Dupixent (dupilumab) is a widely used biologic medication that has revolutionized the treatment of several chronic inflammatory conditions. It works by targeting and blocking the signaling pathways of two key inflammatory proteins, interleukin-4 (IL-4) and interleukin-13 (IL-13). While highly effective for many, some patients may need to seek an alternative due to inadequate response, side effects, or other factors. The best course of action depends entirely on the specific condition being treated, such as atopic dermatitis, asthma, or chronic rhinosinusitis with nasal polyps.
Atopic Dermatitis Alternatives
For moderate-to-severe atopic dermatitis (eczema), the list of available alternatives has grown significantly in recent years. These options vary in their mechanisms of action, from targeting different immune pathways to topical application for localized treatment.
Other Biologics
Similar to Dupixent, these injectable medications target specific inflammatory pathways within the immune system:
- Adbry (tralokinumab): This biologic specifically targets and blocks interleukin-13 (IL-13), a key driver of inflammation and itch in atopic dermatitis. It is approved for adults and adolescents aged 12 and older.
- Ebglyss (lebrikizumab): Also an IL-13 blocker, Ebglyss is approved for moderate-to-severe eczema in people ages 12 and older.
- Nemluvio (nemolizumab): This biologic works differently by blocking the interleukin-31 (IL-31) receptor, which is associated with itch. Nemluvio is approved for moderate-to-severe eczema and prurigo nodularis in adults.
JAK Inhibitors
Janus kinase (JAK) inhibitors are a class of oral, small-molecule drugs that block specific signaling pathways inside immune cells. This can provide an effective alternative for those who prefer oral medication over injections, but they carry boxed warnings regarding potential side effects.
- Cibinqo (abrocitinib): A daily oral tablet approved for moderate-to-severe atopic dermatitis in adults.
- Rinvoq (upadacitinib): An extended-release tablet approved for moderate-to-severe atopic dermatitis and other inflammatory conditions.
- Opzelura (ruxolitinib): A topical cream approved for short-term and non-continuous chronic treatment of mild-to-moderate atopic dermatitis in adults and adolescents 12 and older.
Topical Alternatives
For those with mild-to-moderate disease or those who want to avoid systemic treatments, topical options are available.
- Eucrisa (crisaborole): This is a phosphodiesterase-4 (PDE4) inhibitor ointment that reduces inflammation and is approved for adults and children as young as 3 months.
- Topical Calcineurin Inhibitors (TCIs): Ointments like Protopic (tacrolimus) and Elidel (pimecrolimus) suppress inflammation by inhibiting calcineurin.
- Corticosteroids: Various potencies of topical steroid creams and ointments are often first-line treatments for atopic dermatitis, used before or in combination with biologics.
Asthma Alternatives
For the maintenance treatment of moderate-to-severe asthma, especially with an eosinophilic component, several biologics offer an alternative to Dupixent.
- Nucala (mepolizumab): This biologic blocks interleukin-5 (IL-5), which is a key driver of eosinophilic inflammation. It is administered via injection and is dosed monthly for most adults.
- Fasenra (benralizumab): Also an anti-IL-5 treatment, Fasenra works by depleting eosinophils. After initial monthly injections, it is administered every 8 weeks.
- Tezspire (tezepelumab): This biologic blocks thymic stromal lymphopoietin (TSLP), an upstream regulator of inflammation, and is approved for severe asthma regardless of eosinophil levels.
- Xolair (omalizumab): This monoclonal antibody blocks immunoglobulin E (IgE) and is used for allergic asthma.
Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) Alternatives
For this condition, which involves chronic sinus inflammation and polyps, alternatives also exist in both biologic and more traditional forms.
- Nucala (mepolizumab): As with asthma, Nucala is approved as an add-on treatment for CRSwNP in adults.
- Xolair (omalizumab): This medication is also approved to treat CRSwNP.
- Nasal Steroids: High-volume nasal steroid sprays like Xhance (fluticasone) are an alternative that targets inflammation more directly in the nasal passages.
- Oral Steroids: Prednisone and other oral steroids can be used for short courses to reduce polyps, sometimes before surgery.
- Surgery: Endoscopic sinus surgery to remove polyps is a common option, sometimes followed by biologic or steroid treatment to prevent recurrence.
Eosinophilic Esophagitis (EoE) Alternatives
EoE is a chronic inflammatory condition of the esophagus, and alternatives to Dupixent focus on reducing inflammation and eliminating dietary triggers.
- Corticosteroids:
- Eohilia (budesonide): An oral corticosteroid suspension approved for adults and children ages 11 and up.
- Fluticasone: This medication is delivered via an inhaler but is swallowed instead of inhaled to coat the esophagus.
- Proton Pump Inhibitors (PPIs): Drugs like omeprazole are often a first-line treatment for EoE as they can help reduce inflammation, though additional treatment is often needed.
- Dietary Modifications:
- Six-Food Elimination Diet (SFED): This highly restrictive diet removes common allergens like milk, wheat, soy, egg, peanuts/tree nuts, and seafood to identify triggers.
- Elemental Diet: A liquid-only formula diet may be used for severe cases, especially in children.
Comparison Table of Select Dupixent Alternatives
| Alternative (Brand/Generic) | Primary Condition | Mechanism of Action | Administration | Common Side Effects |
|---|---|---|---|---|
| Adbry (tralokinumab) | Atopic Dermatitis | Blocks IL-13 | Subcutaneous injection | Upper respiratory infection, conjunctivitis, injection site reactions |
| Cibinqo (abrocitinib) | Atopic Dermatitis | Oral JAK inhibitor (blocks JAK1) | Oral tablet (daily) | Headache, nausea, acne, herpes simplex; boxed warnings for serious risks |
| Rinvoq (upadacitinib) | Atopic Dermatitis | Oral JAK inhibitor (blocks JAK1) | Oral tablet (extended-release) | Upper respiratory infection, headache, acne; boxed warnings for serious risks |
| Nucala (mepolizumab) | Asthma, CRSwNP | Blocks IL-5 | Subcutaneous injection | Headache, injection site reactions, back pain |
| Eohilia (budesonide) | EoE | Swallowed corticosteroid | Oral suspension | Respiratory infection, oral thrush, headache |
| Eucrisa (crisaborole) | Mild-to-moderate AD | Topical PDE4 inhibitor | Topical ointment | Application site burning or stinging |
| Opzelura (ruxolitinib) | Mild-to-moderate AD | Topical JAK inhibitor | Topical cream | Common cold, diarrhea, ear infection; boxed warnings for serious risks with systemic use |
| Xolair (omalizumab) | Asthma, CRSwNP | Blocks IgE | Subcutaneous injection | Injection site reactions, viral infections, joint pain |
Conclusion
Finding the right alternative to Dupixent involves close collaboration with a healthcare provider to weigh the risks and benefits of each option. The expanding arsenal of biologics, Janus kinase inhibitors, and targeted topical treatments provides hope for those who find Dupixent ineffective or intolerable. Treatment choice is highly individualized, depending on the patient's specific condition, severity, and personal preferences, including administration route. Many patients find success with newer biologics like Adbry, Ebglyss, or Nemluvio, while others prefer the oral route offered by JAK inhibitors like Cibinqo or Rinvoq. For some, older methods like topical steroids or dietary changes continue to be valuable tools. Given the complexity of these conditions, a robust dialogue with your doctor is key to developing a successful and personalized treatment plan.
