Jerry H. Hodge School of Pharmacy (Dr. Campbell) and Department of Family and Community Medicine (Dr. Sbar), Texas Tech University Health Sciences Center, Amarillo evelyn.sbar@ttuhsc.edu
Dr. Sbar discloses that she has served on the speakers’ bureaus for Teva Pharmaceuticals (makers of Ajovy), Biohaven Pharmaceuticals (Nurtec), and Abbvie (Ubrelvy). Dr. Campbell reports no potential conflict of interest relevant to this article.
Objective data:Patient is in no apparent distress and afebrile, and oxygen saturation on room air is 97%. Ht, 70 inches; wt, 75 kg. Labs: IgE, 15 IU/mL; serum eosinophils, 315/μL.
Which MAb would be appropriate for this patient?Given that the patient has a blood eosinophil level ≥ 300/μL and severe exacerbations, adult-onset asthma, nasal polyposis, and maintenance OCS at baseline, it would be reasonable to initiate mepolizumab 100 mg SC every 4 weeks, or dupilumab 600 mg once, then 300 mg SC every 2 weeks. Both agents can be self-administered.
Atopic dermatitis
Two MAbs—dupilumab and tralokinumab (Adbry; inhibits IL-13)—are approved for treatment of AD in adults that is uncontrolled with conventional therapy.15,19 Dupilumab is also approved for children ≥ 6 months old.20 Both MAbs are dosed at 600 mg SC, followed by 300 mg every 2 weeks. Dupilumab was compared with placebo in adult patients who had moderate-to-severe AD inadequately controlled on topical corticosteroids (TCSs), to determine the proportion of patients in each group achieving improvement of either 0 or 1 points or ≥ 2 points in the 5-point Investigator Global Assessment (IGA) score from baseline to 16 weeks.21 Thirty-seven percent of patients receiving dupilumab 300 mg SC weekly and 38% of patients receiving dupilumab 300 mg SC every 2 weeks achieved the primary outcome, compared with 10% of those receiving placebo (P < .001).21 Similar IGA scores were reported when dupilumab was combined with TCS, compared with placebo.22
In atopic dermatitis, MAbs, unlike other systemic agents, do not require frequent monitoring of factors such as blood pressure and kidney or liver function.
It would be reasonable to consider dupilumab or tralokinumab in patients with: cutaneous atrophy or hypothalamic-pituitary-adrenal axis suppression with TCS, concerns of malignancy with topical calcineurin inhibitors, or problems with the alternative systemic therapies (cyclosporine-induced hypertension, nephrotoxicity, or immunosuppression; azathioprine-induced malignancy; or methotrexate-induced bone marrow suppression, renal impairment, hepatotoxicity, pneumonitis, or gastrointestinal toxicity).23
A distinct advantage of MAbs over other systemic agents in the management of AD is that MAbs do not require frequent monitoring of blood pressure, renal or liver function, complete blood count with differential, electrolytes, or uric acid. Additionally, MAbs have fewer black box warnings and adverse reactions when compared with other systemic agents. For dupilumab, the main adverse reactions (that occurred with > 10% frequency in trials) were injection site reactions and upper respiratory tract infections.15 Antidrug antibody development occurred in 4.2%.15Tralokinumab had > 20%incidence of upper respiratory tract infections.19
