What are the contraindications for Dupixent (dupilumab) on a chest X-ray (CXR)?

Contraindications for Dupixent on Chest X-ray

There are no specific chest X-ray findings that constitute contraindications for Dupixent (dupilumab) therapy. Dupixent's contraindications are primarily related to hypersensitivity reactions rather than radiographic findings 1.

Official Contraindications for Dupixent

According to the FDA label, the only absolute contraindication for Dupixent is:

• Known hypersensitivity to dupilumab or any excipients of Dupixent 1

Chest X-ray Considerations When Using Dupixent

While chest X-ray findings themselves are not contraindications, certain clinical conditions that may be visible on imaging warrant careful consideration:

Eosinophilic Conditions

• Patients being treated with Dupixent may present with features of eosinophilic pneumonia or eosinophilic granulomatosis with polyangiitis (EGPA) 1
• Healthcare providers should be alert to:
  • Worsening pulmonary symptoms
  • Vasculitic rash
  • Cardiac complications
  • Kidney injury
  • Neuropathy in patients with eosinophilia 1

Pulmonary Infections

• Parasitic (helminth) infections should be treated before initiating Dupixent 1
• If patients become infected while receiving Dupixent and do not respond to anti-helminth treatment, discontinue Dupixent until the infection resolves 1

Monitoring Recommendations

When evaluating chest X-rays in patients on Dupixent:

1. Baseline Assessment: Consider obtaining a baseline chest X-ray before initiating therapy, particularly in patients with pre-existing pulmonary conditions

2. Follow-up Imaging: Perform chest imaging if patients develop:

   • Worsening respiratory symptoms
   • New-onset dyspnea
   • Persistent cough
   • Chest pain

3. Specific Findings to Monitor:

   • Pulmonary infiltrates
   • Consolidation
   • Ground-glass opacities that might suggest eosinophilic pneumonia
   • Signs of infection

Special Considerations

Comorbid Conditions

• In patients with comorbid asthma or COPD, Dupixent has shown efficacy and safety 2
• For patients with chronic rhinosinusitis with nasal polyps (CRSwNP), Dupixent is effective regardless of allergic rhinitis status 3

Adverse Events That May Affect Pulmonary Function

• While rare, chest pain has been reported in case reports following Dupixent administration 4
• Most common adverse events are not pulmonary in nature but include:
  • Injection site reactions
  • Conjunctivitis
  • Nasopharyngitis 5, 1

Clinical Approach

When reviewing a chest X-ray in a patient who is a candidate for Dupixent:

1. Rule out active infections, particularly those that might be exacerbated by immunomodulatory therapy

2. Document any baseline pulmonary abnormalities to facilitate future comparisons

3. If significant abnormalities are found, consider pulmonary consultation before initiating therapy

4. For patients already on Dupixent who develop new chest X-ray abnormalities, evaluate for:

   • Eosinophilic pneumonia
   • Opportunistic infections
   • Other pulmonary complications

Remember that Dupixent's safety profile has been established over more than 10 years of follow-up and is generally considered excellent 6, with most adverse events being non-pulmonary in nature.