Opzelura seems to be working well in my mild to moderate AD patients who stop responding to topical steroids - works relatively fast and reduces pruritus well

I agree with the idea that topical JAKs are an excellent addition to the therapeutic armamentarium for treating AD. I am using Opzelura with a great deal of success in my practice, especially adjunctive to steroids and/or as a steroid sparing agents.

It is true that insurance coverage/access is a key issue for topical JAKs. In my experience, this is not only for this class of medicine but for all branded topical products. In my area of the country , we are able to use specialty pharmacies to help patients with commercial insurance get access to these meds the majority of the time. If it were not for specialty pharmacies, I think access to topical JAks would be far more limited.

Thanks, All, for your wonderful contributions! Do you have any tips on how to successfully navigate prior authorization for drugs such as JAK inhibitors? When a necessary drug is denied, what is the recourse?

The most salient complaints are itching That is what needs to be addressed

The insurance companies are getting very aggressive at denials. i had my first denial for hydroxyzine today.

One major issue will be insurance coverage of these Meds

Atopic Dermatitis can be a significant concern for parents/child and later the individual if they do not out grow it. The exacerbations also vary in degree in different individuals.
This in turn both affects the mental and physical health of the individual. Treatment will need to be based on severity of condition, patient's compliance with agreed upon regimen, and financial ability of individual to pay for newer and more effective medications in the event insurance does not cover treatment. Generally, the typical treatment will begin with topicals and then progress onwards. Steroids can be effective but side effects can cause more issues if used inappropriately. Ie skin bleaching with prolonged inappropriate use. Additionally, certain strengths of topical steroids can not be used on sensitive areas of the body, ie face, limiting effectiveness. New generation of topical meds like PDE4 inhibitors (Eucrisa) and JAK inhibitors (Opzelura) have shown great promise and results but insurance coverage can be difficult at times. Patient also do not want to pay the copays required at times.

Patient also need to follow recommended daily lifestyle/hygiene recommendations to help reduce flares (ie - avoiding prolonged hot showers, using emollients, avoid scratching at lesions etc).

When treating mild to moderate AD, what is your stepwise approach? Which agents are first-, second-, and third-line?

Quality of life assesments are critical when treating patients with AD. We often will get a baseline on all patients and then compare pre and post treamtent. We focus on dermatologic as well as non dermatologic questions. Specifically impact on the family, work and insomnia.
The Topical JAK inhibitors may be a game changer in terms of reducing pruritis as well as overall improvement in AD. I do agree coverage for this will be very challenging.

I agree it is very hard to get Eucrisa approved at times

Flares vary in significance with the individual.
Facial flares are very concerning.
Eucrisa produces burning in many patients and particularly on the face.
Topical steroids also have problems long term and need to be avoided particularly on the face.
I have used Opzelura which has been very successful in facial flare control in patients as described.
Recently cost / insurance issues addressed.
Apex pharmacy solves many issues and is recommended.

I believe that there is a place for new medications in this arena however as always, insurance coverage may be an issue. At this time people have to weigh priorities money for co-pays or money for other basic needs. We as providers have to continue to reach for other types of medications such as generics and alternative moisturizers.

I am a Family Doctor that does alot of care of the skin. One major issue will be insurance coverage of these game changing drugs. will the patients be able to afford the co-pays? Its hard to suggest meds that we know that will work/help but are financially out of reach.

I really look at the stress that comes from the AD and how this can create cycle of making it worse. Most pts insurance coverage does not pay for the newer treatments

I discuss with patients any disruption in sleep, activities. I ask about overall mood, if they have depression or anxiety regarding their condition. Have they stopped activities they enjoyed doing in the past. Interfered in their relationships or social interactions. Have they had any complications like infections or needed to go to Emergency Room for treatments. JAK inhibitors can greatly assist in reducing symptoms and exacerbations. It is well tolerated and can reduce utilization of topical steroids and has a relatively fast onset of actions.

JAK inhibitors in both topical and oral formulations may bring the hope of clearer skin and reduction in itch for people living with AD. I will definitely use this agent over topical steroids.

JAK inhibitors target the JAK-STAT pathway, working at an intracellular level to regulate the downstream signaling of AD-related cytokines that contribute to itch and inflammation. By binding to the JAK enzyme and inhibiting both JAK and STAT activation, JAK inhibitors interrupt inflammatory mediators. Therefore I will encourage the use of this drug as opposed to the long term effects of steroid Rx.

Atopic dermatitis is not just skin deep. It has profound psychological impacts from the patient being embarrassed by their appearance. The physical characteristics also cause impairments from occupation to ability to sleep. Traditional treatment with topical CoS, Calcineurin , and the like don’t always provide relief. Sometimes large molecule “biological” therapy is necessary to get it under control. Topical JAK inhibitors are effective and relatively safe, without the inconvenience of requiring an injection.

AD has physical and psychological effects that have detrimental effects on QOL- constant itching and redness can cause social isolation ,also affect quality of sleep and itching can cause cosmetic effects with scratches and possibly secondary infection..Compliance with treatment needs to be stressed along with hydration,,avoiding harsh chemicals like detergent by wearing gloves.
JAK inhibitors work very well for moderate to severe cases and are a great addition to available treatments.

QoL questions I typically ask are about sleep disruption, ability to work, school absence or poor performance, work absence or poor performance, mental health concerns, etc
A topical JAK can rapidly treat flares and return patient to a state of good mental and physical health

The biggest symptoms that I feel affects QOL is pruritus, esp during a flare. I focus on he level of pruritis and its impact on work/school/sleep. I also ask about sleep in general and any sleep disturbance. Finally mood or mood changes that may be more pronounced during a flare. In children, a specific focus on affects of social integrations ( are that able to function in school/sport /leisure activities) , are they terased or feel intimidated. JAK inhibitors offer a very quick onset of action for itch relief and an option for therapy if son has not helped

Discussion of Qol involves skin care. Hydration , avoidance of irritants such as unscented soaps, lotions, detergents, etc which can improve quality of life and also reduce any post secondary infections.
Topical JAKs help with reducing of proinflammatory mediators; thereby improving physical qnd psychosocial factors.

Sleep disturbance is on the top of the list. Additionally the severity of itch, duration and intensity of symptoms with or without treatment, inability to do satisfactory participate in activities of daily living which may involve work, school or social activities. Psychological components regarding self esteem and social withdrawal. An effective topical JAK inhibitor would be a remarkable tool to have for the mild to moderate AD individuals to help control signs/symptoms and intercept or prevent flares.

In addition to the physical itching, edema and pain associated with AD, the cosmetic disturbances also negatively impact on QoL. The insomnia associated with itching throughout the day and night can have psychosocial effects. The topical JAK inhibitors have had dramatic impacts, comparable to topical steroids, without causing the long-term effects of steroids.

Been very pleased by Opzelura as a topical JAK and think this can help improve the journey

A topical JAK inhibitor could definitely help these patients avoid the potential sudd effects of long term topical steroid use

QoL is always big part of visit. We do discuss all types of daily activities at home , school and socially with specific accent on night sleep , psychological aspects , school performance , family dynamics . I think that bringing new medication that has superior safety profile might make a difference , considering chronic course of AD and needs in long term therapy and maintenance. In order to use it widely it has to be proven safe and effective in a real life and reasonably easy to prescribe

Also adding that even at this point, I am having a hard time getting Eucrisa approved for my commercial insurance patients so I can’t even imagine how easy it would be for this..

I look at these aspects of QoL- physical and psychosocial. Are the flare ups causing itching and swelling often leading to secondary infections? Is it leading to recurrent excoriation resulting in scar formation? And then the psychosocial aspect- is a child up all night scratching to the point of reduced sleep which then affects his academic performance? His relationship with his peers?
A topical JAK inhibitor is likely to be a great adjuvant medication during active flare ups with a potential for more long term maintenance usage to prevent flare ups in my opinion. The biggest hindrance is really insurance coverage for it.