Study Examines Dupilumab's Effect on EoE When Given for AD, Other Conditions

A recent study examined the effects of dupilumab on eosinophilic esophagitis (EoE) when it was prescribed for other conditions, including atopic dermatitis, asthma, and nasal polyps, which are all approved indications.

The biologic is being studied in phase 3 trials for EoE, where it has been shown to lead to significant improvements in patients aged 12 and older.

The current study, conducted because of the shared type 2 inflammation of these atopic conditions, consisted of a retrospective chart review of all patients at Children’s Hospital of Philadelphia and Rady Children Hospital in San Diego, California, who were prescribed dupilumab for atopic dermatitis, asthma, or nasal polyps and had a concomitant clinical diagnosis of EoE.

Previous research from the authors found that 60% of pediatric patients with EoE had allergic rhinitis, 60% had asthma, and 18% had atopic dermatitis, which is significantly higher than the population.

In this study, the mean age of the patients was 15.31 and most were male and White. After exclusions, the investigators included 45 patients who had clinical follow-up data available, including 26 patients who had endoscopic biopsy data available.

Of the 45 patients:

• 47% of the patients had 4 atopic conditions (asthma, allergic rhinitis, immunoglobulin E−mediated food allergy, and atopic dermatitis)
• 20% had 3 atopic conditions
• 31% had 2 atopic conditions

Atopic dermatitis was the most common condition for which dupilumab was approved (60%, or 27 patients), followed by asthma (24%, or 11%) and chronic rhinosinusitis with nasal polyps (3 patients). There was no follow-up data for 8 patients.

EoE was defined by greater than or equal to 15 eosinophils/high-power field (eos/hpf) in esophageal biopsies.

The authors noted that dosing for atopic dermatitis, asthma, or nasal polyps is different than for EoE; EoE dosing in trials is weekly, whereas dosing for these other conditions is every 2 weeks or monthly depending on patient age and weight. In this study, subcutaneous dupilumab dosing was administered according to the FDA indication for each condition.

Four patients were prescribed dupilumab for compassionate use specifically for EoE on a twice-weekly schedule. These patients were also highly atopic and had other conditions (asthma, allergic rhinitis, or food allergy).

Asthma control test (ACT) and eczema area severity index (EASI) scores were calculated at follow-up visits for each patient if they had asthma or atopic dermatitis, respectively, as well as the pediatric eosinophilic esophagitis symptom score version 2 (PEESS), if the patient had EoE.

Of the 41 patients treated with dupilumab for an approved indication (not including the patients approved for compassionate use), 39 met the criteria for clinical improvement.

For patients being treated for atopic dermatitis, EASI scores decreased from 38.6 (15.8) to 8.8 (9.25), (P < .005).

Among the 11 patients using the biologic specifically for asthma, the number of exacerbations requiring oral steroids fell from 12 in the 6 months before dupilumab to 2 in the first 6 months after dupilumab (P < .05). In addition, ACT scores improved from 13.9 (2.1) before dupilumab to 22.7 (2.1) after dupilumab (P < .001).

Among all patients with asthma, ACT scores improved from 18.8 (4.7) to 23.1 (2.3) (P < .05).

Follow-up histology was available for 26 patients with EoE, and 22 of those met the criteria for remission of their EoE—less than 6 eos/hpf field starting dupilumab (before, 52.9 [35.1]; after, 4.5[10.9] eos/hpf, P < .005).

A total of 28 patients saw their EoE symptoms improve, with 24 patients noting a complete resolution of symptoms. In addition, 29 patients were able to reduce their EoE treatment medications (swallowed steroids, proton pump inhibitors) or expand their resticted diet.

The authors noted that most of the patients with EoE were using multiple strategies to control their symptoms, including a restricted diet and other medications, so it is not known from this study if dupilumab would work as a single agent on a twice-weekly basis.

They also noted other limitations in the study, including the possibility that patients who were more atopic were overrepresented, and that the results may not be generalizable to adults with EoE.

Still, with multiple biologics being tested to tame the type 2 inflammation present in comorbid atopic diseases, the authors noted that “continued evaluation” of these therapies is necessary in order to gain the most benefit.

Reference

Spergel BL, Ruffner MA, Godwin BC, et al. Improvement in eosinophilic esophagitis when using dupilumab for other indications or compassionate use. Ann Allergy Asthma Immunol. Published online January 25, 2022. doi:10.1016/j.anai.2022.01.019