What are the alternative medications to Dupixent (dupilumab)?

Alternative Medications to Dupilumab for Atopic Dermatitis

For patients requiring an alternative to dupilumab (Dupixent) for moderate-to-severe atopic dermatitis, tralokinumab is the recommended first-line alternative, followed by JAK inhibitors (upadacitinib or abrocitinib) as second-line options. 1

First-Line Alternative: Tralokinumab

• Tralokinumab is a monoclonal antibody that specifically targets IL-13 (unlike dupilumab which targets both IL-4 and IL-13) 1
• Strong recommendation with moderate certainty of evidence for adults with moderate to severe atopic dermatitis 1
• Particularly beneficial for patients who developed dupilumab-associated arthralgia, as it has shown resolution of these symptoms while maintaining control of atopic dermatitis 2
• Similar efficacy profile to dupilumab but with potentially fewer side effects for certain patients 1, 2

Second-Line Alternatives: JAK Inhibitors

Upadacitinib

• Selective JAK-1 inhibitor with strong recommendation (moderate certainty of evidence) 1
• FDA-approved for patients who have failed other systemic therapies (including biologics) 1
• Available in 15mg or 30mg daily oral dosing 1
• Higher efficacy at reducing EASI scores compared to dupilumab in head-to-head trials 1

Abrocitinib

• Selective JAK-1 inhibitor with strong recommendation (moderate certainty of evidence) 1
• FDA-approved for patients who have failed other systemic therapies (including biologics) 1
• Available in 100mg or 200mg daily oral dosing 1
• Demonstrated superior efficacy to dupilumab in head-to-head trials 1

Other Treatment Options

Phototherapy

• Conditional recommendation (low certainty of evidence) for adults with atopic dermatitis 1
• Narrow band UVB is the most commonly used and studied form 1
• Should be supervised by a qualified clinician 1

Baricitinib

• JAK-1 and JAK-2 inhibitor approved in Europe but not FDA-approved for atopic dermatitis in the US 1
• Less efficacious than upadacitinib and abrocitinib based on network meta-analysis 1

Important Safety Considerations

For JAK Inhibitors

• FDA warnings for increased risk of serious cardiovascular events, cancer, blood clots, and death 1
• Baseline laboratory testing recommended: complete blood count with differential, liver enzymes, lipids, viral hepatitis, tuberculosis, and pregnancy 1
• Not considered first-line systemic therapy due to safety concerns 1

For Tralokinumab

• Generally well-tolerated with fewer ocular complications compared to dupilumab 2
• May be preferred in patients planning pregnancy compared to JAK inhibitors 1

Special Considerations

• For patients with dupilumab-related ocular surface disorders (DROSD), switching to JAK inhibitors like abrocitinib has shown resolution of eye symptoms in some cases 1
• For females planning pregnancy, consider tralokinumab over JAK inhibitors 1, 3
• For patients with comorbid conditions:
  • CRSwNP (chronic rhinosinusitis with nasal polyps): dupilumab remains first choice if tolerated 1
  • Eosinophilic COPD: dupilumab remains first choice if tolerated 1

Monitoring Recommendations

• For JAK inhibitors: Monitor complete blood count, liver enzymes, and lipids as recommended 1
• For biologics (tralokinumab): No specific laboratory monitoring required 3
• For all alternatives: Regular assessment of treatment efficacy and adverse effects 1