What is the role of Dupixent (dupilumab) in Chronic Obstructive Pulmonary Disease (COPD) management?

Role of Dupilumab in COPD Management

Dupilumab is indicated for patients with COPD who have type 2 inflammation as indicated by elevated blood eosinophil counts (≥300 cells/μL), despite being on triple therapy, to reduce exacerbations and improve lung function. 1, 2

Current Position in COPD Treatment Algorithm

Dupilumab represents a targeted biological therapy for a specific COPD endotype characterized by:

• Blood eosinophil count ≥300 cells/μL
• Persistent exacerbations despite triple therapy (ICS/LABA/LAMA)
• Evidence of type 2 inflammation

Efficacy Evidence

The most recent high-quality evidence from phase 3 trials shows:

• 31.3% reduction in moderate or severe exacerbations compared to placebo (annualized rate 0.794 vs 1.156) 1
• Longer time to first severe exacerbation 1
• Improvement in pre-bronchodilator FEV1 by 83 mL more than placebo at 12 weeks 2
• Improvements in quality of life measures (SGRQ and E-RS-COPD scores) 2

Patient Selection Criteria

Dupilumab should be considered for patients with:

1. Confirmed COPD diagnosis with post-bronchodilator FEV1/FVC <0.7
2. Moderate to severe airflow limitation (FEV1 30-70% predicted)
3. Blood eosinophil count ≥300 cells/μL
4. History of exacerbations (≥2 moderate or ≥1 severe) in the previous year
5. Symptoms despite maximal triple therapy (ICS/LABA/LAMA)

Treatment Considerations

• Dupilumab is administered as 300 mg subcutaneously every 2 weeks 1, 2
• It should be used as an add-on to standard triple therapy, not as a replacement 1
• Efficacy is consistent regardless of:
  • BODE index scores (both low ≤4 and high >4) 3
  • Presence or absence of emphysema 4

Safety Profile

• Treatment-emergent adverse events, serious adverse events, and adverse events leading to discontinuation or death were similar between dupilumab and placebo groups 1
• No new safety signals specific to COPD patients have been identified

Position in Current Guidelines

Current COPD guidelines do not yet specifically address dupilumab as they predate the recent phase 3 trial results:

• The GOLD 2017 report focuses on bronchodilators, inhaled corticosteroids, and phosphodiesterase inhibitors as the mainstay of pharmacological treatment 5
• Traditional management emphasizes bronchodilators (short-acting for mild disease, long-acting for moderate to severe disease) 5, 6

Clinical Perspective

Dupilumab represents a shift toward precision medicine in COPD by targeting a specific inflammatory pathway (IL-4/IL-13) in patients with type 2 inflammation 7. This contrasts with traditional COPD management that has relied primarily on bronchodilation and non-specific anti-inflammatory approaches.

Practical Implementation

1. Identify patients with frequent exacerbations despite optimal triple therapy
2. Check blood eosinophil count (≥300 cells/μL)
3. Ensure patients meet other criteria (FEV1 30-70% predicted, post-bronchodilator FEV1/FVC <0.7)
4. Continue background triple therapy when initiating dupilumab
5. Monitor for clinical response (reduction in exacerbations, improvement in symptoms and lung function)

Dupilumab represents an important advancement in targeted therapy for COPD, particularly for the subset of patients with type 2 inflammation who continue to experience exacerbations despite maximal conventional therapy.