Expert Panel Makes 7 Recommendations for Vaccinations for Children With AD Receiving Dupilumab

Following a consensus meeting, health care professionals who work with patients with atopic dermatitis (AD) published 7 vaccination recommendations for pediatric patients treated with dupilumab (Dupixent), according to an opinion piece published in the American Journal of Clinical Dermatology.

“These recommendations serve to guide physicians’ decisions about vaccination in children with atopic dermatitis treated with dupilumab,” wrote the panelists.

The guide is the first consensus statement addressing whether vaccinations in children treated with dupilumab for AD are safe and effective. The recommendations also highlighted an unmet need for research on how dupilumab influences the effectiveness of cellular and humoral immune responses to different types of vaccines.

AD affects young children and most patients’ disease presents before they turn 5 years old. The CDC and the Public Health Agency of Canada encourage physicians to dole out vaccinations for immunocompromised patients on a case-by-case basis to avoid infections that could be prevented with vaccines.

In the United States and Europe, dupilumab is the only biologic therapy approved for use in children as young as 6 years of age with severe AD and is often prescribed off-label for younger children, which has raised concerns on how to immunize pediatric patients on dupilumab safely.

A literature review published in February 2020 evaluated studies that tried to answer whether vaccinations were safe for children with AD taking dupilumab. An expert panel consisting of 5 health care professionals working in dermatology, immunology, infectious diseases, and vaccinations held a consensus meeting to discuss the identified literature and develop and vote on recommendations.

For the statements to be included in the publication, at least 75% of the panel had to agree on including them. In the end, all 7 recommendations received 100% consensus. Those statements included:

• Dupilumab does not appear to affect the development of antibodies titers to inactivated vaccines.
• Dupilumab therapy does not need to be interrupted for administration of inactivated vaccines.
• Seasonal inactivated influenza vaccination should continue for dupilumab-treated patients.
• Live attenuated vaccines should be avoided while on dupilumab but could be considered on a case-by case-basis.
• When live attenuated vaccines are required, they should be administered at least 4 weeks prior to starting dupilumab treatment and could be considered on a case-by-case basis.
• Measuring specific antibody levels can be considered to ensure serologic protection after receiving a vaccine while on dupilumab therapy.
• There is no evidence to suggest that immunization while on dupilumab causes AD exacerbations.

Seasonal influenza vaccinations are recommended in pediatric patients treated with dupilumab because of the complications that can stem from influenza infection. However, the panel noted that the type of seasonal flu vaccine is region-specific, meaning that immune responses and efficacy could vary in dupilumab-treated individuals.

Despite having access to some research for the effects of inactivated vaccines in dupilumab-treated patients, the panel said that there is insufficient data on the safety and efficacy of live attenuated vaccines, such as vaccines for measles, mumps, rubella, and varicella, in patients on dupilumab therapy.

The panel suggested that providers should weigh the risks of infection with the risks posed by live attenuated vaccines in dupilumab-treated vaccinations.

“In the absence of an evidence base to guide clinical decision making, our consensus discussions and statements are a starting point/food for thought for clinicians struggling with these decisions,” wrote the investigators.

In situations where a live attenuated vaccine is necessary, such as for patients who live in an area experiencing a measles outbreak, the panel recommended that providers should consult a clinical immunologist and an infectious disease specialist. Additionally, providers should make the parents or guardians of these patients aware of potential risks associated with vaccinations and the dangers of infection.

Generally, the panel said that patients with AD should be vaccinated in accordance with national vaccination plans but should not receive a vaccination if experiencing an acute AD flare.

“In the scenario of an acute AD flare, starting treatment to achieve disease control should be prioritized over vaccination. Good clinical AD control for 2 weeks before receiving vaccinations is optimal to avoid skin complications related to vaccination,” wrote the panel.

The panel noted several limitations, including the small number of panelists, the lack of evidence on vaccine response in pediatric patients with AD on immunosuppressive treatments, that existing international guidelines are based on moderate to low levels of evidence, and that the review took place before the COVID-19 vaccines became available.

Reference

Martinez-Cabriales SA, Kirchhof MG, Constantinescu CM, Murguia-Favela L, Ramien ML. Recommendations for vaccination in children with atopic dermatitis treated with dupilumab: a consensus meeting, 2020. Published online June 2, 2021. Accessed June 16, 2021. doi:10.1007/s40257-021-00607-6