Should I continue taking Dupixent (dupilumab) for severe asthma with persistent cough and mucus despite nasal spray treatment and potential Clarifix procedure?

Should You Continue Dupixent for Persistent Asthma Symptoms?

Yes, you should continue Dupixent while your provider addresses the nasal/upper airway component of your symptoms, as persistent cough and mucus in asthma patients often reflects inadequately controlled upper airway disease rather than Dupixent failure. 1, 2

Understanding Your Situation

Your symptoms likely represent two separate but related problems that need concurrent treatment:

• Chronic rhinosinusitis or nasal disease causing post-nasal drip and mucus production 1
• Underlying severe asthma requiring continued biologic therapy 2

The FDA label for Dupixent explicitly states that patients should not change or stop their asthma medicines without talking to their healthcare provider, and that stopping may cause symptoms that were controlled by those medicines to return 2

Why Dupixent Should Be Continued

Dupixent's Role in Your Treatment

• Dupixent blocks type 2 inflammation that drives both asthma and nasal disease, working on the underlying inflammatory pathway rather than just symptoms 3, 4
• Clinical trials show Dupixent reduces severe asthma exacerbations by 87% in patients with elevated eosinophils, even when other medications are withdrawn 4
• Long-term studies demonstrate sustained efficacy for up to 3 years, with progressive improvements in exacerbation rates, lung function, and asthma control 5

The Nasal-Asthma Connection

• Chronic cough in asthma patients frequently has multiple contributing factors, with upper airway disease (rhinosinusitis, post-nasal drip) being a major contributor 1
• Your provider's approach of treating the nasal component with sprays and potentially Clarifix (cryotherapy for posterior nasal nerve) is appropriate and complementary to continuing Dupixent 1
• Dupixent is FDA-approved for both severe asthma and chronic rhinosinusitis with nasal polyps, suggesting it addresses both conditions simultaneously 2

Treatment Algorithm Moving Forward

Step 1: Continue Current Asthma Regimen

• Maintain Dupixent as prescribed 2
• Continue all other asthma controller medications (inhaled corticosteroids, long-acting beta-agonists) 1
• Do not discontinue or reduce medications without direct physician supervision 2

Step 2: Optimize Nasal/Upper Airway Treatment

• Complete the trial of nasal sprays as your provider recommended 1
• If inadequate response, proceed with Clarifix procedure 1
• Consider evaluation for chronic rhinosinusitis or nasal polyps if not already done 1, 2

Step 3: Reassess After Addressing Upper Airway

• Allow 4-8 weeks after optimizing nasal treatment to reassess cough and mucus 1
• If cough persists despite controlled nasal symptoms, consider:
  • Measuring airway inflammation (sputum eosinophils, FeNO) to assess if type 2 inflammation is controlled 1
  • Adding leukotriene receptor antagonist if not already prescribed 1
  • Increasing inhaled corticosteroid dose 1

Step 4: Consider Alternative Diagnoses Only After Above Steps

• Gastroesophageal reflux disease 1
• Non-asthmatic eosinophilic bronchitis 1
• Vocal cord dysfunction 1

Common Pitfalls to Avoid

Do Not Prematurely Discontinue Dupixent

• Dupixent takes time to achieve full effect, with continued improvements seen over months to years 5, 6
• Stopping biologics prematurely is a common error when patients have co-morbid conditions contributing to symptoms 7, 8
• The presence of persistent cough does not indicate Dupixent failure if other asthma parameters are improving 1, 2

Do Not Ignore the Upper Airway Component

• Up to 24-32% of chronic cough in asthma patients has multiple contributing factors 1
• Treating only the lower airway (lungs) while ignoring upper airway disease leads to persistent symptoms 1

Do Not Reduce Corticosteroids Too Quickly

• If you're on oral or high-dose inhaled corticosteroids, reduction must be gradual and supervised 2
• Abrupt reduction can cause withdrawal symptoms or unmask previously controlled conditions 2

Monitoring Your Response

Signs Dupixent Is Working (Even With Persistent Cough)

• Fewer severe asthma exacerbations requiring oral steroids or emergency care 4, 5
• Improved lung function on spirometry 4, 5
• Reduced rescue inhaler use 1
• Better exercise tolerance 1

When to Reassess the Treatment Plan

• If cough and mucus persist after 8-12 weeks of optimized nasal treatment 1
• If you develop new symptoms such as worsening shortness of breath, wheezing, or chest tightness 2
• If you experience frequent severe asthma exacerbations despite treatment 1, 7

Bottom Line

Your provider's approach is sound: address the nasal component while maintaining Dupixent. The persistent cough and mucus likely reflect upper airway disease rather than Dupixent failure. Discontinuing Dupixent prematurely could lead to loss of asthma control and increased exacerbations. Give the nasal treatment strategy adequate time to work (4-8 weeks), then reassess with your provider. 1, 2