(043) Utilization of newly approved targeted immunomodulating treatments for atopic dermatitis

Background: The FDA has recently approved several efficacious systemic medications targeted to treat atopic dermatitis (AD), a chronic skin disease characterized by a red, flaking, oozing rash and intense itch. Factors influencing treatment choices, including prior treatments, remain unclear.

Objectives: To describe the uptake and patient characteristics associated with preferences for topical ruxolitinib or systemic dupilumab, tralokinumab, upadacitinib or abrocitinib among patients with AD.

Methods: Using United States longitudinal claims data, we identified patients with AD who started a study drug between 2017 and 2023. We determined the proportion of initiators who used each drug by calendar quarter, and assessed a range of patient characteristics in the year before start. Key subgroups included black race and Medicaid insurance.

Results: The number of patients with AD who started dupilumab, tralokinumab, upadacitinib, abrocitinib or topical ruxolitinib increased from 14,081 in 2017 to 69,298 in 2022. More than 70% of users were prescribed dupilumab during all quarters of the study period.
Mean age was 37 years and 50% of patients used oral glucocorticoids in the past year. About 80% of dupilumab starters had no prior systemic treatment other than systemic steroids, compared to only 40% of upadacitinib and abrocitinib starters. A slightly higher percentage of tralokinumab and upadacitinib initiators underwent phototherapy (5% each) compared to the entire study cohort (4%). 7% of dupilumab initiators used topical ruxolitinib compared to 20% of tralokinumab, abrocitinib and upadacitinib initiators. A higher proportion of patients who initiated upadacitinib had alopecia areata, which may reflect off-label use in alopecia (e.g. giving an AD ICD code to get insurance coverage for the use in an alopecia areata patient). Compared to dupilumab, upadacitinib initiators had a similar prevalence of prior hospitalization for MACE (each 0.1%) and VTE (each 0.6%), but a lower prevalence of malignancy (0.9% vs. 0.4%), heart disease (3% vs. 4.3%) and antiplatelet use (1.8% vs. 2.8%), compared to dupilumab. Tralokinumab users generally had more comorbidities compared to all agents. Black patients and those covered by Medicaid insurance had similar usage patterns to other initiators except for lower ruxolitinb use.

Conclusions: Use of targeted treatments for AD increased markedly in the past 6 years, with dupilumab by far most commonly initiated and its use rarely preceded by AD treatments other than steroids. Initiators of tralokinumab, abrocitinib, and upadacitinib had far greater prior use of topical ruxolitinib and other treatments. Overall, we did not observe substantial channeling to any of the 4 treatments.