Expert Perspectives in the Management of Pediatric Atopic Dermatitis - Episode 15

Dupilumab Dosing Considerations for Pediatric Patient Populations

September 15, 2022
Raj Chovatiya, MD, PhD

,
Brittany G. Craiglow, MD

,
Peter Lio, MD

Dr Brittany G. Craiglow reviews dosing considerations and nuances for the use of dupilumab for atopic dermatitis in pediatric populations.

Raj Chovatiya, MD, PhD: We’ll get into the weeds here a bit, and I know that you can probably say this like the back of your hand whereas the rest of us can’t, you can talk about some of the nuances and differences in dosing of dupilumab across the age groups we’re thinking about. I know oftentimes we have a very adult-centric view of things, but the actual regimen does change a little below the age of 18.

Brittany G. Craiglow, MD: What I tell people is that you can always look it up. You need to make sure if you don’t treat a lot of children, and you’re not used to doing a lot of weight-based dosing, you can always look it up, but you also need to have a scale in your office. You can’t be trusting patients for their weight. You said something before, children aren’t just little adults, and it’s true they really aren’t. But with Dupixent [dupilumab], aside from the dosing and aside from thinking about vaccines and the younger patients, it’s really not that different. People who are worried about treating children, or maybe you see them in your practice, but you’re not sure if you can pull the trigger on this—if you can do it in adult, you can do it in a child. You can feel empowered, it’s OK. Like we said, nothing came up different in these groups in terms of adverse effects. It’s a very similar conversation, etc.

For the dosing, if you’re 18 and over, you get loaded with 2- 300 mg doses, and then you get 300 mg every 2 weeks. Once you hit 12 years old, if you’re 60 kg or more, you get treated like a grown-up. You get the same dose. As a side note I will say that if you have asthma and you’re 12, you get treated like an adult no matter how much you weigh. In my children with concomitant asthma or who are near 60 kg, I try to get them the higher dose when I can. Remember, children are always growing. If they’re on the brink, sometimes I try to get them on the higher dose because they’re going to be there in 6 months anyway.

In your 6 to 11 age group, if they’re 60 kg or more, they’re adults, so it doesn’t matter. The cutoffs are 30 to 60 kg. They’re going to be getting the 200 mg dose, but they’re still going to load with 2 doses, and then they get 200 mg every 2 weeks, so the same schedule. Then the next cutoff is 15 to 30 kg patients, these are your early elementary school children usually. What’s a little surprising for people is they get the same loading dose as an adult. So they get loaded with 600 mg, but they don’t get redosed until 4 weeks later. So they get 300 mg monthly. When the indication came out I was so excited because they had done Q every 2 weeks and Q4 weeks in the trials, but when data came out showing Q4 weeks was a little more effective, and had a little better safety, so that was what came on the label. I’m telling you, 12 shots a year we can do. Twelve shots a year is way more doable than 24, and this is something that makes it so the needle is almost never a deal breaker. I’m not saying the children like it, but it’s doable.

Now that we have the 6-month to 5-year-old indication, we have another weight range, which is less than 15 kg. What’s really cool about this age group is there’s no loading dose. You just start with either 200 mg if they’re less than 15 kg, or 300 mg if they’re 15 to 30 kg. Then you just go every 4 weeks. Again, you don’t have to memorize it, you can always look it up.

One thing to note is that as of now, the pen is only approved for ages 12 and up. We only have the syringe for our younger patients. Anecdotally, I have patients who have used both; most of them tend to prefer the syringe. You have a little more control over it, it goes faster. If you do use a pen, you have to know you have to hold it down. If you’re going to do it and teach them with a pen, you want to hold your hand with their hand while they do it because the instinct to lift up is very strong. Another practical note, for children who do get the loading dose over 6 years old, oftentimes what I’ll do is, my nurse will take 1 leg and I take the other, and we do it at the same time. Because I think there’s nothing like giving a child a shot, and then saying now you get to do that again. Sometimes that means I have to come back for teaching with the parent to do it, but I think that makes that initial encounter a little easier for everybody.

Transcript Edited for Clarity

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