Treat-to-target in the management of moderate-to-severe atopic dermatitis in adults: A Canadian perspective

To the Editor: Atopic dermatitis (AD) is a common chronic disease associated with significant impairment in quality of life. While systemic therapies can effectively manage moderate-to-severe AD in adults, deciding when to optimize or modify them is challenging as change may not necessarily lead to improvement and could result in worse outcomes. A recent international consensus recommends assessing patients with validated measures such as Eczema Area and Severity Index (EASI), peak pruritus Numerical Rating Scale, Dermatology Life Quality Index (DLQI), and Patient-Oriented Eczema Measure at 3 and 6 months using a treat-to-target (T2T) strategy.1De Bruin-Weller M. Biedermann T. Bissonnette R. et al.Treat-to-target in atopic dermatitis: an international consensus on a set of core decision points for systemic therapies.Acta Derm Venereol. 2021; 101adv00402https://doi.org/10.2340/00015555-3751Crossref Scopus (40) Google Scholar This T2T improves on current AD guidelines by recommending outcome targets and providing guidance on how to evaluate therapeutic effectiveness and when to optimize or modify treatment if targets are not achieved. However, its application in some jurisdictions is limited by lack of practical considerations to address specific constraints of their health-care systems. To overcome this limitation, a Committee of 12 Canadian dermatologists with extensive experience in managing AD (Supplementary Table I, available via Mendeley at http://doi.org/10.17632/z3vchf7yx6.1) developed a consensus T2T for moderate-to-severe AD in adults with recommendations for assessment time points and treatment target criteria. The Committee combined clinical experience with available recommendations and guidelines, including those by the Harmonizing Outcome Measures for Eczema (HOME)2Centre of Evidence Based Dermatology University of Nottingham Harmonising outcome measures for eczema (HOME).http://www.homeforeczema.org/Date accessed: November 29, 2021Google Scholar,3Chalmers J.R. Simpson E. Apfelbacher C.J. et al.Report from the fourth international consensus meeting to harmonize core outcome measures for atopic eczema/dermatitis clinical trials (HOME initiative).Br J Dermatol. 2016; 175: 69-79https://doi.org/10.1111/bjd.14773Crossref PubMed Scopus (106) Google Scholar, to develop practical T2T criteria (Fig 1). Consensus agreement was reached unanimously to assess patients with at least 1 of 2 physician-rated outcome measures (EASI and Physician Global Assessment) and at least 1 of 3 patient-reported outcome measures (pruritus Numerical Rating Scale, DLQI, and Patient-Oriented Eczema Measure). EASI, Physician Global Assessment, and DLQI scales are commonly used in Canadian practice as they are required for reimbursement purposes. Three visits spanning the course of 1 year are recommended to achieve the ideal therapeutic transition from flare control to induction and maintenance of remission (Fig 2). Allowing for flexibility, these visits should occur at 12 to 16 weeks, 6 to 8 months, and 1 year after the initial visit. Maintenance follow-ups should then be considered every 6 to 12 months. Assessment targets (Fig 2) are set at each time point to decide whether to continue or modify a treatment. The 1-year target sets optimal objectives to ensure minimal residual disease or relapses. A treatment will be considered effective if at least one physician-rated outcome target and at least one patient-reported outcome target are met. If the target criteria are not met, modifications should be made to optimize the current treatment (eg, increase the dose or frequency of the systemic therapy), add an adjunctive treatment (eg, phototherapy or another systemic therapy), or change the current treatment. Physicians should consider rescue therapy to help patients reachieve targets when flares occur. Topical therapies should always be fully optimized. Finally, shared decision-making should occur throughout the process as it increases adherence and results in improved quality of life.4LeBovidge J. Borok J. Udkoff J. Yosipovitch G. Eichenfield L.F. Atopic dermatitis: therapeutic care delivery: therapeutic education, shared decision-making, and access to care.Semin Cutan Med Surg. 2017; 36: 131-136https://doi.org/10.12788/j.sder.2017.029Crossref PubMed Scopus (15) Google Scholar,5Stalder J.F. Bernier C. Ball A. et al.Therapeutic patient education in atopic dermatitis: worldwide experiences.Pediatr Dermatol. 2013; 30: 329-334https://doi.org/10.1111/pde.12024Crossref PubMed Scopus (71) Google Scholar Limitations to this T2T include the lack of nonphysician stakeholders input and the possibility to adapt the recommended targets, for example, to balance the risk of adverse effects. Nonetheless, this consensus T2T provides a valuable tool for physicians engaged in treating moderate-to-severe AD with systemic therapies. Dr Yeung has been an advisor, consultant, speaker, or investigator for AbbVie, Allergan, Amgen, Arcutis, Astellas, Bausch Health, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Centocor, Coherus, Dermavant, Dermira, Forward, Galderma, GlaxoSmithKline, Incyte, Janssen, Kyowa, LEO Pharma, Lilly, Medimmune, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi Genzyme, Sun Pharma, Takeda, UCB, Valeant (Bausch Health), and Xenon. Dr Gooderham has been an investigator, speaker, or advisor for AbbVie, Amgen, Akros, Arcutis, Bausch Health, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Dermira, Dermavant, Eli Lilly, Galderma, GlaxoSmithKline, Incyte, Janssen, Kyowa Kirin, LEO Pharma, MedImmune, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi Genzyme, Sun Pharma, and UCB. Dr Hong has been an investigator or has received honoraria for advisory board, speaker, and consultant services from AbbVie, Amgen, Bausch Health, Celgene, Dermavant, Eli Lilly, Galderma, GlaxoSmithKline, Janssen, LEO Pharma, Novartis, Pfizer, Regeneron/Sanofi, Sun Pharma, and UCB; and has received research grants for investigator services from AbbVie, Akros, Amgen, Arcutis, Boehringer-Ingelheim, Bristol-Myers Squibb, Celgene, Cutanea, Dermira, Dermavant, DS Biopharma, Eli Lilly, Galderma, GlaxoSmithKline, Janssen, LEO Pharma, Medimmune, Novartis, Pfizer, Regeneron/Sanofi, Roche, and UCB. Dr Lynde has been a speaker or consultant and principal investigator for AbbVie, Altius, Amgen, Aralez, Arcutis, Bausch Health, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Cipher, Dermavant, Eli Lilly, Fresnius Kabi, GlaxoSmithKline, Innovaderm, Intega Skin, Janssen, Kyowa, La Roche Posay, LEO Pharma, L'Oreal, Medexus, Merck, Procter & Gamble, Pediapharm, Regeneron, Roche, Sanofi Genzyme, Sentrex, TEVA, Tribute, UCB, Valeant, Viatris, and Volo Health. Dr Prajapati served as an investigator for AbbVie, Amgen, Arcutis, Arena, Asana, Bausch Health, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Concert, Dermavant, Dermira, Eli Lilly, Galderma, Incyte, Janssen, LEO Pharma, Nimbus Lakshmi, Novartis, Pfizer, Regeneron, Reistone, Sanofi Genzyme, UCB, and Valeant; and as a consultant, advisor, or speaker for AbbVie, Actelion, Amgen, Aralez, Arcutis, Aspen, Bausch Health, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Cipher, Eli Lilly, Galderma, GlaxoSmithKline, Homeocan, Incyte, Janssen, LEO Pharma, L'Oreal, Medexus, Novartis, Pediapharm, Pfizer, Sanofi Genzyme, Sun Pharma, Tribute, UCB, and Valeant. Dr Lansang is or has been an investigator, consultant, speaker, or advisor for AbbVie, Amgen, Bausch, Bristol-Myers, Celgene, Galderma, Janssen, LEO Pharma, Eli Lilly, Novartis, Pfizer, Sandoz, Sanofi, Sun Pharma, and UCB. Dr Turchin served as consultant, speaker, or investigator for AbbVie, Amgen, Arcutis, Aristea, Bausch Health, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Galderma, Incyte, Janssen, Kiniksa, LEO Pharma, Mallinckrodt, Novartis, Pfizer, Sanofi, Sun Pharma, and UCB. Dr Wiseman received honoraria for presentations from AbbVie, Bausch Health, Eli Lilly, Galderma, Janssen, LEO Pharma, Novartis, Pfizer, Sanofi Genzyme, Sun Pharma, and UCB; and for participation to advisory boards from AbbVie, Amgen, Arcutis, Bausch Health, Boehringer Ingelheim International, Bristol Myers Squibb, Celgene, Eli Lilly, Galderma, GlaxoSmithKline, Janssen, LEO Pharma, L'Oreal, Lyceum, Novartis, Pfizer, Sanofi Genzyme, Sun Pharma, and UCB. Dr Jack received grants, contracts, consulting fees, payment or honoraria, or participated on data safety monitoring or advisory board from AbbVie, Amgen, AntibioTx, Arcutis, Asana, Bausch, Boston, Boehringer Ingelheim, Bristol Myers Squibb, Canadian Dermatology Foundation, Cara, Celgene, Concert, Dermavant, Eczema Society of Canada, Eli Lilly, Innovaderm Research, Incyte, Janssen, Kiniksa, LEO Pharma, McGill University Department of Medicine, MITACS, Neokera, Novartis, Pfizer, Ralexar, Sanofi, Sienna, Target PharmaSolutions, Valeant, and UCB. Dr Ramien has consulted for AbbVie, Eli Lilly, LEO Pharma, Pfizer, and Sanofi; and has a registered study with Sanofi. Dr Purdy received payment, honoraria, or participated in advisory boards from AbbVie, Amgen, Arcutis, Bausch, Boehringer Ingelheim, BMS, Eli Lilly, Galderma, Janssen, Johnson & Johnson, LEO Pharma, Pfizer, Sun Pharma, Sanofi, and UCB; and occupied leadership or fiduciary roles in CDA executive and the Eczema Society. Dr Grewal is or has been an investigator, consultant, speaker, advisor for or received research funding or honoraria from AbbVie, Aralez, Amgen, Arcutis, Bausch Health, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Cipher, Dermira, Dermtek, Eli Lilly, Galderma, GlaxoSmithKline, Incyte, Johnson & Johnson/Janssen, LEO Pharma, Merck, Novartis, Pfizer, Regeneron, Sanofi, Stiefel, Sun Pharma, Tribute Pharmaceuticals, Takeda, and Vitae. Editorial and medical writing support under the guidance of authors was provided by STA HealthCare Communications, and was funded by LEO Pharma, in accordance with Good Publication Practice guidelines.