Would your patient benefit from a monoclonal antibody?
These unique agents may be the answer when other treatments fail or are intolerable for patients with asthma, atopic dermatitis, hyperlipidemia, osteoporosis, or migraine headaches.
PRACTICE RECOMMENDATIONS
› Consider anti-immunoglobulin E, anti-interleukin 5, or anti-interleukin 4/interleukin 13 for patients with moderate-to-severe asthma and type 2 airway inflammation. B
› Consider dupilumab for patients with moderate-to-severe atopic dermatitis (with or without topical corticosteroids), or when traditional oral therapies are inadequate or contraindicated. B
› Consider proprotein convertase subtilisin/kexin type 9 inhibitors for patients with heterozygous familial hypercholesterolemia or clinical atherosclerotic cardiovascular disease when maximally tolerated statins or ezetimibe have not lowered low-density lipoprotein cholesterol levels far enough. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
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
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.
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