Treat dupilumab-induced ocular surface disease aggressively
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Aggressive therapies can treat dupilumab-induced ocular surface inflammation and, depending on the severity of the inflammation, can allow a patient to continue use of the dermatologic therapy.
Preservative-free artificial tears, ointments at bedtime, punctal plugs and a short course of topical steroids can treat ocular surface symptoms caused by eczema treatment Dupixent (dupilumab, Regeneron/Sanofi), Ashley Brissette, MD, MSc, FRCSC, told Ocular Surgery News.
When ocular side effects of keratitis and conjunctivitis are severe or persistent, stopping dupilumab may be a consideration.
“However, I would discuss options with the dermatologist and the patient because, in my experience, the patients are very hesitant to stop this therapy because it helps significantly with their atopic symptoms,” Brissette said.
Dupilumab works by decreasing interleukin-13 (IL-13), which has benefits in atopy and asthma. However, IL-13 also stimulates goblet cells, which has negative effects on the ocular surface, Brissette said.
Nearly 30% of patients using dupilumab can develop conjunctivitis and keratitis, ranging from mild to severe, more often bilaterally but also unilaterally, according to Brissette.
“By taking a team-based approach, we can better understand the needs for treatment and in making decisions as a team as to whether or not to continue the prescribed medication,” she said.
Kenneth A. Beckman, MD, FACS, co-author of a case report on the topic published in 2019 and a Healio/OSN Board Member, suggested the addition of Xiidra (lifitegrast ophthalmic solution 5%, Novartis) to current steroidal therapies for patients with severe side effects.
The case report presented the results of a 37-year-old male patient who presented with severe conjunctivitis approximately 3 months after initiating therapy with dupilumab.
“Initially, his dry eyes, lid margin disease and inflammation were treated as a typical atopic patient with severe dry eyes. Steroids only partially treated his symptoms, and his symptoms returned upon discontinuing steroids. Even adding cyclosporine, which treated the inflammation and dry eye, did not resolve his symptoms,” Beckman told Ocular Surgery News.
Symptoms resolved once the patient was started on lifitegrast drops twice a day, he said.
Because of the drug’s strong effect on dermatitis, Beckman said he evaluates his patients upon starting dupilumab to manage their symptoms without taking them off the therapy.
“The vast majority, in my experience, already have some component of dry eyes and lid margin diseases, just from the atopic disease. Most are amenable to early intervention from an eye standpoint,” he said.
Beckman said he has yet to have a patient develop severe dupilumab-induced ocular surface disease if they were given lifitegrast before symptoms arose. If any symptoms present while on lifitegrast, they are usually mild and tolerable.
“None of my patients have elected to stop dupilumab as it has been so effective and the eye symptoms have remained tolerable,” he said. – by Robert Linnehan
- References:
- VIDEO: Chronic conjunctivitis from dupilumab requires aggressive treatment. www.healio.com/ophthalmology/cornea-external-disease/news/online/%7B6f2d355a-e660-4ae6-a612-2a93bf48b02f%7D/video-chronic-conjunctivitis-from-dupilumab-requires-aggressive-treatment. Published Jan. 30, 2020. Accessed March. 16, 2020.
- Zirwas MJ, et al. JAAD Case Rep. 2019;doi:10.1016/j.jdcr.2018.10.016.
- For more information:
- Kenneth A. Beckman, MD, FACS, can be reached at Comprehensive Eye Care of Central Ohio, 450 Alkyre Run Drive, No. 100, Westerville, OH 43209; email: kenbeckman22@aol.com.
- Ashley Brissette, MD, MSc, FRCSC, can be reached at Weill Cornell Medicine, New York Presbyterian Hospital, 1305 York Ave., New York, NY 10021; email: asb9040@med.cornell.edu.
Disclosures: Beckman and Brissette report no relevant financial disclosures.
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