Treat-to-Target in Atopic Dermatitis: An International Consensus on a Set of Core Decision Points for Systemic Therapies

Abstract

Currently no treat-to-target framework to guide systemic treatment in adults with moderate-to-severe atopic dermatitis exists. We sought to reach international consensus through an eDelphi process on a core set of recommendations for such an approach. Recommendations were developed by an international Steering Committee, spanning 3 areas (Guiding Principles, Decision Making, and Outcome Thresholds) and 2 specific time-points; an initial acceptable target at 3 months and an optimal target at 6 months, each based on improvements in patient global assessment plus at least one specific outcome domain. These treat-to-target- orientated recommendations were evaluated by an extended international panel of physicians, nurses and patients. Proposed recommendations were rated using a 9-point Likert scale; for each recommendation, consensus agreement was reached if ≥ 75% of all respondents rated agreement as ≥ 7. Consensus on 16 core recommendations was reached over 2 eDelphi rounds. These provide a framework for shared decision-making on systemic treatment continuation, modification, or discontinuation.

Keywords: consensus; eDelphi; surveys and questionnaires; systemic treatment; treat-to-target; atopic dermatitis.

Fig. 1

Algorithm for decision-making in treating moderate-to-severe atopic dermatitis (AD) to target with systemic treatments based on the consensus. Relevant targets are shown in the lower panel. Reaching targets in patient global assessment (Patient self-reported Global Assessment of disease severity; PtGA) plus at least 1 specific domain target should prompt consideration of treatment continuation; failure to reach target in PtGA and disease domain measure should prompt switching to an alternative systemic agent. Where only 1 set of outcome targets are achieved (i.e. only PtGA or only the disease domain measure) then shared decision-making around treatment continuation, or modification, or switching to an alternative treatment is recommended. All decisions should be made on the basis of acceptable treatment safety and tolerability. QOL: quality of life; EASI: Eczema Area and Severity Index; SCORAD: SCORing Atopic Dermatitis; NRS: numerical rating scale; POEM: Patient-Oriented Eczema Measure; DLQI: Dermatology Life Quality Index.