Real-world eosinophilia and other complications associated with dupilumab for respiratory indications
Published online September 23, 2024
Dupilumab, one of the most prescribed biologic therapies in the field of allergy and immunology, has been used with success in the treatment of asthma and chronic rhinosinusitis with nasal polyps (CRSwNP). In clinical trials, common side effects of dupilumab were joint pain, rash, conjunctivitis, and injection site reactions. Dupilumab was also found to increase eosinophil levels. Eosinophilia, defined as absolute eosinophil counts ≥ 1.5 x 103/µL, can be asymptomatic, but other times can result in organ damage or unmask eosinophilic disease, such as eosinophilic granulomatosis with polyangiitis (EGPA).
To add to our knowledge outside of clinical trial data, Li et al. published a study in The Journal of Allergy and Clinical Immunology: In Practice looking at dupilumab-associated eosinophilia and other complications in a real-world setting. Their study included 251 adult patients prescribed dupilumab for asthma, CRSwNP, or both from 2017-2022. The authors reviewed course of treatment, clinical benefit, and any reported complications, including eosinophilia and EGPA, associated with dupilumab.
Li et al. found that in patients who had eosinophil levels checked before and after starting dupilumab, 7.7% developed new eosinophilia within the first 36 weeks of dupilumab treatment. Nearly 75% of these patients remained on dupilumab with an eventual decrease in eosinophil levels. Eosinophilic complications included one patient with worsening respiratory disease who ultimately discontinued dupilumab and two other patients who were diagnosed with EGPA. Both patients with EGPA initially stopped dupilumab but experienced worsening sinonasal symptoms. They later resumed dupilumab in addition to mepolizumab, a biologic used for EGPA, with improvement. The low rates of eosinophilic complications may be because 90% of the patients had eosinophil levels < 1.0 x 103/µL before starting dupilumab, indicating a more conservative approach in real-world prescribing patterns.
Over the course of the study, 25% of patients discontinued dupilumab, including three patients due to eosinophilia (one with respiratory symptoms as above and two with asymptomatic eosinophilia) and 18 patients due to other side effects. Rates of joint pain (5.2%), rash (3.2%), and conjunctivitis (2.8%) were similar to data reported in clinical trials. Most patients experienced improvement in their primary disease while on dupilumab, including those with eosinophilia. Therefore, while providers should remain aware of side effects associated with dupilumab, it remains an overall well-tolerated and effective treatment option for asthma and/or CRSwNP.
The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.
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