What are the considerations for adding Dupixent (dupilumab) to the treatment regimen of a patient with atopic dermatitis (AD) who is already on Remicade (infliximab)?

Using Dupilumab (Dupixent) for Atopic Dermatitis in a Patient on Infliximab (Remicade)

Dupilumab is recommended as a safe and effective treatment option for patients with moderate-to-severe atopic dermatitis who are already on infliximab, as there are no known significant drug interactions between these biologics. 1

Efficacy and Safety Considerations

Efficacy of Dupilumab

• Dupilumab is strongly recommended as a first-line biologic therapy for adults with moderate-to-severe atopic dermatitis who have failed topical therapies 1
• The standard dosing regimen of 300 mg every 2 weeks has demonstrated sustained efficacy in long-term studies, with mean reductions of over 90% in Eczema Area and Severity Index (EASI) scores at week 204 2
• Dupilumab has shown consistent efficacy in maintaining response over time when administered every 2 weeks, which is the FDA-approved regimen 3

Safety Profile with Concurrent Biologics

• There are no specific contraindications for using dupilumab concurrently with infliximab in current guidelines 1
• The most common adverse events with dupilumab include nasopharyngitis, upper respiratory tract infections, and injection site reactions 2, 4
• The safety profile of dupilumab has been consistent across multiple studies with no new safety signals emerging in long-term use 2

Ocular Considerations

Monitoring for Ocular Side Effects

• Dupilumab-related ocular surface disorders (DROSD) occur in approximately 25% of treated individuals, typically within the first 4 months of treatment 1
• Risk factors for developing DROSD include:
  • Pre-existing ocular surface disorders
  • History of atopic conjunctivitis or keratitis
  • Higher baseline AD severity 1
• Patients with pre-existing corneal or conjunctival eye disease should be offered prophylactic preservative-free ocular lubricants before starting dupilumab 1

Management of Ocular Side Effects

• For mild-to-moderate ocular symptoms (irritation, redness), preservative-free ocular lubricants are typically effective 1
• For severe symptoms or if red flags are present (acuity loss, pain, photophobia, corneal damage), urgent referral to ophthalmology within 24 hours is recommended 1
• In cases requiring topical corticosteroid eye drops for more than 6-8 weeks, consider alternative systemic therapies 1

Treatment Algorithm for Dupilumab in Patients on Infliximab

1. Pre-treatment Assessment:

   • Evaluate severity of atopic dermatitis and impact on quality of life 1
   • Screen for pre-existing ocular conditions 1
   • If significant current or chronic eye disease is present, refer to ophthalmology before initiating dupilumab 1

2. Initiation of Therapy:

   • Standard dosing: 600 mg loading dose, followed by 300 mg every 2 weeks 1
   • For patients with pre-existing ocular disease, start prophylactic preservative-free ocular lubricants 1
   • Continue current infliximab regimen as prescribed 1

3. Monitoring:

   • Assess treatment response at 16 weeks using validated measures (EASI, IGA) 1
   • Monitor for ocular symptoms at each visit, particularly in the first 4 months 1
   • Evaluate for other potential adverse events including injection site reactions and nasopharyngitis 2, 4

4. Long-term Management:

   • Maintain the standard dosing regimen of 300 mg every 2 weeks for optimal long-term efficacy 3
   • Consider extended interval dosing (every 3-4 weeks) only in patients with well-controlled disease 5
   • If inadequate response or intolerable side effects occur, consider switching to JAK inhibitors such as upadacitinib 6

Special Considerations and Pitfalls

• Avoid common pitfalls:

  • Do not delay treatment of significant ocular symptoms; early intervention reduces risk of complications 1
  • Do not discontinue dupilumab prematurely due to mild ocular symptoms, as these can often be managed with lubricants 1
  • Do not use systemic corticosteroids as long-term therapy for atopic dermatitis, even with inadequate response to dupilumab 1

• Treatment alternatives if dupilumab is ineffective or not tolerated:

  • JAK inhibitors (upadacitinib, abrocitinib) have shown efficacy in patients who failed dupilumab therapy 6
  • Tralokinumab is an alternative biologic targeting IL-13 specifically 1
  • Traditional immunosuppressants (cyclosporine, methotrexate, azathioprine) may be considered but have less favorable safety profiles 1