From the Guidelines
Dupixent (dupilumab) is a useful treatment option for allergic bronchopulmonary aspergillosis (ABPA), particularly in patients with treatment-dependent ABPA, due to its mechanism of action in blocking interleukin-4 and interleukin-13 signaling, key drivers of type 2 inflammation involved in ABPA. The most recent and highest quality study, a revised clinical practice guideline published in the European Respiratory Journal in 2024 1, suggests that biological agents, including dupilumab, are likely helpful in stable treatment-dependent ABPA based on case reports and small case series.
Key Points to Consider
- Dupilumab has been used in ABPA patients with promising results, although most experience with biological agents in ABPA is with omalizumab 1.
- The typical dosing for adults with other approved indications is 300mg subcutaneously every two weeks, which would likely be the regimen used for ABPA patients.
- Patients with ABPA typically present with poorly controlled asthma, recurrent pulmonary infiltrates, elevated IgE levels, and Aspergillus hypersensitivity, making dupilumab a rational therapeutic option due to its mechanism of action in type 2 inflammation.
- Treatment with dupilumab should be initiated by specialists familiar with both ABPA management and biologics, with regular monitoring of lung function, IgE levels, and radiographic findings to assess response.
Rationale for Use
The use of dupilumab in ABPA is supported by its efficacy in reducing type 2 inflammation, which is a key component of the disease pathology. As noted in the revised clinical practice guideline 1, biological agents have demonstrated clinical benefit in severe eosinophilic asthma, and their use in ABPA is a logical extension of this therapeutic approach. While more research is needed to fully establish the efficacy and safety of dupilumab in ABPA, the available evidence suggests that it is a useful treatment option for patients with this condition.
From the Research
Dupixent and ABPA
- Dupixent (dupilumab) has been studied as a potential treatment for allergic bronchopulmonary aspergillosis (ABPA) 2.
- ABPA is a disease characterized by severe disability with recurrent wheezing and shortness of breath, and current recommended therapy includes daily oral corticosteroids +/- oral antifungal therapy.
- The use of dupilumab as add-on therapy in a patient with ABPA allowed for a reduction in daily steroid dosage 2.
Mechanism of Action
- Dupilumab is a fully human monoclonal antibody against the interleukin (IL)-4 receptor α subunit of IL-4 and IL-4/IL-13 receptor complexes 3, 4.
- IL-4 and IL-13 are key cytokines in driving type 2 inflammation, a dominant and largely eosinophilic inflammatory pathway in asthma and other allergic diseases.
Efficacy in Asthma
- Dupilumab has been shown to be effective in reducing severe asthma exacerbations, improving lung function, and enabling oral corticosteroid (OCS) maintenance doses to be reduced without impacting asthma control in patients with moderate-to-severe asthma 3, 5, 6.
- Dupilumab has also been shown to be effective in patients with uncontrolled, moderate-to-severe allergic asthma, with greater efficacy observed in patients with elevated type 2 inflammatory biomarkers at baseline 5.
Relevance to ABPA
- While the majority of the studies focus on the use of dupilumab in asthma, the mechanism of action and efficacy in reducing type 2 inflammation suggest that dupilumab may be useful in the treatment of ABPA, which is also characterized by type 2 inflammation 2.