Managing Recurrent Upper Respiratory Infections in Patients Taking Dupixent (Dupilumab)
Dupilumab treatment is associated with a reduced incidence of respiratory infections in patients with moderate-to-severe asthma or chronic rhinosinusitis with nasal polyps, and does not increase the risk of overall systemic or cutaneous infections in adults with atopic dermatitis. 1
Understanding the Relationship Between Dupilumab and URIs
Dupilumab is a fully human monoclonal antibody that targets the IL-4 receptor alpha, inhibiting both IL-4 and IL-13 signaling pathways that drive type 2 inflammation. Contrary to concerns about immunosuppression, evidence shows:
- Post-hoc analysis of phase 3 trials demonstrated that dupilumab treatment was associated with a 22% lower incidence of respiratory infections in asthma patients and 38% lower incidence in chronic rhinosinusitis with nasal polyps patients compared to placebo 1
- Long-term studies (up to 4 years) show no increased risk of overall infections in adults with moderate-to-severe atopic dermatitis treated with dupilumab 2
- Meta-analysis data shows dupilumab actually reduces the risk of skin infections (RR 0.54) while having little effect on nasopharyngitis, urinary tract infection, upper respiratory tract infection, and herpes virus infection 3
Management Algorithm for Recurrent URIs in Dupilumab Patients
Step 1: Confirm URI Diagnosis and Rule Out Bacterial Infection
- Distinguish viral URI from bacterial sinusitis based on:
Step 2: Implement Infection Prevention Strategies
- Hand hygiene is the most effective prevention method 5
- Use alcohol-based hand rubs or antimicrobial soap
- Decontaminate hands before and after patient contact
- Regular cleaning of surfaces to prevent viral spread 5
- Consider mask use during outbreaks 5
- Practice social distancing during outbreak periods 5
Step 3: Symptom Management for Confirmed Viral URIs
- Nasal saline irrigation for congestion relief 5
- Acetaminophen or NSAIDs for fever and pain management 5
- First-generation antihistamine with decongestant (e.g., brompheniramine with pseudoephedrine) can reduce cough and other symptoms 5
- Topical decongestants for short-term relief (≤3-5 days) 5
- Avoid antibiotics for uncomplicated viral URIs as they are ineffective and contribute to resistance 4, 5
Step 4: Monitor for Complications or Worsening Symptoms
- Follow up within 72 hours if symptoms worsen or fail to improve 5
- Return for medical evaluation if fever >38°C persists for more than 48 hours 5
- Watch for signs of progression to lower respiratory tract infection 5
Special Considerations
Immunocompromised Patients
- May require closer monitoring and more aggressive treatment 5
- Consider combination therapy with IVIG or specific antibody preparations if severely immunocompromised 5
Elderly Patients
- Monitor closely for progression to lower respiratory tract infection 5
- Consider impact of comorbidities on treatment choices 5
Common Pitfalls to Avoid
Unnecessary Antibiotic Use: Antibiotics are ineffective for viral illnesses and should not be prescribed for uncomplicated viral URIs 4, 5
- Overuse contributes to antibiotic resistance
- Can cause adverse events requiring medical attention
Misdiagnosing Bacterial Sinusitis: Purulent nasal discharge alone is not diagnostic of bacterial infection 4
- In uncomplicated viral URIs, nasal discharge often changes from clear to purulent and back to clear without antibiotics
Prolonged Use of Topical Decongestants: Should not exceed 3-5 days due to risk of rhinitis medicamentosa 5
Discontinuing Dupilumab Due to URIs: Evidence shows dupilumab does not increase respiratory infection risk and may actually reduce it 1
By following this structured approach to managing recurrent URIs in patients on dupilumab, clinicians can effectively treat symptoms while avoiding unnecessary antibiotics and maintaining the benefits of dupilumab therapy.