Co-Treatment with Steroid and Dupilumab for Eosinophilic Chronic Rhinosinusitis after Eosinophilic Pneumonitis Caused by Dupilumab

Abstract

Eosinophilic chronic rhinosinusitis (ECRS) is a Type 2 inflammatory disease that manifests as chronic inflammation of the paranasal sinus. IL-4/IL-13 receptor monoclonal antibodies (dupilumab) to suppress Type 2 inflammation have become a good treatment option for patients who are refractory to surgery. Most patients respond normally, although significant side effects such as eosinophilic pneumonia may occur, requiring discontinuation of dupilumab. Here, we present a case in which dupilumab administration caused a side-effect of eosinophilic pneumonia. A 65-year-old woman presented with nasal obstruction and olfactory dysfunction due to a nasal polyp. Her symptoms temporarily improved with dupilumab; however, dupilumab was discontinued due to eosinophilic pneumonia. Discontinuation of dupilumab resulted in the rapid resolution of eosinophilic pneumonia and reappearance of nasal polyps. We, therefore, resumed dupilumab treatment in combination with low-dose steroids; eosinophilic pneumonia did not flare up, and the nasal polyps shrank steadily. There is no established treatment strategy in cases where a side effect of eosinophilic pneumonia arises while treating ECRS with dupilumab. Based on the described case, we recommend that a combination of a low-dose steroids and dupilumab be considered as a treatment option to counter the side-effect of eosinophilic pneumonia induced by dupilumab alone.

Dupilumab and the potential risk of eosinophilic pneumonia: case report, literature review, and FAERS database analysis

“…Only one patient in the literature ( 11 ), along with our patient, resumed dupilumab therapy. The patient in the literature used it in combination with 10 mg of prednisone for 10 months without recurrence of pneumonia.…”

Feasibility of continued treatment with dupilumab in patients with type 2 inflammatory disease who developed eosinophilic pneumonia: 3 case reports

“…Sudo et al reported a patient with ECRS who developed dupilumab‐induced EP. 8 In that case, dupilumab was resumed in combination with PSL after the treatment of EP.…”

“…Several reports have found that dupilumab can cause EP, while others have described EP treated with dupilumab. 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 The mechanisms underlying dupilumab‐induced EP remain unclear. However, previous reports of EP after dupilumab treatment suggest an association with hypereosinophilia.…”

“… 1 However, several reports have described dupilumab‐induced eosinophilic pneumonia (EP) after treatment with dupilumab (Table 1 ). 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 In most of those reports, dupilumab was discontinued and the patients were treated using prednisolone. Other reports have described the efficacy of dupilumab for chronic EP (CEP).…”

How Can Dupilumab Cause Eosinophilic Pneumonia?

“…Additionally, reports have not been described regarding recurrence of adverse events after restarting dupilumab. Sudo et al recommend that a combination of a low-dose steroids and dupilumab, after countering the side-effect of eosinophilic pneumonia induced by dupilumab alone, be used in order to continue injecting dupilumab [ 11 ]. However, since there is no established method of dealing with the disease, verification of pathological characteristics and factors that trigger the onset of EP, as well as verification of changes in peripheral blood eosinophils, are desirable in the future.…”