, PA-C; and Lakshi Aldredge, MSN, ANP-BC, DCNP, FAANP, focused on common challenges and innovations in treating plaque psoriasis and atopic dermatitis (AD). To foster collaboration and discussion around the cases, the meeting attendees were divided into 3 groups, with each Horizons chair moderating a session.

For the first case, Noor presented a man aged 70 years with a 20-year history of psoriasis. For the second case, DiRuggiero presented a man aged 47 years with a history of moderate psoriasis for 3 years and a recent diagnosis of psoriatic arthritis.

Case 3: Disruptive AD

Aldredge presented a case of a woman aged 35 years with widespread eczematous lesions covering over 50% BSA. She had severe lichenification and excoriations on flexural surfaces and hands, as well as intense pruritus causing sleep disturbance, discomfort at work, and social limitations. She had a previous history of moderate to severe AD since childhood and a history of Staphylococcus aureus skin infections. AD was negatively impacting her quality of life and mental health, as she was wearing long/heavy clothing in the summer to hide her arms and legs.

The patient’s previous treatments included various emollients and barrier repair creams; topical corticosteroids (clobetasol 0.05%); cyclosporine (discontinued due to adverse effects); oral antihistamines; topical calcineurin inhibitors (tacrolimus 0.1%); phototherapy (narrowband UV-B); and short courses of systemic corticosteroids for flares

The patient stated that her treatment goals were to find a therapeutic that can provide rapid relief and serve as a long-term solution, as she was tired of the creams and lotions that have had minimal impact. Additionally, she wanted to decrease the frequency of treatment and possibly taper over time.

Aldredge reviewed the treatment landscape in AD regarding systemic therapies with attendees. For patients with moderate to severe refractory AD or those who are intolerant to or unable to use midpotency topical treatments, dupilumab (Dupixent; Sanofi and Regeneron), tralokinumab (Adbry; LEO Pharma), and lebrikizumab (Ebglyss; Lilly) are gold standards. Dupilumab is approved by the FDA for use by patients as young as 6 months. Tralokinumab and lebrikizumab are approved by the FDA for patients 12 years and older.

Additionally, Aldredge noted that oral JAK inhibitors may benefit patients unable to use mid- to high-potency topical and systemic treatments. Attendees then discussed and compared some key differences between dupilumab, tralokinumab, and lebrikizumab in their pivotal trials (Table).

Table. Summary of Efficacy and Safety Data of IL-4/IL-13 Inhibitors^1-3

EASI, Eczema Area and Severity Index; IGA, Investigator’s Global Assessment.

To determine the best therapeutic option for this patient, Aldredge discussed a review from Blauvelt et al of the phase 3 ADvocate 1 (NCT04146363) and ADvocate 2 (NCT04178967) trials, which evaluated the efficacy and safety of lebrikizumab in patients with moderate to severe AD. Overall, patients who received lebrikizumab every 2 weeks or every 4 weeks maintained similar improvements during the maintenance period.

After 52 weeks, 71.2% of patients who received lebrikizumab every 2 weeks maintained an Investigator’s Global Assessment (IGA) of 0 or 1 with an improvement of 2 points or more, as well as 76.9% of patients who received lebrikizumab every 4 weeks, and 47.9% of patients in the lebrikizumab withdrawal arm. A 75% reduction from baseline in the Eczema Area and Severity Index (EASI 75) was maintained by 78.4% of patients who received lebrikizumab every 2 weeks, 81.7% of patients who received lebrikizumab every 4 weeks, and 66.4% of patients in the lebrikizumab withdrawal arm at week 52.⁴

The phase 3 ADjoin long-term extension study (NCT04392154) evaluated the efficacy and safety of lebrikizumab at 52 weeks in ADvocate 1/2 and up to 100 weeks in ADjoin. IGA 0/1, EASI 75, and EASI 90 were maintained through 3 years of continuous lebrikizumab responders in both dosing every 2 weeks and dosing every 4 weeks regimens. Most patients did not require rescue therapy.⁵

Treatment Decision

Aldredge shared with attendees that regarding the current patient case, after considering the patient’s treatment history and the severity of her condition, the clinician decided to initiate lebrikizumab with a starting dose of 500mg subcutaneously (2 × 250-mg injections) at week 0 and week 2, followed by 250mg every 2 weeks until week 16. The maintenance dose was set at 250mg every 4 weeks. The patient continued to use daily emollients and oral antihistamines as needed for pruritus.

References

1. Dupixent. Prescribing information. Sanofi/Regeneron; 2024. Accessed January 10, 2025. https://www.regeneron.com/downloads/Dupixent_FPI.pdf
2. Adbry. Prescribing information. Leo Pharma; 2024. Accessed January 10, 2025. https://www.adbryhcp.com/dosage-and-administration
3. Ebglyss. Prescribing information. Eli Lilly; 2024. Accessed January 10, 2025. https://pi.lilly.com/ca/ebglyss-ca-pmi.pdf
4. Blauvelt A, Thyssen JP, Guttman-Yassky E, et al. Efficacy and safety of lebrikizumab in moderate-to-severe atopic dermatitis: 52-week results of two randomized double-blinded placebo-controlled phase III trials. Br J Dermatol. 2023;188(6):740-748. doi:10.1093/bjd/ljad022
5. Thaci D, Irvine A, Simpson E, et al. Efficacy and safety of lebrikizumab is maintained up to 3 years in patients with moderate-to-severe atopic dermatitis: ADvocate 1 and ADvocate 2 to ADjoin long-term extension trial. Poster presented at: 33rd European Academy of Dermatology and Venereology Congress; September 25-28, 2024; Amsterdam, Netherlands. Accessed January 10, 2025.