Efficacy and Safety of Dupilumab in Adolescents With Uncontrolled Moderate to Severe Atopic Dermatitis: A Phase 3 Randomized Clinical Trial

Efficacy of dupilumab with concomitant topical calcineurin inhibitors treatment for preschool children with atopic dermatitis: a retrospective cohort study

BACKGROUND/OBJECTIVE

Atopic dermatitis (AD) is a chronic, relapsing inflammatory skin disease that typically occurs in childhood/infancy and is associated with complications like extracutaneous atopic morbidity. Providing systemic treatment for pediatric AD patients with unmet comprehensive medical needs remains challenging. We present a cohort study describing the efficacy and safety of dupilumab combined with topical calcineurin inhibitors (TCI) in children with moderate-to-severe atopic dermatitis under the age of 6 years.

METHODS

A retrospective cohort study was conducted at a single center to analyze the use of dupilumab in combination with topical calcineurin inhibitors (TCI) in children aged 6 years and under moderate-to-severe AD that was inadequately controlled with topical therapy.

RESULTS

Overall, 23 preschool children (mean [SD] age, 4.78 [1.278] years); 10 boys (43.5%) and 13 girls (56.5%) received 300 mg dupilumab every four weeks and TCI. The primary outcome, the average Eczema Area and Severity Index (EASI) percentage reduction from baseline, was -70.85%. Significant improvement was also observed in secondary outcomes: caregiver-reported Peak Pruritus numerical rating scale (P-NRS) (-77.73%), Body Surface Area (BSA) (-62.11%), and Investigators Global Assessment (IGA) (-36.23%) at week 16. A 1-2 grade decrease in IGA after 16 weeks of treatment was achieved by 91.3% of patients. There was a significant improvement in P-NRS and EASI scores from baseline to week 16. Injection-site reaction (one patient) and facial redness (two patients) were recorded. No severe drug-related adverse events were observed.

CONCLUSION

This study demonstrated that the combination of dupilumab and TCIs improved symptoms and quality of life in preschoolers with moderate-to-severe AD.

Real-world efficacy and safety of dupilumab in children with atopic dermatitis under 6 years of age: a retrospective multicentric study

In this multicentric real-world observational retrospective study, we evaluated the efficacy and safety of dupilumab for atopic dermatitis in children <6 years of age who underwent a minimum of 16 weeks of therapy. The analysis focused on EASI (Eczema Area and Severity Index), CDLQI (Children's Dermatology Life Quality Index), and Itch NRS (Numeric Rating Scale) changes from baseline to 4, 16, 24, 48, 72, and 96 weeks of follow-up (when available). Overall 24 children were included, with a mean age of 4.4 years. The baseline mean EASI among these patients was 26.7 (range 11.2-42.5). Since week 16 of therapy, all patients achieved and sustained at least 50% (EASI-50) atopic dermatitis improvement from baseline for the remainder of the follow-up period. At week 16, the mean EASI was 4.6 (0.8-13.1), EASI-75 reached 75% and EASI-90 38% of the patients. Within the initial 16 weeks of dupilumab treatment, 50% of patients experienced at least one adverse event, none of which were deemed severe. Conjunctivitis was among the most common adverse events (8.3%). In conclusion, dupilumab exhibited favorable tolerability, efficacy, and safety in children diagnosed with atopic dermatitis who were below the age of 6.

Allergic-related skin diseases: Global disease burden from 1990 to 2021 and future trends

Background

Allergic-related skin diseases, including atopic dermatitis (AD), urticaria, and contact dermatitis (CD), are significant global public health challenges. Currently, there is a lack of systematic analysis of allergic-related skin diseases globally.

Methods

This study aimed to quantify the global burden of AD, CD, and urticaria and evaluate their global epidemiology patterns. The Global Burden of Diseases (GBD) database was used to assess incidence, prevalence, and disability-adjusted life years (DALYs) for these allergic-related skin diseases. Additionally, the Bayesian Age-Period-Cohort (BAPC) model was employed to predict disease burden for the next 15 years.

Results

From 1990 to 2021, cases of AD, CD, and urticaria rose steadily. In 2021, AD prevalence reached 129 million, a 20.02% increase from 1990. However, average annual percentage change (AAPC) values for the age-standardized prevalence rate (ASPR) of AD declined constantly (AAPC = -0.28). CD had the highest incidence, with 253 million new cases in 2021, though AAPC for ASPR of CD showed minimal changes. AD and urticaria peaked in early life, while CD peaked at ages 75-79. Moreover, AD had the strongest positive correlation with the Socio-demographic Index (SDI) (p = 2.2e-16, ρ = 0.626). AD, CD, and urticaria show the highest age-standardized rate in high, middle, and low-middle SDI regions, respectively, with all 3 conditions declining in high SDI. Health inequality analysis showed AD's burden is now more evenly distributed across SDI groups, while the global burden gap for urticaria and CD change limitedly.

Conclusion

Although the global disease burden of allergic-related skin diseases continues to rise, the overall age-standardized rates of AD have steadily declined and are projected to decrease further. In contrast, CD and urticaria require increased attention.

Increasing dosing intervals for biologics in atopic dermatitis-why, who, when and how?

Biologics approved and in development for atopic dermatitis offer life-changing clinical efficacy with a relatively banal long-term safety profile requiring no laboratory monitoring. Biologic therapies also have their drawbacks, including high payor cost and the need to be administered as every other week subcutaneous injections. Addressing these concerns, studies of longer dosing intervals have been performed in the formal clinical trial setting and during real-world clinical care. Here, we review the current progress and evidence of dose elongation strategies in biologics for atopic dermatitis. We find that across a diverse investigational landscape, a large patient population exists that is able to maintain adequate disease control on a prolonged dosing interval. Evidence of clinical predictors of maintenance of disease control using this approach is emerging, although the impact of increased dosing intervals as a strategy to mitigate side effects is lacking. Patients experiencing good disease control are ideal candidates to engage in a shared decision-making process between patients and providers that will facilitate an individualized dosing approach in practice.

Dupilumab-associated lymphoproliferative disorders: a comprehensive review on clinicohistopathologic features and underlying mechanisms

Dupilumab, a monoclonal antibody targeting interleukin 4 receptor, has shown significant efficacy in treating atopic dermatitis (AD). However, emerging case reports indicate that it may unmask or cause cutaneous T cell lymphoma (CTCL). This review analyzes 29 studies involving 124 patients who developed lymphoproliferative disorders after dupilumab, including 13 cases of lymphoproliferative reactions not meeting lymphoma criteria. The median time from dupilumab initiation to biopsy-confirmed lymphoproliferative disorders was 5 months, with 39.05% of cases in advanced stages. Histopathological examination of dupilumab-induced CTCL reveals epidermotropism with spongiosis and increased superficial lymphoid infiltration. Notably, early lymphoproliferative reaction shows subtle lymphoma features, characterized by perivascular infiltration with sprinkled intraepidermal lymphocytes, CD30 expression, and absence of clonal TCR rearrangement and T-cell markers loss. Adult-onset AD patients, particularly those with atypical skin lesions, short-term exacerbation, or no atopy history, should be closely monitored during dupilumab treatment, and skin biopsy is essential if no clinical improvement occurs. Discontinuation is recommended when lymphoid infiltration increases, even without typical lymphoma features. The mechanisms underlying dupilumab-associated lymphoma remain speculative. Current hypotheses include upregulation of IL13RA2 signaling pathway, prolonged persistence of immune cell populations, and varying responses of different tumor cell subclusters. Additionally, the effects of dupilumab on various cell types are complex and multifaceted. Consequently, the distribution of type 2 inflammatory cytokine receptors and the patterns of cellular infiltration within the microenvironment may impact disease progression following dupilumab treatment. Further research is needed to clarify the mechanisms linking dupilumab to CTCL for better defining dupilumab's safety profile.

A translational approach to improve therapeutics in atopic dermatitis and beyond

Atopic dermatitis (AD) and alopecia areata are highly prevalent inflammatory skin/hair conditions. While previously not fully understood and limited in treatment options, AD is currently undergoing a therapeutic revolution. Our increased understanding of the underlying immunologic and barrier dysregulations and disease heterogeneity across its spectrum is facilitating hypothesis-driven therapeutic development. Early transcriptomic analyses in AD skin and blood have identified disease-specific biomarkers and uncovered immune and barrier abnormalities that may contribute to disease pathogenesis. From these findings, various therapeutic targets were then proposed and investigated in clinical trials, leading to the Food and Drug Administration approval of several biologics and small molecule drugs that are now widely used in the clinical setting. Molecular phenotyping of patient samples before and after treatment has further elucidated the specific immunomodulatory effect of each therapeutic, as well as the relative contributions of various immune pathways to disease pathogenesis. This bench-to-bedside cyclical approach has rapidly broadened our understanding of AD and enabled the rapid expansion of the AD therapeutic pipeline. In this brief review, we detail how molecular and blood profiling studies in AD laid the foundation for a therapeutic revolution, discuss currently approved and potential therapeutics for AD resulting from this bench-to-bedside approach, and highlight how this translational approach is being applied to advancing the therapeutic pipeline of alopecia areata.

Atopic Dermatitis: The Relationship Between Immune Mediators and Skin Lipid Barrier

Atopic dermatitis (AD) is a chronic inflammatory skin disease that is prevalent worldwide with complex etiology. Skin barrier defects and abnormal immune activation are crucial in the occurrence and development of AD. In the classic model of the skin barrier, lipids are essential for the formation and maintenance of this barrier as a "mortar" component. However, abnormally activated immune responses promote the lipid barrier deficiency through the secretion of various types of immune mediators directly or indirectly. In this review, we first introduce the skin lipid barrier (SLB) under both normal and abnormal conditions, highlighting the contributions of lipids derived from keratinocytes and sebaceous glands (SGs). Subsequently, the relationships between the immune mediators of Th1, Th2, Th17, Th22, and other types (adipokines, prostaglandins, leukotrienes) and SLB are elaborated in turn. Finally, the therapies for restoring SLB to treat AD are summarized, with a focus on the restoration effect of dupilumab on SLB. We hope that this review will offer a comprehensive perspective for understanding the pathogenesis of lipid metabolism disorders and SLB deficiency caused by immune mediators in AD. It also aims to provide guidance for further research on targeting inflammatory mediators to restore SLB.

Effects of Dupilumab in Children and Adolescents With Moderate-Severe Asthma: A Systematic Review of Clinical Trials

OBJECTIVE

To evaluate the benefits and harms of Dupilumab in children and adolescents with moderate to severe asthma.

METHODS

We conducted a systematic search in Medline, Embase, Cochrane Controlled Register of Trials, and Clinical Trials Registries up to August 18, 2024. Whenever possible, we performed meta-analyses of the studies. The certainty of the evidence for each outcome was assessed using the GRADE methodology.

RESULTS

Seven publications from two multicenter RCTs were included. These studies included 408 children (6-11 years old) and 134 adolescents (12-17 years old). Both studies were funded by the pharmaceutical company that manufactures Dupilumab. The evidence suggests that Dupilumab probably leads to a substantial reduction in the annual rate of severe exacerbations (incidence rate ratio [IRR]: 0.46, 95% CI: 0.31-0.67; moderate certainty), particularly in children with a Th2 phenotype. Dupilumab probably improves quality of life to a clinically meaningful extent (RR: 1.18, 95% CI: 1.01-1.29; moderate certainty). However, it probably does not lead to a substantial improvement in asthma control (mean difference: -0.43, 95% CI: -0.56 to -0.30; two studies; moderate certainty; minimal-important-difference: 0.5). The frequency of serious adverse events may be similar between Dupilumab and placebo (4.8% vs. 4.5%; RR: 1.05, 95% CI: 0.41-2.68; low certainty). Finally, at 52 weeks, Dupilumab lead to an important increase in the Z-score pre-BD FEV1/FVC (RR: 1.45, 95% CI: 1.22-1.63; high certainty).

CONCLUSION

In children and adolescents with uncontrolled moderate to severe asthma, particularly those with a Th2 inflammatory phenotype, the use of Dupilumab probably reduced the annual rate of severe exacerbations, increases both the percentage of children with good quality of life and pulmonary function parameters, with probably minimal serious adverse events.

Medication-related perceptions of children and adolescents with severe asthma and moderate-to-severe atopic dermatitis: a non-interventional exploratory study

BACKGROUND

Severe asthma and moderate-to-severe atopic dermatitis can significantly impact the lives of children and adolescents. However, real-world data on pediatric patients' perceptions of their medication are limited.

METHODS

This non-interventional cross-sectional study at a university hospital explored patients' perceptions. We included patients aged between 6 and 17 with severe asthma and/or moderate-to-severe atopic dermatitis. For patients treated with dupilumab, a minimum dupilumab treatment duration of 16 weeks was required. We conducted one structured interview per patient, based on a questionnaire consisting of open questions and ratings on 6-point Likert scales (response scale range: "0: not at all" to "5: very strongly").

RESULTS

The study included 57 participants (severe asthma: n = 31; moderate-to-severe atopic dermatitis: n = 21; both: n = 5) who reported a "rather moderate" burden of asthma (median: 2; Q25/Q75: 0.3/2.8) or atopic dermatitis (3; 1.5/3.5). They experienced their current medications as "rather helpful" (asthma: 4; 3/5; atopic dermatitis: 4; 3/5). Twelve of the participants (21%) reported refusing to take their medication because of reluctance, but all resumed treatment. All participants receiving dupilumab therapy (n = 16) reported an improvement in their disease within a maximum of 2.5 months after starting treatment. The median fear of injection decreased from 3 (0/5) before the first injection to 0.5 (0/1) at the time of the survey.

CONCLUSIONS

In this real-world, interview-based study, we found that pediatric patients perceived treatment as highly beneficial for asthma and atopic dermatitis. Furthermore, pediatric patients seemed to respond well to dupilumab therapy in terms of both disease improvement and less fear of injection.

TRIAL REGISTRATION

DRKSID DRKS00028092.

Incidence of upper respiratory tract infections with biological therapies in moderate to severe atopic dermatitis: a systematic review and meta-analysis

Introduction

Atopic dermatitis (AD) is a chronic inflammatory skin condition affecting 5%-20% of children and 2%-10% of adults worldwide. Treatment for moderate-to-severe AD includes biologics like dupilumab, tralokinumab, lebrikizumab, and JAK inhibitors (abrocitinib, upadacitinib). However, upper respiratory tract infections (URTIs) are commonly reported adverse events for these therapies. This meta-analysis aims to estimate the pooled incidence of URTIs associated with these treatments compared to topicals.

Methods

A systematic search was conducted across PubMed, MEDLINE, DOAJ, and ClinicalTrials.gov for randomized controlled trials (RCTs) involving AD patients treated with dupilumab, tralokinumab, lebrikizumab, abrocitinib, or upadacitinib, excluding studies of patients treated with topicals, Studies on other dermatitis types and biologics. Data on URTI events, sample sizes, and incidence were extracted. Study quality was assessed using the Cochrane Risk of Bias Tool (RoB 2). A random-effects meta-analysis was conducted using the Netmeta package in R, calculating odds ratios (ORs) with 95% confidence intervals (CIs).

Results

From 413 retrieved records, 21 studies met the inclusion criteria. URTI incidence of the treatment group in the included studies ranged from 0.35% to 41.5%, while control groups showed rates between 0% and 40%. Across all studies, URTI incidence was 9.70% in intervention groups and 8.03% in placebo groups (MH OR = 1.18, 95% CI: 0.98-1.42). Heterogeneity was low (I 2 = 20.14%), with no evidence of publication bias (p = 0.83). There were no significant subgroup differences between patients taking different biological therapies (Q = 3.90, p = 0.42).

Conclusion

While URTIs are common adverse events for AD therapies, their incidence in intervention groups is similar to control, suggesting no significant increase in risk. These findings provide critical insights for clinicians in balancing efficacy and safety when selecting therapies for AD patients. Further research should explore patient-specific risk factors for URTIs.

Systematic review registration

Prospero registration code: [392093]. PROSPERO, Centre for Reviews and Dissemination: CRD42023392093.

Biologics and small molecules: the re-evolution in the treatment of atopic dermatitis in children and adolescents. Current state of the art and future perspectives

INTRODUCTION

In recent years, the understanding of atopic dermatitis (AD) pathogenetic mechanisms has expanded, and now it is recognized that Th2 immune axis dysregulation is pivotal to AD pathogenesis. The advent of biological drugs and small molecules has marked a revolution in the treatment of AD. Dupilumab, targeting IL-4 and IL-13, has been the first to demonstrate efficacy in treating moderate to severe AD by modulating type-2 inflammation pathways. Increasing knowledge of different immune axis and cytokines has fueled the development of new biologics and small molecules. JAK inhibitors, which target the JAK-STAT pathway, involved in cytokine signaling, represent a promising novel therapeutic strategy, enlarging the treatment options for moderate to severe atopic dermatitis.

AREAS COVERED

This comprehensive review aims to provide an updated and critical overview of the drugs currently in use and under investigation for the treatment of moderate to severe AD in children and adolescents, along with addressing the unmet needs and future research perspectives.

EXPERT OPINION

Biologics and small molecules offer the promise to enlarge the arsenal options for the treatment of AD. Since the patients' response to biologics depends on AD pheno-endotype, choosing the right biologic is crucial for ensuring therapy success.

Emerging treatments for dermatologic diseases in infants, children, and adolescents: a systematic review of clinical trials on biologics and small molecule inhibitors

BACKGROUND

Recent advancements in the treatment of paediatric dermatological conditions have emerged with the introduction of biologics and small molecule inhibitors (SMIs). These therapies target specific inflammatory pathways, which may enhance treatment outcomes for diseases like atopic dermatitis, psoriasis, and alopecia areata.

OBJECTIVES

This systematic review seeks to assess the effectiveness and safety of biologics and SMIs for dermatologic conditions in children and adolescents, with an emphasis on randomised clinical trials.

METHODS

We performed an extensive literature search across PubMed, Scopus, and Web of Science, following PRISMA guidelines. Studies included in the review were those that analysed systemic treatments using biologics and SMIs in subjects under 18 years of age. We extracted data on participant demographics, treatment regimens, effectiveness outcomes, adverse effects, and follow-up details. The risk of bias in the studies was determined using the Cochrane Risk of Bias Tool (RoB2).

RESULTS

From an initial pool of 1,454 studies, 49 articles fitting the inclusion criteria were identified, encompassing 6372 cases. The review found that biologics such as Dupilumab, along with investigational JAK inhibitors like Abrocitinib and Upadacitinib, exhibited considerable efficacy in treating various conditions, particularly atopic dermatitis and psoriasis. Dupilumab specifically demonstrated significant improvements in both disease severity and quality of life. While most reported adverse events were mild to moderate, some serious adverse events were noted with certain treatments.

CONCLUSIONS

Biologics and SMIs show great promise as therapeutic options in paediatric dermatology, offering better efficacy compared to traditional treatments. Despite these encouraging findings, additional research is needed to verify their long-term safety, especially in relation to growth and development in younger patients. Future investigations should aim to include a broader range of patient demographics and dermatological conditions beyond those currently studied.

Evidence-Based Recommendations for Managing Atopic Dermatitis in Pediatric Patients: A Systematic Review and Meta-Analysis From the Pediatric Dermatology Special Interest Group of IADVL

BACKGROUND

Atopic dermatitis (AD) is the most common inflammatory skin disease in the pediatric age group, affecting 15%-20% of children globally. Initial treatment modes include hydration, occlusive topical medicines, antimicrobial treatment, phototherapy, and systemic immune suppressants in the case of severe to moderate refractory AD. However, there is a lack of head-to-head studies on the choice of topical and systemic therapies for moderate to severe AD in the pediatric age group.

OBJECTIVE

This systematic review aimed to determine the efficacy and safety of topical and systemic treatments for moderate-to-severe AD in the pediatric age group.

METHOD

A systematic review was performed following the Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guidelines. A search of articles was done from PubMed and Google Scholar from 1975 to 2023.

RESULTS

We found a total of 1114 possible clinical trials. Of these, 68 articles fulfilled the eligibility criteria. Thirty-four articles discussed topical therapies, which included corticosteroids, calcineurin inhibitors, and emollients, and 34 articles were about systemic therapies, consisting of cyclosporine, dupilumab, upadacitinib, thymopentin, omalizumab, antihistamines, probiotics, and others. Out of 68 studies, 41 were randomized controlled trials.

CONCLUSION

Based on the study results, we conclude that topical steroids and calcineurin inhibitors are effective and safe in mild to moderate pediatric AD. It was also demonstrated that while systemic monotherapy with dupilumab (in age groups younger than 6 months) and JAK inhibitors (like abrocitinib and upadacitinib in those younger than 12 years) is highly effective in rapidly reducing severity scores, their high cost and limited availability restrict their use in countries like India. In such settings, cyclosporine (and sometimes oral prednisolone in tapering doses over 2 weeks) is still recommended as a first-line therapy in severe AD while planning for steroid-sparing agents.

Self-assembled injectable Icariin@ Ti3C2Tx/doxorubicin hydrogel preserving osteogenesis while synergizing photodynamic and chemodynamic therapy for osteosarcoma

Local therapy involving injectable hydrogel systems loaded with doxorubicin (DOX) has garnered significant attention in the realm of osteosarcoma (OS) research. Nevertheless, it has been noted that the local delivery of high-dose DOX exerts a pronounced inhibitory impact on osteogenesis, which is detrimental to the restoration of functional capabilities after OS treatment. To address this challenge, we have designed a self-assembled injectable hydrogel system that integrates photodynamic and chemodynamic therapy, aiming to enhance efficacy while mitigating adverse effects on osteogenic differentiation. In this study, an injectable sodium alginate (SA) hydrogel was fabricated by encapsulating titanium carbide powder (Ti3C2Tx) and osteoprotegerin Icariin (ICA) along with DOX. This hydrogel system demonstrated remarkable drug-loading capacity and sustained drug release. Furthermore, under near-infrared (NIR) irradiation, the hydrogel displayed outstanding photothermal effects, which, in conjunction with chemotherapy and phototherapy, effectively eradicated UMR-106 tumor cells in vitro. The incorporation of ICA not only enhanced the anti-tumor effect but also alleviated the adverse effects of DOX on the osteogenic differentiation inhibition of bone marrow mesenchymal stem cells (BMSCs). In vivo, findings further confirmed that injectable ITD/SA hydrogels can synergistically heighten anti-osteosarcoma effectiveness while mitigating local osteogenic toxicity. Given these benefits, this hydrogel holds extensive application prospects in the local therapy of OS.

Long-term Outcomes of New Systemic Agents in Atopic Dermatitis: Drug Survival Analyses and Treatment Patterns in Daily Practice

In recent years, several new systemic agents (biologics and Janus kinase inhibitors [JAKi]) have been registered for the treatment of moderate-to-severe atopic dermatitis (AD). However, comparisons of real-world drug survival data and insights into treatment patterns of these advanced systemics are limited. Data from a prospective observational single-centre registry were collected from 549 adult AD patients (759 treatment courses) receiving biologics (dupilumab, tralokinumab) or JAKi (abrocitinib, baricitinib, upadacitinib) and analysed using Kaplan-Meier survival curves. Cox regression analyses were used to evaluate predictors of survival. Frequencies and percentages summarized data on the initial and subsequent treatments received, with a Sankey diagram illustrating the switching patterns. The 18-month overall drug survival rates for dupilumab, abrocitinib, upadacitinib, tralokinumab, and baricitinib were 70.0%, 51.5%, 48.4%, 39.4%, and 20.4%, respectively. No significant predictors for drug survival were identified. Dupilumab was the predominant initial treatment (87.2%) and upadacitinib the most frequently used second and third treatment. In the total cohort, 57.9% of patients remained on their initial treatment and 26.8% switched to other treatments. In conclusion, dupilumab showed superior survival rates while baricitinib had the lowest survival rate. Frequent switching highlights the need for biomarkers that predict response to advanced systemic treatments to improve attrition rates.

Advancements in pharmacological interventions for atopic dermatitis current strategies and future directions

Atopic dermatitis (AD) is a complex chronic inflammatory skin disorder, with its incidence significantly increasing in recent years. The pathogenesis of AD is complex, involving multiple factors such as genetic susceptibility, dysbiosis of the skin microbiome, autoimmune abnormalities, impaired epidermal barrier function, and environmental factors. These factors collectively contribute to the high incidence of the disease and its significant socio-economic burden. This article reviews the pathogenesis of AD and analyzes the current traditional treatment approaches, including topical and systemic therapies, highlighting the issues they face. It focuses on the current status and treatment strategies. Specifically, as the significant heterogeneity of AD, treatment paradigms are gradually shifting from a "one-size-fits-all" approach to personalized treatments. The aim is to achieve more effective management of AD and address the issues arising from individual differences. Through these discussions, this article aims to provide new perspectives and strategies for the clinical treatment of AD, in order to reduce the disease burden on patients.

Dupilumab as an Adjunct to Oral Immunotherapy in Pediatric Patients With Peanut Allergy

BACKGROUND

Peanut allergy is a common, life-threatening food allergy in children. We evaluated whether dupilumab, which blocks the activity of interleukin (IL)-4/IL-13, enhances the efficacy of oral immunotherapy (OIT) AR101 in pediatric patients with peanut allergy.

METHODS

A Phase II, multicenter, randomized, double-blind study was conducted in the USA (NCT03682770) in pediatric patients (6-≤ 17 years old) with confirmed peanut allergy. Patients were randomized 2:1 to receive dupilumab + OIT or placebo + OIT during a 28-40-week up-dosing period. Patients in the dupilumab + OIT group were re-randomized 1:1 and received dupilumab + OIT or placebo + OIT during 24-week OIT maintenance, undergoing a 2044 mg (cumulative) of peanut protein double-blind, placebo-controlled food challenge (DBPCFC) following up-dosing, maintenance, and at 12-week post-treatment follow-up.

RESULTS

The study enrolled 148 patients, 123 of whom were included in the modified full analysis set, with a mean age of 11.1 years. Dupilumab + OIT treatment (n = 84) led to a 20.2% increase (p < 0.05) in the number of patients who passed a DBPCFC to 2044 mg (cumulative) of peanut protein following the up-dosing period versus placebo (OIT alone, n = 39). Following the OIT maintenance period, continuous dupilumab treatment improved the number of patients who passed a DBPCFC to 2044 mg (cumulative) of peanut protein versus patients continuously on OIT alone (16.6% difference [95% CI -9.7, 42.8], p = 0.2123). Safety was consistent with known dupilumab safety profile.

CONCLUSIONS

Dupilumab provided a modest increase efficacy of OIT in children and adolescents with peanut allergy, though it did not provide protection against OIT-related anaphylaxis.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03793608.

Lebrikizumab vs Other Systemic Monotherapies for Moderate-to-Severe Atopic Dermatitis: Network Meta-analysis of Efficacy

INTRODUCTION

A systematic literature review and network meta-analysis (NMA) were conducted to compare the short-term efficacy of lebrikizumab to other biologic and Janus kinase (JAK) inhibitor monotherapies approved for moderate-to-severe atopic dermatitis in adults and adolescents.

METHODS

The NMA included randomized, double-blind, placebo-controlled monotherapy phase 2 and 3 trials of biologics (lebrikizumab 250 mg every 2 weeks [Q2W], dupilumab 300 mg Q2W, and tralokinumab 300 mg Q2W) and JAK inhibitors (abrocitinib 100/200 mg daily, baricitinib 2/4 mg daily, and upadacitinib 15/30 mg daily) at approved doses. Efficacy outcomes included the proportions of patients achieving Eczema Area and Severity Index (EASI) improvement, an Investigator Global Assessment of 0 or 1 (IGA 0/1), and a ≥ 4-point improvement in pruritus/itch numeric rating scale score at 12 weeks (abrocitinib) or 16 weeks (other treatments). Itch was also assessed at week 4. A Bayesian NMA employing baseline risk-adjusted random effects models was used to estimate treatment differences.

RESULTS

Twenty-two monotherapy studies involving 8531 patients were included in the NMA. By week 12/16, lebrikizumab had superior odds of achieving IGA 0/1 and itch improvement compared to baricitinib and tralokinumab; similar odds to dupilumab, abrocitinib, and upadacitinib 15 mg; and inferior odds to upadacitinib 30 mg. Additionally, lebrikizumab had a higher probability of improving EASI than baricitinib 2 mg; similar probability to baricitinib 4 mg, tralokinumab, dupilumab, abrocitinib, and upadacitinib 15 mg; and lower probability than upadacitinib 30 mg daily. At week 4, lebrikizumab had superior odds of improving itch compared to tralokinumab; similar odds to baricitinib, dupilumab, and abrocitinib 100 mg; and inferior odds to abrocitinib 200 mg and upadacitinib.

CONCLUSION

Among biologics, lebrikizumab was comparable to dupilumab and superior to tralokinumab in improving response rates at week 16. Upadacitinib 30 mg was the only JAK inhibitor with superior response rates compared to lebrikizumab.

Allergen immunotherapy and dupilumab in atopic dermatitis: Clinical efficacy and disparities in immunological indicators

Objective

Allergen immunotherapy (AIT) and dupilumab have been confirmed to improve symptoms of atopic dermatitis (AD); however, the precise immune mechanisms underlying their efficacy and whether they can elicit synergistic immune effects remain not fully elucidated. We aimed to investigate the clinical efficacy and immunological changes in AD patients undergoing AIT, dupilumab, and a combination of AIT and dupilumab treatment.

Methods

Clinical data, serum samples, and peripheral blood mononuclear cells (PBMC) were collected from house dust mite (HDM)-sensitized AD patients receiving AIT and/or dupilumab at baseline and 6 months. Changes in clinical efficacy, HDM-specific IgE and IgG4, serum cytokines, and lymphocyte subgroups were compared among the treatment groups.

Results

A total of 77 AD patients were included, with 39 in the AIT group, 19 in the dupilumab group, and 19 in the AIT combined dupilumab group. The SCORAD scores significantly improved in all groups after 6 months. Levels of HDM-specific IgE and total IgE remained stable in the AIT group but decreased in the dupilumab and combination groups. Levels of IgG4 against major mite components Der p1 and Der p23 increased in the AIT group and combined treatment group. Serum cytokine levels showed no significant changes, except for a decrease in CCL17 in the dupilumab group. Th1/Th2 and Th17/Th2 ratios increased after dupilumab treatment. There were notable differences in T cell subpopulations when PBMCs were stimulated with HDM extracts after 6-month treatment, tSNE analysis showed the proportion of IL-4+IL-13+CRTH2+T cells increased in the dupilumab group but had no changes in the AIT and combination group.

Conclusions

AIT, dupilumab, and their combination improved clinical symptoms and quality of life in AD patients. AIT promoted allergen-specific IgG4 production, while dupilumab modulated T cell responses and reduced allergen-specific IgE synthesis. The combination of AIT and dupilumab exhibited the immunological parameter changes characteristic of both treatments but did not result in a significantly greater improvement in AD symptoms.

Comparative efficacy and safety of dupilumab versus newly approved biologics and JAKi in pediatric atopic dermatitis: A systematic review and network meta-analysis

BACKGROUND

The newly approved biologics and Janus kinase inhibitors (JAKi) for pediatric atopic dermatitis (AD) offer additional options for clinical treatment. However, the efficacy and safety differences compared to the first approved biologic, dupilumab, remain unclear. Therefore, a network meta-analysis was conducted to evaluate these differences and identify potentially superior agents.

METHODS

This systematic review was PROSPERO-registered (CRD42024583658). Randomized controlled trials involving pediatric patients (<18 years old) published in PubMed, Embase, Web of Science, and the Cochrane Library up to October 27, 2024 were searched and screened. RevMan software was utilized for quality assessment, and  meta-analysis was performed using R version 4.4.1. Efficacy measures included the Investigator's Global Assessment (IGA), the Numeric Rating Scale for Itch (NRS), and the Eczema Area and Severity Index (EASI). The results of these measures were expressed as odds ratios (OR), while treatment rankings of different interventions were determined using the P-score.

RESULT

This study included 11 trials involving 7 agents and 2,352 pediatric patients. The results indicated that dupilumab (300 mg) showed better outcomes than placebo in IGA-0/1 (OR =  4.68, 95% CI: 2.53-8.63), NRS-4 (OR =  6.75, 95% CI: 3.85-11.86), and all EASI outcomes. Tralokinumab may be the most effective option for alleviating pruritus (P-score for NRS-4, 0.8447). Upadacitinib (30 mg) performed best in IGA-0/1 (P-score, 0.9414), EASI-90 (P-score, 0.9926), and EASI-75 (P-score, 0.9707). Dupilumab (300 mg) had a higher risk of nasopharyngitis compared to placebo (OR = 2.15, 95%CI: 1.04-4.43). Compared to both placebo and dupilumab (300 mg), adverse event rates were higher with upadacitinib (15 mg and 30 mg), and upper respiratory tract infection risk was elevated with baricitinib (2 mg and 4 mg) and tralokinumab (300 mg).

CONCLUSION

The efficacy of dupilumab for pediatric AD remains substantial, while other agents including upadacitinib, delgocitinib, and tralokinumab also present certain advantages. Future clinical trials may necessitate further evaluation of safety concerns.

Safety of Dupilumab Therapy for Atopic Dermatitis during Pregnancy: A Systematic Review and Meta-analysis

Atopic dermatitis (AD) is the most common skin condition among pregnant women. However, there is limited information on the safety of biologicals during pregnancy. A systematic review and meta-analysis was conducted following the PRISMA guidelines to evaluate the effects of exposure to biologicals during pregnancy and/or preconception in women with AD, and to estimate the pooled prevalence of spontaneous abortions and congenital malformations in their newborns. MEDLINE, Embase, Scopus, and Web of Science to 31 May 2024 were searched to identify randomized controlled trials and non-randomized studies. To test the robustness of our findings, sensitivity analyses were performed. Fifteen observational studies involving 115 pregnant women with a mean age of 33.46 years (standard deviation [SD] 3.02 were included). All studies evaluated dupilumab. The mean duration of exposure to dupilumab during pregnancy was 27.52 weeks (SD 11.16). The weighted prevalence of spontaneous abortions was 18.9% (95% confidence interval 5.3 to 38.2). There were no reports of congenital malformations. The sensitivity analyses showed no significant differences in weighted prevalences. In conclusion, the current scientific evidence suggests that dupilumab is probably safe during pregnancy and preconception in women with AD, with no significant increase in the risk of miscarriage or congenital malformations compared to the general population. However, the results of this review are inconclusive due to the limited number of large, well-designed clinical studies.

Efficacy and Safety of Omalizumab and Dupilumab in Pediatric Patients with Skin Diseases: An Observational Study

Background: Chronic spontaneous urticaria (CSU) and moderate-to-severe atopic dermatitis (AD) are significant challenges in pediatric populations, negatively impacting quality of life (QoL). Biologic therapies, including omalizumab and dupilumab, showed considerable promise for patients unresponsive to conventional treatments. This study evaluated the real-life efficacy and safety of these biologics in pediatric CSU and AD patients. Methods: A retrospective, monocentric study was conducted enrolling pediatric patients (aged 6-18 years) followed at the "G. Martino" Hospital, University of Messina. This study included patients with CSU unresponsive to antihistamines and those with moderate-to-severe AD refractory to topical therapies. Disease severity and treatment efficacy were evaluated using the Urticaria Activity Score 7 (UAS7) for CSU, the Eczema Area and Severity Index (EASI) for AD, and QoL metrics, including the Dermatology Life Quality Index (DLQI) and numerical rating scales, for pruritus (p-NRS) and sleep (s-NRS), at baseline, 16 weeks, and 52 weeks. Safety was assessed through the monitoring of reported adverse events (AEs). Results: Omalizumab significantly reduced UAS7 scores by 71.9% at 16 weeks and 75.3% at 52 weeks (p < 0.001), with concurrent improvements in c-DLQI. Dupilumab reduced the EASI score by 75.3%, p-NRS by 40%, and s-NRS by 52.9% over 52 weeks, with c-DLQI improving by 72.6%. No severe AEs were observed; mild reactions included injection-site erythema and respiratory symptoms. Conclusions: Omalizumab and dupilumab demonstrated significant efficacy in reducing disease severity and improving QoL in pediatric patients with CSU and AD. Moreover, their safety profile underscores their potential as essential treatments for these conditions.

Efficacy and safety of systemic targeted therapies for atopic dermatitis in children: A systematic review and meta-analysis

BACKGROUND

In recent years, several targeted therapeutic options have become available for the management of atopic dermatitis in children. In this systematic review and meta-analysis, we assessed the efficacy and safety of systemic targeted therapies for atopic dermatitis in children.

METHODS

A systematic review of literature available in CENTRAL, MEDLINE, Embase, and ICHUSHI databases until January 7, 2023, was performed. Randomized controlled trials of systemic targeted therapies (biologics and small molecules) on children aged 18 years or younger with atopic dermatitis were included. The primary outcomes were the eczema area and severity index (EASI) and adverse events. Other efficacy and safety outcomes were also used for meta-analysis and risk of bias analysis.

RESULTS

We included 10 studies reported in 11 articles involving three agents (dupilumab, abrocitinib, and upadacitinib) and 1760 children. Systemic targeted therapies significantly improved eczema severity with an EASI-75 response (risk ratio, 2.99; 95 % confidence interval [CI], 2.66-3.37). However, systemic targeted therapies were associated with treatment-emergent adverse events (risk difference, 0.05; 95 % CI, 0.01-0.09), particularly among small molecules in subgroup analysis, while no such trend was observed with biologics. Systemic targeted therapy also significantly improved other efficacy outcomes, and no significant association was found in the other safety outcomes. There was no risk of bias in any of the outcomes.

CONCLUSIONS

Our findings indicate that systemic targeted therapies are effective and relatively safe for treating atopic dermatitis in children, although small molecules may pose a slightly higher risk of adverse events.

Real-world treatment outcomes of systemic treatments for moderate-to-severe atopic dermatitis in children aged less than 12 years: 2-year results from PEDIatric STudy in Atopic Dermatitis

BACKGROUND

The arrival of biologics and small-molecule therapies (eg Janus kinase inhibitors) changed atopic dermatitis treatment, but older systemic treatments continue to be prescribed.

OBJECTIVE

To provide real-world effectiveness, safety, and adherence data for dupilumab, cyclosporine, and methotrexate.

METHODS

PEDIatric STudy in Atopic Dermatitis (NCT03687359) is a real-world, prospective, observational, 10-year study of children (<12 years) with inadequately controlled moderate-to-severe atopic dermatitis. We report 2-year interim results.

RESULTS

Median treatment durations were 8.1, 13.0, and 10.7 months for dupilumab (n = 144), methotrexate (n = 114), and cyclosporine (n = 121), respectively. Dupilumab had numerically greater within-group improvements than methotrexate and cyclosporine in Eczema Area and Severity Index (-12.4∗ vs -5.7∗ and -3.3); body surface area affected (-19.9%∗ vs -11.8%∗ and -8.8%∗); itching (night-time: -2.1∗ vs -0.4 and + 0.1; daytime: -1.5∗ vs +0.1 and + 0.2; ≥6 years); itching/scratching (-3.6∗ vs -1.4∗ and -0.2; <6 years); and Patient-Oriented Eczema Measure (-7.0∗ vs -4.7∗ and -1.5) (∗P < .05 within-group improvements from baseline). Dupilumab had less discontinuations (8.3% vs 28.9% and 43.0%) and adverse event(s) (18.1% vs 29.8% and 31.4%).

LIMITATIONS

No randomization, placebo, or specified dosages.

CONCLUSION

Dupilumab was associated with numerically greater outcomes and higher adherence than cyclosporine or methotrexate.

Comparative efficacy of biologics and small molecule drugs in treating pediatric atopic dermatitis in patients aged 2-18 years: A 12-16 week network meta-analysis of randomized controlled trials

BACKGROUND

Atopic dermatitis (AD) predominantly manifests before age five, with significant phenotype variations across age groups. Despite increasing systemic treatments for pediatric AD, head-to-head comparisons in network meta-analyses focused on children are scarce.

METHODS

Through systematic searches of PubMed, Embase, Web of Science, and Cochrane Library up to March 2024, we identified randomized controlled trials (RCTs) evaluating systemic treatments for moderate-to-severe AD in children aged 2-18 years. From 900 screened articles, 8 RCTs (n = 2636) met inclusion criteria, comparing dupilumab, baricitinib, upadacitinib, and abrocitinib versus placebo with standard care. Primary outcome was Eczema Area and Severity Index (EASI) scores at 12-16 weeks.

RESULTS

Upadacitinib demonstrated highest efficacy at both 30 mg (risk difference [RD] 0.62 [0.53, 0.71]) and 15 mg (RD 0.52 [0.42, 0.62]). Dupilumab (weight-based dosing with corticosteroids; RD 0.43 [0.29, 0.57]), abrocitinib (200 mg; RD 0.40 [0.29, 0.50]; 100 mg; RD 0.30 [0.20, 0.41]), and baricitinib (4 mg; RD 0.21 [0.06, 0.35]) also showed significant efficacy over placebo.

CONCLUSION

This analysis establishes a hierarchy of effectiveness among systemic therapies for pediatric AD, with upadacitinib showing highest efficacy. However, the predominance of adolescent data emphasizes the need for age-stratified studies in younger children and long-term safety assessments.

Clinical curative effect and quality of life evaluation of dupilumab in treating children with atopic dermatitis and its effect on IgE levels, eosinophil count, Th2 cytokines (IL-4 and IL-13), and thymus and activation-regulated chemokine

Introduction

Atopic dermatitis (AD) is a common chronic skin inflammatory disease. The traditional treatment shows limited effect and side effects. Dupilumab is a monoclonal antibody immunotherapy targeting IL-4 and IL-13, which may become a new direction for treating AD.

Aim

This study was to explore the clinical curative effect of dupilumab in the treatment of children with AD, and its influence on the quality of life (QoL) of children.

Material and methods

54 children with AD, who were treated in the outpatient and inpatient departments of the hospital from August 2023 to July 2024, were included in this study. These children were treated with dupilumab, and their clinical curative effect as well as QoL were evaluated through relevant scales as well as the IgE, eosinophil counts, and Th2 cytokine levels.

Results

After treatment, Eczema Area and Severity Index (EASI) score was 8.8 ±4.5, Scoring Atopic Dermatitis (SCORAD) score was 15.1 ±8.4, and itching Numeric Rating Scale (NRS) score was 1.1 ±0.7. Compared with those before treatment, the scores of 25.4 ±6.2, 38.6 ±10.3, and 6.9 ±2.2 were highly decreased with differences being statistically significant (p < 0.05). Only 3 cases had an Investigator's Global Assessment (IGA) ≥ 3, which was greatly reduced than that before treatment (p < 0.05). 5 cases had the adverse reaction of conjunctivitis after treatment, Patient-Oriented Eczema Measure (POEM) score was 4.8 ±1.6, and Dermatology Life Quality Index (DLQI) was scored as 3.3 ±1.8. These were observably lower than those before the patients were treated, exhibiting significant differences (p < 0.05). There were significant reductions in IgE levels, eosinophil count, Th2 cytokines (IL-4 and IL-13), and thymus and activation-regulated chemokine (TARC) after treatment (p < 0.05).

Conclusions

Dupilumab could effectively treat children with AD and improve their QoL, so it had a clinical application value.

One-Year Insights into the GLOBOSTAD Multinational Prospective Observational Study of Patients Receiving Dupilumab for Atopic Dermatitis

INTRODUCTION

Currently, limited data are available on long-term use of dupilumab to treat atopic dermatitis (AD) in a multinational real-world setting. The aim of this analysis was to report the interim 1-year data for patients with AD enrolled in the GLOBOSTAD registry, including treatment patterns, dupilumab effectiveness and safety, and healthcare burden.

METHODS

GLOBOSTAD is an ongoing, 5-year, multinational, prospective, observational study of adult/adolescent (aged ≥ 12 years at baseline) patients with AD who initiated dupilumab in real-world settings according to their local country-specific prescribing guidelines. Outcomes were evaluated at baseline and at 3, 6 and 12 months and included Eczema Area and Severity Index (EASI) total score, SCORing Atopic Dermatitis (SCORAD) total score, percent body surface area (BSA) affected, Patient-Oriented Eczema Measure (POEM), Dermatology Life Quality Index (DLQI) total score for adults or Children's Dermatology Life Quality Index (CDLQI) total score for adolescents and pruritus Numeric Rating Scale (NRS) total score.

RESULTS

At the interim 1-year cut-off (March 2023), 955 patients were enrolled in GLOBOSTAD, and follow-up data were obtained from 903 patients. After dupilumab initiation, mean improvements in effectiveness outcome measures from baseline to month 3 were EASI from 25.1 to 6.1, SCORAD 59.3 to 25.3, POEM 19.7 to 8.7, DLQI 13.7 to 5.3, CDLQI 12.2 to 2.7 and pruritus NRS 6.3 to 2.5, with each measure exceeding the minimal clinically important difference. These positive changes in effectiveness outcomes were maintained or further improved through 12 months since treatment initiation. AD-related hospitalizations and emergency room or urgent care facility visits decreased from 11.1% to 1.7% from baseline to month 12.

CONCLUSIONS

In a multinational real-world setting, dupilumab demonstrated rapid, robust and sustained effectiveness in patients with moderate-to-severe AD across multiple disease domains, including AD signs, symptoms, quality of life and emergency/urgent care visits. Safety was consistent with the known dupilumab safety profile.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03992417.

Eosinophilic esophagitis in the "atopic march": dupilumab as an "umbrella" strategy for multiple coexisting atopic diseases

Dupilumab is a monoclonal antibody targeting interleukin-4 and interleukin-13, approved for the treatment of multiple T2 diseases and more recently for Eosinophilic Esophagitis (EoE). EoE is a chronic T2 inflammatory disease, believed to be a member of the "atopic march", due to multiple similarities with other atopic diseases, ranging from epidemiology to genetics and pathophysiology. Although often co-existing in the same patient, these diseases are still treated as separated entities by different specialists, resulting in polypharmacy and chronic use of steroids. Thus, a shared-decision approach by a multidisciplinary team composed of different specialists might improve clinical management and outcomes. Yet, prospective data on the effectiveness of dupilumab as a single agent for multiple T2 inflammatory diseases are lacking, since only few case reports and small studies have been published so far reporting outcomes in patients affected by multiple T2 diseases. The purpose of this review is to illustrate the rationale and clinical evidence supporting the possibility of using dupilumab as a single therapeutic agent in those patients affected by multiple T2 diseases in addition to EoE.

Safety of dupilumab in Chinese pediatric patients aged 6 months and older: a prospective real-world study

Objective

This study analyzes the occurrence and characteristics of adverse drug reactions (ADRs) of dupilumab in children in a real-world setting. It aims to enhance clinical practice and minimize medication safety risks in pediatric patients.

Methods

This prospective study included children receiving dupilumab in the hospital between January 2022 and December 2023. Information on ADRs was collected and univariate and multivariate analyses were employed to identify high-risk factors for the occurrence of adverse effects in dupilumab treatment.

Results

A total of 65 ADRs occurred in 1,103 treatments in 127 patients, with an incidence of 27.56% (35/127). A total of 62 patients aged 6 or below participated in this study, accounting for 48.82%. Univariate analysis showed that gender, age, duration of medication, frequency of dupilumab use were risk factors for the occurrence of adverse effects (P < 0.05). Multivariate logistic regression analysis showed that age [odds ratio [OR]: 0.071, 95% confidence interval [CI]: 0.012-0.433; P = 0.004] and frequency of dupilumab use (OR: 3.306, 95% CI: 1.078-10.135; P = 0.036) were risk factors for adverse effects. The outcomes of ADRs were improved in 10 cases (15.38%) and completely recovered in 55 cases (84.62%).

Conclusion

Dupilumab has a good safety profile in Chinese children aged 6 months to 18 years for up to 2 years of treatment, with most adverse reactions being mild to moderate, and no serious ocular adverse reactions were reported. Age and frequency of dupilumab use were risk factors for adverse effects. Younger age and higher frequency of dupilumab use were associated with higher odds of ADRs.

The Association of Inflammatory Indexes Derived from Peripheral Blood Cell Count and Clinical Signs with Response to Treatment with Dupilumab in Pediatric Patients with Moderate-to-Severe Atopic Dermatitis

Background

Dupilumab is a safe and effective treatment for moderate to severe atopic dermatitis (AD), but real-world data in pediatric patients in China are limited. Currently, there is no exploration of changes in blood cell counts derived indexes in pediatric patients, especially under 6 years old.

Purpose

To investigate the changes in blood cell counts derived indexes before and after dupilumab treatment in Chinese children with AD, the relationship with clinical scores, and the potential role of these indexes on treatment efficacy.

Patients and Methods

We conducted a retrospective study of 109 children with moderate to severe AD treated with dupilumab. Derived inflammatory indexes, including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), eosinophil-to-lymphocyte ratio (ELR), eosinophil-to-neutrophil Ratio (ENR), monocyte-to-lymphocyte ratio (MLR), inflammation response index (SIRI), systemic inflammation index (SII), and aggregate inflammation systemic index (AISI) were calculated. The correlation between clinical scores and inflammatory indexes at different treatment time points were analyzed. Logistic regression and ROC curve was employed to explore factors associated with treatment efficacy.

Results

Baseline ELR and ENR were positively correlated with the baseline Eczema Area and Severity Index (EASI) and the Scoring Atopic Dermatitis (SCORAD). Additionally, baseline ENR levels showed a positive correlation with the baseline Peak Pruritus Numeric Rating Scale (PP-NRS). At 4 and 16 weeks of treatment, the percentage reduction in ELR was significantly associated with the percentage reduction in EASI and PP-NRS. Logistic regression results indicated that high baseline ELR could predict a poor response to dupilumab treatment.

Conclusion

ELR was significantly correlated with disease severity score during the treatment with dupilumab. Baseline ELR could act as a predictor of the efficacy of dupilumab in the treatment of children with atopic dermatitis under 6 years of age.

The effect of dupilumab on caregiver- and patient-reported outcomes in young children with moderate-to-severe atopic dermatitis: Results from a placebo-controlled, phase 3 study

BACKGROUND

Moderate-to-severe atopic dermatitis (AD) greatly impacts children/caregivers.

OBJECTIVE

Evaluate the impact of treatment with dupilumab on caregiver- and patient-reported AD symptoms and quality of life (QoL) in young children.

METHODS

In the LIBERTY AD PRESCHOOL (randomized, placebo-controlled) study, children aged 6 months to 5 years with moderate-to-severe AD received dupilumab or placebo plus low-potency topical corticosteroids for 16 weeks. This posthoc analysis assessed the change from baseline to week 16 in caregiver-reported outcome measures of AD symptoms (eg, itch and sleep) and QoL of patients and their caregivers/families.

RESULTS

Dupilumab (n = 83) vs placebo (n = 79) provided significant improvements in caregiver-reported AD symptoms and QoL. Significant improvements were seen as early as week 4 and sustained through the end of the study. Additionally, dupilumab vs placebo provided rapid and significant improvement in QoL measures for the patients' caregivers/families.

LIMITATIONS

Few patients aged <2 years; significance only reported for prespecified endpoints; Infant's Dermatitis QoL Index severity strata adopted from Children's Dermatology Life Quality Index.

CONCLUSION

Dupilumab improved AD symptoms and QoL in patients and their caregivers/families.

Drug Survival of Dupilumab, Methotrexate, and Cyclosporine A in Children With Atopic Dermatitis

Importance

Dupilumab, methotrexate (MTX), and cyclosporine A (CsA) are valuable treatment options for pediatric patients with refractory moderate to severe atopic dermatitis (AD). Yet, comparative data on these treatments in pediatric patients are scarce.

Objective

To evaluate drug survival of dupilumab, MTX, and CsA, and identify associated predictors in a multicenter daily practice cohort study of pediatric patients with AD.

Design, Setting, and Participants

This multicenter daily practice cohort study included patients with AD aged 2 to 17 years treated with dupilumab, MTX, and/or CsA in 5 tertiary centers in the Netherlands between 2013 and 2023. Data were extracted from the prospective BioDay and TREAT Netherlands registries and electronic medical records.

Exposures

Dupilumab, MTX, CsA.

Main Outcomes and Measures

Drug survival was analyzed using Cox proportional hazard regression models. Univariable and multivariable Cox regression analyses were conducted to identify variables associated with drug discontinuation.

Results

A total of 502 treatment episodes in 362 unique patients were included, comprising 192 dupilumab episodes, 94 MTX episodes, and 216 CsA episodes. Overall, the mean (SD) age at treatment initiation was 12.9 (3.8) years, and 272 treatment episodes (54.2%) in female patients. The 1-year, 2-year, and 3-year overall drug survival rates, respectively, were 84.1%, 72.3%, and 62.0% for dupilumab; 60.7%, 39.3%, and 25.3% for MTX; and 43.9%, 21.5%, and 10.4% for CsA. Ineffectiveness was the most frequent reason for drug discontinuation, accounting for 178 episodes (35.5%), mostly in patients treated with CsA, followed by adverse effects in 94 patients (18.7%). Treatment with MTX and treatment with CsA were independently associated with a higher risk for drug discontinuation due to ineffectiveness (hazard ratio [HR], 4.45 [95% CI, 2.38-8.34] and HR, 10.88 [95% CI, 6.23-19.02], respectively) and adverse effects (HR, 4.39 [95% CI, 2.05-9.39] and HR, 3.83 [95% CI, 1.85-7.92], respectively) compared to treatment with dupilumab. Patients aged 12 to 17 years starting systemic treatment were independently associated with a higher risk for drug discontinuation due to ineffectiveness (HR, 1.55 [95% CI, 1.10-2.20]) and adverse effects (HR, 2.39 [95% CI, 1.33-4.30]).

Conclusions and Relevance

This multicenter daily practice cohort study demonstrated a superior 1-year, 2-year, and 3-year overall drug survival for dupilumab, followed by MTX, with the lowest rates observed for CsA in pediatric patients with AD. This study also identified characteristics associated with discontinuation. These results provide insight into drug survival resulting from the effectiveness, safety, and tolerability of these systemic treatments in pediatric patients with AD and contribute to the optimization of patient outcomes.

Dupilumab reduces inflammatory biomarkers in pediatric patients with moderate-to-severe atopic dermatitis

BACKGROUND

Patients with atopic dermatitis (AD) often have elevated type 2 inflammatory serum biomarkers.

OBJECTIVE

The aim was to report changes in thymus and activation-regulated chemokine (TARC)/CC chemokine ligand 17 (CCL17), total IgE, lactate dehydrogenase (LDH), and eosinophils in pediatric patients treated with dupilumab or placebo.

METHODS

Biomarker data were analyzed from 3 randomized, double-blind, placebo-controlled, phase 3 studies of patients with moderate-to-severe AD. Patients ages 6 months to 5 years were randomly assigned to weight-dependent dupilumab 200/300 mg every 4 weeks (q4w) or placebo; ages 6 to 11 years, to dupilumab 100/200 mg every 2 weeks (q2w), dupilumab 300 mg q4w, or placebo; ages 12 to 17 years, to dupilumab 200/300 mg q2w, dupilumab 300 mg q4w, or placebo. In the youngest 2 groups, topical corticosteroids were also applied. Median percent changes from baseline to week 16 were reported using last observation carried forward analysis, censoring after rescue treatment.

RESULTS

Pediatric patients who received dupilumab versus placebo achieved significantly greater median percent reductions at week 16 in TARC/CCL17 (-83.3% to -72.4% vs -14.9% to -1.8%), total IgE (-71.2% to -58.4% vs -21.0% to +28.1%), and LDH (-26.2% to -9.8% vs -1.5% to +1.5%). All comparisons were significantly different (P < .0001) between each dupilumab dosing group and respective placebo groups. In contrast, absolute changes in eosinophils were small in all groups.

CONCLUSIONS

Dupilumab treatment for pediatric patients with moderate-to-severe AD significantly reduced levels of TARC/CCL17, total IgE, and LDH to levels comparable with those of healthy controls, reflecting a reduction in systemic type 2 and general inflammation.

Drug Survival, Retention, and Persistence of Dupilumab in Adults and Adolescents with Atopic Dermatitis: A Narrative Literature Review

Atopic dermatitis (AD) is a chronic, relapsing inflammatory skin condition that can have a negative impact on a patient's quality of life. Long-term effectiveness is required to manage the symptoms of AD (skin inflammation, eczematous lesions, and itching). Because some of the systemic immunosuppressants used to treat AD have been associated with serious adverse events (AEs), other safer, more effective options, including dupilumab, have been proven effective long-term for treatment of adult and adolescent patients with moderate-to-severe AD. The long-term safety and effectiveness of a drug are usually confirmed in real-world studies by evaluating its performance over time. Measures such as drug survival, drug retention, drug persistence, or retention rates reflect whether treatment may be considered as satisfactory by both patients and physicians, meeting key clinical needs. This review aimed to describe the survival, retention, or persistence of dupilumab therapy in adults and adolescents with moderate-to-severe AD by conducting a PubMed search in March 2023 and screening for relevant publications. Globally, real-world studies with dupilumab have regularly reported high drug survival rates after 1, 2, and 3 years of observation, being consistently at 80-90%, with low rates of treatment discontinuation due to lack of efficacy or AEs. These findings are notably higher than 1- and 2-year drug survival rates of systemic immunosuppressants (including cyclosporine [37% and 20%, respectively] and methotrexate [41% and 33%, respectively]). Overall, real-world data on drug survival have confirmed that dupilumab provides long-term sustained efficacy and acceptable safety in patients with moderate-to-severe AD.

Comparative effectiveness of upadacitinib versus dupilumab for moderate-to-severe atopic dermatitis: A retrospective cohort study

BACKGROUND

Although efficacy and safety of Upadacitinib and Dupilumab in moderate to severe atopic dermatitis (AD) have been shown in clinical trials, real world data are still limited. The aim of this retrospective study is to indirectly compare the efficacy and safety of Upadacitinib and Dupilumab in patients with moderate to severe AD in real world practice.

METHODS

A single-center retrospective cohort study was conducted. The study included patients with moderate to severe AD, who were enrolled from May 2022 to March 2024, to indirectly compare the efficacy and safety of Upadacitinib and Dupilumab over 12 weeks duration.

RESULTS

Eighty-seven patients were included (46 received Upadacitinib and 41 Dupilumab). Compared with week 0, there was a significant decrease in EASI score, ADCT score and NRS score in patients of both groups in weeks 4, 8, and 12. In week 4, the reduction in EASI score, ADCT score and NRS score was significantly greater in patients of Upadacitinib group compared to those in Dupilumab group. Compared to baseline, in week 12, the decrease in IL-4, IL-13, and IL-31 level in the serum of patients in Upadacitinib group was significantly greater than that of patients in Dupilumab group. The total IgE of patients in Dupilumab group decreased significantly, while there was no significant change in patients of Upadacitinib group. Although Upadacitinib group reported more adverse events than Dupilumab group, no serious adverse events were observed.

CONCLUSIONS

Both Upadacitinib and Dupilumab groups showed effective trend in patients with moderate to severe AD. Upadacitinib has better efficacy and rapid onset in the treatment of patients with moderate to severe AD.

Dupilumab treatment in paediatric atopic dermatitis (2-18 years): Spanish multicentre retrospective real-world study

BACKGROUND

Moderate-to-severe atopic dermatitis (AD) can be difficult to manage in paediatric patients, and there are few licensed treatments available for this age group. Dupilumab is approved for the treatment of AD in children older than 6 months.

OBJECTIVES

To assess the effectiveness and safety of dupilumab in a real-world cohort of paediatric patients with AD in Spain.

METHODS

A multicentre, retrospective real-world study on the effectiveness and safety of dupilumab in patients aged 2-18 years with moderate-to-severe AD was conducted. Demographic and clinical characteristics were analysed, and effectiveness (Eczema Area and Severity Index, Investigator's Global Assessment, Dermatology Life Quality Index, Numerical Rating Scale itch), safety and drug survival measures were assessed. A comparison of our results with other real-world outcomes and with clinical trials was made.

RESULTS

Data from 243 patients from 19 centres were collected, with a mean follow-up of 85 weeks. Dupilumab exhibited significant effectiveness, with marked reductions in severity scores from week 4. By week 16, 79.4% of patients achieved ≥ 75% improvement in Eczema Area and Severity Index (EASI) score (EASI 75) and 40.5% achieved ≥ 90% improvement in EASI score (EASI 90). Mean percentage reduction in EASI was 79.7%. Increasing improvements were observed until week 52, with 85.8% and 49.6% of patients achieving EASI 75 and EASI 90, respectively. Forty-three patients developed adverse events (AEs) (43 of 243, 17.7%). The most frequent AEs were ocular surface diseases (20 of 243, 8.2%), injection site reactions (8 of 243, 3.3%) and facial redness (7 of 243, 2.9%). Drug survival was high (96.9% and 93.1% after 1 and 2 years of follow-up, respectively), with only 19 patients (7.8%) interrupting treatment: 7 (2.9%) owing to AEs; 2 (0.82%) owing to secondary failure; 5 (2.1%) were lost to follow-up; and 5 (2.1%) entered remission and stopped treatment.

CONCLUSIONS

Real-world use of dupilumab in paediatric AD demonstrated sustained effectiveness, high drug survival and acceptable safety profiles. Longer-term studies are crucial for AE surveillance and understanding how to manage disease remission.

Atopic dermatitis

Atopic dermatitis (AD) is a common, chronic skin disorder that can significantly impact the quality of life (QoL) of affected individuals as well as their families. Although the pathogenesis of the disorder is not yet completely understood, it appears to result from the complex interplay between defects in skin barrier function, environmental and infectious agents, and immune dysregulation. There are no diagnostic tests for AD; therefore, the diagnosis is based on specific clinical criteria that take into account the patient's history and clinical manifestations. Successful management of the disorder requires a multifaceted approach that involves education, optimal skin care practices, anti-inflammatory treatment with topical corticosteroids, topical calcineurin inhibitors (TCIs) and/or phosphodiesterase-4 (PDE-4) inhibitors, the management of pruritus, and the treatment of skin infections. Systemic immunosuppressive agents may also be used, but are generally reserved for severe flare-ups or more difficult-to-control disease. Newer systemic agents, such as Janus Kinase (JAK) inhibitors and biologics, have a more favourable safety and efficacy profile than the older, traditional systemic immunosuppressives. Topical corticosteroids are the first-line pharmacologic treatments for AD, and evidence suggests that these agents may also be beneficial for the prophylaxis of disease flare-ups. Although the prognosis for patients with AD is generally favourable, those patients with severe, widespread disease and concomitant atopic conditions, such as asthma and allergic rhinitis, are likely to experience poorer outcomes. Newer systemic agents have been approved which are greatly improving the QoL of these patients.

A systematic review investigating the proportion of clinical images shared in prospective randomized controlled trials involving patients with atopic dermatitis and systemic pharmacotherapy

For individuals with atopic dermatitis (AD), interpreting scientific papers that present clinical outcomes including the Eczema Area and Severity Index (EASI) and Investigators Global Assessment may be difficult. When compared to tabulated data and graphs, images from before and after treatment are often far more meaningful to these patients that ultimately will be candidates for the treatment. This systematic review focused on determining the frequency of clinical image sharing in AD research.

Conducted in accordance with PRISMA guidelines, the review concentrated on randomized controlled trials that investigated predefined and available systemic treatments for AD. The search was performed in the MEDLINE database for studies published from the inception until 21 December 2023.

The review included 60 studies, encompassing 17,799 randomized patients. Across these studies, 16 images representing 6 patients were shared in the manuscripts, leading to a sharing rate of 0.3‰.

The almost missing inclusion of patient images in clinical trial publications hinders patient understanding. Adding images to scientific manuscripts could significantly improve patients' comprehension of potential treatment outcomes. This review highlights the need for authors, the pharmaceutical industry, study sponsors, and publishers to enhance and promote patient information through increased use of visual data.

Dupilumab is Efficacious in Young Children with Atopic Dermatitis Regardless of Type 2 Comorbidities

INTRODUCTION

Patients with atopic dermatitis (AD) often have other comorbid type 2 inflammatory conditions. The aim of this study was to evaluate the impact of type 2 comorbidities on the response to and safety of dupilumab in young children with AD.

METHODS

LIBERTY AD PRESCHOOL part B was a randomized, placebo-controlled trial in children aged 6 months to 5 years with moderate-to-severe AD. In this post hoc analysis, patients were stratified by the presence or absence of caregiver-reported selected type 2 comorbidities at baseline: asthma, allergic rhinitis (AR), and food allergies (FAs).

RESULTS

At week 16, significantly more patients receiving dupilumab versus placebo, with or without asthma and AR, achieved an Investigator's Global Assessment (IGA) score of 0/1 and a ≥ 75% improvement in Eczema Area and Severity Index (all p < 0.05). Significantly more patients receiving dupilumab versus placebo with FAs and numerically more patients without FAs achieved an IGA score of 0/1 (p = 0.0007 and p = 0.06). Numerically more patients receiving dupilumab versus placebo with asthma and significantly more patients without asthma achieved a ≥ 4-point reduction in the weekly average of daily score on the Worst Scratch/Itch Numeric Rating Scale (WSI-NRS) (p = 0.6 and p < 0.0001). Additionally, significantly more patients receiving dupilumab versus placebo with or without AR (p = 0.008 and p < 0.0001) and with or without FAs (p = 0.0002 and p = 0.004) achieved a ≥ 4-point reduction in the weekly average of daily score on the WSI-NRS. Overall safety was consistent with the known dupilumab safety profile.

CONCLUSIONS

Dupilumab treatment improves AD signs and symptoms in children aged 6 months to 5 years with and without type 2 comorbidities such as asthma, AR, and FAs.

TRIAL REGISTRATION

ClinicalTrials.gov registration number NCT03346434.

INFOGRAPHIC

Do type 2 comorbidities impact the response to dupilumab in children with atopic dermatitis? (MP4 103,451 KB).

Efficacy of lebrikizumab in adolescent patients with moderate-to-severe atopic dermatitis: 16-week results from three randomized phase 3 clinical trials

BACKGROUND

Lebrikizumab, a high-affinity monoclonal antibody targeting IL-13, previously demonstrated clinical efficacy in three randomized, double-blind, placebo-controlled Phase 3 trials that included adults and adolescents with moderate-to-severe atopic dermatitis (AD): ADvocate1, ADvocate2, and ADhere.

AIM

This subset analysis evaluated 16-week physician- and patient-reported outcomes of lebrikizumab in the adolescent patients enrolled in these three trials.

METHODS

Eligible adolescents (≥12 to <18 years weighing ≥40kg) were randomized 2:1 to subcutaneous lebrikizumab (500 mg loading doses at baseline and Week 2 followed by 250 mg every 2 weeks) or placebo as monotherapy in ADvocate1&2, and in combination with topical corticosteroids (TCS) in the ADhere study. Week 16 analyses included clinical efficacy outcomes (IGA (0,1) with ≥2-point improvement, EASI 75, EASI 90), patient-reported Pruritus NRS ≥4-point improvement and Sleep-Loss Scale ≥2-point improvement.

RESULTS

Pooled ADvocate1&2 16-week results in lebrikizumab (N = 67) vs placebo (N = 35) were: IGA (0,1) 46.6% vs 14.3% (p < 0.01), EASI 75 62.0% vs 17.3% (p < 0.001), EASI 90 40.7% vs 11.5% (p < 0.01), Pruritus NRS 48.9% vs 13.1% (p < 0.01), and Sleep-Loss Scale 26.9% vs 6.9% (p = 0.137). Corresponding results for ADhere, (lebrikizumab + TCS, N = 32; placebo + TCS, N = 14), were consistent.

CONCLUSIONS

Lebrikizumab treatment demonstrated efficacy in improving the signs and symptoms of AD in adolescent patients, consistent with the ADvocate and ADhere overall population results.

Residual facial erythema in atopic dermatitis patients treated with dupilumab stratified by machine learning

BACKGROUND

Persistent facial erythema represents a significant complication in atopic dermatitis (AD) patients undergoing treatment with dupilumab. Stratifying patients based on the erythema course is crucial for elucidating heterogeneous phenotypes and facilitating advanced drug efficacy predictions.

OBJECTIVES

This study aimed to identify factors associated with facial erythema severity in dupilumab-treated AD patients and to establish a prediction model for drug response based on the identified factors.

METHODS

Data from a retrospective study conducted between July 2018 and July 2021 were collected and analysed. Patients were categorized into three groups via hierarchical clustering based on the course of facial erythema: early remission, low remission and persistent residual. LightGBM, a supervised gradient boosting decision tree algorithm, was employed to discern group differences and construct a prediction model. The model incorporated patient demographic and clinical profiles, including pre- and post-treatment examinations. The model's performance was evaluated using accuracy and the area under the receiver operating characteristic curve (AUC).

RESULTS

The binary classification model demonstrated an accuracy of 89.10% and an AUC of 0.862 when distinguishing between early remission and persistent residual patients. The eight prominent factors associated with facial erythema severity included age, sex, lactate dehydrogenase (LDH), immunoglobulin E (IgE), eosinophil count, white blood cell count, Alnus allergy and cedar allergy.

CONCLUSIONS

This study has two main significances: first, three clusters were identified through unsupervised learning; second, a classification model was constructed that proved more accurate than random prediction. The stratification and identification of crucial factors associated with residual facial erythema in dupilumab-treated AD patients lay the foundation for AI-powered prognostic models. This groundwork provides a substantial basis for enhancing future medical AI support in AD treatment selection, potentially improving personalized treatment approaches and outcomes.

Natural Compounds Targeting Thymic Stromal Lymphopoietin (TSLP): A Promising Therapeutic Strategy for Atopic Dermatitis

Atopic dermatitis (AD) is a chronic inflammatory skin disease with rising prevalence, marked by eczematous lesions, itching, and a weakened skin barrier often tied to filaggrin gene mutations. This breakdown allows allergen and microbe entry, with thymic stromal lymphopoietin (TSLP) playing a crucial role by activating immune pathways that amplify the allergic response. TSLP's central role in AD pathogenesis makes it a promising therapeutic target. Consequently, in this study, we used the virtual drug screening, molecular dynamics simulation, and binding free energies calculation approaches to explore the African Natural Product Database against the TSLP protein. The molecular screening identified four compounds with high docking scores, namely SA_0090 (-7.37), EA_0131 (-7.10), NA_0018 (-7.03), and WA_0006 (-6.99 kcal/mol). Furthermore, the KD analysis showed a strong binding affinity of these compounds with TSLP, with values of -5.36, -5.36, -5.34, and -5.32 kcal/mol, respectively. Moreover, the strong binding affinity of these compounds was further validated by molecular dynamic simulation analysis, which revealed that the WA_0006-TSLP is the most stable complex with the lowest average RMSD. However, the total binding free energies were -40.5602, -41.0967, -27.3293, and -51.3496 kcal/mol, respectively, showing the strong interaction between the selected compounds and TSLP. Likewise, these compounds showed excellent pharmacokinetics characteristics. In conclusion, this integrative approach provides a foundation for the development of safe and effective treatments for AD, potentially offering relief to millions of patients worldwide.

Short-, mid- and long-term efficacy of dupilumab in moderate-to-severe atopic dermatitis: a real-world multicentre Italian study of 2576 patients

BACKGROUND

The efficacy and safety of dupilumab in atopic dermatitis (AD) have been defined in clinical trials but limited real-world evidence on long-term treatment outcomes is currently available to inform clinical decisions.

OBJECTIVES

To describe the long-term effectiveness and safety of dupilumab up to 48 months in patients with moderate-to-severe AD.

METHODS

A multicentre, retrospective, dynamic cohort study was conducted to assess long-term effectiveness and safety of dupilumab in patients with moderate-to-severe AD in a real-world setting. Predictors of minimal disease activity (MDA) optimal treatment target criteria [defined as the simultaneous achievement of a 90% reduction in Eczema Area and Severity Index score, itch-numeric rating scale (NRS) score ≤ 1, sleep-NRS score ≤ 1 and Dermatology Life Quality Index ≤ 1] were investigated.

RESULTS

In total, 2576 patients were enrolled from June 2018 to July 2022. MDA optimal treatment target criteria were achieved by 506/2309 (21.9%), 769/1959 (39.3%), 628/1247 (50.4%), 330/596 (55.4%) and 58/106 (54.7%) of those that reached 4, 12, 24, 36 and 48 months of follow-up, respectively. Logistic regression revealed a negative effect on MDA achievement for conjunctivitis and food allergy at all timepoints. Adverse events (AEs) were mild and were observed in 373/2364 (15.8%), 166/2066 (8.0%), 83/1291 (6.4%), 27/601 (4.5%) and 5/110 (4.5%) of those that reached 4, 12, 24, 36 and 48 months of follow-up. Conjunctivitis was the most frequently reported AE during the available follow-up. AEs led to treatment discontinuation in < 1% of patients during the evaluated time periods.

CONCLUSIONS

The high long-term effectiveness and safety of dupilumab were confirmed in this dynamic cohort of patients with moderate-to-severe AD, regardless of clinical phenotype and course (persisting or relapsing) at baseline. Further research will be needed to investigate the effect of T helper cell 2 comorbidities and disease duration on the response to dupilumab and other newer therapeutics for AD.

An expert consensus on managing dupilumab-related ocular surface disorders in people with atopic dermatitis 2024

Atopic dermatitis (AD) is the most common inflammatory skin condition and affects people of all ages. New therapies, including the monoclonal antibody therapy dupilumab, offer excellent efficacy. However, in clinical trials, and emphasized in real-world observations, an unexpected increased frequency of ocular adverse effects has become apparent. The effectiveness of dupilumab and the unpredictability of ocular adverse effects mean that clinicians need guidance on counselling patients prior to treatment and on managing them if adverse effects arise. The British Association of Dermatologists (BAD) and Royal College of Ophthalmologists collaborated on this consensus guidance on managing dupilumab-related ocular surface disorders (DROSD). A multidisciplinary group was formed of adult and paediatric dermatologists and ophthalmologists with expertise in DROSD, patient representatives and the BAD Clinical Standards Unit. A literature search was conducted and the results reviewed. All recommendations were reviewed, discussed and voted on. The recommendations pertain to dermatology and ophthalmology management, and apply to people of all ages, unless otherwise stated. Importantly, initiation of dupilumab for AD should not be delayed for most eye disorders except acute new problems (e.g. infections) or potentially severe conditions (e.g. a history of corneal transplant; ophthalmology advice should be sought first). There is insufficient evidence to recommend lubricant drops prophylactically. Dermatologists should assess eye complaints to diagnose DROSD; a severity grading system is provided. DROSD management differs slightly in those aged < 7 years, as ocular complications may affect neuro-ocular development. Therefore, irrespectively of DROSD severity, this population should be referred for ophthalmology advice. In those aged ≥ 7 years, dermatologists should feel confident to trial treatment and reserve ophthalmology advice for severe or nonresponding cases. Discussion about dupilumab withdrawal should be prompted by a significant impact on quality of life, threat to sight, or other complications. Although dupilumab is a highly effective agent for treating AD, the risk of ocular adverse effects should not inhibit clinicians or patients from using it, but clinicians should be aware of them. If a patient develops DROSD, there are clear pathways to assess severity and offer initial management. Where this is ineffective, dermatologists should assess the urgency and seek advice from or initiate referral to ophthalmology. While the evidence reviewed for these guidelines reflects the extensive literature on dupilumab, we believe our advice has relevance for ocular surface disorders in patients with AD treated with tralokinumab and lebrikizumab.

Biologics in allergology and clinical immunology: Update on therapies for atopic diseases, urticaria, and angioedema and on safety aspects focusing on hypersensitivity reactions

The development of targeted therapies for atopic diseases, urticaria, and angioedema with biologics is progressing rapidly: New "targets" of clinical-therapeutic relevance have been identified, the corresponding targeted antibodies developed, tested in clinical trials, and approved for therapy. These include the anti-IgE antibody omalizumab (also effective and approved for the treatment of urticaria), the anti-IL-4/13 receptor-specific antibody dupilumab, the two anti-IL-13 antibodies lebrikizumab and tralokinumab, the anti-TSLP antibody tezepelumab, the two anti-IL-5 antibodies mepolizumab and reslizumab, and the anti-IL5 receptor-specific antibody benralizumab for the treatment of atopic diseases. For the treatment of hereditary angioedema, C1 inhibitor and the antibody lanadelumab (directed against kallikrein) have also long been approved as biologics in addition to low-molecular substances. Other therapeutic antibodies are in various stages of development. Furthermore, the range of indications for some very effective biologics has been successfully expanded to include additional diseases. In this context, the first results on biologic therapy of food allergy and eosinophilic esophagitis are interesting. Biologics that address different target structures are also increasingly being administered in combination, either simultaneously or sequentially, in order to achieve optimal efficacy. A developing area is the use of biologics in children and the observation of immunological and non-immunological side effects. In some cases, new unexpected side effects and hypersensitivity reactions have emerged, which in turn raise pathomechanistic questions, such as conjunctivitis with dupilumab therapy, which only appears to occur in the treatment of atopic dermatitis but not in the treatment of other atopic diseases. In dermatology, paradoxical reactions have been described under therapy with some biologics. And immune reactions of type alpha to epsilon to biologics (hypersensitivity reactions) continue to be a clinically relevant problem, whereby the selection of an alternative therapeutic agent is a challenge and the diagnostics that support this have not yet been sufficiently incorporated into routine work.

Amenorrhea in an Adolescent Female as a Rare Adverse Event of Upadacitinib Treatment for Atopic Dermatitis

Atopic dermatitis (AD) is a common chronic inflammatory cutaneous disease. Upadacitinib, a selective JAK-1 inhibitor, has been approved as a systemic medication for moderate-to-severe AD in patients aged ≥12 years. Although previous studies have examined the safety profile of upadacitinib, this is the first report to describe a potential association between amenorrhea and upadacitinib or other JAK inhibitors. Herein, we report a rare adverse event of amenorrhea in an adolescent female patient who was treated with upadacitinib for AD. This case report expands the range of adverse events potentially associated with upadacitinib therapy.

Immunogenicity of dupilumab in adult and pediatric patients with atopic dermatitis

Background

Development of anti-drug antibodies (ADAs) and neutralizing antibodies (NAbs) to monoclonal antibodies may adversely impact pharmacokinetics, efficacy, and/or safety.

Objective

To describe incidence, titer, and persistence of dupilumab ADAs and NAbs, and their effects on pharmacokinetics, efficacy, and safety in patients with atopic dermatitis (AD).

Methods

This analysis included seven phase 3 randomized, placebo-controlled (N=2,992) and two long-term open-label extension (N=2,287) trials of subcutaneous dupilumab in adults and pediatric patients with moderate-to-severe AD. ADA, NAb, and dupilumab concentration in serum were assessed using validated immunoassays. ADA impacts on efficacy (EASI) and safety were assessed.

Results

Treatment-emergent ADAs were observed in up to 8.6% (aged ≥18 years), 16.0% (12-17 years), 5.3% (6-11 years), and 2.0% (6 months to 5 years) dupilumab-treated patients. Among dupilumab-treated patients, ≤3.7% had persistent responses, <1% had high titers (≥10,000), and ≤5.1% were NAb-positive. NAbs were more common in patients with moderate- and high-titer ADA responses. High-titer ADAs, while infrequent, were the variable most associated with lower dupilumab concentrations in serum and loss of efficacy, independent of NAb status. Efficacy was generally similar in ADA-positive and -negative patients. For most patients with high- or moderate-titer ADAs, titers decreased and efficacy improved over time with continued dupilumab treatment. ADA-positive and -negative patients had similar incidences of treatment-emergent and serious treatment-emergent adverse events. One patient with high-titer ADAs developed serum sickness.

Conclusion

In patients with AD, ADAs and NAbs had minimal impact on dupilumab concentration, efficacy, and safety, except for high-titer ADAs in a small number of patients.

Clinical trial registration

ClinicalTrials.gov, identifiers (NCT02277743, NCT02277769, NCT02260986, NCT02395133, NCT01949311, NCT03054428, NCT03345914, NCT02612454, and NCT03346434).

Current and Emerging Biologics for Atopic Dermatitis

Atopic dermatitis (AD) is a common chronic pruritic inflammatory skin disease that affects all ages and is recognized as a global health problem. Pathophysiology is complex with skin barrier abnormalities, immune dysregulation, and microbial dysbiosis all implicated. Markers of immune and inflammatory activation in the circulation provide a rationale for systemic therapy. Type 2 immune polarization is central, though other cytokine pathways including Th22 and Th17/IL-23 have been described, suggesting additional therapeutic targets in a subset of patients. Dupilumab and tralokinumab are monoclonal antibodies currently approved for moderate-to-severe AD with lebrikizumab and nemolizumab in late stages of development.