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Newer therapies, notably upadacitinib (Rinvoq), are particularly efficacious in adults with atopic dermatitis (AD). However, clinical and patient decision-making should also consider matters of safety and adherence, particularly when evaluating more potent systemic options.

That's according to the authors of a literature review published recently in .

Using Eczema Area and Severity Index (EASI) scores from 11 randomized control trials, the highest efficacy was seen with 30 mg of upadacitinib; 70% of patients taking this dosage achieved EASI-75. By comparison, 58% of patients taking abrocitinib (Cibinqo) 200 mg, 53% taking upadacitinib 15 mg, 45% taking dupilumab (Dupixent) 300 mg, and 39% taking abrocitinib 100 mg all achieved the EASI-75 threshold.

Further, a meta-analysis of 39 randomized control trials concluded that high-dose cyclosporine is more effective at improving quality of life and itch than azathioprine and methotrexate.

Co-author Steven Feldman, MD, PhD, director of the Center for Dermatology Research at Wake Forest University School of Medicine in North Carolina discussed the analysis and its findings with the Reading Room. The exchange has been edited for length and clarity.

What was the context for this investigation, what were its objectives, and what agents were assessed?

Feldman: We've got all of these new treatments for AD, and people are wondering how they compare in efficacy. There aren't many head-to-head trials. We did our best to analyze the literature and compare the efficacy of these different medications.

The medications we assessed were agents like dupilumab, tralokinumab (Adbry), and upadacitinib, which are more recently approved drugs. We also included topical agents like steroids, crisaborole, and ruxolitinib (Opzelura). And we assessed older immunomodulating drugs like cyclosporine, methotrexate, and azathioprine.

How would you summarize what you found?

Feldman: The new drugs are great, and they offer patients a lot of benefit. Using EASI-50 responses from 11 randomized control trials, upadacitinib 30 mg and abrocitinib 200 mg exhibited a >97.5% probability of greater clinical efficacy over dupilumab 300 mg. Upadacitinib was more effective than dupilumab at both doses. At the higher dose, upadacitinib was something like three-and-a-half times as effective at getting people completely clear of their AD.

Our study did not assess drug safety. More effective drugs are not necessarily better drugs, they're just more effective. Dupilumab has a fairly clean safety profile and may still be a good first choice for many patients.

Were there any other overarching takeaways?

Feldman: We have a general sense that dupilumab is better than our older treatments, both in terms of efficacy and safety. Also, the newer JAK inhibitors, while they may come with a little bit of safety risk, are perhaps the most effective agents we have now for AD. They're extremely fast in getting itch under control.

What are the bottom-line take-home messages? This could apply to the agents themselves or related issues like adherence.

Feldman: Adherence is an issue that's near and dear to my heart. Adherence is an enormous hurdle with topical treatment, even for patients with relatively limited disease. When people have extensive disease, topicals are just not a practical solution in real-life.

Adherence to injectable therapies is better than with other forms of treatment, but it's still not perfect. I think it's a really good idea to tell patients on oral agents to get a 7-day pill container. Giving patients a bunch of pills and bottles is just asking for them to be non-adherent.

Anything else you'd like dermatologists to be aware of regarding this particular study or this topic more globally?

Feldman: Things get out of date really fast in healthcare -- and the whole world these days. There are new drugs coming that we didn't include in this analysis. For example, I think before too long, we may have an interleukin-31 inhibitor. We'll want to know how the new drugs compare for AD treatment efficacy compared to the drugs that we covered in this paper.

Key points

• Upadacitinib (Rinvoq) found to be most efficacious in head-to-head evaluation of treatments for AD in adults.
• Consider safety and adherence matters when determining proper agents for a given patient.
• A basic pill dispenser can help improve adherence among patients taking oral agents.