What is the proper protocol for initiating dupilumab (dupilumab) treatment in a patient with a history of atopic dermatitis, asthma, or chronic rhinosinusitis with nasal polyposis who has failed other treatments?

How to Start a Patient on Dupilumab

Before initiating dupilumab, screen all patients for pre-existing ocular disease and ensure appropriate vaccinations are up to date, then begin with a loading dose followed by regular maintenance dosing based on the specific indication. 1

Pre-Treatment Screening and Risk Assessment

Ocular Assessment (Critical for Atopic Dermatitis Patients)

Patients with current or pre-existing corneal or conjunctival eye disease require prophylactic preservative-free ocular lubricants before starting dupilumab. 1

• Delay dupilumab initiation in patients with a history of corneal transplant until ophthalmology consultation is obtained 1
• Delay dupilumab initiation in patients with reversible acute eye conditions (e.g., infectious conjunctivitis) until complete resolution 1
• Refer to ophthalmology (standard/routine pathway) for patients with significant current or chronic corneal or conjunctival eye disease before starting therapy 1

Key risk factors for developing dupilumab-related ocular surface disorders (DROSD): 1

• History of atopic conjunctivitis, keratitis, or other ocular surface disorders
• Pre-existing dry eye disease (OR 6.3) 2
• Any prior eye disease (OR 2.97) 2
• Prior use of ophthalmic medications (OR 5.16) 2
• Eyelid or facial eczema 1

Vaccination Requirements

Complete all age-appropriate vaccinations, particularly for helminth infections, prior to initiating dupilumab therapy. 3

Dosing Protocols by Indication

Atopic Dermatitis

Adults and adolescents (≥12 years): 3

• Loading dose: 600 mg subcutaneously (two 300 mg injections)
• Maintenance: 300 mg every 2 weeks

Children (specific weight-based dosing applies): 3

• Refer to FDA prescribing information for pediatric weight-based dosing

Asthma

Standard dosing: 3

• Loading dose: 400 mg or 600 mg subcutaneously (depending on specific patient factors)
• Maintenance: 200 mg or 300 mg every 2 weeks

Chronic Rhinosinusitis with Nasal Polyps (CRSwNP)

All patients receive concomitant intranasal corticosteroids (mometasone furoate nasal spray 100 μg in each nostril twice daily). 1, 4

Standard dosing: 1, 3, 4

• Loading dose: 300 mg subcutaneously
• Maintenance: 300 mg every 2 weeks

This regimen significantly improves nasal polyp scores, Lund-Mackay CT scores, nasal congestion, sense of smell (UPSIT), and quality of life (SNOT-22) at 24 weeks. 1, 5, 4

Eosinophilic Esophagitis, Prurigo Nodularis, and COPD

Refer to FDA prescribing information for specific dosing regimens for these indications. 3

Administration Technique

Subcutaneous injection sites: 3

• Abdomen (except 2 inches around navel)
• Thigh
• Upper arm (if administered by caregiver)
• Rotate injection sites with each dose

Patient Education and Monitoring

Ocular Monitoring (Especially Critical for Atopic Dermatitis)

Educate patients to immediately report any eye symptoms, as ocular complications occur in 10-42% of atopic dermatitis patients, typically within the first 4 months. 2

RAPID criteria requiring urgent ophthalmology referral within 24 hours: 1, 2

• Redness PLUS any of the following:
• Acuity loss or worsening
• Pain (ocular pain, moderate or severe, not just irritation)
• Intolerance of light (photophobia)
• Damaged cornea visible or opacity

Important caveat: Unilateral eye symptoms are very unlikely to be dupilumab-related and should be managed through existing pathways, not attributed to the medication. 1, 2

Mild-to-Moderate Ocular Symptoms Management

First-line treatment: 2

• Preservative-free ocular lubricants
• Topical antihistamine eyedrops
• Continue dupilumab in most cases (only 4.2% of patients discontinue due to ocular complications) 2

Environmental modifications: 2

• Avoid smoke, pollution, and cooling fans directed at the face

Asthma and COPD Patients

Do not use dupilumab to treat acute bronchospasm or acute exacerbations. 3

When initiating dupilumab in patients on systemic corticosteroids, taper corticosteroids gradually under medical supervision; do not discontinue abruptly. 3

Common Pitfalls to Avoid

• Do not skip pre-treatment ocular assessment in atopic dermatitis patients with any history of eye disease 1
• Do not start dupilumab in patients with active infectious conjunctivitis until resolved 1
• Do not attribute all eye problems to dupilumab without proper ophthalmologic evaluation, especially if symptoms are unilateral 1, 2
• Do not forget concomitant intranasal corticosteroids for CRSwNP patients 1, 4
• Do not use dupilumab as rescue therapy for acute asthma or COPD symptoms 3

Expected Outcomes

Atopic dermatitis patients: Significant improvement in skin disease with excellent overall safety profile over 10+ years of follow-up data 2

CRSwNP patients: Significant reductions in nasal polyp score (-1.80 to -2.06), Lund-Mackay CT scores (-5.13 to -7.44), nasal congestion scores (-0.87 to -0.89), and improved sense of smell at 24 weeks 1, 4

Asthma patients with CRSwNP: Additional improvements in lung function (FEV1) and asthma control regardless of baseline eosinophil count 1, 6