What are the considerations for using Dupixent (dupilumab) in a female teenager?

Dupilumab Considerations for Female Teenagers with Atopic Dermatitis

Dupilumab is an effective and generally well-tolerated treatment option for female teenagers with moderate-to-severe atopic dermatitis, with ocular surface disorders being the most significant consideration requiring monitoring and management. 1

Efficacy and Approval Status

• Dupilumab is approved for patients aged 6 years and above with moderate-to-severe atopic dermatitis (AD) inadequately controlled by conventional therapies 1
• In clinical trials, dupilumab demonstrated EASI-75 improvement (75% reduction in Eczema Area Severity Index) in 41.5% of adolescents with uncontrolled moderate-to-severe AD after 16 weeks of treatment 1
• Real-world data shows even better outcomes, with one study showing all patients who received dupilumab for 1 year or more achieved 75% improvement in EASI 2

Administration and Dosing

• Dupilumab is administered as a subcutaneous injection with dosing based on age and weight 3
• For adolescents, the standard regimen typically starts with a loading dose followed by maintenance dosing every 2 weeks 3
• Can be used as monotherapy or in combination with topical corticosteroids for enhanced efficacy 1

Key Safety Considerations

Ocular Surface Disorders

• The most prevalent adverse effect is dupilumab-related ocular surface disorders (DROSD), occurring in 6-15% of patients in clinical trials but up to 26.1% in real-world data 1

• Common ocular manifestations include:

  • Conjunctivitis (15.6% in real-world studies) 4
  • Dry eyes (7.8% in real-world studies) 4
  • Blepharitis 1

• Risk factors for developing ocular complications include:

  • Pre-existing eye disease 1
  • History of atopic keratoconjunctivitis 1

• Management approach for ocular symptoms:

  1. Prophylactic preservative-free ocular lubricants should be offered to patients with pre-existing eye disease 1
  2. For mild symptoms: preservative-free ocular lubricants 1
  3. For moderate symptoms: referral to ophthalmology within 4 weeks 1
  4. For severe symptoms (using RAPID criteria: Redness plus Acuity loss, Pain, Intolerance to light, or Damaged cornea): urgent ophthalmology referral within 24 hours 1

Other Common Adverse Effects

• Injection site reactions 1, 5
• Facial redness 1
• Herpes simplex virus infections 1, 5
• Head and neck dermatitis (19.5% in real-world studies) 4

Less Common but Important Considerations

• Blood eosinophilia has been reported in real-world data 6
• Patients should be monitored for signs of eosinophilic conditions and report symptoms consistent with eosinophilic pneumonia or vasculitis 3
• New-onset psoriasis and psoriatic arthritis have been reported 3

Special Considerations for Female Teenagers

• Pregnancy: No definitive data on safety during pregnancy, but patients who become pregnant while on dupilumab should be encouraged to enroll in the pregnancy exposure registry 3
• Menstrual cycle: No reported effects on reproductive organs or menstrual cycle length in animal studies 3
• Unlike methotrexate (another systemic therapy for severe AD), dupilumab is not known to have teratogenic effects, which is an important consideration for females of reproductive age 1
• Long-term safety profile appears favorable with over 10 years of follow-up data available 1

Monitoring Recommendations

• Baseline eye examination for patients with pre-existing eye disease 1
• Regular assessment for ocular symptoms at follow-up visits 1
• No specific laboratory monitoring requirements (unlike other systemic immunomodulators such as methotrexate or cyclosporine) 1
• Monitor for signs of parasitic (helminth) infections 3

Vaccination Considerations

• Live vaccines are not recommended immediately prior to or during dupilumab therapy 3
• Patients should inform healthcare providers about dupilumab use before receiving vaccinations 3

Treatment Discontinuation

• Approximately 4.2% of patients discontinue dupilumab due to ocular complications 1
• Most side effects are mild and do not require discontinuation of therapy 4
• Benefits typically outweigh risks for patients with moderate-to-severe AD 5, 2

Dupilumab represents a significant advancement in the treatment of moderate-to-severe atopic dermatitis in adolescents, with a favorable safety profile compared to traditional systemic immunosuppressants. The most important consideration is monitoring for and managing ocular surface disorders, which are generally treatable and rarely require discontinuation of therapy.