Concerns with Starting Dupixent in a 7-Year-Old with Diffuse Eczema
The primary concern with starting dupixent (dupilumab) in a 7-year-old with diffuse eczema is the development of ocular complications, particularly dupilumab-related ocular surface disorders (DROSD), which occur in approximately 5-26% of pediatric patients. 1, 2
Ocular Complications
Risk Assessment
- Children aged 7 years are at particular risk for developing ocular complications that require monitoring
- Pre-existing eye conditions significantly increase risk for DROSD 3
- Patients with the following should be referred to ophthalmology before starting dupilumab:
- Significant current or chronic corneal/conjunctival disease
- History of corneal transplant or keratoconus
- Pre-existing dry eye disease with keratitis
- Eyelid eczema
- Previous ophthalmology attendance for ocular surface disorders 3
Monitoring and Management
- Assess ocular redness using the Efron grading system to classify DROSD as mild, moderate, or severe 1
- For mild DROSD: Preservative-free ocular lubricants 2-4 times daily 1
- For moderate DROSD: Add topical antihistamine eyedrops (e.g., olopatadine) 1
- For severe DROSD: Urgent ophthalmology referral within 24 hours or 4 weeks based on clinical judgment 1
- Children aged 7-17 years with severe DROSD should be referred to ophthalmology for assessment as an emergency or urgent assessment within 4 weeks 1
Other Safety Considerations
Common Adverse Effects
- Injection site reactions (approximately 10% of patients) 2
- Nasopharyngitis (approximately 17% of patients) 3
- Conjunctivitis (5-26% of patients) 3, 2, 4
- Head and neck dermatitis (19.5% in real-world studies) 4
Monitoring Requirements
- No routine laboratory monitoring is required before or during dupilumab treatment 3
- Transient eosinophilia may occur around week 16 of treatment but typically resolves by week 48 without requiring discontinuation 3
Efficacy in Pediatric Patients
Despite these concerns, dupilumab has demonstrated significant efficacy in pediatric patients:
- In children 6 months to 6 years: 53% achieved EASI-75 (75% improvement in eczema severity) vs 11% with placebo 5
- In children 6-11 years: 67-70% achieved EASI-75 vs 27% with placebo 6
- Real-world data shows 75% of pediatric patients achieve EASI-75 and 71% achieve EASI-90 7
- In children under 6 years (off-label use): 75% achieved EASI-75 by week 16 8
Decision Algorithm for Starting Dupixent in a 7-Year-Old
Pre-treatment assessment:
- Evaluate for pre-existing eye conditions
- If present, refer to ophthalmology before initiating dupilumab
- No routine laboratory testing required
Patient/caregiver education:
- Explain risk of conjunctivitis (5-26% of patients)
- Teach recognition of early eye symptoms (redness, irritation, discharge)
- Emphasize importance of reporting eye symptoms promptly
Treatment initiation:
- For children ≥30 kg: 200 mg every 2 weeks
- For children <30 kg: 300 mg every 4 weeks 1
- Can be used with or without topical corticosteroids
Monitoring plan:
- Regular assessment for ocular symptoms
- Immediate evaluation if eye symptoms develop
- No routine laboratory monitoring required
When to Consider Withdrawal of Dupilumab
Consider withdrawing dupilumab when ophthalmological assessment confirms:
- Significant risk to visual acuity from inadequately controlled DROSD inflammation
- Progressive conjunctival cicatrization
- Progressive loss of visual acuity
- Significant loss of quality of life caused by inadequately controlled DROSD 1
Conclusion
While ocular complications are the primary concern when starting dupilumab in a 7-year-old with diffuse eczema, the medication has demonstrated excellent efficacy and an overall favorable safety profile in pediatric patients. With appropriate monitoring and prompt management of ocular symptoms, most children can safely benefit from dupilumab therapy.