Dupilumab in atopic dermatitis: rationale, latest evidence and place in therapy

Safety and efficacy of amlitelimab, a fully human nondepleting, noncytotoxic anti-OX40 ligand monoclonal antibody, in atopic dermatitis: results of a phase IIa randomized placebo-controlled trial

BACKGROUND

Atopic dermatitis (AD) is an inflammatory skin disease with significant unmet need. Blockade of the OX40-OX40 ligand (OX40L) costimulation pathway by targeting OX40L on antigen-presenting cells (APCs) with a fully human noncytotoxic, nondepleting anti-OX40L monoclonal antibody (amlitelimab; SAR445229; KY1005) is a novel way to modulate persistent inflammation.

OBJECTIVES

To assess the safety and efficacy of amlitelimab over 16 weeks in adults with AD in a phase IIa double-blind placebo-controlled study.

METHODS

The study was conducted at 19 hospitals in Germany, Poland, Spain and the UK. Eligible patients with moderate-to-severe AD were randomized (1 : 1 : 1) to low-dose intravenous (IV) amlitelimab (200 mg), high-dose IV amlitelimab (500 mg) or placebo, followed by three maintenance doses (50% of loading dose) at 4, 8 and 12 weeks, with safety follow-up to week 36. The co-primary endpoints were the incidence of treatment-emergent adverse events (all patients who received ≥ 1 dose of the study drug) and mean percentage change in Eczema Area and Severity Index (EASI) to week 16 (full analysis set).

RESULTS

Between 13 December 2018 and 12 May 2020, 89 patients were randomly assigned to low- (n = 29) or high-dose amlitelimab (n = 30) or placebo (n = 29), of whom 88 proceeded to treatment [37 women (42%), 51 (58%) men; mean (SD) age 33.6 (11.9) years]. Amlitelimab was generally well tolerated with an unremarkable safety profile; no hypersensitivity events were reported. For the primary endpoint, the least square mean percentage change in EASI from baseline to week 16 was -80.12% [95% confidence interval (CI) -95.55 to -64.68; P = 0.009 vs. placebo] and -69.97% (95% CI -85.04 to -54.60; P = 0.07 vs. placebo) for the low- (n = 27) and high-dose (n = 27) amlitelimab groups, respectively, vs. -49.37% (95% CI -66.02 to -32.72) for placebo (n = 24). Numerically greater reductions in EASI were observed for amlitelimab vs. placebo from weeks 2 to 16.

CONCLUSIONS

Novel targeting of OX40L-expressing APCs with amlitelimab was well tolerated and resulted in clinically meaningful improvements in AD.

Blood Cells Count Derived Inflammation Indexes as Predictors of Early Treatment Response to Dupilumab in Patients with Moderate-to-Severe Atopic Dermatitis

Derived inflammatory indexes from routine hematological parameters might be useful for predicting early-response vs. late/non-response to dupilumab, the first biological agent approved for moderate-to-severe atopic dermatitis (AD). We tested this hypothesis by retrospectively investigating the association between pre-specified baseline inflammatory indexes and dupilumab response (≥50% reduction in the Eczema Area and Severity Index, EASI 50) at 4 and 16 weeks in a consecutive series of 66 AD patients (38 males and 28 females). Forty-six patients (69.7%) were early-responders at 4 weeks, whereas the remaining twenty (30.3%) were late/non-responders at 16 weeks. In logistic regression, the platelet-to-lymphocyte ratio (PLR) was independently associated with early-response (OR = 1.0159, 95% CI 1.0005 to 1.0315, p = 0.0426). The predictive performance of PLR and other derived indexes towards early-response was further improved by their combination with serum IgE concentrations, with a maximum AUC value for the combined systemic immune inflammation index (SII)-IgE of 0.797 (95% CI = 0.677 to 0.884, p < 0.0001). Derived inflammatory indexes, particularly SII-IgE, might be useful to identify early-responders to dupilumab and develop alternative treatment protocols for late/non-responders.

Mesenchymal Stem Cells Profile in Adult Atopic Dermatitis and Effect of IL4-IL13 Inflammatory Pathway Inhibition In Vivo: Prospective Case-Control Study

Atopic dermatitis (AD) is an inflammatory disease that typically begins in childhood and may persist into adulthood, becoming a lifelong condition. The major inflammatory mediators of AD are known to be interleukin IL4 and IL13, so Dupilumab, which is able to inhibit both interleukins by blocking the shared IL4Rα subunit, has become an attractive option for treating AD. Mesenchymal stem cells (MSCs) are involved in the onset and development of AD by secreting specific interleukins. The aim of this study was to isolate MSCs from healthy controls (C-MSCs) and patients with AD before (AD-MSCs T0) and after 16 weeks of treatment with Dupilumab (AD-MSCs T16); to evaluate the expression mainly of IL4 and IL13 and of other inflammatory cytokines in C-MSCs, AD-MSCs at T0 and at T16; and to evaluate the efficacy of Dupilumab on MSCs immunobiology. C- and AD-MSCs (T0, T16) were isolated from skin specimens and characterized; the expression/secretion of IL4 and IL13 was evaluated using immuno-cytochemistry (ICC), indirect immune-fluorescence (IIF) and an ELISA test; secretion of IL2, IL4, IL5, IL6, IL10, IL12, IL13, IL17A, Interferon gamma (IFNγ), Tumor necrosis factor alpha (TNFα), Granulocyte Colony-Stimulating Factor (G-CSF), and Transforming Growth Factor beta1 (TGFβ1) were measured with ELISA. IL13 and IL6 were over-expressed, while IL4 was down-regulated in AD-MSCs at T0 compared to C-MSCs. IL6 and IL13 expression was restored after 16 weeks of Dupilumab treatment, while no significant effects on IL4 expression were noted. Finally, IL2, IL5, IL10, IL12, IL17A, INFγ, TNFα, G-CSF, and TGFβ1 were similarly secreted by C- and AD-MSCs. Although Dupilumab blocks the IL4Rα subunit shared by IL4 and IL13, it is evident that its real target is IL13, and its ability to target IL13 in MSCs reinforces the evidence, already known in differentiated cells, of the central role IL13 rather than IL4 in the development of AD. The inflammatory cascade in AD begins at the mesenchymal level, so an upstream therapeutic intervention, able to modify the immunobiology of atopic MSCs, could potentially change the natural history of the disease.

Real-life experience in the effectiveness, impact on quality of life and safety of dupilumab treatment in patients with moderate to severe atopic dermatitis in the Czech Republic

OBJECTIVES

The aim of the study was to assess the effectiveness and safety of dupilumab therapy in patients with moderate-to-severe atopic dermatitis (AD) in a real-life Czech bicentric cohort.

METHODS

We retrospectively analysed 50 patients with moderate-to-severe AD treated with dupilumab in two centres in the Czech Republic. Baseline characteristics, the Eczema Area and Severity Index (EASI) score and Dermatology Life Quality Index (DLQI) were collected at baseline and each 3 following months. The proportion of patients achieving EASI50, EASI75, EASI90 and EASI100 were analysed. Levels of immunoglobulin E (IgE) were collected before and after 6 and 12 months of therapy. Adverse events were recorded as well.

RESULTS

Thirty-two men and 18 women with mean body mass index (BMI) of 25.7 were enrolled in our analysis. The mean age of the patients was 37.6 years and the mean time from diagnosis until the initiation of dupilumab therapy was 35.0 years. After 4 months, EASI75 was achieved by 75.7%, out of which 40.5% achieved EASI90 and 10.8% achieved complete clearance. Improvement continued with time, and the proportion of patients with EASI90 increased to 71.4% at the 6th month and at the 12th month of therapy the EASI90 was 65.2%. EASI100 was achieved by 14.3% and 13.0% at the 6th and 12th month, respectively. A marked reduction was observed in the DLQI and also in IgE levels. EASI responses were independent of BMI. No new safety issues were identified. Adverse events were experienced by 44% (22/50) of the patients and they were all mild in intensity. Conjunctivitis and herpes simplex virus infection were the most common adverse events.

CONCLUSION

Our results confirmed the effectiveness and safety of dupilumab in a real-life setting in adult patients with moderate-to-severe AD in the Czech Republic. Dupilumab was well-tolerated and resulted in a significant clinical improvement in combination with improvement of quality of life.

Treatment Guidelines for Atopic Dermatitis Since the Approval of Dupilumab: A Systematic Review and Quality Appraisal Using AGREE-II

Introduction

Since its approval for adults with moderate-to-severe atopic dermatitis (AD) in 2017, dupilumab has been incorporated into clinical practice guidelines (CPGs). However, recommendations differ internationally, and the quality assessment of their development is unclear.

Objective

We aimed to systematically review and appraise the quality of CPGs for adult AD reported since 2017 and map the recommendations for dupilumab initiation relative to conventional systemic therapy (CST).

Materials and Methods

A literature search was conducted in June 2020 in MEDLINE, EMBASE, SCOPUS, and CINAHL. Twelve CPGs were retrieved. Methodological quality was assessed using the validated Appraisal of Guidelines for Research & Evaluation II tool (AGREE-II). Recommendations were extracted and compared.

Results

AGREE-II median scores per domain of the CPGs were (%, r = range): scope/purpose, 78% (50-96); stakeholder involvement, 54% (28-85); rigor of development, 39% (21-63); clarity of presentation, 85% (69-100); applicability, 27% (6-51); and editorial independence, 76% (42-100). Neither met the threshold of 70% quality criteria for rigor of development nor the applicability domains. Three CPGs met the criteria for recommendation without modification. CPGs' approach to dupilumab initiation was as follows: second line, preferred over CST and nbUVB (n = 1/12 CPG); second line, equivalent to CST or nbUVB (n = 3/12 CPGs); third line, after nbUVB or CST (n = 5/12 CPGs); and fourth line after nbUVB and CST (n = 2/12). No consensus was reached for n = 1/12 CPG.

Conclusion and Relevance

Dupilumab is now incorporated into CPGs for adult AD. These CPGs exhibited good quality in scope/purpose, clarity, and editorial independence domains. However, none met AGREE-II criteria for methodological rigor/applicability. Gaps were found in mechanisms for updates, facilitators/barriers, resource implications, and stakeholder involvement. Only n = 3/12 CPGs met quality criteria for recommendation without modifications. Of these, two favored a conservative sequential approach for the initiation of dupilumab relative to CST, while one did not reach consensus. Our findings highlight divergent recommendations AD treatment, underlining a need to incorporate quality criteria into future guideline development.

Management of inadequate response and adverse effects to dupilumab in atopic dermatitis

Atopic dermatitis (AD) is a chronic inflammatory skin disease characterized by pruritus, skin pain, and sleep disturbances. Currently, dupilumab is the only systemic therapy and biologic medication approved by the United States Food and Drug Administration for moderate-to-severe AD in adults and children. There is a sparsity of literature available on determining treatment failure with dupilumab and the next steps health care providers can take to treat AD. Individual goals and quality of life and not just body surface area should be considered when defining treatment failure. Possible confounding dermatoses also should be ruled out. Early identification of dupilumab-induced adverse events is important. For most patients, dupilumab can be continued while treatment for the adverse event is initiated. Adjusting the frequency of dupilumab dosing also may be considered in some circumstances. Adjuvant therapies, such as methotrexate, azathioprine, mycophenolate mofetil, cyclosporine, or phototherapy can be added but the safety and efficacy of these combination treatments are not known at this time.

Effect of a combination of Korean red ginseng extract and probiotics on the prevention of atopic dermatitis in a murine model

ETHNOPHARMACOLOGICAL RELEVANCE

Panax ginseng C.A.Mey. (Korea red ginseng) has been used in Asia to treat inflammatory skin diseases. Recently, Korea red ginseng (KRG) is emerging as a good candidate for treating atopic dermatitis (AD) because of its anti-allergic and anti-inflammatory effects.

AIM OF THE STUDY

Despite much effort, no systemic prevention strategy has been established for AD currently. Therefore, the aim of this study was to determine the preventive effect of a combination of KRG extract and probiotics on AD-like skin lesions of mice.

MATERIALS AND METHODS

Forty NC/Nga mice were randomly divided into eight groups: Sham, AD control, Cyclosporine, KRG, Duolac ATP® (ATP), BYO Plant Origin Skin Probiotics (BYO), KRG + ATP, and KRG + BYO. Mice were administered orally with KRG and/or other agents using a gastric tube for 5 days prior to challenge with 1-chloro-2,4-dinitrobenzene (DNCB). AD-like skin lesions were induced by percutaneous challenge with DNCB on ears and backs of NC/Nga mice. Effects of each treatment were evaluated based on the following: Clinical severity score, ear thickness, transepidermal water loss (TEWL), total serum Immunoglobulin E (IgE) level, mRNA expression levels and immunohistochemistry analysis of IFN-γ, IL-4, and TSLP in cutaneous lesions.

RESULTS

TEWL, serum IgE level, and expression of immunohistopathologic markers were more improved in the group using KRG combined with probiotics than in the group using KRG or probiotics alone. ATP, KRG + ATP, and KRG + BYO groups showed reduced TEWL increase (ΔTEWL) at 48 h (p < 0.005). KRG + ATP showed a preventive effect on the increase of serum IgE level (p = 0.009). In immunohistopathologic analysis, KRG, ATP, BYO, KRG + ATP, and KRG + BYO groups showed significantly reduced expression levels of IFN-γ at 1 h, 6 h, and 48 h (all p < 0.05). KRG, ATP, BYO, and KRG + BYO groups showed reduced expression levels of IL-4 compared to the AD control group at 6 h and 24 h. KRG, ATP, BYO, KRG + ATP, and KRG + BYP groups showed significantly lower expression levels of TSLP than the AD control group at 1 h and 24 h.

CONCLUSION

KRG can suppress increases of allergic and inflammatory cytokines and increase of TEWL. A combination of KRG and probiotics might have better effects than KRG or probiotics alone for preventing an AD flare-up.

Prevalence of type 2 inflammatory diseases in pediatric patients with atopic dermatitis: real-world evidence

BACKGROUND

Patients with atopic dermatitis (AD) are considered at increased risk of developing other type 2 inflammatory diseases. However, real-world evidence based on large US commercially insured pediatric populations is scarce.

OBJECTIVE

To use a large US claims database (IBM® MarketScan® 2013-2017) to assess prevalence and incidence of type 2 inflammatory diseases in pediatric AD patients.

METHODS

Pediatric AD patients were matched 1:1 to non-AD patients. Prevalence was assessed for conjunctivitis, rhinitis, urticaria, asthma, eosinophilic esophagitis and chronic rhinosinusitis/nasal polyps, 12 months post-index date (first AD diagnosis date for AD patients; a randomly selected outpatient visit for control patients). Incidence of other type 2 inflammatory diseases post-index was assessed among patients 0-2 years old.

RESULTS

244,776 AD and matched non-AD patients were selected. The prevalence and incidence of type 2 inflammatory diseases were higher among AD patients. Overall, the prevalence more than doubled for asthma, eosinophilic esophagitis, urticaria, and rhinitis, and increased with AD severity.

LIMITATIONS

AD identification based on billing diagnoses; observation period of only 12 months; limited to commercially insured patients CONCLUSION: The burden of type 2 inflammatory diseases in pediatric AD patients is substantial, highlighting the need to optimize management of AD and its numerous associated morbidities.

Optimization of approaches to the management of adult patients with severe atopic dermatitis: analysis of real clinical practice outcomes

Atopic dermatitis (AD) is a multifactorial genetically determined immune-mediated skin disease. It is difficult to treat and significantly affects patients quality of life. The development of an integrated approach focusing on atopic multimorbidity, implementation of validated control tools and distinction of clinical parameters specific for different phenotypes of severe forms of disease is especially relevant to patients resistant to standard therapy techniques. Dupilumab, a biologic, is approved for the treatment of the resistant group of patients with moderate to severe AD in the Russian Federation. Dupilumab inhibits the functions of two key cytokines of T2-mediated inflammation IL-4 and IL-13. The article presents personal experience of the authors concerning individual approach to the choice of therapy for the management of this cohort of patients in routine clinical practice. The disease aggravating criteria were determined, which are fundamental for the formation of individual patient portrait for the biologic (dupilumab) treatment for severe AD.

Epithelial-immune crosstalk with the skin microbiota in homeostasis and atopic dermatitis - a mini review

The skin is a complex and dynamic ecosystem, wherein epithelial cells, immune cells and the skin microbiota actively interact and maintain barrier integrity and functional immunity. Skin microbes actively tune the functions of the resident immune cells. Dysbiosis - alterations in the resident microbiota - leads to the dysregulation of host immunity. Microbiome analyses in humans and dogs with atopic dermatitis (AD) have shown shifts in microbial diversity, and in particular, an increased proportion of staphylococci. Monogenic diseases that manifest AD-like symptoms provide insights into the pathogenesis of AD and the mechanisms of dysbiosis, from both the epithelial and immunological perspectives. The symbiotic relationships between the host and microbiota must be maintained constitutively. Detailed mechanisms of how host immunity regulates commensal bacteria in the steady state have been reported. The skin harbours multiple tissue-resident immune cells, including both innate and adaptive immune cells. Recent studies have highlighted the fundamental role of innate lymphoid cells (ILCs) in the maintenance of barrier functions and tissue homeostasis. ILCs directly respond to tissue-derived signals and are instrumental in barrier immunity. Epithelial cells produce alarmins such as thymic stromal lymphopoietin (TSLP) and interleukins (IL)-33 and IL-25, all of which activate group 2 ILCs (ILC2s), which produce type 2 cytokines, such as IL-5 and IL-13, boosting type 2 immune reactions. Dysregulation of the epithelial-ILC crosstalk results in allergic inflammation. This review highlights our understanding of the active interactions between the host epithelial and immune cells, and microbiota, providing a foundation for novel therapeutic strategies for inflammatory skin diseases.

Prevalence of ocular disease during dupilumab treatment for atopic dermatitis: a bicentric retrospective comparative cohort study

BACKGROUND

Dupilumab is the first human monoclonal antibody approved for the treatment of atopic dermatitis (AD). Clinical trials have reported an increase of ocular side effects in patients who receive dupilumab, with a prevalence of 5-37%.

OBJECTIVE

To compare the prevalence of ocular disease between AD patients receiving dupilumab treatment and AD reference group and to study the profile of the patients who developed ocular disease secondary to dupilumab treatment.

METHODS

Efficacy outcomes were collected both at baseline and at month 4 (M4). Presence of ocular disease was recorded at M4.

RESULTS

Data from 100 patients were examined. At M4, ocular disease was significantly more frequent in the dupilumab group (36% vs. 10%, P = 0.002). Severe allergic conjunctivitis and blepharitis were significantly more frequent in the dupilumab group (30% vs. 4%, P < 0.001, and 22% vs. 2%, P = 0.004, respectively). Six of 18 patients permanently discontinued therapy.

CONCLUSION

This study observed a prevalence of 36% of ocular disease in AD patients treated with dupilumab. Additional studies are required to confirm the risk factors we found for dupilumab-associated ocular disease and to identify new ones. Consultation with an ophthalmologist before the introduction of dupilumab might limit the occurrence of complications.

Extent and Impact of Inadequate Disease Control in US Adults with a History of Moderate to Severe Atopic Dermatitis Following Introduction of New Treatments

Introduction

Atopic dermatitis (AD) is a chronic inflammatory disorder which, despite recent therapeutic developments, leads to significant burden and morbidity, impacting on daily functioning, physical and mental health, and health-related quality of life. The objective of this study was to investigate the impact of new therapeutic approaches in the treatment of moderate to severe AD and quantify subsequent differences in disease and symptom control.

Methods

Data were drawn from the 2018 Adelphi US AD Disease Specific Programme™ (DSP™), a cross-sectional survey of physicians (n = 150) and their patients with a history of moderate to severe AD (n = 749, 52.7% female, 72.1% white, mean age 40.1 ± 16.3 years). Inadequately controlled AD as rated by the physician was defined as currently flaring, and/or deteriorating/changeable AD and/or physician dissatisfaction with disease control on current treatment.

Results

The overall inadequate control rate was 42.3%, an improvement from 58.7% as identified in the 2014 DSP survey. The proportion of inadequately controlled patients increased as physician subjective severity (ranked from mild through to severe) increased; 15.4% of patients classified as having mild disease were inadequately controlled, compared to 94.5% of patients classified with severe disease. Relative to patients with controlled disease, patients with inadequately controlled disease were more likely to be unemployed, reported more frequent flares, and had a greater burden of symptoms and worse quality of life measures including itch, stress, anxiety, depression, and sleep disturbance (all p < 0.0001).

Conclusion

Despite the introduction of new therapies, the burden and impact of AD and lack of symptom control, although reduced compared with previous studies, still remains high.

Efficacy and Safety of Biologic Agents in Chronic Urticaria, Asthma and Atopic Dermatitis - A Real-life Experience

Introduction:

Several biologic agents have been approved for the treatment of asthma, chronic urticaria and atopic dermatitis. These therapeutic agents are especially useful for patients with severe or refractory symptoms. We present the real-life experience of four of the commonly used biologic agents in the United Arab Emirates.

Methods:

In this retrospective observational study, we reviewed the demographic, clinical, laboratory and treatment parameters for all patients treated with biologic agents.

Results:

270 patients received biologics at our centre between May 2015 and December 2019 with a median age of 36.5 years. Omalizumab was the most prescribed agent (n=183, 67.8%) followed by dupilumab (n=54, 20%), benralizumab (n=22, 8.1%) and mepolizumab (n=11, 4.1%). Urticaria was the commonest treatment indication (n=148, 55%) followed by asthma (n=105, 39%) and atopic dermatitis (n=13, 5%). All chronic urticaria patients were treated with omalizumab and showed improvement in the mean urticaria control test score from 6.7±4.47 to 12.02±4.17, with a p-value of 0.001. Dupilumab was found to be the most commonly prescribed drug for asthma (37%), followed by omalizumab (32%), benralizumab (21%) and mepolizumab (10%). The mean Asthma control test score for all asthmatics combined increased from 17.06 ± 5.4 to 19.44 ± 5.6, with p-value 0.0012 with treatment; FeNO reduced from 60.02 ± 45.74 to 29.11 ± 27.92, with p-value 0.001 and mean FEV1 improved from 2.38L ± 0.8 to 2.67L ± 0.78, with p-value 0.045. Only 4 patients in the entire cohort reported adverse events.

Conclusion:

Our study demonstrated that biological agents are a safe and effective treatment for atopic asthma, chronic urticaria and atopic dermatitis.

Effects of Resveratrol on Thymic Stromal Lymphopoietin Expression in Mast Cells

Background and objectives: Cytokine thymic stromal lymphopoietin (TSLP) plays a pivotal role in the pathogenesis of atopic diseases such as atopic dermatitis, allergic rhinitis, and asthma. Resveratrol (RSV) exerts various pharmacological effects such as antioxidant, anti-inflammatory, neuroprotective, and anticancer. Although, it has been verified the beneficial effects of RSV on various subjects, the effect of RSV on thymic stromal lymphopoietin (TSLP) regulation has not been elucidated. Materials and Methods: Here, we examined how RSV regulates TSLP in HMC-1 cells. Enzyme-linked immunosorbent assay, real-time polymerase chain reaction, Western blotting, and calcium assay were performed to evaluate the effect of RSV. Results: TSLP production and mRNA expression were reduced by RSV. RSV down-regulated nuclear factor-κB activation, IκBα phosphorylation as well as activation of receptor-interacting protein2 and caspase-1 in HMC-1 cells. In addition, RSV treatment decreased the up-regulation of intracellular calcium in HMC-1 cells. Conclusions: These results suggest that RSV might be useful for the treatment of atopic diseases through blocking of TSLP.

Something to Sweat About: Two Cases of Dupilumab-Induced Hyperhidrosis and Bromhidrosis

Introduction

Atopic dermatitis (AD, eczema) is familial chronic inflammatory skin disease of complex etiology and increasing prevalence. Dupilumab is an IL-4 receptor subunit alpha (IL-4Rα) antagonist that is the first Food and Drug Administration-approved biological therapy for moderate-to-severe adult AD inadequately controlled with topical therapies. Adverse effects reported in the literature include injection site reactions, conjunctivitis, headache, and nasopharyngitis.

Objective

We report the first cases of hyperhidrosis and bromhidrosis as side effects from dupilumab (Dupixent®) for the treatment of AD.

Case Reports

Case 1 is a 20-year-old woman with controlled allergic rhinitis and severe AD reported axillary hyperhidrosis with bromhidrosis, comparable to sweat from high-intensity exercise, with no relief from several different over-the-counter antiperspirants. Case 2 is a 61-year-old woman with history of chronic asthma, allergic contact dermatitis, allergic rhinitis, and AD noticed markedly increased sweating with bromhidrosis that was reminiscent of her menopausal symptomology, about 3 months after initiating dupilimab.

Discussion

Traditional immunosuppressive agents and corticosteroids have limited efficacy, numerous side effects, and increased risk of infection. The safety profile and efficacy of the newly approved IL-4Rα antagonist dupilumab may be favorable to oral immunosuppressants, but its use remains limited to severe recalcitrant cases, due to financial implications and lack of long-term safety data and comparative head-to-head trials.

Conclusion

We report improved outcomes with dupilumab, in addition to unpublished cases of bromhidrosis and hyperhidrosis in 2 patients with AD. This report of additional complications may inspire further clinical research and assist clinicians in considering the option of dupilumab for uncontrolled AD, despite aggressive traditional treatment.

Real-life studies of biologics used in asthma patients: key differences and similarities to trials

Introduction: The precision medicine approach that is now mandatory for severe asthma management includes the use of novel biologic agents blocking specific immunological mechanisms that are responsible for disease phenotypes and endotypes: monoclonal antibodies blocking IgE, IL-5 and IL-4/IL-13 immunological pathways are so far available. Areas covered: Clinical trials involving a large number of patients proved their efficacy in reducing asthma exacerbations, improving lung function and quality of life, and reducing the need for systemic corticosteroid treatment. Since biologics have been available for routine use, a series of real-life experiences on severe asthmatics treated with them have been published: these studies confirmed the beneficial effects in a real-world setting (effectiveness) of these drugs and showed novel aspects that were not covered by clinical trials, such as their effect on particular subgroup of patients, unexpected adverse events, and potential novel indications. Expert opinion: Both clinical trials and real-life experiences are needed to establish robust data on biologic agents for severe asthma, with real-life studies giving more broader insights on different aspects related to the biologics themselves and to the disease.

A clinician's reference guide for the management of atopic dermatitis in Asians

Background

Atopic dermatitis (AD) is a common skin condition among Asians. Recent studies have shown that Asian AD has a unique clinical and immunologic phenotype compared with European/American AD.

Objective

The Asian Academy of Dermatology and Venereology Expert Panel on Atopic Dermatitis developed this reference guide to provide a holistic and evidence-based approach in managing AD among Asians.

Methods

Electronic searches were performed to retrieve relevant systematic reviews and guidelines on AD. Recommendations were appraised for level of evidence and strength of recommendation based on the U.K. National Institute for Health and Care Excellence and Scottish Intercollegiate Guidelines Network guidelines. These practice points were based on the consensus recommendations discussed during the Asia Pacific Meeting of Experts in Dermatology held in Bali, Indonesia in October 2016 and April 2017.

Results

The Expert Panel recommends an approach to treatment based on disease severity. The use of moisturizers is recommended across all levels of AD severity, while topical steroids are recommended only for flares not controlled by conventional skin care and moisturizers. Causes of waning efficacy must be explored before using topical corticosteroids of higher potency. Topical calcineurin inhibitors are recommended for patients who have become recalcitrant to steroid, in chronic uninterrupted use, and when there is steroid atrophy, or when there is a need to treat sensitive areas and pediatric patients. Systemic steroids have a limited role in AD treatment and should be avoided if possible. Educational programs that allow a patient-centered approach in AD management are recommended as an adjunct to conventional therapies. Recommendations on the use of phototherapy, systemic drugs, and emerging treatments are also included.

Conclusion

The management of AD among Asians requires a holistic approach, integrating evidence-based treatments while considering accessibility and cultural acceptability.

Dupilumab: A Review in Moderate-to-Severe Atopic Dermatitis

Dupilumab (Dupixent^®), a subcutaneously administered, fully human IgG4 monoclonal antibody directed against the IL (interleukin)-4 receptor α subunit, blocks the signalling of IL-4 and IL-13, two T helper cell type 2 cytokines implicated in the immunopathology of atopic dermatitis (AD). It is the first biologic therapy to have been approved for the treatment of adult patients with moderate-to-severe AD in the EU and USA. In phase III trials in adults with moderate-to-severe AD who were inadequately controlled with topical medications and/or systemic treatments, such as ciclosporin, or for whom these therapies were not advisable, 16 weeks' treatment with dupilumab as monotherapy or in combination with topical corticosteroids (TCS) improved multiple measures of disease severity, pruritus, sleep disturbance, anxiety and depression, and quality of life compared with placebo. Moreover, the benefits of combination therapy at week 16 were maintained during long-term treatment for up to 1 year. Dupilumab, alone or added to TCS, was generally well tolerated, with low rates of serious adverse events and treatment discontinuations due to adverse events. Common adverse reactions included conjunctivitis, injection-site reactions and oral herpes. Thus, dupilumab represents a valuable new treatment option for adults with moderate-to-severe AD deemed appropriate for systemic therapy, a patient population for whom historically there has been a lack of safe and effective long-term treatments.