Uncovering Systemic Corticosteroid Use and Updates on Long-Term Management Benefits of Upadacitinib in AD

“This data is very encouraging to clinicians. When you put a patient on a JAK inhibitor, you can tell them that the oral JAK inhibitors have this ability to maintain response for a long period of time. You're not necessarily going to have to be changing medicines all the time. This one medicine, upadacitinib, can get the job done for a long period of time,” said Christopher Bunick, MD, PhD, in an interview with Dermatology Times at Fall Clinical 2024 in Las Vegas, Nevada.

Bunick, associate professor of dermatology and translational biomedicine at the Yale University School of Medicine in New Haven, Connecticut, and Dermatology Times’ 2024 Winter Editor in Chief, discussed data from 2 posters presented at Fall Clinical. Bunick was an author on “Utilization and Duration of Systemic Corticosteroid Exposure in Atopic Dermatitis Patients After the Introduction of Advanced Therapies: A Population-Based Study From the United States” and “Real-World Effectiveness of Upadacitinib in Moderate‑to‑Severe Atopic Dermatitis (AD): Results From Longitudinal Analyses of the CorEvitas AD Registry.”

Bunick’s Highlights

Study 1: Systemic Corticosteroid Use in Atopic Dermatitis

Bunick’s first discussion centered around systemic corticosteroid use in patients with AD. The study included data from approximately 30,000 patients with AD in the United States and categorized corticosteroid use into short-term (30 days or less), medium-term (1 to 3 months), and long-term (more than 3 months) durations.¹

Key findings showed that around 20% of patients with AD are still prescribed systemic corticosteroids, with short-term use being the most common at approximately 67% of cases within this subgroup. However, approximately 24% of patients prescribed corticosteroids received long-term treatment exceeding 3 months of continuous or intermittent chronic use. This reliance on long-term corticosteroid use contrasts with the American Academy of Dermatology (AAD) guidelines, which conditionally recommend against systemic corticosteroids in AD due to their significant adverse event profile.

Bunick emphasized that systemic corticosteroids have higher adverse event rates than many other systemic therapies available today, including JAK inhibitors and traditional immunosuppressants. His previous research, published in the Journal of Drugs in Dermatology, supported this concept, highlighting the potential safety risks of corticosteroids in AD management. Bunick stressed the importance of reducing systemic corticosteroid use, except for short duration as a transition to advanced systemic therapies, in favor of other advanced therapies that offer safer profiles and sustainable outcomes.

For patients whose AD is insufficiently controlled with corticosteroids, transitioning to targeted therapies such as oral JAK inhibitors can lead to more effective and safer long-term disease management. Following the Aiming High in Eczema and Atopic Dermatitis consensus (AHEAD), clinicians should aim for optimal disease control, defined as achieving EASI 90 or IGA 0/1 (clear or almost clear skin) and an itch score of 0/1 (minimal or no itch). Meeting these optimal targets, especially when combined, has been shown to correlate with enhanced quality of life and disease control.

Study 2: Long-Term Maintenance with Upadacitinib in Atopic Dermatitis

In his second discussion, Bunick reviewed data on the durability of response with upadacitinib (Rinvoq; AbbVie) an oral JAK inhibitor, using data from the Measure Up 1 and 2 clinical trials. The study evaluated response durability out to 140 weeks for patients who achieved EASI 90 and itch 0/1 response at week 16 of treatment. According to Bunick, an important aspect of this research was its focus on countering the concern of tachyphylaxis—a gradual reduction in drug efficacy over time—often associated with treatments like topical corticosteroids.²

Key findings demonstrated robust response durability with upadacitinib. For patients achieving EASI 90 at week 16, 74% of those on the 15 mg dose and 84% on the 30 mg dose maintained this response through 140 weeks. Bunick highlighted this high maintenance rate as a strong indicator of upadacitinib’s potential for long-term disease control, making it a reliable option for patients seeking optimal management of atopic dermatitis. Additionally, among those who did not sustain an EASI 90 response, the majority still achieved at least EASI 75, a moderate treatment target, resulting in over 95% of patients maintaining clinically meaningful improvement. These findings underscore that upadacitinib not only reaches but sustains both moderate and optimal treatment goals for extended durations, showing no signs of tachyphylaxis with this JAK inhibitor.

Similar durability was observed for itch control. Of patients achieving WP-NRS 0/1 at week 16 with upadacitinib 15 mg, 62.3% maintained WP-NRS 0/1 at week 140; and 17.8% had a ≥4-point improvement in WP-NRS at week 140, with a total of around 80% maintained a clinically meaningful response at week 140.

Approximately 66% of patients maintained the simultaneous achievement of EASI 90 and itch 0/1 at week 140. This highly stringent endpoint is especially encouraging, as it represents the highest level of disease control or minimal disease activity according to the AHEAD framework

The sustained efficacy of upadacitinib over nearly 3 years provides clinicians and patients with a reliable option for stable, long-term management of atopic dermatitis. Bunick emphasized that these findings are essential in addressing concerns about the durability of oral JAK inhibitors. Clinicians can now recommend upadacitinib with greater confidence for patients requiring long-term systemic therapy, assured that it maintains treatment response without the need for frequent adjustments or medication switches. This stability not only supports AHEAD’s treat-to-target approach but also simplifies treatment regimens, potentially enhancing adherence and patient satisfaction.

References

1. Bunick CG, Vleugels RA, Lebwohl M, et al. Utilization and duration of systemic corticosteroid exposure in atopic dermatitis patients after the introduction of advanced therapies: a population-based study from the United States. Poster presented at: Fall Clinical Dermatology Conference; October 24-27, 2024; Las Vegas, Nevada.
2. Silverberg JI, Gooderham M, Bunick CG, et al. Real-world effectiveness of upadacitinib in moderate‑to‑severe atopic dermatitis (AD): results from longitudinal analyses of the CorEvitas AD registry. Poster presented at: Fall Clinical Dermatology Conference; October 24-27, 2024; Las Vegas, Nevada;

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