What is Dupilumab?
Dupilumab is the first biologic used to treat moderate-to-severe eczema. It is marketed under Dupixent. You may not have heard of it as it was only recently approved for use in older children.
Younger children may have access to it soon. Positive results came in from a clinical trial for children from 6 to 11 years old. Therefore, we cannot rule out that governments will approve it for younger children.
Let’s look at when various countries approved Dupilumab:
- EU EC – August 2019, for adolescents age 12-17
- Singapore HSA – April 2019, for adults
- USA FDA – March 2019, for adolescents age 12-17
- Japan – January 2018, for adults
- Australia TGA – January 2018, for adults
- EU – September 2017, for adults
- USA FDA – March 2017, for adults
How does Dupilumab Work?
For those of us who do not know the (possibly) billion types of proteins in our body, Dupilumab works by targeting two cytokines. These cytokines (IL-4 and IL-13) regulate the body’s immune response to inflammation. Dupilumab works by injection and its list price is US$3019.50 per 4-week supply.
Update on 26 Oct 2019: This is another company that is working on Etokimab that targets IL-33, and improvement seen after single dose (study).
What is the Current Dosage for Older Children with Eczema?
Similar to oral medication, the weight of your child is one factor that determines the dosage. Drugs.com listed the dosage as:
For Adolescents lighter than 60 kg
- Initial dose: 2 injections (each 200 mg) at different part of the body
- Maintenance dose (each 200 mg) injected every other week
If your child is 60 kg and heavier, each dosage is 300 mg.
What if My Child does not like Needles?
Biologic drug means it is made from proteins – interesting, it is made from Chinese hamster! (I found out this from Australia TGA’s information leaflet.) Dupilumab cannot be taken orally, otherwise, our body will break down the proteins before the medication can get to work. Its molecules are also too large to be absorbed through the skin (that I learnt from US National Eczema Association).
Dupilumab can only be taken via injection
Does Dupilumab Work?
From the studies, yes, Dupilumab works.
It works by effectively targeting the two proteins that have been studied to be the most related to Atopic Dermatitis. These proteins cause more itch and inflammation, so targeting them will mean ‘short-circuiting’ the pathway that the skin gets hypersensitive.
Side-track: Dupilumab is also approved for use for asthma patients and those with chronic rhinosinusitis with nasal polyposis
Should I request this for my Child?
Hang on. Even if you can afford it, certain conditions must be met before a doctor can prescribe Dupilumab. And not any doctor – it has to be a specialist e.g. dermatologist.
What ‘Moderate-to-Severe Eczema’ Means?
Dupilumab can only be prescribed for moderate to severe eczema, that cannot be controlled with topical medicines.
I cannot find information on whether your dermatologist has to prove the eczema severity. I guess that a dermatologist is assumed to have both the expertise and the duty to prescribe only when needed.
So what does Moderate to Severe Eczema look like?
Several guidelines are helpful in giving a common understanding of mild vs moderate vs severe eczema, one of which is UK’s NICE guideline.
Moderate eczema means:
- Areas of dry skin
- Frequent itching
- Redness (with or without excoriation (skin picking) and localised skin thickening)
- Moderate impact on everyday activities
- Frequently disturbed sleep.
Severe eczema means:
- Widespread areas of dry skin
- Incessant itching
- Redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation)
- Severe limitation of everyday activities
- Nightly loss of sleep.
For those of us, who are into something quantifiable, you can work out your child’s eczema severity through SCORAD. If the score is from 25 to 50, your child has moderate eczema and above 50, is severe.
Many Moderate Eczema Cases
My child’s eczema would fall under moderate. And I suspect, there are many children with moderate eczema. Does this mean all these children would be prescribed Dupilumab?
Proof that Topical Medicines Do Not Work
Approval for use specifically states that Dupilumab can only be prescribed if topical medicines had not worked. My deduction, therefore, is that your child first has to have tried topical corticosteroids or topical calcineurin inhibitors, in order for the dermatologist to CONCLUDE that these have not worked.
To put it simply, if you are scared of steroids and have not applied it for your child, the dermatologist may not be able to prescribe Dupilumab.
No need for History of Eczema Oral Medications
Your child do not need to have taken oral medications for eczema, before the dermatologist can prescribe you Dupilumab. My guess is that the current oral medications are not optimal for eczema treatment. They come with side effects that are severe enough that they cannot be taken over a long duration.
Oral systemic steroids is usually for 2-week dose and side effects can include hypertension, glucose intolerance, gastritis, weight gain etc. Rebound flares are also common. Read more in this journal.
Similarly, systematic immunosuppressive treatments have many side effects which require blood testing to monitor toxicity and organ functioning.
Is Dupilumab Safe and Effective?
I have compiled recent studies on Dupilumab in this forum post, and it is considered safe and effective. There are side effects though, but given its efficacy, the side effects are acceptable.
Just from the studies in the second half of 2019, 11 studies concluded it is effective, including for hand eczema, for reducing staph bacteria and not increasing skin infections. 3 studies focused on its side effects, which are mainly injection site reactions (pain, redness), conjunctivities and herpes infection. You can see the statistics from Rxlist.com
If you are considering Dupilumab, you should first inform your dermatologist of any eye problem. You may be asked to consult an eye doctor to establish a baseline for your eye condition before starting Dupilumab.
The Other Thing – Duration
Because of the way Dupilumab works, it is an ongoing treatment. Meaning, if you stop the injections, the protein cells in your body may go back to triggering skin inflammation. You should give it 16 weeks to see if the treatment works for you (National Eczema Society’s fact sheet).
To Dupilumab or Not?
There is no easy answer.
It is a decision to consider based on:
- Severity of your child’s eczema
- Emotional aspect of injection
- Possible side effects, including the current eye condition (for instance, if your child already has dry eyes, it may worsen)
- Whether topical prescription has been properly explored (because applying something is still safer than injecting something)
- Whether other treatments and triggers have been sufficiently explored. For instance, allergen avoidance, control of staph bacteria colonization and other therapeutics.
Currently, Dupilumab is very expensive because it is generally not subsidized nor included in insurance. But should it be more affordable, I still believe that given it is via injection and comes with side effects, we have to be sure that it is only prescribed as needed.
To put it bluntly, it should not be an easy (or lazy) way out of the due care needed for your eczema child.
Have you tried Dupilumab? It helps for fellow eczema patients to read of your experience, so please do share in the comments below or in the forum post.