Dupilumab treatment for atopic dermatitis may mitigate COVID-19 symptoms

Patients taking dupilumab for atopic dermatitis experienced less severe COVID-19 symptoms than patients who used different or no treatment, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.

“At the beginning of the pandemic, we started to notice that many patients who you would think would have risk factors for more severe infections had very minor manifestations,” Emma Guttman-Yassky, MD, PhD, the Waldman Professor and System Chair of the Kimberly and Eric J. Waldman Department of Dermatology at the Icahn School of Medicine at Mount Sinai, told Healio. “The commonality between them is that they were on dupilumab.”

Dupilumab (Dupixent; Regeneron, Sanofi Genzyme) inhibits the IL-4 and IL-13 Th2 cytokines and modulates the Th2 pathway without affecting Th1 signaling, which could attenuate COVID-19 responses, according to the researchers.

Emma Guttman-Yassky

“There was a publication from China that suggested that these types of cytokines were elevated during the cytokine storm of COVID-19,” said Guttman-Yassky, who also is director of the Center of Excellence in Eczema and the Laboratory of Inflammatory Skin Diseases. “So, I put things together, and then I proposed this study.”

The large-scale, prospective study included 1,237 patients aged 9 years and older with moderate-to-severe atopic dermatitis enrolled in a prospective registry related to COVID-19 at Icahn School of Medicine’s department of dermatology. This cohort included 632 patients on dupilumab, 107 patients on other systemic treatments and 498 patients on limited or no treatment.

Each patient provided their past medical history, demographics and the presence and duration of individual symptoms related to COVID-19. The researchers then assigned a COVID-19 symptom severity score ranging from 0 to 5, with 0 being asymptomatic and 5 being fatal.

The patients on dupilumab appeared less likely to experience moderate-to-severe COVID-19 symptoms than patients who were on other systemic treatments (OR = 3.89; P = .008) or on limited or no treatment (OR = 1.96; P = .04).

Also, the study showed significant associations between BMI and moderate-to-severe COVID-19 symptoms across patients treated with biologic and systemic therapies (P < .001).

There was a significant association between nonbiologic systemic treatment and COVID-19 symptomology compared with dupilumab treatment (OR = 1.87; P = .01), but there were no differences in symptoms among patients on dupilumab relative to the no-treatment group.

The researchers also examined a subgroup of patients who had a laboratory-confirmed COVID-19 infection history or who had high-risk COVID-19 exposures (dupilumab, n = 164; other systemics, n = 26; limited/no treatment, n = 116).

In this subgroup, compared with dupilumab treatment, there also was a significant association between nondupilumab systemic treatment (OR = 13.79; P = .002) and limited or no treatment (OR = 2.44; P = .05) and moderate-to-severe COVID-19. The association between BMI and moderate-to-severe symptoms persisted in this subgroup (P = .005), as did the association between nondupilumab systemic therapies and symptomology relative to treatment with dupilumab (OR = 2.97; P = .03).

“We indeed found that patients treated with this biologic are more likely to have more minor symptoms if they have COVID-19, whereas those who are treated with immune suppressants or even with topicals are more likely to have more severe manifestations,” Guttman-Yassky said.

According to the researchers, these findings suggest that the Th2 suppression that dupilumab provides may normalize the Th1/Th2 imbalance and reduce the incidence and severity of COVID-19 symptoms.

Guttman-Yassky noted that other researchers are now investigating whether patients who don’t have atopic dermatitis could take dupilumab to attenuate COVID-19 symptoms. Meanwhile, the researchers said that their findings may have implications for other common viral infections such as influenza and possibly for future pandemics, pending additional study. For example, biomarker-based studies may help support the proposed mechanism of how Th2 blockades may produce these results.

“From the same patients, we also have biomarker data and will want to look closely at how the biomarkers change in these patients,” Guttman-Yassky said. “We have this huge registry that we developed, which will be very important.”

Investigations into other inflammatory conditions such as psoriasis and immunomodulatory medications with broader populations would be needed as well, they added.

“We basically proved the original hypothesis that dupilumab is likely protective of COVID-19 responses,” Guttman-Yassky said. “I think this has applications beyond this pandemic for other infections when we know that cyclosporine targets so many pathways and increases risk for infections.”

For more information:

Emma Guttman-Yassky, MD, PhD, can be reached at emma.guttman@mountsinai.org.