Achieving high treatment goals with the Minimal Disease Activity concept

Patients with moderate to severe atopic dermatitis suffer from the physical and psychological effects of the disease and yet do not receive adequate treatment with systemic therapies, or often only after a delay [1-3]. The Minimal Disease Activity approach aims to consistently identify patients who are candidates for advanced treatment, combining the treat-to-target concept with shared decision-making between patients and physicians [4].

Atopic dermatitis (AD) is characterized by eczematous skin lesions with severe itching and shows great heterogeneity in clinical features and severity [5]. In everyday life, the disease often represents a physical and psychological burden that restricts the quality of life (QOL) of those affected [1]. For patients with moderate to severe AD who are refractory to topical treatment, there are targeted systemic therapies that can reduce relapses and also alleviate psychosocial effects such as anxiety, depression and absence from work [6-8]. Nevertheless, only a minority (7-8%) of patients with moderate to severe AD receive systemic therapy [2, 3]. Delaying treatment can have a negative impact on the course of the disease, while early use of effective, systemic treatment options can prevent the lifelong effects of uncontrolled inflammatory skin disease [9-12].

Consensus for a treat-to-target approach for AD

With the collaboration of Swiss dermatologists Prof. Dr. med. Peter Schmid-Grendelmeier from the University Hospital Zurich and Prof. Dr. Peter Häusermann from the Dermatologie am Rhein Basel practice in a global program, the concept of the Minimal Disease Activity (MDA) with 100% approval for AD and now for the first time on World Congress of Dermatology 2023 will be presented at a symposium in Singapore. MDA is a new treat-to-target approach to identify patients with moderate to severe AD who are candidates for systemic treatment [4]. The MDA is defined as a level of disease activity that is considered a reasonable treatment goal by both patients and the treating physicians, taking into account the available treatment options [13]. This can optimize long-term treatment outcomes and be helpful for physicians when choosing treatment options [14, 15].

MDA concept in practice

In practice, the MDA criteria involve a combination of at least oneclinician-reported and onepatient-reported criterion. reported (patient-reported) outcome The selected targets are then listed according to priority (Fig. 1). In both categories, there are moderate goals that should be achieved within 3 months and, if not achieved, lead to modification or escalation of the therapy. Optimal goals should be achieved in the long term (from 6 months) and are considered MDA. The MDA approach combines the treat-to-target concept with shared decision-making between physicians and patients [4].

Fig. 1: Criteria for the MDA approach, which combinesclinically-reported and patient-reported outcomes. EASI, Eczema Area and Severity Index; SCORAD, SCORing Atopic Dermatitis; IGA, Investigator Global Assessment; BSA, Body Surface Area; NRS, Numerical Rating Scale; POEM, Patient Oriented Eczema Measure; HADS, Hospital Anxiety and Depression Scale; (C)DQOL, (Children’s) Dermatitis Quality of Life Index. Adapted from [4].

Achieving therapy goals

For patients, the most important therapeutic goals are relief of itching, improvement of symptoms and complete skin healing. The achievement of these patient-reported outcomes is also directly related to an improvement in QOL [1]. These treatment goals are now achievable thanks to the advanced treatment options for AD. For example, the oral JAK* inhibitor upadacitinib (RINVOQ®), which selectively inhibits JAK-1, achieved an EASI* 75 response in 82.0% of patients and an EASI 90 response in 62.7% of patients after 52 weeks in the pivotal, randomized, double-blind, placebo-controlled Phase III studies MEASURE Up-1 and MEASURE Up-2 with a dosage of 15 mg once daily [16]. In addition, a rapid response to RINVOQ® was observed – after just two days, significantly more patients reported significant relief from itching compared to patients on placebo [17]. RINVOQ® is indicated in the oral dosage of 15 mg once daily since November 2021 for the treatment of adults with moderate to severe AD when therapy with conventional topical medications does not provide adequate disease control or could not be used [18].

Conclusion

Suitable systemic therapies are available for moderate to severe AD to achieve high treatment goals [18-23]. MDA can be used to ensure that patients who are eligible for systemic treatment also receive it. It combines the treat-to-target concept and joint decision-making.

* JAK, Janus kinase; EASI, Eczema Area and Severity Index

Brief technical information RINVOQ®

Literature

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18. current ^RINVOQ® (upadacitinib) prescribing information at www.swissmedicinfo.ch
19. current technical information Sandimmun Neoral® (cyclosporin A) at www.swissmedicinfo.ch.
20. current technical information ^DUPIXENT® (dupilumab) at www.swissmedicinfo.ch.
21 Current ^OLUMIANT® (baricitinib) prescribing information at www.swissmedicinfo.ch.
22. current ^ADTRALZA® (tralokinumab) prescribing information at www.swissmedicinfo.ch.
23 Current information for healthcare professionals ^CIBINQO® (abrocitinib) at www.swissmedicinfo.ch.