dupilumab dupixent can have transient elevation in blood eosinophils

Transient elevation of circulating blood eosinophils during dupilumab treatment is well documented, with levels generally returning to baseline or lower over time. Hypereosinophilia was observed in 4% to 14% of patients in clinical trials, with real-life studies documenting higher rates. Increased eosinophil counts are commonly reported at around 16 to 20 weeks after starting therapy and can persist after 6 months in 14% of patients. For the vast majority of patients, the increase in absolute eosinophil count (AEC) has not been associated with clinical symptoms, nor does it affect efficacy, and therefore dose adjustment or discontinuation of treatment is not necessary. Expert opinion guidelines suggest repeating an AEC every 4 weeks for patients with an AEC greater than 1,500/μL (1.5 × 109/L) and stopping dupilumab for those with an AEC greater than 5,000/μL (5 × 109/L) or if there is evidence of hypereosinophilic organ infiltration (such as heart dysfunction, neurological symptoms, or dyspnea). Further monitoring and evaluation for eosinophilic granulomatosis with polyangiitis is also appropriate when such eosinophil counts persist, especially if associated with new pulmonary symptoms or infiltrates, and may be negative for antineutrophil cytoplasmic autoantibodies.

Although there are no standard guidelines, patients with a baseline eosinophil level equal to or greater than 300/μL (0.3 × 109/L) should be screened for nonallergic causes, including Strongyloides infection (even without symptoms) before considering biologic therapy. The luciferase immunoprecipitation systems assay is a sensitive and specific immunoassay to detect Strongyloides stercoralis infection, and the negative test result before treatment would make this diagnosis less likely.1

Footnotes

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