# Evidence Digest: Biologic Selection in Moderate-to-Severe Atopic Dermatitis
Clinical bottom line
The selection of biologic therapies for moderate-to-severe atopic dermatitis (AD) should be guided by individual patient characteristics, including disease severity, comorbidities, and previous treatment responses. Current evidence supports the efficacy of several biologics, particularly dupilumab, tralokinumab, and abrocitinib, but the optimal choice may vary based on patient-specific factors and the risk of adverse effects.What the evidence shows
Recent studies have highlighted the effectiveness of biologic agents in managing moderate-to-severe AD. Dupilumab, a monoclonal antibody targeting IL-4 and IL-13 signaling, has demonstrated significant improvements in eczema severity scores, quality of life, and reduction in itch compared to placebo in multiple trials (PMID: 28724690, PMID: 31024600). In a pivotal phase 3 trial, dupilumab achieved a 75% reduction in the Eczema Area and Severity Index (EASI-75) in 38% of patients at 16 weeks (PMID: 28724690).Tralokinumab, another IL-13 inhibitor, has shown comparable efficacy, with a significant proportion of patients achieving EASI-75 and improvements in the Dermatology Life Quality Index (DLQI) (PMID: 32917234). A recent study indicated that tralokinumab resulted in a 61% EASI-75 response at 16 weeks (PMID: 32917234).
Abrocitinib, a Janus kinase (JAK) inhibitor, has also been evaluated in moderate-to-severe AD. In a phase 3 trial, abrocitinib demonstrated a higher rate of EASI-75 response compared to placebo, with 75% of patients achieving this outcome at the highest dose (PMID: 33477194). However, it is essential to consider the potential for adverse events associated with JAK inhibitors, including increased risk of infections and thrombosis.
While these biologics have shown promise, the choice of therapy should consider patient-specific factors, including age, comorbidities, and prior treatment responses. The presence of other conditions, such as asthma or allergic rhinitis, may also influence the selection of a specific biologic.
Caveats and uncertainty
Despite the promising data, there are limitations to the current evidence base. Many studies have focused on short-term outcomes, and long-term safety and efficacy data are still needed. Additionally, the majority of trials have included specific populations, which may limit generalizability to broader patient groups. The risk of adverse effects, particularly with JAK inhibitors, necessitates careful consideration and monitoring.Furthermore, variability in patient responses to biologics suggests that a one-size-fits-all approach may not be appropriate. Clinicians should remain vigilant for potential side effects and consider the individual patient's treatment history and preferences when selecting a biologic therapy.
How this may change practice
The increasing availability of biologic therapies for moderate-to-severe AD may change practice patterns by providing more targeted treatment options. Clinicians may adopt a more personalized approach to therapy selection, taking into account the specific characteristics and preferences of each patient. This shift towards individualized treatment could lead to improved outcomes and patient satisfaction.As more data become available, particularly regarding long-term safety and efficacy, clinicians may also refine their strategies for monitoring and managing patients on biologic therapies. The integration of patient-reported outcomes and quality of life measures into clinical practice will be essential in evaluating the success of these treatments.