Combining Biologics in a Young Patient with Atopic Dermatitis

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Dr. Leo:
Welcome to Clinical Consults. I’m Dr. Peter Leo, and I’m joined again by my colleagues Dr. Eric Simpson and Dr. Mark Boguniewicz.

A few months ago we asked our learners to submit their difficult atopic dermatitis cases for us to discuss. Thank you all for participating. Today’s submission is about a pediatric patient, and this is a patient who is 4 years old with atopic dermatitis, food allergy, chronic rhinosinusitis and sleep disturbance. She was doing well on omalizumab for her allergy symptoms, but her atopic dermatitis is still very poorly controlled.

Would it be appropriate to have her on both omalizumab and dupilumab? Is dupilumab even an option in such a young age? Dr. Boguniewicz, how would you start us off in thinking about this patient’s treatment, and where would you begin with this discussion?

Dr. Boguniewicz:
So, right away I would want to state the following, that currently, omalizumab, or anti-IgE, is approved for allergic asthma in patients 6 years or older, and the dosing is based both on weight and total serum IgE levels. It’s also approved in chronic urticaria in patients at present 12 years and older, and there the dosing is not based on weight or a serum IgE level, so you would want to recognize that this patient, as far as what you just told us, Peter, does not have asthma and is 4 years old so is definitely being treated off-label. While that’s been done, it raises some questions. I don’t know if Eric wants to comment further.

Dr. Simpson:
Yes, I agree, Mark. I would really be interested to know is the patient on omalizumab for atopic dermatitis or were they placed on omalizumab for the allergic symptoms. But in terms of atopic dermatitis treatment… So let’s say the omalizumab... Are you assuming, Peter, that the patient was placed on omalizumab for atopic dermatitis?

Dr. Leo:
That’s my sense from the question. Maybe they have a bunch of allergic symptoms plus the AD and they were hoping to kind of treat everything in this younger patient.

Dr. Simpson:
I see. From my understanding and reviewing the literature with omalizumab, there are a lot of positive case reports that it can treat atopic dermatitis, but in the controlled studies when it’s been looked at more rigorously, I’ve been very underwhelmed by the efficacy of omalizumab for atopic dermatitis, so from my perspective I would... If the atopic dermatitis is still raging, as it appears to be, I would switch course, actually. And the question is would you put this patient on dupilumab off-label, or would you use the more traditional systemic as per guidelines, and I think at this stage—this is just my perspective—I would probably do... Since we don’t have a lot of safety or efficacy data down at this age group just quite as yet—we are gathering it, and I’ve put patients on in studies down to 6 months of age—I would probably… This is the type of patient that I would probably optimize topical therapy with proactive treatment, of course, and then consider cyclosporin.

Dr. Boguniewicz:
I would just add that while I have had patients on omalizumab where dupilumab has been added, these have been adult patients, so no one close to this young age, and in the patients who have been started with dupilumab added to omalizumab, the goal was to get those patients and, in fact, successfully taper off the omalizumab while continuing on dupilumab.

Dr. Leo:
That makes a lot of sense. I agree. I think in the under 12 range, so anybody under the age of 12, it probably is most reasonable to start with the conventional immunosuppressants like cyclosporin, and then if they can’t tolerate that or fail that, then I think we can think about going off-label with dupilumab, so maybe that’s the first step. And then step 2 is just sort of the general question of combining these biologics.

Dr. B, you stated that it seems okay in adults to do both of those but with the intention of tapering off the omalizumab. I definitely have had a patient or 2 on both. I don’t think there’s any major contraindication at baseline, but right, it’s really a goal question. What are we trying to do? Can dupilumab cover both of our bases? Or I suppose there could be a patient that needs both biologics. I actually do have some patients that have either arthritis or psoriasis and atopic derm that are on 2 different biologics, but these are pretty different pathways, as opposed to omalizumab and, of course, dupilumab which are similar in terms of being in that TH2-driven system.

Dr. Simpson:
Yes, I agree. I have nothing to add to that.

Dr. Boguniewicz:
Agree.

Dr. Leo:
Perfect. Well, that’s a really great question.

Thank you so much for joining us today. Please don’t forget to take the posttest and complete the evaluation to receive your CME credit.

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