Dupilumab as Adjunct Treatment for Persistent Food Allergy in Adulthood

Abstract

Atopic disease affects both immunocompetent and immunodeficient patients. Known risk factors for atopic disease, such as atopic dermatitis (AD) and IgE mediated food allergy, include impaired skin integrity, Th2 predominance, and altered T-regulatory activity. Food allergies in particular can be life-threatening and there is no known cure, although immunomodulatory (anti IL-4Rα/IL-13, anti IL-5, and anti IgE) trials for food allergy are underway. The allergen-specific IgE levels and skin prick tests of atopic dermatitis patients often decrease while on dupilumab (anti IL-4Rα/IL-13) therapy but the question remains: does dupilumab improve or eliminate food allergy? One case report has reported success with dupilumab in an adult woman. Here we describe the de-labeling of several allergenic foods in an adult patient being treated for AD with dupilumab.A 29-year-old man presented to our allergy clinic with a history of severe AD and multiple food allergies. His eczema had been recalcitrant to high-dose topical steroids, BB-UVB phototherapy, cyclosporine, methotrexate, and both intramuscular and intralesional Kenalog (ILK). He finally improved on weekly dupilumab dosing and did not have adverse effects from dupilumab therapy. His food allergies posed significant morbidity with multiple reactions requiring epinephrine as well as ongoing anxiety regarding cross-contact. His history is notable for childhood reactions to peanut, tree nuts, fish, and shellfish, with concordantly elevated skin prick and specific IgE levels. After dupilumab therapy, these reactions decreased, leading to a risk/benefit discussion and agreement to perform physician-guided oral food challenges in an effort to broaden his diet (Figure 1). The majority of challenges were passed and the patient has maintained those foods in his diet (Figure 2). In addition, the patient reports substantial improvement in his anxiety at work as well as in social interactions. In this case, dupilumab as an immodulatory agent for AD offered the additional benefit of decreasing morbidity from food allergies. Given the persistence of food allergy, further research into adjunctive therapeutic options is vital to improving patient quality of life. Unlike other therapies like JAKinhibitors and systemic steroids used for atopic dermatitis, anti-IL-4Rα/IL-13 therapy is not immunosuppressive and has a favorable side-effect profile for patients. [Display omitted] [Display omitted]