Starting this month, the health insurance authorities expanded reimbursement for two atopic dermatitis treatments – oral JAK inhibitor Rinvoq (upadacitinib) and biological agent Dupixent (dupilumab) – from adult to children and adolescent patients.

Experts expect the expanded insurance benefits to improve the domestic environment to treat atopic dermatitis.

However, the current reimbursement standard that does not recognize the cross-administration of biological drugs and JAK inhibitors makes it difficult to provide optimal treatment for patients, leading to calls for improvement.

Against this backdrop, Korea Biomedical Review met with Professor Lee Dong-hoon of the Dermatology Department at Seoul National University Hospital, who also serves as the information director of the Korean Atopic Dermatitis Association (KADA), to learn about the effects the expanded reimbursement for Dupixent and Rinvoq will have on treatment environment.

Question: As the insurance authorities expanded reimbursement to a biological agent and JAK inhibitors, the treatment access of children and adolescent atopic dermatitis patients is expected to increase.

Answer: So far, severe children and teenage dermatitis patients could not receive optimal treatments due to the lack of reimbursement. Luckily, reimbursement and special calculation cases have been applied, expanding treatment options for these young patients.

Q: Are there some important points to consider when treating adolescent atopic dermatitis patients?

A: In adolescence, wounds (lesions) frequently occur on visible parts, such as hands and faces. However, these affected areas significantly impact the quality of life, no matter how small they are, requiring swift treatment.

Besides, when children and adolescents cannot sleep well because of itching, families may also be unable to sleep well to care for them. The resulting stress affects the quality of life of the whole family, so it is important to receive sufficient treatment. Therefore, in adolescence, it is necessary to treat aggressively and maintain a positive state.

Q: Will the recent expansion of reimbursement help aggressive treatment? We are also curious about the difference between biological agents and JAK inhibitors.

A: Some patients show effects by using traditional immunosuppressants like cyclosporine or methotrexate (MTX) properly, but these drugs are hard to use for a long. So what came out later was a biological agent, an antibody treatment, such as dupilumab. In addition, JAK inhibitors that can be administered orally have recently been released.

Antibody treatments work well, but it has the disadvantage of being an injection. Severe patients must take it every two weeks. However, as dupilumab has other indications, including asthma, it is very helpful for atopic dermatitis patients accompanied by asthma.

Three JAK inhibitors can be used to treat atopic dermatitis. Among them, upadacitinib and abrocitinib have won approval for adolescent patients. JAK inhibitors have the characteristics of very immediate effects. Patients can usually feel the effects in the second week of administration. As proven by clinical trial results, JAK inhibitors improve not only itchiness but the symptom itself after about a week, showing improvement faster than injections.

Therefore, we prescribe JAK inhibitors if patients want the symptom’s rapidly improvement. Although these drugs entail the inconvenience of regular blood tests, they are convenient to administer and relatively easy to store when traveling since they are pills,

Q: What must be done to improve the reimbursement environment for atopic dermatitis treatments?

A: Patients’ financial burdens remain because although insurance benefits are provided for severe patients, mild to moderate patients cannot. KADA has also voiced an opinion that in determining the severity level, the authorities need to regard patients with severe symptoms on exposed parts like hands and face as severe cases. However, their EASI (Eczema Area and Severity Index) points belong to moderate cases, considering such symptoms sharply degrade the patients’ quality of life. In the case of adolescent patients having study stress in particular, I think their degraded quality of life due to atopic dermatitis should be reflected in deciding the severity of the disease.

Q: The government, while expanding reimbursement for new atopic dermatitis treatments, ruled out insurance benefits for the alternative administration of different treatments. Right?

A: A similar but different case is psoriasis, where the authorities allow alternative administration. However, atopic dermatitis patients cannot change treatments once they decide on one. I think it is natural to allow the change of treatments. If the current drug produces fewer effects or side effects, shouldn’t it change it? From an economic aspect, it is not good to continue to use drugs with less effectiveness.

Also, some patients can show poorer-than-expected effects or side effects, although medical professionals had selected the drugs, fully considering the patients’ characteristics. In these cases, they must be able to change drugs naturally.

Q: What is your association’s next agenda requiring solution?

A: The issue of insurance benefits for children and adolescents has been one of society's long-cherished projects, and I think it is fortunate that this has been resolved. However, I hope there will be a systemic change, which provides insurance benefits, if not special calculation cases, for moderate patients if their quality of life falls severely or cannot be cured with the existing fixed treatment formula.

Besides, I hope they provide insurance benefits for severe patients so that they can attempt alternative administration for optimal treatment. Currently, severe patients must wait for their symptoms to aggravate after stopping the existing treatment from receiving benefits. They find it fortunate if symptoms aggravate immediately after the cessation of treatment. Some patients don’t manage situations until their symptoms aggravate. The process itself is very painful. After all, these patients have symptoms so severe as to be subject to special calculation cases. Therefore, it is necessary to allow the change of treatments with insurance benefits to provide them with “optimal treatment,” which is also the ultimate purpose of atopic dermatitis treatment.