What are the current biologic drugs, including dupilumab (dupilumab), indicated for atopic dermatitis and are any preferred?

Current Biologic Drugs for Atopic Dermatitis: Guidelines and Preferences

Dupilumab is the preferred first-line biologic therapy for moderate-to-severe atopic dermatitis, with tralokinumab as the second FDA-approved biologic option, though it shows somewhat less effectiveness than dupilumab. 1

FDA-Approved Biologic Therapies

Dupilumab

• Mechanism: Monoclonal antibody targeting interleukin-4 receptor α, blocking both IL-4 and IL-13 signaling 1
• Dosing: 600 mg subcutaneously at initiation, then 300 mg every 2 weeks 1, 2
• Efficacy: Established in multiple large RCTs, including a 52-week trial 1
• Safety profile: Excellent safety record in clinical trials with few major concerns after more than 5 years in clinical practice 1
• Expert consensus: Unanimously favored as first-line systemic agent by guideline workgroup members 1

Tralokinumab

• Mechanism: Monoclonal antibody specifically targeting interleukin-13 1
• Dosing: 600 mg at initiation followed by 300 mg every 2 weeks 1
• Efficacy: Significantly improves signs, symptoms, and quality of life in AD, but network meta-analysis suggests it is somewhat less effective than dupilumab at 16 weeks 1
• Safety profile: No major safety concerns identified in clinical trials 1

Emerging Biologic Therapies (Not Yet FDA-Approved)

• Lebrikizumab: Targets IL-13, similar to tralokinumab 3
• Nemolizumab: Anti-IL-31 receptor antibody, likely to be used second-line to other biologics, primarily for pruritus 3

JAK Inhibitors for Atopic Dermatitis

While not biologics, JAK inhibitors are important newer systemic therapies for AD:

• FDA-approved options: Abrocitinib, baricitinib, and upadacitinib 1
• Efficacy comparison: Higher doses of JAK inhibitors may be somewhat more efficacious than standard-dose dupilumab, with abrocitinib 100 mg daily showing less efficacy than dupilumab 1
• Recommendation strength: Strong recommendations for use in appropriate patients 1

Clinical Decision-Making Algorithm

1. For moderate-to-severe AD refractory to topical therapies:

   • First-line biologic: Dupilumab
   • Second-line biologic: Tralokinumab
   • Alternative options: JAK inhibitors (abrocitinib, baricitinib, upadacitinib)

2. Special populations:

   • Patients with renal disease: Dupilumab appears safe without dose adjustment, even in severe renal failure 4
   • Patients with cancer history: Dupilumab may be safer than traditional immunosuppressants like cyclosporine or azathioprine 5

3. Concomitant therapy:

   • Topical agents can be used concurrently with systemic therapies for maintenance, rescue, or treatment of flares 1
   • Combination of dupilumab with topical corticosteroids is more effective than dupilumab monotherapy 6

Important Considerations and Caveats

• Vaccination: Consider vaccination status prior to treatment initiation; simultaneous use of live vaccines with dupilumab is contraindicated 2, 6
• Monitoring: Watch for common adverse effects including:
  • Injection site reactions
  • Conjunctivitis and keratitis (particularly with dupilumab)
  • Nasopharyngitis
  • Headache 6
• Treatment failure: If inadequate response to biologic therapy, consider alternative diagnoses such as contact dermatitis or cutaneous lymphoma 1

Pediatric Considerations

In pediatric patients, dupilumab is recommended for the treatment of severe to very severe AD that is refractory to conventional topical treatment 1.

The evidence strongly supports dupilumab as the preferred first-line biologic therapy for moderate-to-severe atopic dermatitis, with tralokinumab as an alternative option when dupilumab is not suitable or effective.