Summary

Dupilumab may increase the risk of infection from live vaccines due to its immunosuppressive effects. Live vaccines are generally contraindicated or require careful consideration in patients receiving dupilumab therapy.

Introduction

Dupilumab is a monoclonal antibody that targets interleukin-4 and interleukin-13 receptors, primarily used to treat moderate-to-severe atopic dermatitis, asthma, and chronic rhinosinusitis with nasal polyps. Live vaccines contain weakened but living microorganisms that stimulate immune responses to provide protection against specific diseases. Common live vaccines include MMR (measles, mumps, rubella), varicella (chickenpox), live influenza vaccine, and yellow fever vaccine.

Mechanism of Interaction

Dupilumab works by blocking IL-4 and IL-13 signaling pathways, which play crucial roles in Th2-mediated immune responses. While dupilumab primarily affects type 2 immunity and has less impact on overall immunosuppression compared to other biologics, it may still alter immune function sufficiently to affect the body's ability to mount appropriate responses to live vaccines. The concern is that patients receiving dupilumab may have reduced ability to control the replication of live vaccine organisms, potentially leading to vaccine-strain infections.

Risks and Symptoms

The primary risk of administering live vaccines to patients on dupilumab is the potential for vaccine-strain infections, where the weakened organisms in the vaccine could cause disease in immunocompromised individuals. While dupilumab's immunosuppressive effects are generally considered mild to moderate, there is still theoretical risk of inadequate immune response to live vaccines, potentially resulting in either vaccine failure or vaccine-related illness. Additionally, patients may experience reduced vaccine efficacy, leading to inadequate protection against the targeted diseases.

Management and Precautions

Live vaccines should generally be avoided in patients currently receiving dupilumab therapy. If vaccination is necessary, consider using inactivated vaccine alternatives when available (such as inactivated influenza vaccine instead of live nasal spray). Live vaccines should ideally be administered before starting dupilumab therapy when possible. If live vaccination is absolutely necessary during dupilumab treatment, consult with infectious disease specialists and consider temporary discontinuation of dupilumab, though the optimal timing for this approach is not well-established. Monitor patients closely for signs of vaccine-strain infections if live vaccines are administered. Always verify current vaccination guidelines and consult with healthcare professionals for individual patient management decisions.