P113 JAK in the box: unlocking real-world factors influencing Janus kinase inhibitor and dupilumab prescribing in atopic dermatitis

Abstract Several new targeted therapies have been approved for atopic dermatitis (AD) in recent years, resulting in improved patient outcomes. These medications fall into two broad groups, injectable monoclonal antibodies and oral Janus kinase inhibitors (JAKis). Our aim was to assess real-world patient and physician factors that influence preference for biologics over JAKis, and vice versa, in eligible patients with AD. A retrospective review was carried out of patients aged ≥ 12 years prescribed dupilumab or a JAKi (upadacitinib, abrocitinib or baricitinib) for AD in our tertiary dermatology centre between 2021 and 2024. Tralokinumab and lebrikizumab were excluded as all patients had prior dupilumab. Patient demographics and patient and physician factors influencing drug choice were assessed. In total, 91 patients were included (average age 33 years, range 12–88). Following failure or contraindication of at least one conventional systemic, 72 patients were prescribed dupilumab and 19 a JAKi first line. Among the 72 prescribed dupilumab, the average age was 34 years (range 13–68). Seventeen had cardiovascular risk factors, including smoking, hyperlipidaemia and hypertension, and one had a previous deep vein thrombosis. Thirty had a coexisting diagnosis of moderate or severe asthma, for which dupilumab is also licensed. Five patients were commenced on dupilumab over a JAKi based on their own preference. In total, 27 of 72 patients treated with dupilumab (38%) were subsequently switched to a JAKi due to primary or secondary failure (n = 17) or intolerable side-effects, including flare of facial eczema (n = 5), ocular surface disorder (n = 2) and joint pains (n = 2). Ten patients on dupilumab had stable manageable facial eczema and three had stable ocular surface disorder. Among the 19 patients commenced on a JAKi in preference to dupilumab, the average age was 27 years (range 12–49), and 5 were under < 18 years. Reasons for commencing a JAKi over dupilumab included speed of response, ease of dispensing an oral medication, prominent facial eczema at baseline, patient preference (n = 5), needle phobia (n = 4) and comorbidities (alopecia, inflammatory bowel disease, potential drug interaction). Interestingly, 13 of 91 patients within our cohort had a documented needle phobia at baseline, 5 of 7 of whom were established on dupilumab successfully (2 of 7 switched to a JAKi). Although dupilumab is an injectable medication this is partially offset by the absence of blood monitoring required with JAKi. Here, we provide real-world insight into physician and patient considerations that influence dupilumab and JAKi prescribing for AD. Factors favouring dupilumab prescribing include older age, asthma status and cardiovascular risk factors. Factors favouring JAKi prescribing included speed of onset, ease of prescribing, younger age and needle phobia.