Treat-to-Target in Atopic Dermatitis: An International Consensus on a Set of Core Decision Points for Systemic Therapies

Abstract

Currently no treat-to-target framework to guide systemic treatment in adults with moderate-to-severe atopic dermatitis exists. We sought to reach international consensus through an eDelphi process on a core set of recommendations for such an approach. Recommendations were developed by an international Steerng Committee, spanning 3 areas (Guiding Principles, Decision Making, and Outcome Thresholds) and 2 specific time-points; an initial acceptable target at 3 months and an optimal target at 6 months, each based on improvements in patient global assessment plus at least one specific outcome domain. These treat-to-target-orientated recommendations were evaluated by an extended international panel of physicians, nurses and patients. Proposed recommendations were rated using a 9-point Likert scale; for each recommendation, consensus agreement was reached if ≥ 75% of all respondents rated agreement as ≥ 7. Consensus on 16 core recommendations was reached over 2 eDelphi rounds. These provide a framework for shared decision-making on systemic treatment continuation, modification, or discontinuation.

Dupilumab in Adults with Moderate-to-Severe Atopic Dermatitis and Prior Use of Systemic Non-Steroidal Immunosuppressants: Analysis of Four Phase 3 Trials

“…Systemic non-steroidal immunosuppressants (NSISS), including cyclosporin A (CsA), methotrexate (MTX), mycophenolate mofetil, and azathioprine, are frequently prescribed to treat severe AD refractory to topical therapy (EUROSTAD [10]; TREAT [11,12]); however, there is a lack of robust evidence from large, well-designed randomized clinical trials (RCT) to support their use, and their toxicity profile requires frequent laboratory monitoring, and long-term treatment is not recommended because of a poor benefit-risk profile [13][14][15][16][17][18]. Patients treated with these broad-spectrum NSISS can suffer relapses and substantial side effects, including nephrotoxicity, liver dysfunction, and an increased risk of infection and cancer, and they are contraindicated in many patients [13,[15][16][17][18][19][20][21][22].…”

Establishing Consensus on the Treatment of Toxicodendron Dermatitis

“…Delphi surveys methods have previously been used to establish consensus regarding specific treatment guidelines within the field of dermatology. [24][25][26] Delphi surveys consist of a series of questionnaires in which respondents are asked to provide their level of agreement with specific items or statements. Each subsequent survey then builds off of the results from the previous round in the survey to either eliminate, refine, or retain the items in question.…”

Practical Management of Patients with Atopic Dermatitis on Dupilumab

“…An international treat-to-target clinical approach for AD was recently published, which recommended patient evaluation at 3 and 6 months for initial and optimal disease control targets, respectively [ 12 ]. Briefly, treatment continuation should be considered for patients who achieve benchmarks in both patient self-reported global assessment (PtGA) and at least one disease domain (EASI, SCORAD, NRS, DLQI or POEM).…”