I recently presented the case of Alejandra, a 19-year-old woman with atopic dermatitis. Given the patient’s moderate-to-severe atopic dermatitis, its negative effects on her quality of life, and the significant rash findings on exam, I determined that dupilumab should be considered using shared decision-making. Thank you for the feedback on this case. Like you, I have been frustrated by the difficulty in obtaining insurance coverage for biologic treatment for atopic dermatitis.
The Scope of the Problem
A study by Loiselle and colleagues assessed this issue in the US. Nearly 1000 adults with atopic dermatitis or caregivers of children with atopic dermatitis responded to a survey regarding their experience with delays in various prescriptions for atopic dermatitis. The investigators found that 48.1% of respondents reported experiencing at least one denial or delay in the past year. The rate of denials or delays for biologics specifically was 43.6%, and that was followed closely by denials/delays for topical corticosteroids (39.2%).
Upon receiving a denial for coverage, 20.7% of participants did not appeal. Appeals originating from healthcare professionals’ offices were more successful than appeals from patients directly, but the overall rate of successful appeals was just 62.8%.
Navigating the Appeals Process
One of the most common reasons for denial of biologics was the lack of demonstrated step therapy for atopic dermatitis. Patients with moderate-to-severe atopic dermatitis may qualify for immediate treatment with systemic therapy without a trial of topical therapy, but most cases will require a trial of topical therapy before approval of biologic treatment. Generally, patients should fail topical calcineurin inhibitors plus higher potency topical corticosteroids or suffer significant side effects from topical therapy before biologics may be considered for approval.
One challenge is the documentation of exactly which treatment was applied and for how long before treatment failure. These details will help in getting prior authorization.
Why It's Worth the Fight
Responding to insurance companies is difficult and often thankless work, but it is heartening to know drugs like dupilumab go beyond relieving atopic dermatitis symptoms.
In two phase 3 trials of dupilumab vs placebo, adults treated with dupilumab saw depression and anxiety scores improve by roughly 40% from baseline by week 16, compared with 6%-12% in the placebo group. The effect of dupilumab on depression/anxiety was more muted among adolescents.
Additionally, biologics applied in atopic dermatitis can improve quality of life. A systematic review and meta-analysis that included 17 randomized controlled trials of dupilumab with a total of 6665 participants confirmed a positive effect of dupilumab on depression and anxiety. Participants receiving dupilumab also reported significantly favorable effects on sleep quality and improvements across multiple quality-of-life measures. This effect was noted among both adolescents and adults.
Although there remains work to be done in terms of improving the efficiency of treatment for patients with moderate-to-severe atopic dermatitis, the compensation for that work includes significantly reduced cutaneous symptoms along with better sleep and quality of life. And that makes the effort even more worth it.
Thank you for participating in this activity, and see you next time!