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Dupilumab, nasal polyps, pediatrics

Question:

8/6/2020
Have a 16 year-old male with recurrent nasal polyposis since last for five years. No history to asthma or aspirin sensitivity to date. Sweat chloride test has been negative CF TR mutation test is pending. He was immunotherapy for year no help. He stopped. Parents and patient feeling very frustrated. Other autoimmune workup is negative. Since he already had two nasal polypectomy and has recurrence of nasal polyps (really huge again per ENT) I was thinking if he could be a reasonable candidate to go on Dupilumab? Repeat CBC pending for eosinophilia. Total IgE level also pending. If so can you please guide loading dose since there is confusion. He weighs 60 kg and < 18 yrs.

Option A: Loading dose 400 mg thereafter 200 mg subcu every two weeks.
OR
Option B: Loading dose 600mg thereafter 300 mg subcu every two weeks.

Answer:

As you are aware dupilumab has been approved for patients 18 years old and older for treatment of nasal CRS and nasal polyposis. A search of medline using the terms dupilumab, nasal polyps and pediatric did not return any papers. A recent review in JACI (J Allergy Clin Immunol 2020 Mar;145(3):725-739) highlights the current treatment paradigms for nasal polyps - as you will note there is a lack data in the pediatric age range. The lack of data on dupilumab use in pediatric population for nasal polyps makes it a challenge to suggest an appropriate dose to use off label.

I hope this is helpful.
Andrew Murphy, MD, FAAAAI