AD with Asthma and Sinonasal Conditions: Dupilumab’s Impact

Marc Serota, MD, is a board-certified dermatologist located in Denver, CO, who also works in the areas of asthma immunology and pediatrics. He is a medical expert on asthma, allergies, food allergy, rashes, dermatology procedure-related injuries, skin cancer, scabies, vaccine-related injuries, and more. In addition, he has published various online reference articles and peer-reviewed studies regarding dermatologic and allergic diseases. In this recent interview, Dr Serota discusses recent updates on dupilumab’s impact on asthma and sinonasal conditions, particularly for patients with atopic dermatitis (AD).

What is known about the impact of dupilumab on asthma and sinonasal conditions?
It's very impactful. It targets the T_H2 mediated pathway of information, and it blocks the 2 key radio signals for allergic cell diseases, which are IL-4 and IL-13. Those are what we call the cytokines, the radio signals that the allergic cells use to communicate.

When we jam their radios, they can no longer communicate and trigger the reactions that those cells would normally create. In the case of asthma and sinonasal conditions, that is the main pathway that those cells use to communicate and therefore cause those conditions.

How can dermatologists go about identifying if AD patients suffer from asthma and sinonasal conditions in addition to their eligibility for dupilumab?
My colleagues in dermatology are very good at screening for other comorbid conditions. Specifically, when we see patients with psoriasis, we're very good about screening for psoriatic arthritis and asking questions about joint pain. We need to move in that direction now for asthma.

When we see patients for atopic dermatitis, we need to screen patients, asking them questions like, "How often are you using your albuterol? Are you waking up at night with coughing or wheezing? Have you been to the hospital in the past year for asthma? Have you been hospitalized or gone to the ER for asthma? Have you ever been intubated for asthma?"

Asking some screening questions, just like in psoriatic arthritis, we might not be the primary specialist managing that condition, but we still screen for those comorbidities, because we have a medication that can potentially treat both problems at the same time.

I always encourage my colleagues in dermatology to ask about asthma or allergy symptoms, because it may push them over the edge of recommending a systemic treatment like dupilumab if they are not well controlled with their other comorbidities.

It also helps confirm your diagnosis of atopic dermatitis. If you are wondering what type of dermatitis is it, or is it even atopic dermatitis at all versus something like psoriasis, it's helpful to know if they have a significant atopic personal history or family history when you're actually making the diagnosis.

Can you share what areas of future research are needed to better understand dupilumab’s mechanism of action when treating AD and asthma/sinonasal conditions?
The primary focus now is that we understand this pathway and what blocking IL-4 and IL-13 means. Those are the key cytokines in combating atopic diseases. There are other areas of interest for other cytokines that are also involved in these pathways, and also pursuing other indications, looking at younger age groups, looking at other allergic diseases.

Because these cytokines are very important for the T_H2 mediated pathway of inflammation, there's a lot of other potential disease states that they could have a positive effect on. I know some of those are actively being researched currently.

In your opinion, what other specialties should dermatologists turn to when working with patients with AD and asthma/sinonasal conditions?
The primary specialist is whoever is managing either their asthma, their allergic rhinitis, or their sinusitis condition. The 2 primary specialists would be an allergy/immunology doctor, which I'm both an allergy-immunology doctor and a dermatologist.

If patients have asthma or allergies, then you should also be consulting with them, and if the patients have significant chronic sinusitis or nasal polyps, then they would be seeing an ENT doctor.

Those are the2 primary specialists. I always remind my colleagues that it doesn't preclude you from initiating treatment for something that treats both conditions, just like in the psoriatic arthritis world, but we do want to refer patients to have their asthma managed by someone who specializes in treating patients with asthma.

Are there any other pearls you would like to share with your colleagues regarding dupilumab, AD, or asthma and sinonasal conditions?
It's really important to explain to the patients the pathophysiology of what's happening in their body before you start recommending an injectable type of medication, whether it's a biologic for psoriasis or for atopic dermatitis.

The way I explain it to a patient, and this is the immunologist in me, is that your immune system in your body is like the military. You have the Army, the Navy, the Air Force, and the Marines.

Occasionally, one part gets it wrong and starts attacking something that's a normal part of your body—those are the autoimmune diseases—or starts reacting to something that's a normal part of your environment, and those are the allergic diseases.

When that happens, what we want to do is turn off just that part of the military that's getting it wrong, and leave the rest of the immune system alone to do its job. Before we had the newer medicines, we would just give you something that suppresses the whole military. Now, we can jam the radio signals of just that battalion that's getting it wrong.

All the soldiers are still there. They're waiting to make an attack. They just never get the go signal because we're jamming their radios.

If you explain that first, then when you say, "There's an injection I want to give you," the patient understands, and is much more accepting of why you're recommending that treatment. Setting the patient up for why you are recommending the treatment from a pathophysiology perspective is incredibly important.   

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