Dupilumab and viral infection
Question:
5/14/2020
I realize dupixent can increase herpes infections in patients with atopic dermatitis. Is history of HSV infection, but well controlled or not currently active, considered a contraindication for trial of dupixent use for atopic dermatitis or can one still try dupixent if HSV is not active? HSV is not listed as a contraindication on the package insert. Also, is the same issue regarding HSV risk present for asthma or nasal polyp patients when considering dupixent, since the package insert does not list this as a warning for asthma? If someone has history of herpes infection history, but it is well controlled, would a trial of dupixent for asthma or nasal polyps still be okay?
Answer:
If you check prior Ask The Expert questions, you will see that Dr Ledford provided a nice response to a question about proceeding with resumption of dupilumab use in a patient who had a severe HSV infection. I found another article which pooled data from 7 randomized placebo controlled dupilumab trials in adults with atopic dermatitis. Although overall herpes viral infection rates were slightly (but not statistically significantly) higher (less than 1%) with dupilumab than placebo, these were mainly oral infections. Clinically important herpetic infections such as eczema herpeticum and herpes zoster were less common with dupilumab compared to placebo (risk ratio 0.31; p < 0.01). Serious or severe infections were significantly less common in the dupilumab groups.
A recent publication pooled 5 randomized, placebo-controlled trials of dupilumab for asthma and found similar safety profiles aside from injection site reactions. These findings are consistent with a 2019 meta-analysis.
Based upon the literature, I would not hesitate to proceed with dupilumab in the scenarios that you described. I would be sure to thoroughly discuss the risks and benefits with the patient and document the prior medical history and discussion in the medical record.
References:
Eichenfield LF et al. Infections in dupilumab clinical trials in atopic dermatitis: a comprehensive pooled analysis. Am J Clin Dermatol 2019; 20(3):443.
Rathinam KK et al. Dupilumab in the treatment of moderate to severe asthma: an evidence-based review. Curr Ther Res Clin Exp 2019;91:45.
Xiong X et al. Efficacy and safety of dupilumab for the treatment of uncontrolled asthma: a meta-analysis of randomized clinical trials. Respir Res 2019:20:108
I hope this information is helpful to you and your patient.
Jacqueline A. Pongracic, MD, FAAAAI