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Summer AAD 2016
28–31 JULY 2016 • BOSTON,
MASSACHUSETTS, USA
Having attended the
Summer AAD 2016,
Drs Sheila Friedlander,
Mark Kaufmann and
Misha Rosenbach share
their perspective on
advanced systemic
therapeutics.
Dr Mark Kaufmann discusses systemic therapeutics
Mark Kaufmann MD is Associate
Clinical Professor of Dermatology,
Icahn School of Medicine at Mount
Sinai, New York, New York.
SYM S001 – advanced systemic therapeutics
At the Summer Academy symposium on systemic therapeutics, I spoke about the “forgotten”
systemic drugs. These include methotrexate, cyclosporin, and dapsone – drugs that we all
trained in how to use, but, with newer larger molecules (like biologics), we tend to forget
about.
I reviewed appropriate patient selection, how to dose the drugs, and how to best monitor
our patients while on these medications.
I also (re-)introduced subcutaneous methotrexate. The rheumatologic literature points to
the subcutaneous form as having more predictable bioavailability, superior efficacy, and
better GI tolerability.
In addition, there was a recent article in the
Journal of Drugs in Dermatology
(2016;15:345-
349) which suggested that subcutaneous methotrexate should be considered in the first
line (rather than the oral form), and that, by doing so, there would potentially be more
patients achieving a positive response to methotrexate. This, in turn, would lead to fewer
patients requiring treatment with biologics, thereby lowering the total cost to the healthcare
system. The authors suggested a randomised controlled head-to-head study of oral versus
subcutaneous methotrexate to help further clarify this issue.
Dr Sheila Friedlander
discusses advanced systemic
therapeutics for paediatrics
Sheila Friedlander MD is Director of the Dermatology Fellowship
Training Program at Rady Children’s Hospital-San Diego and
Professor of Pediatrics and Dermatology at UC San Diego,
California.
SYM S001 – advanced systemic
therapeutics
Atopic dermatitis
Atopic dermatitis (AD) poses a tremendous
therapeutic challenge in paediatric dermatology,
and systemic therapy is sometimes required.
There are several options, and one is the “old”
drug melatonin. The hormone melatonin is
produced by the pineal gland and is crucial for
normal sleep cycling and circadian rhythm. It
also has immunomodulatory and antioxidant
effects. Patients with AD have disrupted sleep
cycles, affecting both sleep latency and duration,
and exogenous melatonin is generally a safe drug
when used in doses of 0.5 to 10 mg at bedtime
and is a reasonable option for children with AD
whose sleep disturbance has not responded
to traditional therapies. Reported side effects
include morning drowsiness, bedwetting,
headache, and nausea.
Melatonin comes in a liquid formulation, tablet,
sublingual dissolving tablet, and time-released
form. The regular tablet can be split in four if
necessary for proper paediatric dosing. Many
experts initiate low-dose therapy (eg, 0.25 mg at
bedtime), but most children tolerate dosing in
the 2- to 6-mg range.
A recent randomised clinical trial with crossover
conducted by Chang et al enrolled 73 patients
with AD and sleep disturbance (
JAMA Pediatr
2016;170:35-42). A significant improvement in
sleep latency (P = 0.005) and SCORAD scores
was achieved by 9 patients treated with 3 mg
melatonin at bedtime.
In children with severe AD, dupilumab may be
an option. This injectable monoclonal antibody
to the IL-4 receptor has shown excellent efficacy
in adults, and paediatric trials are ongoing. Thaci
and colleagues recently published the results of
a randomised placebo-controlled trial assessing
several dosing regimens in adults (
Lancet
2016;387:40-52). The most optimal effect was
seen with 300 mg dupilumab once a week.
There was a small increase in perioral herpes
infections, but the safety profile was reassuring.
PRACTICEUPDATE RHEUMATOLOGY & DERMATOLOGY
AMERICAN ACADEMY OF DERMATOLOGY 2016 SUMMER ACADEMY MEETING
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