Dr Steve Feldman: Dupilumab Has Become the "Gold Standard" for Atopic Dermatitis Treatments

Steve Feldman, MD, PhD, a dermatology professor at Wake Forest University School of Medicine, considers dupilumab the "gold standard" for itch control in patients with atopic dermatitis (AD), as it causes few adverse effects.

Conversely, he notes that methotrexate and cyclosporine have severe adverse effects, including potential liver and kidney damage, respectively.

This transcript has been lightly edited for clarity.

Transcript

What are some potential adverse events associated with treatments that are effective for itch control in patients with AD?

The older medication, methotrexate, can destroy your liver, destroy your blood, kill you. Well, I haven't killed anybody with it yet, but we have to be real careful and do a lot of blood tests.

The next medicine that we don't use much anymore, but it works very fast, we might use it for somebody who needed to be hospitalized, would be cyclosporine. It's a drug used to turn off the immune system in people who've had a transplant. It turns off the part of the immune system also causing atopic dermatitis and itch—but you don't want to turn off people's immune systems. And cyclosporine destroys your kidney gradually over time, and so we've really gotten away from using that.

Dupilumab, I think, has become the gold standard. It inhibits interleukins-4 and -13, key signaling molecules that cause atopic dermatitis. It has very little, I think, in the way of side effects. I think it's not even classified as an immune suppressant, because there were fewer infections in the people on the drug than there were in the placebo group in the trials.

You can get eye irritation. I think that is the most common side effect. Normally, that eye irritation is not terribly bothersome. If it is, you just use some saline eyedrops. If it [gets] really, really bad, we could consider moving to some other therapy.

The JAK [Janus kinase] inhibitors are immune inhibitors. They're very fast for the itch; they're inhibiting probably the key signaling molecules that directly cause the itch, as well as the ones that cause the inflammation.

They're not as specific for only the part of the immune system that causes atopic dermatitis. They're not like methotrexate and cyclosporine, where they destroy the liver or the kidneys, thank goodness; they're more of a general immunosuppressant. So, there's some increased risk of infections with JAK inhibitors that I don't think we see with dupilumab.