Safety Profile of Dupilumab in managing Atopic Dermatitis

Andrew Alexis, MD, MPH, FAAD: Candrice just mentioned some of the potential risks of dupilumab, namely conjunctivitis. Is this something you see in your patients? How do you counsel your patients about conjunctivitis? When it does occur, what do you do? Anything you can share?

Jamie Weisman, MD: You want to gain the confidence from your patients. If something is going to happen, you don’t want to say, “I never expected that to happen.” We do know that a case of conjunctivitis is generally allergic conjunctivitis, not infectious conjunctivitis. It typically occurs in patients who have already had it. It is a comorbidity of atopic disease. It’s not as common as asthma or allergic rhinitis, but it happens. I make sure to ask about a history of that and warn them that it might recur or flare up. It also tends to happen more in patients who have a lot of disease around the eye area. I warn them they may be at increased risk as well. 

It’s certainly treatable. I have some good ophthalmologists. The ophthalmologist in my building has a daughter on dupilumab, he’s particularly interested in these complications. I can also pop them right up. He’s willing to see them right away. Most of the time, it can be managed with eye drops. It often goes away with continued use of the medication. Again, it’s something to anticipate. It generally occurs in 10% to 20% of my patients, and it does happen in the pediatric population as well. I absolutely warn my patients about it. On the other hand, the interesting thing about dupilumab is that there are some things that we associate with atopic dermatitis [AD], like staph [staphylococcus] infections. And going back to this issue that Heather brought up about the microbiome, it happened at a decreased rate in our dupilumab-treated population as the skin barrier repairs. We don’t know the whole story here. Is there a restoration of the natural microbiome after the skin-barrier repairs? Do we have a restoration of normal immune surveillance in the skin?

Because what we’ve got untreated is an infiltrate of Th2 cells, as you alluded to before, with an expression of type 2 cytokines that are good at fighting off parasitic infections but not so good at fighting off viral infections and staph infections. We see a decreased rate of skin infections in many of our dupilumab patients. I like to say we’re going to take the good with the bad, some of these advantages in addition to just the effective treatment of the underlining disorder. The drugs are approved for ages 6 and up, so we have experience in a variety of patients. In addition to just managing your skin, we’re going to see some other benefits that we may not have anticipated. 

Andrew Alexis, MD, MPH, FAAD: Well said. Another thing I’ve noticed in my patients is how broadly dupilumab can work across the spectrum of this heterogenous disease, atopic dermatitis, across the spectrum of age groups, across the spectrum of racial ethnic populations. In my own experience. And even morphologies—taking those patients who have a more prurigo nodularis type of morphology associated with their atopic dermatitis—see improvement. I’ve observed improvement in those lesions as well. It’s been remarkable. Heather, what’s your experience?

Heather Woolery-Lloyd, MD: I agree. As I mentioned earlier, I primarily have used systemics in the research setting. There’s a benefit to that, because in the research setting, we’re looking and measuring every factor. As I mentioned earlier, we’re checking the improvement in itch, the improvement in sleep, the improvement in their erythema. We’re checking all the boxes. I do see improvement, as you said, across all morphologies. As I mentioned earlier, what strikes me is just improvement in quality of life, and that is what the patients care about the most, so that has been my experience.

Andrew Alexis, MD, MPH, FAAD: When looking at the clinical trials, the published pivotal trial data for dupilumab, specifically at the racial-ethnic makeup of the patient population, it’s just like in many other trials. It’s a little underrepresentation of the Black and African American population, and that’s not unique to this particular drug or these particular studies. It’s a larger issue where there’s a general underrepresentation of patients of color in clinical trials. In my anecdotal practice experience, I haven’t observed any notable differences in response or incidence of adverse events in my different patient populations. Have you seen any differences or observed any trends in your own patient populations, or has it been universally effective and safe?

Candrice Heath, MD: It’s been universal in my patient population.

Transcript Edited for Clarity