Delayed onset localized urticarial reactions to Dupilumab

Abstract

Dupilumab is an anti-IL-4 receptor monoclonal antibody used to treat persistent uncontrolled asthma. We characterize a previously undescribed injection-site urticarial reaction in patients receiving Dupilumab. Case series of two patients evaluated at Emory University Hospital in 2019-2020 who developed injection-site urticaria after receiving Dupilumab. Patient 1 is a 31-year-old female with history of asthma, allergic rhinitis receiving Dupilumab 200mg biweekly. Her first injection-site urticaria was after 16 doses of treatment and lasted 1-2 weeks. It required topical triamcinolone 0.1% cream to manage symptoms. Her blood eosinophil count was 30/mcL at the time and prior to therapy was 80/mcL. The urticarial reaction spontaneously remitted over 6 weeks despite continued dupilumab. Patient 2 is a 72-year-old male with history of nasal polyps, chronic sinusitis, and asthma receiving Duupilumab 300mg biweekly. He experienced a large pruritic wheal at injection site after 9 doses of treatment. His symptoms started at time of injection and self-resolved in 3-4 days each time. Symptoms were unresponsive to oral antihistamines, requiring topical clobetasol 0.05%. Initial symptoms were more severe and improved over time, however remained persistent. Early onset, dose dependent injection-site reactions have been documented with Dupilumab; however, our patients developed a previously unreported delayed localized urticarial reaction months after receiving therapy uneventfully. Topical steroid treatment alleviated symptoms and allowed for continuation of therapy.