What is the recommended approach for restarting Dupixent (dupilumab) after missing doses?

Restarting Dupixent After Missing Doses

Resume dupilumab at the standard maintenance dose (300 mg every 2 weeks) without repeating loading doses if you miss doses within your scheduled interval, but restart with loading doses if more than 3-4 half-lives have elapsed (approximately 8-16 weeks) and the patient is experiencing disease flare. 1

Dosing Schedule Based on Time Elapsed

For Weekly Dosing Schedule

• If missed dose is remembered within 7 days: Give the injection as soon as possible and start a new weekly schedule from that time 1
• No backup measures needed for short delays 1

For Every 2-Week Dosing Schedule

• If within 7 days of missed dose: Give the injection and continue with your original schedule 1
• If more than 7 days have passed: Start a new every 2-week schedule from when you remember to take the injection 1

For Every 4-Week Dosing Schedule

• If within 7 days of missed dose: Give the injection and continue with your original schedule 1
• If more than 7 days have passed: Start a new every 4-week schedule from when you remember to take the injection 1

When to Consider Loading Doses Upon Restart

The decision to repeat loading doses depends on two critical factors: disease severity at restart and duration of treatment interruption. 2

Repeat Loading Doses If:

• More than 3-4 half-lives have elapsed since the previous dose (dupilumab half-life is approximately 2 weeks, so this means roughly 8-16 weeks without treatment) 2, 3
• Patient is experiencing active disease flare with significant worsening of atopic dermatitis, asthma, or other indication 2, 3
• Both conditions together strongly indicate need for loading dose reinitiation 2

Resume Maintenance Dosing Without Loading If:

• Treatment gap is brief (within the timeframes specified above for each dosing schedule) 1
• Disease remains well-controlled despite the missed doses 4, 5
• Patient achieved and maintained good clinical response before the interruption 4, 5

Evidence for Dosing Flexibility

The SOLO-CONTINUE trial demonstrated that continuing dupilumab weekly or every 2 weeks maintained optimal efficacy with negligible change in disease severity (-0.06% change in EASI score), while longer intervals showed dose-dependent worsening (every 4 weeks: -3.84%; every 8 weeks: -6.84%; placebo: -21.67%). 4

More patients maintained EASI-75 response with weekly or every 2-week dosing (71.6%) compared to every 4 weeks (58.3%), every 8 weeks (54.9%), or placebo (30.4%). 4

Clinical Considerations for Restart

Assess Disease Activity Before Restart

• Evaluate current Eczema Area and Severity Index (EASI) score or disease-specific severity measures 4, 6
• Consider quality of life impact, not just body surface area involvement 6
• Rule out confounding dermatoses that may mimic disease flare 6

Monitor for Treatment Response

• Most patients who maintain good control can successfully restart at maintenance dosing without loss of efficacy 5
• Real-world data shows that 34 of 35 patients (97%) who extended to every 3 weeks maintained clinical response at 16 weeks 5
• Retreatment after discontinuation may result in a small percentage of patients not recapturing their previous robust response 2

Common Pitfalls to Avoid

Do not automatically restart the entire loading regimen for brief treatment interruptions within the scheduled dosing window - this wastes medication and increases unnecessary exposure. 1

Do not ignore disease flare status when deciding on restart strategy - active flares with prolonged gaps (>8-16 weeks) warrant loading dose reinitiation rather than jumping back to maintenance. 2, 3

Do not assume all patients will recapture their previous response after prolonged interruption - some patients may require dose optimization or adjunctive therapy. 2, 6

Avoid restarting during active febrile illness or infection - wait until full resolution of symptoms and completion of any antibiotic course before resuming dupilumab. 2

Safety Monitoring Upon Restart

• Treatment-emergent antidrug antibody incidence is lower with more frequent dosing (1.2% weekly, 4.3% every 2 weeks, 6.0% every 4 weeks, 11.7% every 8 weeks) 4
• Overall adverse event rates remain similar across dosing frequencies (70-82%) 4
• Conjunctivitis rates do not significantly differ with standard dosing intervals, though some evidence suggests extended intervals may reduce ocular adverse events 4, 7, 5