Dupilumab in Practice: Navigating Use Across Clinical Scenarios

In this episode of Topical Conversations, David Rosmarin, MD, joins Mary Gail Mercurio, MD, to discuss practical approaches to treating atopic dermatitis (AD) with dupilumab. The conversation covers treatment selection, patient counseling, insurance navigation, and evolving data on safety and adjunctive options. 

When to initiate systemic therapy 

Both note that the threshold for initiating systemic therapy, particularly dupilumab, has decreased as confidence in its safety and efficacy continues to grow. The broad range of FDA-approved indications, including approval down to 6 months of age, can help reassure patients who are hesitant to begin biologic therapy. The lack of lab monitoring requirements is also a significant benefit for both patients and clinicians. 

Patient counseling and injection hesitancy 

Patient hesitation around injectables can often be addressed through hands-on education and support from office staff. Dr Mercurio highlights the importance of in-office instruction in the use of the injection device. The growing body of safety data in pregnancy is also discussed, with both clinicians emphasizing the importance of forthcoming registry data and growing real-world evidence supporting dupilumab’s use during pregnancy. 

Follow-up and documentation 

Follow-up frequency varies based on patient preference and disease severity, often extending to 6 to 12 months once stable. Both clinicians document body surface area (BSA), symptom severity, and impact on quality of life, such as interference with sleep or daily functioning. 

Insurance considerations 

While dupilumab is typically approved without significant barriers, both clinicians note challenges when BSA is below 10%. Documenting involvement of high-impact areas like the face and hands and the broader impact on quality of life can aid in securing coverage. 

Assessing response and treatment duration 

The decision to continue or switch therapy is patient-specific. Some improvement may be expected within 3 months; if no response is observed by 3 to 4 months, a change in therapy may be warranted, especially in more severe cases. Mild cases may allow for a longer trial period before considering alternative options. 

Adjunctive therapies and managing residual disease 

For patients with residual symptoms despite dupilumab, both clinicians use topical therapies—steroids or nonsteroidals—based on body site. Phototherapy is viewed as a beneficial option but may be inaccessible due to cost or insurance limitations. Tapinarof and roflumilast are emerging nonsteroidal options, though access can be restricted by formulary status. 

Approach to acute flares 

In select cases, a short course of oral corticosteroids may be used to control acute flares while initiating dupilumab, helping to bridge the gap until biologic response is achieved. 

Looking ahead 

The discussion concludes with anticipation for new therapeutic options, including oral JAK inhibitors, oral STAT6 inhibitors, and other novel mechanisms. Dupilumab remains a foundational therapy in AD management, with new data, particularly regarding pregnancy safety and additional indications, expected to further shape clinical practice. 

Key takeaways 

• Dupilumab is increasingly used earlier in the treatment course of AD due to a favorable safety profile and lack of lab monitoring requirements
• Patient education and support can ease concerns around injectable administration
• Documentation of quality-of-life impact and involvement of special sites can improve insurance approval likelihood, particularly for patients with <10% BSA involvement
• Adjunctive therapies, including topical agents and phototherapy, are frequently used to manage residual disease
• Treatment response is typically evaluated within the first 3 to 4 months to guide continuation or change in therapy