Case of the Month
A 34-year-old man, with a history of chronic atopic dermatitis, was started on a biologic agent to treat his atopic eczema. One month after the initiation of the biologic agent, he returned for a routine follow up visit with this clinical presentation. He said his eyes were “sore and very itchy.” He said the eye concern started about 2-3 weeks after the first injection of the biologic agent.What's Your Diagnosis?
Dupilumab (Dupixent) associated conjunctivitis
The U.S. Food and Drug Administration approved Dupixent (dupilumab) injection to treat adults with moderate-to-severe eczema (atopic dermatitis) on Mar 28, 2017.
Fortunately, for dermatologists treating atopic/chronic eczema and patients who have atopic/chronic dermatitis, Dupixent (dupilumab), has been a real game changer. Unfortunately, in 5-10% of patients receiving Dupixent (dupilumab), they develop significant conjunctivitis, usually 2-4 weeks after beginning the medication.
Generally: DUPIXENT is an injectable prescription medicine used to treat adult patients with moderate-to-severe eczema whose disease is not well controlled with prescription therapies used on the skin (topical), or who cannot use topical therapies. DUPIXENT can be used with or without topical corticosteroids.
Specifically: Dupilumab is a human monoclonal IgG4 antibody that inhibits interleukin-4 (IL-4) and interleukin-13 (IL-13) signaling by specifically binding to the IL-4Ra subunit shared by the IL-4 and IL-13 receptor complexes. Dupilumab inhibits IL-4 signaling via the Type I receptor and both IL-4 and IL-13 signaling through the Type II receptor. Blocking IL-4a with dupilumab inhibits IL-4 and IL-13 cytokine-induced responses, including the release of pro-inflammatory, cytokines, chemokines, and IgE. The injections are done twice monthly, with a double loading dose (600 mg) done the very first treatment and then a single dose (300 mg), twice monthly, after that. Dupixent is FDA approve for patients 18 years and older. Studies are currently underway to evaluate safety and effectiveness in patients under age 18.
For patients who develop conjunctivitis while on Dupixent (dupilumab), the first approach is to use a moisturizing eye drop (like systane eye drops, OTC), four times daily for 5-7 days. If that does not control the condition, they should be referred to an ophthalmologist for additional evaluation/treatment or discontinuation of the medication. In the majority of cases where the conjunctivitis is unmanageable or incompatible with staying on Dupixent (dupilumab), conjunctivitis will resolve within a month of discontinuation of Dupixent (dupilumab). In a small percentage of cases, conjunctivitis can be long-lasting, even after discontinuation of the biologic and will require long-term ophthalmologist care.
For more information on Biologic Medications, please see: https://www.crutchfielddermatology.com/biologicmedicationinformation/
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