What is the best treatment plan for a 79-year-old male patient with a chronic recurring rash on the left thigh, starting Dupixent (dupilumab) and prednisone, and discontinuing Clobetasol (clobetasol propionate)?

From the Guidelines

The best treatment plan for this 79-year-old male patient with a chronic recurring rash on the left thigh involves initiating Dupixent (dupilumab) with a loading dose, using prednisone as a short-term bridge therapy, and discontinuing Clobetasol gradually. According to the most recent guidelines, dupilumab is strongly recommended for the management of atopic dermatitis in adults 1. The patient should start with a loading dose of 600 mg (two 300 mg injections) of Dupixent, followed by 300 mg injections every other week.

The prednisone regimen should be adjusted to minimize steroid exposure, considering the patient's advanced age and potential risks associated with systemic corticosteroids 1. A more appropriate prednisone regimen would be to start at 20 mg daily for one week, then taper by 5 mg every 3-4 days until discontinuation. This approach helps manage any flare-ups during the transition period as Dupixent typically takes 2-4 weeks to reach full effectiveness.

The Clobetasol should be discontinued gradually to prevent rebound inflammation, using it every other day for a week, then twice weekly for another week before stopping completely. Gentle skin care with fragrance-free moisturizers, such as Cerave cream, applied immediately after bathing and avoiding potential irritants will complement the medication regimen. The patient should be monitored for injection site reactions with Dupixent and potential side effects of prednisone, including blood glucose elevation.

Key considerations in this treatment plan include:

• Minimizing systemic corticosteroid use due to the associated risks, as recommended by recent guidelines 1
• Gradual discontinuation of Clobetasol to prevent rebound effects
• Close monitoring for potential side effects of Dupixent and prednisone
• Emphasis on gentle skin care practices to support the treatment regimen.

From the FDA Drug Label

Of the 1539 subjects with AD exposed to DUPIXENT in a dose-ranging study and placebo-controlled trials, 70 subjects were 65 years or older. Clinical trials of DUPIXENT in AD did not include sufficient numbers of subjects aged 65 years and over to determine whether they respond differently from younger subjects No overall differences in safety or effectiveness of DUPIXENT have been observed between subjects 65 years of age and older and younger adult subjects.

The patient's treatment plan with Dupixent (dupilumab) 300 mg SQ every two weeks and prednisone, as well as discontinuing Clobetasol (clobetasol propionate) and starting Cerave cream, may be acceptable for a 79-year-old male patient with a chronic recurring rash on the left thigh.

• Key considerations:
  • The FDA label does not provide sufficient information to determine whether patients 65 years or older respond differently to Dupixent.
  • No overall differences in safety or effectiveness have been observed between subjects 65 years of age and older and younger adult subjects.
  • The treatment plan should be monitored closely for any signs or symptoms of adverse reactions. 2

From the Research

Treatment Plan for Chronic Recurring Rash

The patient's treatment plan includes Dupixent (dupilumab) injections and prednisone, with discontinuation of Clobetasol (clobetasol propionate) and initiation of Cerave cream.

• The use of dupilumab for moderate-to-severe atopic dermatitis has been supported by studies, which have shown its efficacy in improving disease severity, pruritus, sleep disturbance, anxiety, and depression, and quality of life 3, 4.
• The treatment plan also includes prednisone, which is often used in combination with dupilumab to manage symptoms of atopic dermatitis 5.
• Discontinuation of Clobetasol and initiation of Cerave cream may be beneficial in managing the patient's skin symptoms, as topical corticosteroids like Clobetasol can have adverse effects with long-term use, and Cerave cream can help with skin hydration and barrier repair.

Potential Benefits and Risks

• The benefits of dupilumab include its ability to block the signaling of IL-4 and IL-13, two T helper cell type 2 cytokines implicated in the immunopathology of atopic dermatitis, leading to improved disease severity and quality of life 3, 4.
• Common adverse reactions to dupilumab include conjunctivitis, injection-site reactions, and oral herpes, which should be monitored and managed accordingly 3, 4.
• The use of prednisone may also have potential risks, such as adrenal suppression and osteoporosis, which should be considered and monitored 5.

Management of Treatment Response

• The patient's response to treatment should be closely monitored, and adjustments made as needed to optimize disease control and minimize adverse effects 6.
• If the patient experiences inadequate response or adverse effects to dupilumab, alternative treatment options, such as adjuvant therapies or adjusting the frequency of dupilumab dosing, may be considered 6.