Association of Dupilumab with Intraocular Inflammation

Non-Infectious Uveitis Secondary to Dupilumab Treatment in Atopic Dermatitis Patients Shows a Pro-Inflammatory Molecular Profile

Severe uveitis is a rare complication of interleukin-4 receptor alpha blocking by dupilumab in topic dermatitis (AD) patients. The aim of this study was to describe five moderate-to-severe AD patients who developed uveitis during dupilumab treatment and to compare the proteomic profile of aqueous humor (AqH) of dupilumab-associated uveitis (n=3/5 available samples) with non-infectious uveitis (n=27) and cataract controls (n=11). Included patients were treated at the University Medical Center Utrecht (the Netherlands). Active dupilumab-associated uveitis complicated by serous detachment, cystoid macular edema, or secondary glaucoma developed within a median of 6.0 months (interquartile range 2.3-16.5 months) after starting dupilumab. Uveitis resolved after discontinuation of dupilumab and/or treatment with local or systemic corticosteroids. Proteomic profiling of AqH revealed that the molecular profile of dupilumab-associated uveitis resembled that of non-infectious uveitis. In conclusion, dupilumab-associated uveitis is a severe adverse event of dupilumab therapy, requiring urgent referral to an ophthalmologist.

Purtscher-Like Retinopathy in a Patient of Atopic Dermatitis Associated with Dupilumab Use: A Case Report

PURPOSE

Purtscher-like retinopathy is a rare and vision-threatening eye disease, which is usually associated with acute pancreatitis, autoimmune diseases, and renal failure. We here reported a case of Purtscher-like retinopathy after dupilumab treatment in atopic dermatitis.

CASE REPORT

A 48-year-old woman with a history of severe atopic dermatitis developed ocular manifestations after second exposure to dupilumab. Best-corrected visual acuity (BCVA) was count fingers at 2 feet in the right eye and 20/133 in the left eye when she referred to our hospital. Fundus examination demonstrated bilateral serous macular off, thickening of papillomacular bundle, intraretinal hemorrhage, cotton-wool spots and Purtscher flecken surrounding the optic disc. Optical coherence tomography (OCT) angiography showed flow void in the superficial and deep capillary plexuses. And early hypofluorescence corresponding to grayish-white retinal thickening was observed in fundus fluorescein angiography. Laboratory tests revealed hypereosinophilia after symptoms appeared. A diagnosis of Purtscher-like retinopathy was made, which may associate with dupilumab. The patient accepted the treatment with glucocorticoids. At six months follow up, BCVA was 20/40 in the right eye and 20/25 in the left eye.

CONCLUSION

The Purtscher-like retinopathy we report may be the adverse event of dupilumab. Rare adverse reactions to biologics deserve the attention of ophthalmologists.

A Review of Dupilumab-Induced Adverse Events to Dermatologists and the Potential Pathogenesis in the Treatment of Atopic Dermatitis

Dupilumab, a monoclonal antibody targeting interleukin-4 antibody, is approved for use in many type 2 inflammatory diseases, including atopic dermatitis. It is generally well tolerated with no need of routine laboratory monitoring. However, several adverse events have been reported during real-world practice and in pivotal trials. We conducted a systematic literature research of the PubMed, Medline, and Embase databases to identify articles recording the clinical manifestation and potential pathogenesis of these adverse events with interests (AEIs) to dermatologists. In total, 547 cases from 134 studies have developed 39 AEIs 1 day to 2.5 years after dupilumab treatment. The most common AEIs are facial and neck dermatitis (299 cases), psoriasis (70 cases), arthralgia (56 cases), alopecia (21 cases), cutaneous T cell lymphoma (19 cases), severe ocular diseases (19 cases), and drug eruption (6 cases). Most of the AEIs recorded in this review resolved or improved after dupilumab discontinuation or the addition of another treatment, whereas 3 of the cases died of severe AEI. The potential pathogenesis included T help type 1 (Th1)/T help type 2 (Th2) imbalance, Th2/T help type 17 (Th17) imbalance, immune reconstitution, hypersensitivity reaction, transient hypereosinophilia related, and Th1 suppression. Clinicians should be alert of these AEIs for timely diagnosis and appropriate treatment.

Dupilumab-associated ocular surface disease: An interdisciplinary decision framework for prescribers in the Australian setting

BACKGROUND/OBJECTIVES

Dupilumab-associated ocular surface disease (DAOSD) is of particular relevance in patients with atopic dermatitis (AD). Guidance on DAOSD assessment and management in the Australian setting is needed to reduce its impact and minimise disruption to treatment.

METHODS

A systematic review of the literature was undertaken to identify data pertaining to the incidence, pathophysiology, risk factors and management of DAOSD. A critical review of this literature was used to inform a decision framework for dupilumab-prescribers and develop a graded severity scoring tool to guide appropriate management options.

RESULTS

DAOSD typically emerges within 4 months of commencing dupilumab and the occurrence of new events diminishes over time. The reported incidence varies widely depending on the nature and source of the data: 8.6-22.1% (clinical trials programme), 0.5-70% (real-world data; differences in study size, duration of follow-up, ophthalmologist intervention, use of prophylaxis). Occurrence increases with AD severity and in patients with prior history of ocular disease; pathophysiology is still to be fully characterised. Management options have evolved over time and include lubricants/artificial tears, corticosteroids, calcineurin inhibitors, antihistamines, anti-inflammatory agents and antimicrobial agents. Current therapies aim to resolve symptoms or reduce severity to levels sufficiently tolerable to enable continuation of dupilumab therapy.

CONCLUSIONS

Recommendations for DAOSD assessment and management include identification of high-risk patients, vigilance for red flags (keratoconus, herpetic and bacterial keratitis), regular assessment of symptom severity (before and during dupilumab therapy), conservative management of mild DAOSD by the prescribing physician and ophthalmologist referral for collaborative care of moderate-severe DAOSD and high-risk patients.

Dupilumab-associated ocular manifestations: A review of clinical presentations and management

Dupilumab is a first-in-class biologic approved by the European Medicines Agency (EMA) and the US Food and Drug Administration (US FDA) for the treatment of multiple atopic diseases, including atopic dermatitis, asthma, and chronic rhinosinusitis with nasal polyposis. Since gaining traction as an effective treatment modality, multiple reports have highlighted the many ocular side effects associated with dupilumab usage. These range from mild diseases such as conjunctivitis, dry eyes, and blepharitis, to more severe manifestations such as intraocular inflammation and cicatrising conjunctivitis. The pathogenesis behind these manifestations remains controversial but are likely multi-factorial. We review the current evidence surrounding ocular manifestations of dupilumab-associated disease and proposed treatments to provide an overview of this unique disease entity. With increasing usage of dupilumab, formal recommendations regarding the treatment of dupilumab-associated ocular disease are warranted to provide standardised clinical guidance. Furthermore, it is important for healthcare practitioners to remain abreast with existing literature to adequately counsel and empower patients with the knowledge surrounding contemporary treatments for atopic diseases and their associated side-effects.

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.