Moderate-to-Severe Atopic Dermatitis After Dupilumab or Tralokinumab Has Not Achieved Treatment Goals
This protocol applies to adults and adolescents with moderate or severe atopic dermatitis
who received a biologic agent — dupilumab or tralokinumab — combined with topical therapy,
yet did not achieve adequate reduction in disease severity, itch, or sleep disturbance.
Clinical Scenario
Moderate atopic dermatitis or severe atopic dermatitis, refractory to or unable to
achieve adequate goals with prior systemic treatment that included a recommended biologic.
The treatment targets are reduction in atopic dermatitis severity, itch, and sleep disturbance.
Previous Line: Goals Not Achieved
The prior treatment step added dupilumab (patients aged 6 months or older)
or tralokinumab (patients aged 12 years or older) on top of continued
topical treatment. The goals of that line — reduction in AD severity, itch, and sleep
disturbance, and improvement in AD-related quality of life — were not reached. This
protocol defines the recommended next step.
Next-Step Approach (Partial Overview)
The protocol involves replacing the current systemic treatment with an alternative systemic
option — which may include an oral class of targeted agents — or adding a specific
clinic-based phototherapy. Which approach is appropriate, and for whom, is detailed in
the full structured regimen.
References
DOI: 10.1016/j.anai.2023.11.009
- Recommendation 11: In patients with moderate-severe atopic dermatitis, the JTF panel suggests, in addition to topical therapy, dilute bleach baths over usual (no dilute bleach-based) baths (conditional recommendation, low-certainty evidence).
- Recommendation 16: In patients 6 months of age or older with moderate-severe AD refractory, intolerant, or unable to use mid-potency or greater topical treatment, the JTF panel recommends adding dupilumab over continued standard topical treatment without dupilumab (strong recommendation, high-certainty evidence).
- In adults and adolescents with moderate-severe AD refractory, intolerant, or unable to use mid- to high-potency topical treatment and systemic treatment inclusive of a biologic recommended previously, the panel suggests replacing the systemic treatment with one of the following oral JAK inhibitors (alphabetical order: abrocitinib 100-200 mg [age 12 years or above], baricitinib 2-4 mg [age 18 years or above], upadacitinib 15-30 mg [age 12 years or above]) over not using one of these JAK inhibitors (conditional recommendation, low-certainty evidence).
- In patients with moderate-severe AD refractory, intolerant, or unable to use mid- to high-potency topical treatment and systemic treatment inclusive of a biologic recommended previously, the JTF panel suggests replacing cyclosporine as the systemic treatment over continued topical and systemic standard care (conditional recommendation, low-certainty evidence).
- Cyclosporine has conventionally been administered at either low (2-3 mg/kg) or high doses (4-5 mg/kg).
- In patients with moderate-severe AD refractory, intolerant, or unable to use mid- to high-potency topical treatment and systemic treatment inclusive of a biologic recommended previously, the JTFPP panel suggests adding clinic-based narrow-band UV-B treatment (conditional recommendation, low-certainty evidence).
- Patients, however, will likely pursue only 1 of these 3 therapies.
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