Adverse events of Dupilumab in adults with moderate-to-severe atopic dermatitis: A meta-analysis

A comparison of doxycycline and conventional treatments of refractory chronic rhinosinusitis with nasal polyps: a systematic review and meta-analysis

PURPOSE

To compare the effects of doxycycline (DOX) and conventional management in patients with refractory chronic rhinosinusitis and nasal polyps (CRSwNP).

METHODS

Six databases were searched to September 2023. We retrieved studies that compared improvements in refractory chronic sinusitis-related symptoms between DOX-treated and control groups.

RESULTS

DOX significantly reduced the Lund-Kennedy (LK) score [- 0.3670 (range - 0.6173; - 0.1166); I2 = 92.8%], the nasal polyposis score [- 0.9484 (- 1.2287; - 0.6680); I2 = 92.5%], the patient-reported Sinonasal Outcome Test (SNOT) score [- 0.3141 (- 0.4622; - 0.1660); I2 = 91.2%], and the nasal obstruction score [- 0.1813 (- 0.3382; - 0.0243); I2 = 86.2%]. On subgroup analyses by the measurement timepoints, the extent of nasal polyposis was significantly lower in the DOX group during treatment, at the end of treatment, and 4 and 8 weeks later. The LK scores also indicated improvements during treatment and at the end of treatment. The SNOT score tended to decrease with time in the treatment group. Nasal obstruction symptoms improved during treatment and 4 weeks later.

CONCLUSION

DOX enhances the postoperative endoscopic outcomes of refractory CRSwNP patients by reducing recurrent polyposis and inflammation.

Ocular Surface Adverse Events are not Associated with Dupilumab use in Nasal Polyp Treatment

OBJECTIVES

Ocular surface reactions (OSR) have been associated with dupilumab for atopic dermatitis (AD) treatment. However, the association of dupilumab-associated OSR (DA-OSR) for nasal polyps (CRSwNP) treatment has not been studied. We evaluated DA-OSR for CRSwNP treatment using the FDA Adverse Event Reporting System (FAERS).

METHODS

FAERS was queried for any general ocular reactions (DA-GOR) from 2019Q1 to 2022Q4. DA-OSR were subcategorized from DA-GOR and compared between treatment groups (CRSwNP, asthma, AD). Logistic regression was used to predict DA-OSR. Disproportionality analysis (DPA) of DA-OSR was performed using OpenVigil.

RESULTS

There were 60,198 total observations, of which 5344 were treated for CRSwNP. The prevalence of DA-GOR and DA-OSR was greatest for AD (15.3%, 7.8%), followed by CRSwNP (12.2%, 6.7%) and asthma (9.2%, 3.5%). The most commonly reported OSRs were dry eyes (35.9%), conjunctivitis (15.7%), and increased lacrimation (11.0%). The reported odds ratio (ROR) of CRSwNP-treated DA-OSR was 0.84 (0.73-0.97; p = 0.015), compared to 1.29 (1.20-1.40; p < 0.001) for AD and 0.66 (0.59-0.73; p < 0.001) for asthma. For CRSwNP treatment, the DA-OSR ROR was 0.97 (0.90-1.03; p = 0.3) for men and 0.78 (0.73-0.83, p < 0.001) for older adults (age > 50). ROR in the DPA for DA-OSR was 12.5 (12.2-12.8; p < 0.001) for any indication and 0.58 (0.53-0.64; p < 0.001) for CRSwNP treatment only.

CONCLUSIONS

While there are limitations to FAERS, this study confirms the association between dupilumab and OSR for AD treatment, and does not support an association between dupilumab and OSR for CRSwNP treatment. Younger adults experience more DA-OSR in CRSwNP treatment without a specific predilection for sex.

LEVEL OF EVIDENCE

IV Laryngoscope, 134:2602-2608, 2024.

Efficacy and Safety of Dupilumab in Chinese Elderly Patients with Atopic Dermatitis: A Real-World Study

INTRODUCTION

With the aging of the population in China, the prevalence of atopic dermatitis (AD) is high in elderly patients. These patients usually have more comorbidities and they need more effective and safer treatments. Dupilumab is an anti-interleukin-4 (IL-4) receptor monoclonal antibody which was approved for the treatment of moderate-to-severe AD.

METHODS

Elderly patients (60 years or older) with moderate-to-severe AD who treated with dupilumab were included. Eczema Area and Severity Index (EASI) score, Peak Pruritus Numerical Rating Scale (PP-NRS), EASI-50, EASI-75, and EASI-50 were evaluated. The efficacy in subgroups was also investigated.

RESULTS

Fifty-eight patients were enrolled. The EASI score and PP-NRS score were significantly reduced at weeks 4, 16, 28, and 52. 91.2% and 79.4% of the patients achieved EASI-50 and EASI-75 at week 16, respectively. 95.8% and 87.5% patients achieved EASI-50 and EASI-75 at week 52, respectively. Adverse events were reported in 10 (17.2%) patients, and no severe adverse event was reported. Male, older age, and moderate AD (EASI <21) were related to better efficacy.

CONCLUSIONS

This study demonstrated that dupilumab is effective and safe in elderly patients with AD.

Dupilumab induced ocular surface disease: A prospective case series

PURPOSE

To identify the incidence, risk factors, demographics, and clinical profile of dupilumab-induced ocular surface disease (DIOSD) in patients with atopic dermatitis (AD), propose a standardised treatment protocol (STP) and evaluate the response.

METHODS

Prospective case series of AD patients treated in the Dermatology Department, Royal Victoria Infirmary, Newcastle upon Tyne, UK developing ocular symptoms after commencing Dupilumab between September 2018 and February 2020. A standard history and examination protocol were used including subjective symptom severity grading and Ocular Surface Disease Index (OSDI) questionnaire on each visit. Standard treatment was prescribed, and response evaluated.

RESULTS

32 of 113 included patients (28.31%) developed DIOSD, of which 20 (62.5%) were referred to the Cornea Service. Median age was 38.0 years (IQR 26.8; range 19-74). Male to female ratio was 1:1. Average time to onset of ocular symptoms from starting dupilumab was 9.2 weeks (IQR 8.8; range 0.1-40). 90% patients had bilateral conjunctival inflammation and blepharitis at presentation. Significant improvement in the subjective severity scale and the median OSDI score (from 34.0 to 10.2) was noted in response to topical eye treatment. Dupilumab was discontinued in none.

CONCLUSIONS

DIOSD is not uncommon although, with timely referral and appropriate topical treatment better clinical outcome and patient satisfaction can be achieved without the need to discontinue Dupilumab. Prior allergic conjunctivitis did not affect the incidence or severity of DIOSD. Further prospective studies with longer follow-up and more focus on possible disease mechanism such as goblet cell related changes and immune response are needed.

Efficacy and safety of rademikibart (CBP-201), a next-generation mAb targeting IL-4Rα, in adults with moderate to severe atopic dermatitis: A phase 2 randomized trial (CBP-201-WW001)

BACKGROUND

Rademikibart (CBP-201) is a next-generation IL-4 receptor alpha-targeting antibody.

OBJECTIVE

We sought to evaluate rademikibart in adults with moderate to severe atopic dermatitis.

METHODS

A total of 226 patients were randomized, double-blind, to subcutaneous rademikibart (300 mg every 2 weeks [Q2W], 150 mg Q2W, 300 mg every 4 weeks [Q4W]; plus 600-mg loading dose) or placebo. Randomization began in July 2020. The trial was completed in October 2021.

RESULTS

The WW001 phase 2 trial achieved its primary end point: significant percent reduction from baseline in least-squares mean Eczema Area Severity Index (EASI) to week 16 with rademikibart 300 mg Q2W (-63.0%; P = .0007), 150 mg Q2W (-57.6%; P = .0067), 300 mg Q4W (-63.5%; P = .0004) versus placebo (-39.7%). EASI scores decreased significantly with 300 mg Q2W and Q4W at the earliest assessment (week 2), with no evidence of plateauing by week 16. Significant improvements were also observed in secondary end points, including pruritus. Across the primary and secondary end points, efficacy tended to be comparable with 300 mg Q2W and Q4W dosing. Rademikibart and placebo had similar, low incidence of treatment-emergent adverse events (TEAEs) (48% vs 54%), serious TEAEs (1.8% vs 3.6%), TEAEs leading to treatment discontinuation (1.2% vs 1.8%), conjunctivitis of unspecified cause (2.9% vs 0%), herpes (0.6% vs 1.8%), and injection-site reactions (1.8% vs 1.8%). Although no discontinuations were attributed to coronavirus disease 2019, pandemic-related restrictions likely had an impact on trial conduct.

CONCLUSIONS

Rademikibart was efficacious and well tolerated at Q2W and Q4W intervals. Q4W dosing is a more convenient frequency than approved for current therapies.

Efficacy of dupilumab in real-life settings: a STROBE study

BACKGROUND

Dupilumab, a monoclonal antibody targeting IL-4 and IL-13, has demonstrated its efficacy in several clinical trials. However, to date, real-life data remains limited.

OBJECTIVE

The aim of our study was to assess the real-life impact of dupilumab on patients with severe and uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP) quality of life.

MATERIALS AND METHODS

This was a retrospective, monocentric, observational, real-life study, conducted in accordance with the STROBE guidelines. The following parameters were collected before treatment and at 1, 4, and 12 months: Sino-Nasal Outcome Test-22 (SNOT-22), nasal polyp score (NPS), Sniffin' Sticks-16 (SST-16), visual analog scale (VAS) for loss of smell, nasal congestion score (NCS), gustatory VAS, asthma control, oral corticosteroid usage, surgery rates, and occurrence of side effects.

RESULTS

The study included 47 patients. SNOT-22 scores decreased from 52.4 ± 24.3 to 12.7 ± 10.5 at 12 months (p < 0.001). NPS decreased from 6.15 ± 1.71 to 1.57 ± 1.40 at 12 months (p < 0.001). SST-16 scores increased from 1.6 ± 2.83 to 9.1 ± 5.4 at 12 months (p < 0.001). NCS decreased from 2.45 ± 0.72 to 0.38 ± 0.63 at 12 months (p < 0.001). Prior to treatment, 72.3% were using oral corticosteroids, compared to 17.0% at 12 months (p < 0.01). Two patients required additional surgery, and 17% reported completely uncontrolled asthma, compared to 0% at 12 months (p < 0.01).

CONCLUSION

Our real-life results confirm the efficacy of Dupilumab in the treatment of severe and uncontrolled CRSwNP.

Skin infections during dupilumab monotherapy in moderate-to-severe atopic dermatitis - a meta-analysis of randomized clinical trials

OBJECTIVE

Atopic dermatitis (AD) increases the risk of bacterial and viral cutaneous infections. This study assesses the risk of skin infections related to dupilumab monotherapy in moderate-to-severe AD.

METHODS

We searched PubMed/Medline, Embase, Web of Science, ClinicalTrials.gov, and Cochrane Library. For gray literature, Google Scholar was searched. A meta-analysis of randomized clinical trials (RCTs) for overall skin infections, eczema herpeticum, nonherpetic skin infections and subgroup meta-analysis based on overall herpetic infection type was performed.

RESULTS

We observed a statistically significant (p < 0.005) lower incidence rate in the dupilumab group compared to placebo for overall skin infections (Risk Ratio [RR] = 0.59, 95% confidence interval [CI]: [0.47, 0.75], P < 0.0001) and nonherpetic skin infections (RR = 0.42, 95% CI: [0.27, 0.66], P = 0.0001). For herpetic infections in 2b phase studies a meta-analysis demonstrated significantly higher events in dupilumab group compared to placebo (RR = 3.38, 95% CI: [1.98, 5.76], P < 0.00001, test for subgroup differences: P = 0.02, I2 = 65.6%).

CONCLUSIONS

In moderate-to-severe AD, dupilumab in monotherapy may be an effective and safe therapeutic approach, not associated with an increased risk of overall skin infections and nonherpetic skin infections. Due to the lack of statistical significance in heterogeneity associated with potential confounders in some cases, results should be interpreted cautiously.

REGISTRATION

The meta-analysis was registered in PROSPERO, ID: CRD42023441346.

Efficacy and safety profile of dupilumab for the treatment of atopic dermatitis in children and adolescents: A systematic review and meta-analysis

BACKGROUND

Dupilumab is the first biologic approved for the treatment of moderate-to-severe atopic dermatitis (AD) in children and adolescents. Previous systematic reviews explored the effectiveness and safety of dupilumab in adults with AD. However, the underlying mechanisms of AD can vary among different age groups, emphasizing the need for separate investigation into the use of dupilumab in children and adolescents with AD.

OBJECTIVE

To evaluate the efficacy and safety of dupilumab in children and adolescents with AD based on evidence from clinical trials and observational studies.

METHODS

The process of meta-analysis was conducted according to preferred reporting items for systematic reviews and meta-analyses guidelines.

RESULTS

Seven clinical trials and 11 observational studies involving 1275 children and adolescents with AD were eligible for quantitative analysis. Overall, the pooled percentages of eczema area and severity index (EASI) 50, EASI 75, EASI 90, EASI 100, and investigator's global assessment (IGA) 0/1 were 72.9% (95% CI: 61.6%-81.9%), 57.4% (48.1%-66.2%), 31.3% (24.0%-39.7%), 29.7% (23.3%-37.0%), and 35.2% (29.3%-41.5%). With prolonged treatment time, an increase was seen in the pooled rate of EASI response, indicating that dupilumab may provide sustained benefits for children and adolescents over the long term. The reported adverse events were primarily mild and manageable, with an overall incidence rate of 7.2% across clinical trials and 7.6% across observational studies.

CONCLUSION

Dupilumab was an effective and safe treatment option for children and adolescents with AD, with positive results observed from long-term use and an acceptable safety profile. More long-term, high-quality, controlled studies in different regions are needed for further verification.

Optimal Use of Jak Inhibitors and Biologics for Atopic Dermatitis on the Basis of the Current Evidence

Recently, Jak inhibitors such as baricitinib, upadacitinib, and abrocitinib were approved for the treatment of atopic dermatitis (AD) in addition to biologics, including dupilumab, tralokinumab, and nemolizumab. The increase in treatment options can be a benefit to patients with AD. Meanwhile, it could make it difficult for physicians to choose the best treatment among those treatment options. Biologics and Jak inhibitors differ in efficacy, safety, route of administration, and whether or not there is a concern about immunogenicity in addition to the evidence on comorbidities. Among the three Jak inhibitors, the degree of inhibition of signal transducer and activator of transcription differs in each Jak inhibitor. Therefore, the efficacy and safety profiles of the three Jak inhibitors are different. Physicians who treat patients with AD with Jak inhibitors and biologics need to understand the current evidence and choose the best treatment for individual patients. In this review, we discuss how integrating knowledge of the mechanisms of action of Jak inhibitors and biologics, the potential significant adverse events of these drugs, and the age and comorbidities of the patient can help achieve optimal clinical benefit for patients with moderate-to-severe AD refractory to topical agents.

Effectiveness and safety of dupilumab in adults with moderate and severe atopic dermatitis in Colombia: Real-life experience

Background

Dupilumab is a treatment approved for uncontrolled moderate-to-severe atopic dermatitis (AD). Tropical and developing countries such as Colombia have characteristics that may impact the natural history of AD and access to medical treatments. In that sense, we aimed to describe the effectiveness and safety of dupilumab in adults with moderate to severe AD in a Colombian multicenter cohort.

Methods

Multicenter descriptive study that included patients who started treatment between March 2018 and May 2020 in 6 centers. Disease severity was assessed using the following: Scoring Atopic Dermatitis (SCORAD), Eczema Area and Severity Index (EASI), Patient Oriented Eczema Measure (POEM), and Dermatology Life Quality Index (DLQI). These measurements were collected according to availability at baseline, 3-5 months, 6-12 months, and more than 12 months. Days of sick leave, hospitalizations, and AD flares before and after dupilumab treatment were reported. Adverse events (AEs) were recorded during follow-up.

Results

Ninety-three patients were included, with a median age of 32 years (IQR: 24.0; 40.0) and a disease evolution time of 21 years (IQR: 16.0; 29.5). 88.2% had at least 1 allergic disease other than AD. An improvement greater than or equal to 75% EASI was observed in 41.7% of patients at 3-5 months, in 73.7% of patients at 6-12 months, and in 75.0% of patients after 12 months. For those reporting SCORAD and POEM, the median percent change ([IQR], n) from baseline in SCORAD was -67.1 ([-79.2; -54.2], n = 16), -70.5 ([-85.8; -47.9], n = 36) and -66.7 ([-77.3; -51.0], n = 13); and POEM, -58.6 ([-66.4; -55.5], n = 4), -73.0 ([-86.5; -66.7], n = 16) and -87.3 ([-93.4; -69.6], n = 8), respectively. Before initiation of dupilumab treatment, 82 (88.2%) patients reported at least 1 flare of AD in the past 12 months. During the follow-up period, 30 (32.3%) patients reported at least 1 exacerbation or flare. Twelve patients (12.9%) presented an AE and 3 (3.2%) patients discontinued dupilumab for this cause.

Conclusions

Dupilumab was effective and safe for the treatment of moderate to severe AD in point-of-care settings, with results similar to randomized controlled and other real-life studies. These positive results are still maintained even though a high number of patients had short interruptions in the use of dupilumab due to administrative problems.

Association between Dupilumab and Conjunctivitis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Conjunctivitis is commonly reported in dupilumab users with atopic dermatitis (AD), and few studies have compared the risk of conjunctivitis among patients with different indications. This study aimed to investigate the association between dupilumab and conjunctivitis in various diseases. The protocol of this study was registered on PROSPERO (ID CRD42023396204). The electronic search of PubMed, Embase, Cochrane Library, and ClinicalTrials.gov was conducted for the period from their inception to January 2023. Only placebo-controlled, randomized controlled trials (RCTs) were included. The main outcome was the incidence of conjunctivitis during the study period. The subgroup analysis was performed for patients with AD and non-AD indications, which include asthma, chronic rhinosinusitis with nasal polyps, and eosinophilic esophagitis. In total, 23 RCTs involving 9153 patients were included for meta-analysis. Dupilumab users exhibited significantly higher risk of conjunctivitis (risk ratio [RR], 1.89; 95% confidence interval [CI], 1.34–2.67) than placebo users. Notably, significantly increased incidence of conjunctivitis was observed in the dupilumab group relative to the placebo group among patients with AD (RR, 2.43; 95% CI, 1.84–3.12) but not among patients with non-AD indications (RR, 0.71; 95% CI, 0.43–1.13). In conclusion, only dupilumab users with AD but not those with non-AD indications reported an elevated incidence of conjunctivitis.

Review of Tralokinumab in the Treatment of Atopic Dermatitis

OBJECTIVE

To review pharmacokinetics, efficacy, and safety of tralokinumab in treatment of atopic dermatitis (AD).

DATA SOURCES

Literature review was conducted using MEDLINE (PubMed), EMBASE, and ClinicalTrials.gov for articles published between January 2010 and May 2022.

STUDY SELECTION AND DATA EXTRACTION

Articles in English discussing tralokinumab in AD were included.

DATA SYNTHESIS

In one phase 2 trial, more subjects treated with tralokinumab 150 and 300 mg achieved an Investigator's Global Assessment (IGA) of 0/1 with minimum ≥2 point IGA reduction (23%), versus placebo (11.8%, P = 0.10). During 2 phase 3 trials, more subjects treated with tralokinumab achieved IGA success (ECZTRA 1: 15.8% and ECZTRA 2: 22.2%), versus placebo (7.1% and 10.9%, respectively; P = 0.002 and P < 0.001). During one phase 3 trial, in conjunction with topical corticosteroids (TCS), more subjects treated with tralokinumab 300 mg achieved IGA success (ECZTRA 3: 38.9%), versus placebo (26.2%, P = 0.015). During another phase 3 trial in subjects with resistance or contraindication to oral cyclosporine, more subjects treated with tralokinumab 300 mg achieved an Eczema Area Severity Index 75 (64.2%), versus placebo (50.5%, P = 0.018).

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Tralokinumab is efficacious for moderate-to-severe AD, as monotherapy, in conjunction with TCS, and resistance or contraindication to cyclosporine. Although IL-4 and IL-13 are both implicated in AD's pathogenesis, IL-13 is overexpressed, and head-to-head trials are needed to assess efficacy of tralokinumab, versus dupilumab. Compared with upadacitinib and abrocitinib, tralokinumab is not associated with black-box warnings.

CONCLUSIONS

Tralokinumab is an efficacious and safe systemic treatment for moderate-to-severe AD.

Multicenter prospective observational study of dupilumab-induced ocular events in atopic dermatitis patients

BACKGROUND

Although ocular adverse events are frequent in AD patients treated with dupilumab, their characterization remains limited due to a lack of prospective studies with a systematic ophthalmological examination.

OBJECTIVE

To examine the incidence, characteristics and risk factors of dupilumab-induced ocular adverse events.

METHODS

A prospective, multicenter, and real-life study in adult AD patients treated with dupilumab.

RESULTS

At baseline, 27 out of 181 patients (14.9%) had conjunctivitis. At week 16 (W16), 25 out of 27 had improved their conjunctivitis and 2 remained stable and 34 out of 181 patients (18.7%) had dupilumab-induced blepharoconjunctivitis: either de novo (n = 32) or worsening of underlying blepharoconjunctivitis (n = 2). Most events (27/34; 79.4%) were moderate. A multivariate analysis showed that head and neck AD (OR = 7.254; 95%CI [1.938-30.07]; p = 0.004), erythroderma (OR = 5.635; 95%CI [1.635-21.50]; p = 0.007) and the presence of dry eye syndrome at baseline (OR = 3.51; 95%CI [3.158-13.90]; p = 0.031) were independent factors associated with dupilumab-induced blepharoconjunctivitis.

LIMITATIONS

Our follow-up period was 16 weeks and some late-onset time effects may still occur.

CONCLUSION

This study showed that most dupilumab-induced blepharoconjunctivitis cases are de novo. AD severity and conjunctivitis at baseline were not found to be associated risk factors in this study.

Dupilumab for Atopic Dermatitis-From Clinical Trials to Molecular and Cellular Mechanisms

Dupilumab is a monoclonal antibody that represents the first approved targeted biological therapy for adults, adolescents, and children older than 6 years with moderate-to-severe atopic dermatitis (AD). Dupilumab binds the shared chain of the interleukin-4 and interleukin-13 receptor blocking the downstream signaling of these cytokines. The clinical improvements induced by dupilumab were associated with remission of the dysregulated immune mechanisms linked with AD. Dupilumab reversed the epidermal barrier defects and improved the global molecular signature of AD. This review seeks to provide an overview on the development of dupilumab as the first target-specific biological treatment for AD, with a description of the clinical trials that have been performed in different age groups, their outcomes, and reported adverse effects. Novel aspects of dupilumab treatment, as well as the current knowledge on the molecular and cellular mechanisms underlying the treatment of AD with dupilumab, are summarized and discussed.

Dupilumab: Advances in the off-label usage of IL4/IL13 antagonist in dermatoses

Type 2 immune response refers to a complicated series of immune responses characterized by Th2 polarization and Th2 cytokines secretion. The IgE secretion, airway hypersensitivity, and effector cell recruitment (eosinophils, mast cells, basophils) in skin lesion and peripheral blood stream could be upregulated during the activation of type 2 immune response. Th1/Th2 ratio, also referred as Th1/Th2 balance, represent the T lymphocytes immune pattern to a certain degree: Th1-dominated responses are often involved in intracellular infections (e.g., mycobacterium tuberculosis) and autoimmune diseases (e.g., Graves' disease) while Th2-dominated responses are involved in allergic conditions (e.g., atopic dermatitis, eczema), IgE mediated diseases (e.g., urticaria), and fibrotic dermatoses (e.g., keloids). Dupilumab, as one of the most widely applied Th2 cytokine inhibitors, could block the bioactivity of IL-14/IL-13 via competitively binding to the common IL-4Rα subunit shared by IL-4 and IL-13 receptors. In addition to the direct inhibition of type 2 response, dupilumab is also effective in autoimmune and some infectious skin diseases through indirect regulation of type 1 immune response. The pathological mechanism of Th2 responses and advanced clinical application of dupilumab in skin diseases will be summarized and discussed in the review.

Subgroups in the treatment of nasal polyposis with dupilumab: A retrospective study

Dupilumab has been shown to be safe and effective in treating chronic rhinosinusitis with polyposis (CRSwNP). There is to this date no published data whether subgroups like patients with aspirin exacerbated respiratory disease (AERD), increased histologic eosinophilia or elevated blood eosinophil or IgE-levels benefit greater from dupilumab therapy. Moreover, there is no data comparing the efficacy of functional endoscopic sinus surgery (FESS) with dupilumab therapy. We conducted a retrospective chart review of all patients that were treated at a tertiary referral center for CRswNP with dupilumab. We also contacted the patients with a questionnaire to evaluate the efficacy of previous surgeries and dupilumab therapy by visual analogue scale (VAS) and the glasgow benefit inventory (GBI) as well as report on side effects. Overall, 75 patients were included in the study at hand that reported back 138 times. While dupilumab treatment was efficient, we found no systematic evidence of greater efficacy of dupilumab in patients with AERD, histologic eosinophilia or increased blood eosinophil or IgE-levels. All patients showed a considerable decrease in subjective burden of disease, objective smell tests and endoscopic findings. From the patients point of view, dupilumab therapy showed greater efficacy both in the VAS and the GBI overall and all subcategories but "social support." Dupilumab is efficient in treating CRSwNP; this effect is independent from disease characteristics like AERD, histologic eosinophilia, serum IgE-levels or eosinophil counts. There seems to be a group of patients that benefit greater from dupilumab therapy compared to FESS.

Executive summary: Japanese guidelines for allergic conjunctival diseases 2021

Allergic conjunctival disease (ACD) is an inflammatory disease of the conjunctiva that is mainly caused by type I hypersensitivity response to allergens and accompanied by subjective symptoms and other findings induced by antigens. ACD is classified as allergic conjunctivitis, atopic keratoconjunctivitis, vernal keratoconjunctivitis, and giant papillary conjunctivitis. This article summarizes the third edition of the Japanese guidelines for allergic conjunctival diseases published in 2021 and outlines the diagnosis, pathogenesis, and treatment of ACD. Since the introduction of immunosuppressive eye drops, the treatment strategies for severe ACDs have significantly changed. To clarify the recommended standard treatment protocols for ACD, the advantages and disadvantages of these treatments were assessed using clinical questions, with a focus on the use of steroids and immunosuppressive drugs. This knowledge will assist healthcare providers and patients in taking an active role in medical decision making.

Cutaneous T-cell lymphoma following dupilumab use: a systematic review

In recent years, studies have associated dupilumab with unmasking or progression of cutaneous T-cell lymphoma (CTCL). The objective of this study was to synthesize reported cases of CTCL in the setting of dupilumab use. Two independent reviewers conducted a systematic review using PubMed and Embase databases. Twelve studies, of 27 total patients, were included. Dupilumab-associated CTCL was diagnosed on average 7.8 months following dupilumab initiation. Of reports that included body surface area (BSA), 100% had a BSA >50% prior to diagnosis, and the majority of patients were diagnosed at later stages of disease: stage III (4/18) or IV (6/18). Post-dupilumab biopsies revealed a greater density of cells and a predominant lichenoid pattern, compared to various histologic patterns and less cell density in pre-dupilumab biopsies. The majority of TCR gene rearrangement studies were equivocal (20%) or negative (60%), posing a potential diagnostic pitfall. Limitations included lack of standardized data collection and reporting and a small number of studies. We suggest that earlier biopsies, three to four months after initiation of dupilumab, may be helpful for earlier recognition of CTCL in patients who are not improving, progressing, or have morphologic changes on dupilumab.

A Review of Phase 3 Trials of Dupilumab for the Treatment of Atopic Dermatitis in Adults, Adolescents, and Children Aged 6 and Up

Atopic dermatitis (AD) is a chronic pruritic skin disease that can have a profound negative impact on patients' quality of life, especially in cases of inadequate disease control. Dupilumab, a dual inhibitor of IL-4 and IL-13 signaling, is approved in the United States for the treatment of moderate-to-severe AD in adults (≥ 18 years old) and in children (≥ 6 years old). In this review, we present results from phase 3 trials evaluating dupilumab's efficacy and safety in adults, adolescents, and children. These trials demonstrate that dupilumab provides rapid improvements (in as little as 1 week) and sustained efficacy (up to 4 years) when used as a treatment for moderate-to-severe AD. Dupilumab not only improves skin signs and symptoms, but also provides multiple health benefits beyond the skin, including improvements in quality of life, itch, sleep disturbances, and pain/discomfort. Dupilumab is generally well tolerated, has a favorable safety profile in adults, adolescents, and children, has no serious drug-drug interactions, does not require routine laboratory testing, and is not an immunosuppressant. Taken together, phase 3 trials demonstrate that dupilumab provides rapid and sustained efficacy and is generally well tolerated for the treatment of moderate-to-severe AD across age groups.

Current and Emerging Strategies to Inhibit Type 2 Inflammation in Atopic Dermatitis

Type 2 immunity evolved to combat helminth infections by orchestrating a combined protective response of innate and adaptive immune cells and promotion of parasitic worm destruction or expulsion, wound repair, and barrier function. Aberrant type 2 immune responses are associated with allergic conditions characterized by chronic tissue inflammation, including atopic dermatitis (AD) and asthma. Signature cytokines of type 2 immunity include interleukin (IL)-4, IL-5, IL-9, IL-13, and IL-31, mainly secreted from immune cells, as well as IL-25, IL-33, and thymic stromal lymphopoietin, mainly secreted from tissue cells, particularly epithelial cells. IL-4 and IL-13 are key players mediating the prototypical type 2 response; IL-4 initiates and promotes differentiation and proliferation of naïve T-helper (Th) cells toward a Th2 cell phenotype, whereas IL-13 has a pleiotropic effect on type 2 inflammation, including, together with IL-4, decreased barrier function. Both cytokines are implicated in B-cell isotype class switching to generate immunoglobulin E, tissue fibrosis, and pruritus. IL-5, a key regulator of eosinophils, is responsible for eosinophil growth, differentiation, survival, and mobilization. In AD, IL-4, IL-13, and IL-31 are associated with sensory nerve sensitization and itch, leading to scratching that further exacerbates inflammation and barrier dysfunction. Various strategies have emerged to suppress type 2 inflammation, including biologics targeting cytokines or their receptors, and Janus kinase inhibitors that block intracellular cytokine signaling pathways. Here we review type 2 inflammation, its role in inflammatory diseases, and current and future therapies targeting type 2 pathways, with a focus on AD. INFOGRAPHIC.

Efficacy and Safety of Multiple Dupilumab Dose Regimens in Patients with Moderate-To-Severe Atopic Dermatitis: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Dupilumab ameliorates the signs and symptoms of atopic dermatitis (AD) and improves the patient's quality of life. Multiple-dose regimens of dupilumab have been applied by clinicians, but the efficacy of some regimens remains unclear.

OBJECTIVES

The aim of the study was to systematically evaluate the efficacy and safety of multiple dupilumab dose regimens in patients with moderate-to-severe AD in terms of comprehensive outcomes.

METHODS

We searched electronic databases and subjected the selected studies to risk-of-bias assessment and network meta-analysis (NMA). Efficacy and safety outcomes were compared using a random-effects NMA to estimate pooled relative risk ratio (RR) of direct and indirect comparisons among multiple dupilumab dose regimens. The Eczema Area Severity Index, Investigator's Global Assessment, and pruritus numerical rating scale were analyzed to assess the efficacy, while adverse events (AEs) and serious adverse events to represent the safety.

RESULTS

Eight randomized controlled trials involving 3,679 patients were identified. Most patients received therapy for 16 weeks. Multiple dupilumab dose regimens, including 300 mg weekly (QW), 300 mg every 2 weeks (Q2W), 200 mg Q2W, 300 mg monthly (QM), 300 mg every 2 months (Q2M), and 100 mg QM were analyzed. All regimens, except 100 mg QM, had significantly better efficacy than placebo. 300 mg QW and 300 mg Q2W appeared to have similar efficacy. Notably, both 300 mg QW and 300 mg Q2W had no significantly better efficacy than 300 mg QM. As for 300 mg Q2M, significantly reduced efficacy was noted in only one efficacy outcome when compared to 300 mg QW and 300 mg Q2W. In terms of safety outcomes, AEs occurring with any of the regimens were comparable with the placebo. No significant inconsistency was noted within the network in all efficacy outcomes.

CONCLUSIONS

Our NMA indicated that the administration of the following dupilumab regimens was effective for patients with moderate-to-severe AD: 300 mg QW, 300 mg Q2W, 200 mg Q2W, 300 mg QM, and 300 mg Q2M. Our data can improve the understanding of the relative efficacy and safety of multiple dupilumab dose regimens, which will help in shared decision-making between clinicians and patients.

Dupilumab for Atopic Dermatitis-From Clinical Trials to Molecular and Cellular Mechanisms

Dupilumab is a monoclonal antibody that represents the first approved targeted biological therapy for adults, adolescents, and children older than 6 years with moderate-to-severe atopic dermatitis (AD). Dupilumab binds the shared chain of the interleukin-4 and interleukin-13 receptor blocking the downstream signaling of these cytokines. The clinical improvements induced by dupilumab were associated with remission of the dysregulated immune mechanisms linked with AD. Dupilumab reversed the epidermal barrier defects and improved the global molecular signature of AD. This review seeks to provide an overview on the development of dupilumab as the first target-specific biological treatment for AD, with a description of the clinical trials that have been performed in different age groups, their outcomes, and reported adverse effects. Novel aspects of dupilumab treatment, as well as the current knowledge on the molecular and cellular mechanisms underlying the treatment of AD with dupilumab, are summarized and discussed.

Effectiveness and safety of dupilumab in patients with chronic rhinosinusitis with nasal polyps and associated comorbidities: a multicentric prospective study in real life

BACKGROUND

Biologics are currently one of the main treatment options for a number of diseases. The IgG4 monoclonal antibody dupilumab targets the Interleukin-4 receptor alpha chain, thus preventing the biological effects of the cytokines IL-4 and IL-13, that are essential for the Th2 response. Several controlled trials showed that dupilumab is effective and safe in patients with atopic dermatitis (AD), severe asthma and chronic rhinosinusitis with nasal polyps (CRSwNP), thus resulting in approval by regulatory agencies. Aim of the study was to evaluate the efficacy and safety of dupilumab in adult patients with CRSwNP stratified by common overlapping comorbid conditions.

METHODS

We performed a multicenter, observational, prospective study enrolling adult patients with severe CRSwNP who had started dupilumab treatment in the context of standard care from January 2021 to October 2021. Data were collected from twentynine Italian secondary care centers for allergy and clinical immunology, all of which were part of the Italian Society of Allergy, Asthma and Clinical Immunology (SIAAIC). A number of efficacy parameters were used. Patient data were compared using the Wilcoxon test for paired data. All statistical analyses were performed with SPSS version 20 (IBM, Armonk, NY, USA).

RESULTS

In total, 82 patients with nasal polyposis were identified. A significant improvement was detected for all the applied efficacy parameters, i.e. 22-item Sino-Nasal Outcome Test (SNOT-22) and bilateral endoscopic nasal polyp score (NPS) scores for CRSwNP, Rhinitis Control Scoring System (RCSS) and Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) scores for allergic perennial rhinitis, Forced Expiratory Volume in the 1st second (FEV1) and Asthma Quality of Life Questionnaire (AQLQ) scores for asthma, Eczema Area and Severity Index (EASI) and Dermatology Life Quality Index (DLQI) scores for AD. A non-significant improvement was also obtained in the Urticaria Activity Score over 7 days (UAS7) for chronic spontaneous urticaria. Treatment with dupilumab was well tolerated.

CONCLUSIONS

These data suggest that dupilumab treatment in patients suffering from CRSwNP and associated comorbidities may be suitable. Such outcome, although confirmation by trials is warranted, suggests the possibility to treat different disorders with a single therapy, with favorable effects especially under the cost-effectiveness aspect.

Ocular Adverse Effects in Atopic Dermatitis Patients Treated With Dupilumab: A Bibliometric Analysis

Background

Atopic dermatitis (AD) is one of the most common chronic inflammatory skin disorders. Dupilumab, the first targeted biological drug approved for the treatment of AD, has been widely used, along with increasing ocular adverse effects (AEs).

Objective

To perform a bibliometric analysis of all the qualified literature involving ocular AEs during the treatment of AD with dupilumab.

Methods

Relevant studies were extracted from the Web of Science database and screened by researchers. The bibliographic analysis was performed using the VOSviewer.

Results

A total of 138 articles were enrolled in this study. The first study was published in 2016 by Oregon Health and Science University from the United States. The majority of publications were published in the past 3 years. British Journal of Dermatology published the highest number of articles. The United States was the country with the most publications. Sanofi (France) and Regeneron Pharmaceuticals (USA) were the leading organizations with the most contributions. Conjunctivitis was the most common ocular AE. The management of AD will continue to be the research hotspot and development trend in this area. The milestone research is the first article “Two Phase 3 Trials of Dupilumab vs. Placebo in Atopic Dermatitis” published in the New England Journal of Medicine. Most of the top 10 papers were mainly randomized, placebo-controlled phase 2 and phase 3 clinical trials and real-life large cohort studies.

Conclusions

This study may help better understand ocular AEs in the dupilumab treatment of AD, and grasp the research trends and most influential topics in this field.

Immunobiologicals in dermatology

Immunobiologicals are a reality in current clinical practice and have increasingly gained space in the inflammatory disease scenario, especially in dermatology, with approved drugs for psoriasis, atopic dermatitis, and hidradenitis suppurativa, in addition to many others undergoing study. It is important for dermatologists to have knowledge of the medications approved in Brazil, for the best management of dermatoses, in addition to the fact that they represent hope for improvement in patients with chronic diseases.

The efficacy and safety of Dupilumab for the Treatment of Atopic Dermatitis Among Chinese Patients in Clinical Practice: A Single-Center Retrospective Study

Little real-work data regarding the efficacy and safety of dupilumab in the treatment of atopic dermatitis (AD) is available at present. To assess the efficacy and safety of dupilumab at 12 weeks in the treatment of AD in clinical routine clinical practice. Retrospective, single-centre study of adult patients with moderate to severe AD treated with dupilumab for 12 weeks in China. In total, 60 patients (48 male, 12 female; mean age:53.2 ± 15.6) were enrolled in this retrospective study. These patients exhibited a mean AD disease course of 10.6 years (6.0), 30% exhibited a family history of allergies, and 31 (51.7%) had one or more allergic comorbidities. Following dupilumab treatment for 12 weeks, 83.3% and 42% of patients had achieved EASI-50 and EASI-75, respectively. Overall, adverse events(AEs) were reported by 15% of patients, with the most common being conjunctivitis, injection site reactions, and herpes simplex virus infections. Laboratory testing after 12 weeks revealed pronounced decreases in both circulating eosinophil counts [from 0.6(0.1-2.8) to 0.3(0.1-9.7) 10^/L] and total IgE concentrations [from 327(2.46-2500) to 230(47.6-2200) U/ml] in these patients. These real-world data reaffirm the safety and efficacy of dupilumab as a treatment for moderate-to-severe AD among Chinese patients in clinical practice. This article is protected by copyright. All rights reserved.

Dupilumab ocular side effects in patients with atopic dermatitis: a systematic review

Atopic dermatitis (AD) is a chronic, inflammatory skin disorder that most frequently occurs in children, but it can also affect adults. Even though most AD cases can be managed with topical treatments, moderate-to-severe forms require systemic therapies. Dupilumab is the first human monoclonal antibody approved for the treatment of AD. Its action is through IL-4 receptor alpha subunit inhibition, thus blocking IL-4 and IL-13 signaling pathways. It has been shown to be an effective, well tolerated therapy for AD, as well as for asthma, chronic rhinosinusitis with nasal polyposis (CRSwNP) and eosinophilic esophagitis (EoE). However, an increasing incidence of Dupilumab-induced ocular surface disease (DIOSD) has been reported in patients treated with Dupilumab, as compared to placebo. The aim of this study was to summarize scientific data regarding DIOSD in AD patients treated with Dupilumab. A search of PubMed and clinicaltrials.gov databases was performed. There was no limit to study design. All AD cases were moderate-to-severe. DIOSD was either dermatologist-, allergist-, or ophtalmologist-assessed. Evidence shows that DIOSD occurs most frequently in patients with atopic dermatitis and not in other skin conditions, neither in patients with asthma, CRSwNP, nor EoE who are on Dupilumab treatment. Further studies are warranted in order to establish a causal relationship between Dupilumab and ocular surface disease. Nevertheless, ophtalmological evaluations prior to Dupilumab initiation can benefit AD patients with previous ocular pathology or current ocular symptomatology. Also, patch testing for ocular allergic contact dermatitis might be advantageous in patients with a history of allergic conjunctivitis. Furthermore, TARC, IgE and circulating eosinophils levels might be important biomarkers for a baseline assessment of future candidates to Dupilumab treatment. However, TARC measurements should be resumed for research purposes only.

Anaphylaxis to Drugs, Biological Agents, and Vaccines

Anaphylaxis is a multi-system syndrome resulting from the release of mediators from mast cells and basophils. Drugs are common causes. Anaphylaxis to certain drugs, vaccines, and biological agents present clinical challenges, and merit referral to a board-certified allergist/immunologist for further evaluation and management.

Real-life effectiveness and safety of dupilumab in adult patients with moderate-to-severe atopic dermatitis

Atopic dermatitis (AD) is a common, chronic inflammatory condition with a substantial negative impact on the quality of life. Dupilumab, the first biologic approved for the treatment of moderate-to-severe AD, binds IL-4Rα and inhibits signaling of both IL-4 and IL-13. This study aimed to determine the real-life effectiveness and safety of dupilumab treatment in patients with moderate-to-severe AD. The results of the study indicates high effectiveness and safety of dupilumab in real-life conditions. The treatment was continued during the COVID-19 pandemic in most of the patients without any adverse outcome. The rate of conjunctivitis was higher compared to clinical trials, nevertheless treatment was not discontinued in any patients due to adverse effects.

Experience using dupilumab for pediatric atopic dermatitis at a tertiary care c enter: Inadequate response and adverse events

BACKGROUND/OBJECTIVE

Dupilumab is highly effective in treating atopic dermatitis (AD). However, some patients experience difficulties with dupilumab therapy, such as inadequate clinical response, failure to achieve long-term disease control, or adverse events (AEs). Our objective is to assess inadequate response and AEs occurring in children on dupilumab therapy for AD.

METHODS

This is a retrospective cohort study of children on dupilumab for AD. Collected variables included patient demographics, medical histories, and dupilumab therapy characteristics. Response analysis was conducted in those with ≥3 months of dupilumab therapy: primary poor responders were defined as those whose EASI scores did not decrease by >50%, and secondary poor responders were those who initially responded but had significant AD flares while on therapy.

RESULTS

We included 200 patients on dupilumab for AD in our cohort; 192 received ≥3 months of therapy and were included in our response analysis. Twelve children experienced inadequate primary response, and 4 were secondary poor responders. Four of these 16 children discontinued therapy due to inadequate response. The most common dupilumab-associated AEs were facial erythema (n = 24, 12.0%) and injection-site reactions (n = 24, 12.0%). Female sex was significantly associated with experiencing injection-site reactions, and prior hospitalization was significantly associated with HSV infection on dupilumab. Eight patients discontinued therapy due to an AE.

CONCLUSION

A small but significant number of patients experienced treatment difficulties while on dupilumab. The risk of inadequate response to dupilumab and dupilumab-associated AEs should be discussed thoroughly with patients and their families prior to initiation.

Retrospective analysis of adverse events with dupilumab reported to the United States Food and Drug Administration

BACKGROUND

Atopic dermatitis (AD) is one of the most common inflammatory skin diseases and has aesthetic, physical, and emotional-social sequelae when left untreated.

OBJECTIVE

To classify the most common adverse reactions associated with dupilumab treatment in patients with AD.

METHODS

The United States Food and Drug Administration Adverse Event Reporting (FAERS) database was analyzed for common adverse reactions associated with dupilumab, topical pimecrolimus, and topical tacrolimus. Phase III clinical trial data were used to compare the rate of herpes infections between the treatment group and placebo group.

RESULTS

The most common adverse reaction associated with dupilumab was ocular complications. Herpes infections were extremely rare in the patients with AD being treated with dupilumab.

LIMITATIONS

Prescribing information for dupilumab, topical pimecrolimus, and topical tacrolimus is not available. Adverse effects are reported by patients, health care providers, and pharmaceutical companies, they have not been corroborated.

CONCLUSIONS

Ocular complications are the most common complication associated with dupilumab. The rate of herpes infection is low in patients being treated with dupilumab, topical pimecrolimus, and topical tacrolimus. There is no significant difference for the rate of herpes infection between, placebo, dupilumab, topical pimecrolimus, and the topical tacrolimus treatment group, suggesting that dupilumab does not affect herpes infection rates.

Safety of dupilumab in patients with atopic dermatitis: expert opinion

Introduction: Dupilumab, the first biologic drug to be approved for the treatment of moderate to severe atopic dermatitis in adolescents and adults, has shown efficacy and safety in clinical trials. Data on long-term safety is limited but crucial for pharmacovigilance. Therefore, we performed this review to evaluate available real-world data on the long-term safety of dupilumab in atopic dermatitis.Areas covered: PubMed and Google Scholar databases were searched for randomized controlled clinical trials (RCTs), observational studies, case series, and case reports regarding the use of dupilumab for the treatment of atopic dermatitis. Adverse events were summarized and critically evaluated.Expert opinion: Atopic dermatitis patients receiving dupilumab reported ocular surface disease more often than patients receiving placebo. Real-world data show previously unreported adverse events (blood eosinophilia, rosacea-like skin lesions, weight gain), but their mechanistic association to dupilumab treatment still requires clarification. Cutaneous T-cell lymphomas occurring under the therapy with dupilumab might be unrelated to the drug use itself but long-term follow-up data of large patient cohorts is necessary to rule out such possibility. Real-world data show that dupilumab is well tolerated in atopic dermatitis; however, ocular adverse events are not rare. Registries are needed to monitor future adverse events.

Prevalence of ocular disease during dupilumab treatment for atopic dermatitis: a bicentric retrospective comparative cohort study

BACKGROUND

Dupilumab is the first human monoclonal antibody approved for the treatment of atopic dermatitis (AD). Clinical trials have reported an increase of ocular side effects in patients who receive dupilumab, with a prevalence of 5-37%.

OBJECTIVE

To compare the prevalence of ocular disease between AD patients receiving dupilumab treatment and AD reference group and to study the profile of the patients who developed ocular disease secondary to dupilumab treatment.

METHODS

Efficacy outcomes were collected both at baseline and at month 4 (M4). Presence of ocular disease was recorded at M4.

RESULTS

Data from 100 patients were examined. At M4, ocular disease was significantly more frequent in the dupilumab group (36% vs. 10%, P = 0.002). Severe allergic conjunctivitis and blepharitis were significantly more frequent in the dupilumab group (30% vs. 4%, P < 0.001, and 22% vs. 2%, P = 0.004, respectively). Six of 18 patients permanently discontinued therapy.

CONCLUSION

This study observed a prevalence of 36% of ocular disease in AD patients treated with dupilumab. Additional studies are required to confirm the risk factors we found for dupilumab-associated ocular disease and to identify new ones. Consultation with an ophthalmologist before the introduction of dupilumab might limit the occurrence of complications.

Association of Dupilumab with Intraocular Inflammation

Purpose: To report four cases of uveitis after treatment with dupilumab for atopic dermatitis.Methods: Retrospective case series.Results: Data was collected from four patients with inflammation that developed after treatment with dupilumab. The first patient was thought to have developed posterior scleritis or Harada's-type disease related to her treatment with dupilumab, with recurrence of intraocular inflammation upon restarting treatment. The second patient developed anterior and intermediate uveitis as well as cystoid macular edema in her right eye about two years after starting dupilumab treatment. The third patient developed a distinct relentless placoid chorioretinitis while on therapy with dupilumab. The fourth patient developed bilateral cystoid macular edema while on treatment with dupilumab.Conclusion: We report a case series of patients treated with dupilumab who developed intraocular manifestations of inflammatory disease.

Systemic treatments in the management of atopic dermatitis: A systematic review and meta-analysis

BACKGROUND

As an evidence resource for the currently planned European Academy of Allergy and Clinical Immunology (EAACI) clinical practice guideline "systemic treatment of atopic dermatitis (AD)," we critically appraised evidence on systemic treatments for moderate-to-severe AD.

METHODS

We systematically identified randomized controlled trials (RCTs) investigating the safety and efficacy of systemic treatments for AD up to February 2020. Primary efficacy outcomes were clinical signs, AD symptoms and health-related quality of life. Primary safety outcomes included cumulative incidence rates for (serious) adverse events. Trial quality was assessed applying the Cochrane Risk of Bias Tool 2.0. Meta-analyses were conducted where appropriate.

RESULTS

50 RCTs totalling 6681 patients were included. Trial evidence was identified for apremilast, azathioprine (AZA), baricitinib, ciclosporin A (CSA), corticosteroids, dupilumab, interferon-gamma, intravenous immunoglobulins (IVIG), mepolizumab, methotrexate (MTX), omalizumab, upadacitinib and ustekinumab. Meta-analyses were indicated for the efficacy of baricitinib [EASI75 RD 0.16, 95% CI (0.10;0.23)] and dupilumab [EASI75, RD 0.37, 95% CI (0.32;0.42)] indicating short-term (ie 16-week treatment) superiority over placebo. Furthermore, efficacy analyses of AZA and CSA indicated short-term superiority over placebo; however, nonvalidated scores were used and can therefore not be compared to EASI.

CONCLUSION

The most robust, replicated high-quality trial evidence is present for the efficacy and safety of dupilumab for up to 1 year in adults. Robust trial evidence was further revealed for AZA, baricitinib and CSA. Methodological restrictions led to limited evidence-based conclusions for all other systemic treatments. Head-to-head trials with novel systemic treatments are required to clarify the future role of conventional therapies.

Targetable pathogenic mechanisms in nasal polyposis

Chronic rhinosinusitis with nasal polyps (CRSwNP) represents a challenging disease entity with significant rates of recurrence following appropriate medical and surgical therapy. Recent approval of targeted biologics in CRSwNP compels deeper understanding of underlying disease pathophysiology. Both of the approved biologics for CRSwNP modulate the type 2 inflammatory pathway, and the majority of drugs in the clinical trials pathway are similarly targeted. However, there remain multiple other pathogenic mechanisms relevant to CRSwNP for which targeted therapeutics already exist in other inflammatory diseases that have not been studied directly. In this article we summarize pathogenic mechanisms of interest in CRSwNP and discuss the results of ongoing clinical studies of targeted therapeutics in CRSwNP and other related human inflammatory diseases.

Biologics for atopic diseases: Indication, side effect management, and new developments

With the advent of biologicals, more and more therapeutics are available that specifically address specific switch points in the pathomechanism of immunologically dominated diseases. Thus, the focus of diagnostics and therapy (precision medicine) is more on the individual disease characteristics of the individual patient. Regarding the different phenotypes of atopic diseases, severe asthma was the first entity for which biologicals were approved, followed by urticaria, and finally atopic dermatitis and chronic rhinosinusitis with nasal polyps. Experience in the treatment of severe bronchial asthma has shown that the intensity of the response to biological therapy depends on the quality of clinical and immunological phenotyping of the patients. This also applies to different diseases of the atopic form, as patients can suffer from several atopic diseases at the same time, each with different characteristics. Biologics are already emerging that may represent a suitable therapy for allergic bronchial asthma, which often occurs together with severe neurodermatitis, and chronic rhinosinusitis with nasal polyps. In practice, however, the question of possible combinations of biologicals for the therapy of complex clinical pictures of individual patients is increasingly arising. In doing so, the side effect profile must be taken into account, including hypersensitivity reactions, whose diagnostic and logistical management must aim at a safe and efficient therapy of the underlying disease. Increased attention must also be paid to biological therapy in pregnancy and planned (predictable) vaccinations as well as existing infections, such as SARS-CoV-2 infection. Before starting a biological therapy, the immune status should be checked with regard to chronic viral and bacterial infections and, if necessary, the vaccination status should be refreshed or missing vaccinations should be made up for before starting therapy. Currently, reliable data on the effect of biologicals on the immunological situation of SARS-CoV-2 infection and COVID-19 are not available. Therefore, research and development of suitable diagnostic methods for detection of immunologically caused side effects as well as detection of potential therapy responders and non-responders is of great importance.

Efficacy and Safety of Lebrikizumab, a High-Affinity Interleukin 13 Inhibitor, in Adults With Moderate to Severe Atopic Dermatitis: A Phase 2b Randomized Clinical Trial

Question

Is lebrikizumab, a novel, high-affinity, monoclonal antibody targeting interleukin 13 that selectively inhibits interleukin 13 signaling, efficacious and safe in adults with moderate to severe atopic dermatitis?

Findings

Among 280 patients with moderate to severe atopic dermatitis in this phase 2b, placebo-controlled randomized clinical trial, lebrikizumab statistically significantly improved measures of clinical manifestations of atopic dermatitis, pruritus, and quality of life in a dose-dependent manner vs placebo during 16 weeks of treatment.

Meaning

Lebrikizumab was efficacious for adults with moderate to severe atopic dermatitis, was generally well tolerated, and had a favorable safety profile consistent with previous lebrikizumab studies; these data support the central role of interleukin 13 in the pathophysiology of atopic dermatitis.

Importance

Interleukin 13 (IL-13) is a central pathogenic mediator driving multiple features of atopic dermatitis (AD) pathophysiology.

Objective

To evaluate the efficacy and safety of lebrikizumab, a novel, high-affinity, monoclonal antibody targeting IL-13 that selectively prevents formation of the IL-13Rα1/IL-4Rα heterodimer receptor signaling complex, in adults with moderate to severe AD.

Design, Setting, and Participants

A phase 2b, double-blind, placebo-controlled, dose-ranging randomized clinical trial of lebrikizumab injections every 4 weeks or every 2 weeks was conducted from January 23, 2018, to May 23, 2019, at 57 US centers. Participants were adults 18 years or older with moderate to severe AD.

Interventions

Patients were randomized 2:3:3:3 to placebo every 2 weeks or to subcutaneous injections of lebrikizumab at the following doses: 125 mg every 4 weeks (250-mg loading dose [LD]), 250 mg every 4 weeks (500-mg LD), or 250 mg every 2 weeks (500-mg LD at baseline and week 2).

Main Outcomes and Measures

The primary end point was percentage change in the Eczema Area and Severity Index (EASI) (baseline to week 16). Secondary end points for week 16 included proportion of patients achieving Investigator’s Global Assessment score of 0 or 1 (IGA 0/1); EASI improvement of at least 50%, 75%, or 90% from baseline; percentage change in the pruritus numeric rating scale (NRS) score; and pruritus NRS score improvement of at least 4 points. Safety assessments included treatment-emergent adverse events.

Results

A total of 280 patients (mean [SD] age, 39.3 [17.5] years; 166 [59.3%] female) were randomized to placebo (n = 52) or to lebrikizumab at doses of 125 mg every 4 weeks (n = 73), 250 mg every 4 weeks (n = 80), or 250 mg every 2 weeks (n = 75). Compared with placebo (EASI least squares mean [SD] percentage change, −41.1% [56.5%]), lebrikizumab groups showed dose-dependent, statistically significant improvement in the primary end point vs placebo at week 16: 125 mg every 4 weeks (−62.3% [37.3%], P = .02), 250 mg every 4 weeks (−69.2% [38.3%], P = .002), and 250 mg every 2 weeks (−72.1% [37.2%], P < .001). Differences vs placebo-treated patients (2 of 44 [4.5%]) in pruritus NRS improvement of at least 4 points were seen as early as day 2 in the high-dose lebrikizumab group (9 of 59 [15.3%]). Treatment-emergent adverse events were reported in 24 of 52 placebo patients (46.2%) and in lebrikizumab patients as follows: 42 of 73 (57.5%) for 125 mg every 4 weeks, 39 of 80 (48.8%) for 250 mg every 4 weeks, and 46 of 75 (61.3%) for 250 mg every 2 weeks; most were mild to moderate and did not lead to discontinuation. Low rates of injection-site reactions (1 of 52 [1.9%] in the placebo group vs 13 of 228 [5.7%] in all lebrikizumab groups), herpesvirus infections (2 [3.8%] vs 8 [3.5%]), and conjunctivitis (0% vs 6 [2.6%]) were reported.

Conclusions and Relevance

During 16 weeks of treatment, lebrikizumab provided rapid, dose-dependent efficacy across a broad range of clinical manifestations in adult patients with moderate to severe AD and demonstrated a favorable safety profile. These data support the central role of IL-13 in AD pathophysiology. If these findings replicate in phase 3 studies, lebrikizumab may meaningfully advance the standard of care for moderate to severe AD.

Trial Registration

ClinicalTrials.gov Identifier: NCT03443024

Real-World Experience and Laboratory Monitoring of Dupilumab in Patients with Moderate to Severe Atopic Dermatitis in a Tertiary Centre

INTRODUCTION

Dupilumab is a biologic therapy approved for treatment of moderate to severe atopic dermatitis (AD). Our objective was to assess the real-world effectiveness, safety and laboratory monitoring practices for dupilumab in a tertiary centre.

METHODS

A retrospective review of medical records of all patients receiving dupilumab between September 2017 and October 2019 was undertaken. Eczema Area and Severity Index (EASI) and Dermatology Life Quality Index (DLQI) were collected at weeks 0, 12-16 and 26-30. Data on laboratory tests undertaken for dupilumab screening and monitoring were also collected.

RESULTS

At 12-16 weeks, 58.9% and 37.3% of patients achieved ≥ EASI 75 and ≥ EASI 90, respectively (n = 156). Ninety-four patients underwent further analysis at weeks 26-30 with those achieving ≥ EASI 75 increasing from 61.7% (12-16 weeks) to 75.31%, and EASI 90 increasing from 35.8% (12-16 weeks) to 49.8%. The most common side effects were eye symptoms occurring in 43.1% of patients, with 16.3% developing conjunctivitis. The mean treatment duration was 255 days, during which an average of three sets of blood tests were performed (n = 149). Of all laboratory abnormalities recorded, 24% started after initiation of dupilumab, and 93% were classified as 'mild'. Dupilumab was not documented as causative in any of the cases, nor was treatment stopped on account of laboratory abnormalities.

CONCLUSION

Dupilumab provides an effective and safe treatment option for patients with AD. Clinical response continued to improve past 16 weeks in this real-world population. No laboratory abnormalities were felt to be secondary to dupilumab; screening and monitoring tests did not influence dupilumab prescribing.

Bidirectional association between atopic dermatitis, conjunctivitis, and other ocular surface diseases: A systematic review and meta-analysis

BACKGROUND

Conjunctivitis and several other ocular surface diseases (OSDs) have been linked to atopic dermatitis (AD) and its treatment.

OBJECTIVES

To examine the association between AD, conjunctivitis, and other OSDs.

METHODS

A systematic review and meta-analysis was performed. Two authors independently searched EMBASE, PubMed, SCOPUS, and Web of Science and performed title/abstract and full-text review and data abstraction. Pooled random-effects prevalence and odds ratios (ORs) with 95% confidence intervals (CIs) were estimated.

RESULTS

The search yielded 5719 nonduplicate articles; 134 were included in the quantitative analysis. AD was associated with conjunctivitis compared to reference individuals (OR, 2.78; 95% CI, 2.33-3.32); the prevalences of conjunctivitis in patients with AD and reference individuals were 31.7% (95% CI, 27.7-35.9) and 13.3% (95% CI, 11.0-15.7), respectively. Keratoconus (OR, 3.71; 95% CI, 1.99-6.94) and ocular herpes simplex (OR, 3.65; 95% CI 2.04-6.51) were also associated with AD.

LIMITATIONS

Disease definitions differed and often relied on self-reports. Few studies provided data concerning AD phenotype or OSDs other than conjunctivitis.

CONCLUSIONS

Conjunctivitis is the most common ocular comorbidity in AD. Signs and symptoms of conjunctivitis and other OSDs in AD may be underreported, making proactive inquiry and examination by physicians treating patients with AD important.

Dupilumab use in atopic dermatitis and beyond in skin diseases

Atopic dermatitis (AD) is a chronic inflammatory condition that affects 5-10% of adults and 9-18% of children and its pathology is rooted in the Th-2-mediated immune response. Dupilumab is a fully human IgG4 monoclonal antibody that targets the IL-4 receptor alpha subunit that is endogenously bound by the Th-2 cytokines IL-4 and IL-13. Successful clinical trials of dupilumab showing marked improvements in clinical signs of AD, patient reported symptoms and quality of life measures led to its approval for clinical use for moderate-to-severe AD in 2017. This review details the current body of evidence on the drug's mechanism of action, pharmacology, clinical efficacy and safety as well as post market and real world use.

Real-world evidence of dupilumab efficacy and risk of adverse events: A systematic review and meta-analysis

BACKGROUND

Dupilumab, the first biological drug to be approved for the treatment of moderate to severe atopic dermatitis in adolescents and adults, has shown good efficacy and safety in clinical trials.

OBJECTIVE

To evaluate real-world data on the efficacy and safety of dupilumab in atopic dermatitis.

METHODS

PubMed and EMBASE were searched for observational studies with data on efficacy, drug survival, and safety of dupilumab for the treatment of atopic dermatitis. Primary outcomes were mean percentage change in Eczema Area and Severity Index (EASI) score and proportion of atopic dermatitis patients achieving 50%, 75%, and 90% improvement in EASI score after dupilumab therapy.

RESULTS

Twenty-two unique studies encompassing 3303 atopic dermatitis patients were included. After 16 weeks of dupilumab therapy, the pooled proportion of patients achieving 50%, 75%, and 90% EASI score improvement was 85.1%, 59.8%, and 26.8%, respectively, and the weighted mean reduction in EASI score was 69.6%. Conjunctivitis was the most common adverse event, reported in a pooled proportion of 26.1%.

LIMITATIONS

Limited data in terms of size and follow-up time were available.

CONCLUSION

Real-world data show that dupilumab is a successful and well-tolerated therapy for atopic dermatitis, but ocular adverse events commonly occur. Registries are needed to monitor for adverse events.

Seborrhoeic dermatitis and sebopsoriasis developing in patients on dupilumab: Two case reports

Cutaneous adverse events to dupilumab can be varied; this necessitates keeping a broad differential diagnosis to identify seemingly paradoxical reactions. It may be possible to treat the adverse event concurrently without stopping dupilumab.

Dupilumab after the 2017 approval for the treatment of atopic dermatitis: what's new and what's next?

PURPOSE OF REVIEW

The IL-4/13 antagonist dupilumab was approved in 2017 as the first biologic for atopic dermatitis. Here, we comprehensively review compelling new data regarding dupilumab published following the approval.

RECENT FINDINGS

Daily clinical practice reports of dupilumab in atopic dermatitis are favorable and in line with the registration trials. Dupilumab does not appear to negatively affect pharmacokinetics of CYP450-metabolized drugs nor vaccination responses. Type 2 inflammation biomarkers in skin and serum are reduced following dupilumab treatment. Dupilumab increases the risk for conjunctivitis, especially with higher baseline atopic dermatitis severity and a history of conjunctivitis, but the underlying mechanisms are unknown. Favorable effects of dupilumab have been reported in treatment-recalcitrant hand eczema and prurigo nodularis cases; for allergic contact dermatitis and alopecia areata, there are conflicting responses to dupilumab, possible stemming from pathophysiological heterogeneity.

SUMMARY

Daily practice data support the continued use of dupilumab for atopic dermatitis. The only safety signal is an increased risk for conjunctivitis; mechanistic studies into dupilumab-associated conjunctivitis should lead to risk mitigation strategies. Prospective, controlled evaluations are needed for dupilumab in hand eczema and prurigo nodularis. A precision medicine-driven drug-development approach is essential to assess dupilumab for diseases with heterogeneous pathophysiologies, such as alopecia areata and allergic contact dermatitis.