What is the recommended dupilumab dosing regimen for adults, adolescents, and children based on age and weight for atopic dermatitis, asthma, and chronic rhinosinusitis with nasal polyps?

Dupilumab Dosing Regimens

The FDA-approved dupilumab dosing varies by indication, age, and weight, with specific loading doses followed by maintenance regimens tailored to each patient population. 1

Atopic Dermatitis Dosing

Adults

• Initial dose: 600 mg (two 300 mg injections) subcutaneously, followed by 300 mg every 2 weeks (Q2W) 1
• This regimen achieves EASI 75 in 63-64% of patients at 16 weeks when combined with topical corticosteroids 2

Pediatric Patients (6 months to 5 years)

• 5 to <15 kg: 200 mg every 4 weeks (Q4W) 1
• 15 to <30 kg: 300 mg every 4 weeks (Q4W) 1

Pediatric Patients (6 years and older)

Weight-tiered dosing with loading doses: 1

• 15 to <30 kg: 600 mg loading dose (two 300 mg injections), then 300 mg Q4W 1
• 30 to <60 kg: 400 mg loading dose (two 200 mg injections), then 200 mg Q2W 1
• ≥60 kg: 600 mg loading dose (two 300 mg injections), then 300 mg Q2W 1

Clinical context: The Q4W regimen in adolescents proved inadequate in long-term studies, with 70.9% requiring uptitration to the approved Q2W dosing for adequate disease control, supporting Q2W as the optimal regimen for this age group 3

Asthma Dosing

Adults and Adolescents (≥12 years)

Standard dosing: 1

• Initial: 400 mg (two 200 mg injections), then 200 mg Q2W
• OR Initial: 600 mg (two 300 mg injections), then 300 mg Q2W

Higher dose required for: 1

• Oral corticosteroid-dependent asthma
• Co-morbid moderate-to-severe atopic dermatitis
• Adults with co-morbid chronic rhinosinusitis with nasal polyps
• Dosing: 600 mg loading dose, then 300 mg Q2W 1

Pediatric Patients (6-11 years)

• 15 to <30 kg: 300 mg Q4W 1
• ≥30 kg: 200 mg Q2W 1
• For co-morbid moderate-to-severe atopic dermatitis: Follow the atopic dermatitis dosing table with loading doses 1

Chronic Rhinosinusitis with Nasal Polyps (CRSwNP)

Adults and Adolescents (≥12 years)

• 300 mg every 2 weeks (Q2W) 1
• All patients must continue intranasal corticosteroids concurrently 4
• This regimen significantly improves nasal polyp scores, SNOT-22, disease severity, nasal congestion, smell, and CT scores 4, 5
• Improvements occur regardless of comorbid asthma, NSAID-exacerbated respiratory disease, or previous nasal polyp surgery 4

Eosinophilic Esophagitis

Patients ≥1 year and ≥15 kg

• 15 to <30 kg: 200 mg Q2W 1
• 30 to <40 kg: 300 mg Q2W 1
• ≥40 kg: 300 mg every week (QW) 1

Prurigo Nodularis (Adults)

• Initial: 600 mg (two 300 mg injections), then 300 mg Q2W 1

Chronic Obstructive Pulmonary Disease (Adults)

• 300 mg Q2W 1

Chronic Spontaneous Urticaria

Adults

• Initial: 600 mg (two 300 mg injections), then 300 mg Q2W 1

Adolescents (12-17 years)

• 30 to <60 kg: 400 mg loading dose (two 200 mg injections), then 200 mg Q2W 1
• ≥60 kg: 600 mg loading dose (two 300 mg injections), then 300 mg Q2W 1

Bullous Pemphigoid (Adults)

• Initial: 600 mg (two 300 mg injections), then 300 mg Q2W 1
• Must be used in combination with a tapering course of oral corticosteroids 1

Critical Management Considerations

Concomitant Therapy

• Continue topical agents for maintenance, rescue, or flare treatment in atopic dermatitis 2
• Maintain intranasal corticosteroids with dupilumab for CRSwNP 4

Ocular Adverse Events

• Counsel all patients about ocular adverse events before initiation 2
• Conjunctivitis occurs in 6-15% of clinical trial patients and up to 26.1% in real-world data 2, 6
• Only 4.2% discontinue due to ocular complications 2
• Offer prophylactic preservative-free ocular lubricants to patients with pre-existing corneal or conjunctival disease 7
• Urgently refer to ophthalmology (within 24 hours) for RAPID symptoms: Redness plus Acuity loss, Pain, Intolerance to light, or Damaged cornea 7

Common Pitfalls

• Avoid discontinuing therapy prematurely for mild ocular symptoms 2
• Do not use Q4W dosing in adolescents with atopic dermatitis expecting adequate control—Q2W is optimal 3
• Establish ophthalmology referral pathways before initiating therapy 2