What is the use and dosing of Dupixent (dupilumab) for atopic dermatitis, asthma, and chronic rhinosinusitis with nasal polyposis?

Dupixent (Dupilumab) Usage and Dosing for Atopic Dermatitis, Asthma, and Chronic Rhinosinusitis with Nasal Polyposis

Dupilumab is strongly recommended for patients with inadequately controlled chronic rhinosinusitis with nasal polyps (CRSwNP), moderate-to-severe asthma, and moderate-to-severe atopic dermatitis, with specific FDA-approved dosing regimens for each condition. 1, 2

Indications and Clinical Benefits

Chronic Rhinosinusitis with Nasal Polyps (CRSwNP)

• First biologic approved for CRSwNP 1
• Indicated for adults and pediatric patients ≥12 years with inadequately controlled disease 2
• Significant clinical benefits:
  • Reduces nasal polyp score (MD -1.79) 1
  • Improves SNOT-22 quality of life scores (MD -19.61) 1
  • Reduces rhinosinusitis disease severity (VAS) (MD -2.54) 1
  • Improves nasal congestion/obstruction (MD -0.86) 1
  • Significantly improves sense of smell (UPSIT score MD 10.83) 1
  • Reduces sinus opacification on CT (Lund-Mackay score) 1

Asthma

• Indicated for add-on maintenance treatment in patients ≥6 years with:
  • Moderate-to-severe asthma with eosinophilic phenotype
  • Oral corticosteroid-dependent asthma 2
• Real-world effectiveness shows:
  • 44% reduction in asthma exacerbation risk 3
  • 48% reduction in systemic corticosteroid prescriptions 3
  • Improved lung function (FEV1) 1, 4

Atopic Dermatitis

• Indicated for moderate-to-severe atopic dermatitis inadequately controlled with topical therapies 2
• Can be used with or without topical corticosteroids 2

Dosing Regimens

Chronic Rhinosinusitis with Nasal Polyps

• Adults and pediatric patients ≥12 years: 300 mg every 2 weeks (Q2W) subcutaneously 2

Asthma

• Adults and pediatric patients ≥12 years:
  • Standard dosing: Initial 400 mg (two 200 mg injections), then 200 mg Q2W
  • OR Initial 600 mg (two 300 mg injections), then 300 mg Q2W
  • For oral corticosteroid-dependent asthma or comorbid conditions (atopic dermatitis or CRSwNP): Initial 600 mg, then 300 mg Q2W 2
• Pediatric patients 6-11 years:
  • 15 to <30 kg: 300 mg every 4 weeks (Q4W)
  • ≥30 kg: 200 mg Q2W 2

Atopic Dermatitis

• Adults: Initial 600 mg (two 300 mg injections), then 300 mg Q2W 2
• Pediatric patients 6 months to 5 years:
  • 5 to <15 kg: 200 mg Q4W
  • 15 to <30 kg: 300 mg Q4W 2
• Pediatric patients 6 years and older:
  • 15 to <30 kg: Initial 600 mg, then 300 mg Q4W
  • 30 to <60 kg: Initial 400 mg, then 200 mg Q2W
  • ≥60 kg: Initial 600 mg, then 300 mg Q2W 2

Administration Guidelines

• Administer subcutaneously into thigh, abdomen (except 2 inches around navel), or upper arm 2
• Rotate injection sites with each injection 2
• For initial loading doses, administer each injection at different sites 2
• Pre-filled pen for patients ≥2 years; pre-filled syringe for patients ≥6 months 2
• Consider completing all age-appropriate vaccinations prior to initiating treatment 2

Special Considerations

Patient Selection

• The Joint Task Force on Practice Parameters suggests biologics for CRSwNP patients who have not sufficiently benefited from other treatments such as intranasal corticosteroids or surgery 1
• Particularly beneficial for patients with:
  • High baseline disease severity
  • Comorbid asthma (improves both conditions simultaneously) 1, 4
  • Comorbid atopic dermatitis (treats multiple conditions) 1

Adverse Effects

• Most common adverse events: nasopharyngitis, injection site reactions, headache 1, 5
• Dupilumab may induce conjunctivitis in patients with atopic dermatitis but not typically in asthma or CRSwNP patients 1
• Dupilumab-associated ocular surface disease: bilateral conjunctival and limbal injection, watery or mucous discharge 1
  • Typically mild to moderate, presents within weeks to months of treatment initiation
  • Often manageable with treatment while continuing dupilumab 1

Clinical Pearls

• Rapid onset of action observed in real-world studies (significant improvements within 4 weeks) 4
• Effective in both allergic and non-allergic patients with severe asthma and nasal polyposis 4
• Works by inhibiting IL-4 and IL-13 signaling, key drivers of type 2 inflammation 6
• Effective regardless of presence of comorbid asthma or NSAID-exacerbated respiratory disease 6

Monitoring and Follow-up

• Assess response using validated measures:
  • CRSwNP: nasal polyp score, SNOT-22, VAS, smell testing
  • Asthma: lung function (FEV1), exacerbation rates, asthma control tests
  • Atopic dermatitis: disease severity and extent

By targeting the shared IL-4/IL-13 pathway, dupilumab effectively treats multiple type 2 inflammatory conditions simultaneously, making it particularly valuable for patients with overlapping conditions such as asthma, CRSwNP, and atopic dermatitis.