What considerations should be taken for a 6-year-old patient with atopic dermatitis on Dupixent (dupilumab) injection for maintenance to ensure effective symptom control while minimizing potential side effects?

Dupixent Maintenance Therapy for a 6-Year-Old with Atopic Dermatitis

For a 6-year-old patient with atopic dermatitis on Dupixent maintenance, the FDA-approved dosing is weight-based: if the child weighs 15 to <30 kg, administer an initial loading dose of 600 mg (two 300 mg injections) followed by 300 mg every 4 weeks; if 30 to <60 kg, give 400 mg (two 200 mg injections) initially followed by 200 mg every other week. 1

Dosing and Administration

Weight-Based Dosing Protocol

• For children 15 to <30 kg: Initial loading dose of 600 mg (two 300 mg injections at different sites), then 300 mg every 4 weeks (Q4W) 1
• For children 30 to <60 kg: Initial loading dose of 400 mg (two 200 mg injections at different sites), then 200 mg every other week (Q2W) 1

Administration Requirements

• A caregiver must administer all injections in children under 12 years of age 1
• Use the pre-filled syringe (approved for ages ≥6 months) rather than the pen device (approved for ages ≥2 years but self-administration not appropriate at this age) 1
• Inject subcutaneously into the thigh or abdomen (avoiding 2 inches around navel), or upper arm if caregiver administers 1
• Rotate injection sites with each dose and avoid tender, damaged, bruised, or scarred skin 1

Missed Dose Management

• If an every 4-week dose is missed, administer within 7 days and resume the original schedule 1
• If not given within 7 days, administer the dose and start a new schedule based on that date 1

Concomitant Topical Therapy

• Dupixent can be used with or without topical corticosteroids 1
• Reserve topical calcineurin inhibitors for problem areas only: face, neck, intertriginous areas, and genitalia 1
• Continue liberal moisturization as adjunctive therapy 2

Monitoring for Ocular Complications

Baseline and Ongoing Surveillance

Children under 7 years require heightened vigilance because even mild ocular disease should be managed by ophthalmology due to limited ability to communicate symptoms and risk of interference with normal ocular development. 2

Red Flag Symptoms Requiring Emergency Ophthalmology (Within 24 Hours)

• Visual acuity loss 2, 3
• Eye pain 2, 3
• Photophobia (light intolerance) 2, 3
• Corneal damage or ulceration 2, 3

Note: Unilateral eye symptoms are unlikely to be dupilumab-related and suggest alternative pathology requiring standard ophthalmology evaluation. 3

First-Line Ocular Management

• Start preservative-free ocular lubricants 2-4 times daily at the first sign of any eye symptoms or facial redness 2, 3
• Preservative-free formulations are essential due to increased risk of allergic contact dermatitis in this population 2
• Implement lid hygiene protocols 2

Escalation for Moderate-to-Severe Ocular Disease

• For moderate symptoms: Add preservative-free antihistamine eyedrops 2
• For severe symptoms or refractory mild disease: Short-term topical corticosteroids (preservative-free dexamethasone 0.1%) with maximum 8-week duration 2
• Start corticosteroid-sparing agents early (tacrolimus ointment or ciclosporin drops) to facilitate tapering 2
• Any child <7 years with ocular symptoms requires ophthalmology referral within 4 weeks 2, 3

When to Consider Discontinuing Dupixent

• Progressive conjunctival cicatrization not responding to treatment with risk of reduced visual acuity 2
• Requirement for prolonged ocular corticosteroids (>8 weeks) despite corticosteroid-sparing agents 2
• Treatment-resistant disease requiring combination topical corticosteroids, tacrolimus, and ciclosporin 2

Important: Only 0.5-4.2% of patients require dupilumab discontinuation due to ocular complications, so most cases are manageable while continuing therapy. 2, 3

Safety and Efficacy Data

Real-World Effectiveness

• In children <6 years, 90% achieved EASI-75 and 73% achieved EASI-90 4
• In children 6-11 years, 76% achieved EASI-75 and 59% achieved EASI-90 4
• Long-term data through 52 weeks shows sustained improvement with mean EASI improvement of -84% to -92% 5

Safety Profile

• Most treatment-emergent adverse events are mild to moderate 6, 7
• Common adverse events include nasopharyngitis (47-56%) and injection site reactions 6, 5
• Conjunctivitis incidence is 5% in young children 8
• No serious adverse events led to treatment discontinuation in pediatric trials 4, 8, 6
• Serious infections are actually less frequent with dupilumab than placebo 6

Pre-Treatment Considerations

• Complete all age-appropriate vaccinations before initiating Dupixent per current immunization guidelines 1
• Evaluate for food and inhalant allergies as part of comprehensive AD management 2
• Treat any active infections before starting therapy 2

Common Pitfalls to Avoid

• Do not use the pre-filled pen device in children under 12 years; only the pre-filled syringe is appropriate for caregiver administration 1
• Do not delay ophthalmology referral for any child <7 years with ocular symptoms, even if mild 2
• Do not use preserved ocular lubricants due to high risk of allergic contact dermatitis in AD patients 2
• Do not continue topical ocular corticosteroids beyond 8 weeks without introducing corticosteroid-sparing agents and discussing alternative systemic therapy 2
• Do not assume unilateral eye symptoms are dupilumab-related; bilateral involvement is typical for drug-related ocular surface disease 3