Dupixent in patient on immunosuppressant therapy
Question:
12/8/2020
One of our ENT doctors has referred a patient for possible treatment with Dupixent. The patient is a 66 year-old woman who has chronic sinusitis. She is post sinus surgery. During surgery a few small polyps were found. Patient responds favorably to Cipro plus Diflucan but relapses as soon as the medications are stoped. She also also on a budesonide plus saline rinse. The patient had a kidney transplant 19 years ago and in on an immunosuppresive treatment with Rapamune. Is there any information on Dupixent being used with a patient on immunosuppresive therapy?
Answer:
I was unable to find any reference addressing Dupixent is immunosuppressed patients. There were articles addressing titrating off immunosuppressive drugs, such as Cyclosporine, that had been used in the management of atopic dermatitis, after starting Dupilumab. Additionally, many patients started on Dupixent are also on oral steroids.
The package insert does report an increased risk for oral herpes infection. Additionally, there is concern for helminth infections.
I found one study, Eichenfield, et al. (1) reporting an analysis of pooled data from seven randomized, placebo-controlled dupilumab trials in adults with moderate-to-severe AD. The authors found that Dupilumab is actually associated with reduced risk of serious/severe infections and non-herpetic skin infections and does not increase overall infection rates versus placebo in patients with moderate-to-severe AD.
There was a caution statement regarding co-medications that use the enzyme CYP3A4, which includes Rapamune and Dupixent. (2)
I researched this further and found a study that specifically looked at this. In a study specifically addressing this, Davis J, Bansal A, et al. (3) reported that there was no evidence for a meaningful influence of dupilumab treatment on CYP3A.
In summary, I am unable to find any contraindication for the use of Dupixent in conjunction with Rapamune or any other immunosuppressive therapy. Nor can I find evidence that there is significant impact on drug metabolism between Dupixent and Rapamune. Since oral HSV has been reported and there is caution with active helminth infection, these issues should be addressed with your patient.
1) Eichenfield LF, Bieber T, Beck LA, Simpson EL, Thaçi D, de Bruin-Weller M, Deleuran M, Silverberg JI, Ferrandiz C, Fölster-Holst R, Chen Z, Graham NMH, Pirozzi G, Akinlade B, Yancopoulos GD, Ardeleanu M. Infections in Dupilumab Clinical Trials in Atopic Dermatitis: A Comprehensive Pooled Analysis. Am J Clin Dermatol. 2019 Jun;20(3):443-456.
2) https://www.rxwiki.com/dupixent. Accessed on 12/11/20
3) Davis JD, Bansal A, Hassman D, Akinlade B, Li M, Li Z, Swanson B, Hamilton JD, DiCioccio AT. Evaluation of Potential Disease-Mediated Drug-Drug Interaction in Patients with Moderate-to-Severe Atopic Dermatitis Receiving Dupilumab. Clin Pharmacol Ther. 2018 Dec;104(6):1146-1154. doi: 10.1002/cpt.1058. Epub 2018 Apr 2. PMID: 29498038; PMCID: PMC6282936.
I hope you find this helpful.
Respectfully submitted,
Jeffrey G Demain, MD