How long should Dupixent (dupilumab) be held in a child before administering a live vaccine?

Dupilumab Hold Time Before Live Vaccines in Children

For children receiving dupilumab (Dupixent) who need live vaccines, the medication should be held for 1 dosing interval before administering the live vaccine, and then resumed no sooner than 4 weeks after vaccination. 1

Specific Recommendations for Dupilumab and Live Vaccines

• Dupilumab should be held for 1 dosing interval before administering a live attenuated vaccine, similar to other biologic agents that target interleukin pathways 1
• After live vaccine administration, dupilumab should be held for 4 weeks to prevent potential interference with vaccine efficacy and safety 1
• For medications with multiple approved dosing intervals, the longest interval should be chosen for the pre-vaccination hold period 1

Special Considerations for Children with Severe Atopic Dermatitis

• In children with severe atopic dermatitis where the risk of disease flare is very high if dupilumab is held, shorter hold times before vaccination can be considered if live attenuated vaccination is critical and cannot be delayed 1
• Shared decision-making with the child's parents/guardians is important in this setting, and they should be alerted to the signs and symptoms of attenuated vaccine-associated infection 1
• The recommendation to hold immunosuppressive medications for 4 weeks after live attenuated vaccination is conservative, as the typical duration of viremia after live attenuated vaccination is 2 weeks, although it can be longer in some patients 1

Evidence on Dupilumab and Live Vaccines

• Limited clinical data are available regarding the safety of administering live vaccines to patients on dupilumab 2
• A small case series of nine children with severe atopic dermatitis who received MMR vaccine with or without varicella vaccine while on dupilumab reported no adverse effects within 4 weeks after vaccination 2
• Five of these children had a ≤12-week gap (ranging from 1-7 weeks) between dupilumab administration and vaccination, and four resumed treatment as early as 2 days after vaccination 2

Common Live Vaccines in Children

• Measles, mumps, and rubella (MMR) vaccine is routinely administered at 12-15 months of age and 4-6 years 1
• Varicella vaccine is recommended at 12 months of age for susceptible children 1
• Rotavirus vaccine is administered at 2 and 4 months, or at 2,4, and 6 months 1

Post-Vaccination Considerations

• Medication hold times after vaccination can be shortened if vaccination is critical and the risk of disease flare when the patient is not receiving immunosuppression is high 1
• The 4-week post-vaccination hold period is based on the duration of viremia, which is typically 2 weeks but can be longer, especially after primary vaccination compared to booster vaccinations 1

Important Caveats

• These recommendations are based on guidelines for biologic agents in rheumatic diseases, as specific guidelines for dupilumab in atopic dermatitis are limited 1
• The risk of disease flare versus the risk of vaccine-preventable illness should be carefully weighed, especially in very young children who may require biologic therapy before their primary vaccination series is complete 1
• Close monitoring for signs of vaccine-associated infection is recommended if shortened hold times are used 1