Is a loading dose required when switching back to Dupixent (dupilumab) after prematurely discontinuing it for Rinvoq (upadacitinib) due to new disease findings?

From the Guidelines

You will likely need a loading dose when restarting Dupixent after switching to Rinvoq, as the medication levels in your body would have decreased significantly after discontinuation, even for just a few weeks. The decision to repeat the loading dose depends on disease severity and the number of doses missed, as stated in the joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics 1. When considering the restart of Dupixent, it's essential to take into account the time elapsed since the last dose and the patient's current disease state. According to the guidelines, repeating loading doses upon restarting administration of the medication should be considered if the patient is flaring and/or if more than 3-4 half-lives have passed since the previous dose 1. Some key points to consider when deciding on a loading dose include:

• The duration of the gap in treatment, in this case, 3 weeks
• The severity of the disease and the patient's current symptoms
• The number of doses missed and the time elapsed since the last dose
• The presence of any new disease findings that may impact treatment decisions Given these factors, it's crucial to consult with your healthcare provider to determine the best course of action for your specific situation, as they can assess your individual needs and create a personalized treatment plan 1.

From the Research

Switching from Dupixent to Rinvoq and Back to Dupixent

• The provided studies do not directly address the question of whether a loading dose is needed when switching back to dupixent after prematurely switching to rinvoq due to new disease findings 2, 3, 4, 5, 6.
• However, the studies suggest that switching between dupilumab and upadacitinib (rinvoq) may be feasible, with some patients experiencing improved outcomes when switched to upadacitinib after not achieving adequate response with dupilumab 3.
• The safety profile of upadacitinib was consistent with previous phase 3 AD studies, with no new safety risks observed when switching from dupilumab to upadacitinib 3.
• There is no information available on the specific scenario of switching back to dupixent after prematurely switching to rinvoq, and therefore, it is unclear whether a loading dose would be necessary in this situation.

Factors to Consider

• The decision to switch back to dupixent and whether to use a loading dose may depend on various factors, including the patient's disease severity, prior response to dupixent, and the reason for switching to rinvoq in the first place.
• The studies suggest that clinical and therapeutic factors, such as disease duration and prior systemic corticosteroid use, may influence treatment success with upadacitinib 4.
• However, without direct evidence addressing the specific question, it is unclear how these factors may impact the decision to use a loading dose when switching back to dupixent.