Monitoring for Patients Starting on Dupilumab (Dupixent)
When starting a patient on dupilumab (Dupixent), the AGACNP should primarily monitor for anaphylaxis reactions, as this is the most critical safety concern requiring immediate intervention.
Primary Monitoring Parameters
Anaphylaxis reactions: Monitor for hypersensitivity reactions including anaphylaxis, serum sickness, angioedema, urticaria, rash, erythema nodosum, and erythema multiforme, especially during and immediately after administration 1
Ocular symptoms: Closely monitor for development of conjunctivitis, keratitis, dry eyes, and blepharitis, which occur in approximately 25% of treated individuals, typically within the first 4 months of treatment 2, 3
Ocular assessment: Evaluate for redness, irritation, discharge, foreign body sensation, and visual changes at each follow-up visit 2, 4
Risk Factors for Ocular Complications
Pre-existing ocular surface disease: Patients with history of atopic conjunctivitis, keratitis, or other ocular surface disorders have higher risk of developing dupilumab-related ocular surface disorders (DROSD) 2, 4
Higher baseline disease severity: More severe atopic dermatitis at baseline may increase risk of ocular complications 4
Management Algorithm for Ocular Complications
For mild-to-moderate ocular symptoms:
- Initiate preservative-free ocular lubricants as first-line treatment 2, 3
- Add topical antihistamine eyedrops if lubricants alone are ineffective 2, 4
For severe ocular symptoms or red flags:
- Urgent ophthalmology referral within 24 hours if any of the following occur 2, 3:
- Decreased visual acuity
- Ocular pain
- Sensitivity to light
- Visible corneal damage
Other Important Monitoring Considerations
Arthralgia: Monitor for new onset or worsening joint symptoms, which may require rheumatological evaluation if persistent 1
Eosinophilic conditions: Be alert for vasculitic rash, worsening pulmonary symptoms, and/or neuropathy, especially when reducing oral corticosteroids 1
Parasitic infections: Monitor for signs of helminth infections, particularly in patients with risk factors 1
Important Clinical Pearls
Despite the risk of adverse effects, only about 4.2% of patients discontinue dupilumab due to ocular complications 3
Unilateral eye symptoms are very unlikely to be dupilumab-related and should prompt evaluation for other causes 3
Advise patients to avoid environments with ocular irritants such as smoke, pollution, and cooling fans 3
Do not discontinue systemic, topical, or inhaled corticosteroids abruptly upon initiation of dupilumab therapy; decrease gradually if appropriate 1
Live vaccines should be avoided during dupilumab treatment 1