B-QuiCK: Treatment resistant atopic dermatitis
Approach atopic dermatitis treatment in a stepwise manner; begin with emollients and topical corticosteroids (or topical calcineurin inhibitors, i.e. tacrolimus or pimecrolimus). Increase potency of topical corticosteroids as required.
Consider referral for phototherapy for patients with inadequate response to first-line treatments.
Oral systemic immunosuppressants are the usual next step. Continue emollients and topical corticosteroids alongside. Trial conventional immunosuppressants first: ciclosporin, methotrexate, mycophenolate mofetil or azathioprine.
- Consider patient-specific factors when deciding which to prescribe. In general, methotrexate may be chosen first by primary care clinicians due to familiarity (but avoid if pregnancy is possible), or ciclosporin given it is indicated for atopic dermatitis (but avoid if renal dysfunction). Click here for prescribing information for all options.
- A dermatologist is usually involved (via written/verbal advice or referral) as these medicines are associated with significant adverse effects and ongoing monitoring requirements; however, dermatologist input is not a requirement for funded prescribing of most of these treatments in primary care
- Refer to NZF or check local HealthPathways for information on laboratory testing, adverse effects and monitoring requirements for each medicine, in general:
- Perform baseline laboratory testing, e.g. FBC, LFTs, renal function, and hepatitis B/C, HIV, varicella zoster serology, tuberculosis (Quantiferon TB-Gold) screening
- Monitor for hepatotoxicity, neutropenia, anaemia and serious infections
- Trial for at least 12 weeks before assessing response; ongoing use depends on the medicine, e.g. ciclosporin should not be used long term
Patient still experiencing inadequate response? If adding one of these conventional systemic immunosuppressants to the treatment regimen does not control symptoms (or is contraindicated), consider upadacitinib, an oral JAK inhibitor.
- Take care when switching patients from a conventional systemic immunosuppressant to upadacitinib as disease flare may occur; a bridging course of oral corticosteroids may be appropriate
Prescribing upadacitinib
- Upadacitinib is approved for the treatment of moderate to severe atopic dermatitis in people aged ≥ 12 years
- It is funded with Special Authority approval for patients (of any age) with moderate to severe atopic dermatitis (defined by an EASI score ≥ 16 or DLQI ≥ 10) who have achieved insufficient benefit from at least one month of topical treatment and three months of conventional systemic immunosuppressant treatment, where appropriate. Special Authority applications can be made by any relevant practitioner. Click here for full Special Authority criteria.
Key prescribing and monitoring information for upadacitinib. N.B. Seek dermatology advice where needed.
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Moderate to severe atopic dermatitis
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15 mg, once daily, increased to 30 mg, once daily, for patients aged under 65 years if there is inadequate response. N.B. Doses > 15 mg are not recommended for patients aged ≥ 65 years, or patients with severe renal impairment.
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Before starting
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- Assess for cardiovascular risk factors, including risk/history of thromboembolism, history of malignancy, pregnancy and breast-feeding status (consider a pregnancy test if relevant) and the presence of an active infection
- Check immunisation status. Ensure patients are up to date with National Immunisation Schedule vaccinations, as well as influenza and COVID-19. Offer catch-up vaccinations prior to starting treatment, including varicella zoster (Shingrix; recommended but not funded for patients before, during or after immunosuppressant treatment, unless they meet other criteria for funding). Immunisation with live vaccines is not recommended during treatment.
- Request baseline laboratory testing, including FBC, LFTs, renal function and lipids. Screen for tuberculosis (Quantiferon TB-Gold), HIV, varicella zoster serology and hepatitis B and C. Include “pre-immunosuppression screen” on these requests. N.B. These screening tests may have previously been requested if the patient was recently started on a conventional systemic immunosuppressant, but consider repeating relevant tests if subsequent disease exposure is possible.
Click here for upadacitinib contraindications and cautions
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Ongoing monitoring
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- Initially, monitoring should occur more often, e.g. after one month, and reduce in frequency over time, e.g. every three months or as clinically indicated
- Monitor for adverse effects, in particular infection and venous thromboembolism or MACE. Temporarily stop treatment if an infection or signs of venous thromboembolism occur; evaluate/manage as indicated.
- Perform skin examinations periodically, especially for patients at increased risk of skin cancer
- Monitor laboratory parameters (e.g. FBC, LFTs, lipids) throughout treatment as clinically indicated. Usually, re-check levels one month after treatment initiation, and then every three months or as clinically indicated.
- Temporarily stop treatment if laboratory parameters become abnormal (Table 2) or if medicine-induced liver injury is suspected. Initiate or optimise lipid-lowering treatment as needed.
- Monitor response to treatment. Repeat EASI and DLQI to assess severity and quality of life from baseline. Special Authority renewals every six months need a ≥ 75% reduction in EASI score, or a DLQI improvement of ≥ 4, compared to baseline.
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Notes
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- Females of child-bearing potential should use effective contraception during, and for four weeks after, treatment. Upadacitinib should be stopped if patients become pregnant during treatment.
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Refer following inadequate response
Seek dermatology advice (verbal or written) or refer the patient for dermatology assessment if intolerable adverse effects are experienced or response to upadacitinib is insufficient following six months of treatment.
Best Practice Tip. Ensure dermatology referral requests contain as much information as possible, including photographs showing the size and extent of the affected areas(s), information about treatments trialled and their duration and the impact on the patient’s quality of life (e.g. DLQI score).
