Dupilumab (Dupixent): Uses and Dosing
Dupilumab is a fully human monoclonal antibody that blocks the IL-4 receptor α subunit, inhibiting both IL-4 and IL-13 signaling pathways to treat multiple type 2 inflammatory conditions including atopic dermatitis, asthma, chronic rhinosinusitis with nasal polyps, eosinophilic esophagitis, prurigo nodularis, and chronic obstructive pulmonary disease.
FDA-Approved Indications
Atopic Dermatitis
- Adults: Initial dose of 600 mg (two 300 mg injections), followed by 300 mg every 2 weeks 1
- Pediatric patients (6 months to 5 years):
- 5 to <15 kg: 200 mg every 4 weeks
- 15 to <30 kg: 300 mg every 4 weeks 1
- Pediatric patients (6-17 years):
- 15 to <30 kg: 600 mg loading dose, then 300 mg every 4 weeks
- 30 to <60 kg: 400 mg loading dose, then 200 mg every 2 weeks
- ≥60 kg: 600 mg loading dose, then 300 mg every 2 weeks 1
Asthma
- Adults and pediatric patients ≥12 years:
- Standard: 400 mg loading dose, then 200 mg every 2 weeks OR 600 mg loading dose, then 300 mg every 2 weeks
- For oral corticosteroid-dependent asthma or comorbid conditions: 600 mg loading dose, then 300 mg every 2 weeks 1
- Pediatric patients (6-11 years):
- 15 to <30 kg: 300 mg every 4 weeks
- ≥30 kg: 200 mg every 2 weeks 1
Chronic Rhinosinusitis with Nasal Polyps
- Adults and pediatric patients ≥12 years: 300 mg every 2 weeks 1
- Significantly improves nasal polyp score, quality of life, nasal congestion, sense of smell, and sinus opacification 2, 3
Eosinophilic Esophagitis
- Adults and pediatric patients ≥1 year (≥15 kg):
- 15 to <30 kg: 200 mg every 2 weeks
- 30 to <40 kg: 300 mg every 2 weeks
- ≥40 kg: 300 mg every week 1
Prurigo Nodularis
- Adults: Initial dose of 600 mg, followed by 300 mg every 2 weeks 1
Chronic Obstructive Pulmonary Disease
- Adults: 300 mg every 2 weeks for patients with inadequately controlled COPD and an eosinophilic phenotype 1
Administration
- Administered by subcutaneous injection into the thigh, abdomen (except within 2 inches of navel), or upper arm 1
- Rotate injection sites with each administration 1
- Pre-filled pen is for patients ≥2 years; pre-filled syringe for patients ≥6 months 1
- For patients ≥12 years, self-administration is possible after proper training 1
Important Considerations
Pre-Treatment Assessment
- Consider completing all age-appropriate vaccinations prior to initiating dupilumab 1
- Assess for pre-existing eye conditions, particularly in patients with atopic dermatitis 2
- Refer patients with significant corneal or conjunctival eye disease to ophthalmology before starting treatment 2
- Delay treatment in patients with corneal transplant until discussion with ophthalmology 2
- Delay treatment in patients with acute eye conditions (e.g., infectious conjunctivitis) until resolution 2
Monitoring
- Monitor for ocular symptoms, particularly in patients with atopic dermatitis 2
- Watch for potential adverse effects:
Risk Factors for Dupilumab-Related Ocular Surface Disorders
- Atopic dermatitis diagnosis
- Previous ophthalmology attendance for ocular surface disorders
- Eyelid or facial eczema
- Elevated baseline IgE or eosinophil count 2
Clinical Efficacy
- In chronic rhinosinusitis with nasal polyps, dupilumab significantly improves:
- Benefits observed regardless of comorbid asthma or NSAID-exacerbated respiratory disease 3, 5
- Improves lung function in patients with comorbid asthma 3
Missed Doses
- Weekly dosing: Administer as soon as possible and start a new weekly schedule
- Every 2 weeks dosing: Administer within 7 days of missed dose and resume original schedule
- Every 4 weeks dosing: Administer within 7 days of missed dose and resume original schedule 1
Dupilumab represents a significant advancement in treating multiple type 2 inflammatory conditions, with demonstrated efficacy and a generally favorable safety profile across various indications.