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The Clinical Use of Dupilumab for Elderly Patients With Severe COPD Exacerbations: A Case Series
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Hui Cai, Zi-xuan Chen, Hai-ying Ji, Qin-jun Shen, Jing Bi, Lin Tong, Shu-jing Chen, Lin-lin Wang, Jin-jun Jiang, Jing Zhang
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zhang.jing@zs-hospital.sh.cn

Corresponding author.
Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
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Table 1. The Baseline Characteristics, Disease Condition and Withdrawal of Systemic Corticosteroids in Three Cases With COPD Exacerbations Receiving Dupilumab.
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To the Director,

Chronic obstructive pulmonary disease (COPD) exacerbations are critical events that markedly accelerate the decline in lung function and worsen quality of life.1 However, they remain inadequately addressed by conventional treatment (including bronchodilators, corticosteroids and antibiotics), particularly in severe cases. This underscores an urgent need for innovative strategies. Dupilumab, a fully human monoclonal antibody that dually blocks IL-4 and IL-13 signaling, offering a novel therapeutic option in multiple diseases characterized with type 2 (T2) inflammation.2,3 Recent phase III trials demonstrated its potential in reducing moderate or severe exacerbations in patients with stable COPD exhibiting T2 inflammation features (blood eosinophils ≥300/μL).4,5 Nevertheless, clinical data supporting dupilumab use during COPD exacerbation is lacking. Herein, we reported the first use of dupilumab in elderly patients with COPD exhibiting T2 phenotype and corticosteroid dependence during severe exacerbations.

We presented the first case of an 80-year-old male with a ten-year history of COPD who experienced recurrent dyspnea and wheezes triggered by Pseudomonas aeruginosa pneumonia, leading to hypercapnic respiratory failure (Table 1). Although pneumonia significantly improved after invasive mechanical ventilation, effective antibiotics, and systemic methylprednisolone, his symptoms persisted, accompanied with irreducible intravenous corticosteroids and elevated eosinophils (560/μL). The second case, a 79-year-old male presented with worsening dyspnea and disturbance of consciousness, requiring intubation and invasive mechanical ventilation. After receiving antibiotics against Klebsiella pneumoniae pneumonia, triple inhalation therapy and methylprednisolone, his condition improved but then deteriorated again during corticosteroid tapering. The hematology showed IgE 340IU/mL and eosinophils rebounded from 80/μL to 760/μL. Our third case, a 71-year-old male was diagnosed with ever asthma and current COPD based on spirometry. He had been suffering from episodes of chest tightness and dyspnea, with cough and expectoration, after non-invasive ventilation and treatment against invasive pulmonary aspergillosis and pneumocystis pneumonia. He was identified as asthma-COPD overlap (ACO), relied on large doses of systemic corticosteroids and presented with elevated IgE level of 91IU/mL and positive Aspergillus fumigatus-specific IgE. Although severe pneumonia improved, their hypoxic dyspnea persisted and failed to achieve a stable condition.

Table 1.

The Baseline Characteristics, Disease Condition and Withdrawal of Systemic Corticosteroids in Three Cases With COPD Exacerbations Receiving Dupilumab.

Characteristics  Case 1  Case 2  Case 3 
Age (year)  80  79  71 
Gender  Male  Male  Male 
Smoking status  Former smoker  Current smoker  Former smoker 
Smoking history (pack*year)  100  100  20 
COPD history (year)  10  – 
Asthma history (year)  –  –  10 
Background medication  Compound methoxamine intermittently  –  Budesonide/formoterol 320μg/9μg bid for 10 years, prednisone 10mg bid in previous year 
Cause of onset  Pseudomonas aeruginosa pneumonia  Klebsiella pneumoniae pneumonia  Invasive pulmonary aspergillosis, pneumocystis pneumonia 
Severity of COPD exacerbation  Severe  Severe  Severe 
PaO2/FiO2 ratio  162  112  144 
PaCO2 (mmHg)  >115  102  79 
Respiratory support  Invasive mechanical ventilation  Invasive mechanical ventilation  Non-invasive ventilation 
Antibiotics or antifungal agents  Meropenem, inhaled tobramycin  Ceftazidime/avibactam, colistin E nebulization  Isavuconazole, SMZ-TMP, caspofungin 
Biomarkers of T2 inflammation
Blood eosinophil, maximum (/μL)  560  760  10 
Serum IgE, maximum (IU/mL)  95 (normal range <200)  340 (normal range <200)  91 (normal range <60) 
Specific allergen  –  –  Aspergillus fumigatus 
Initial dose of IvCS  MP 40mg qd  MP 40mg qd  MP 40mg qd 
Maximum dose of IvCS  MP 80mg  MP 60mg  MP 120mg 
Initiating time of dupilumab use  Day 5  Day 8  Day 26 
Dupilumab use  Twice  Twice  Thrice 
Withdrawal of corticosteroids
Mean dose of IvCS before 1st injection  MP 53mg qd  MP 40mg qd  MP 68mg qd 
Reduction of IvCS after 1st injectiona  42%  65%  18% 
Reduction of IvCS after 2nd injectiona  54%  80%  65% 
Reduction of IvCS after 3rd injectiona  –  –  93% 
Persistent reduction of IvCS  After 2nd injection  After 1st injection  After 2nd injection 
Total time from IvCS to OCSd  20d  9d  48d 
Time from IvCS to OCS after 1st injection  14d  2d  23d 
Time from IvCS to OCS after 2nd injection  3d  –  7d 
Maintenance of OCS after last dupilumab use  17d  7d  9d 
Clinical outcome  Improved, off the ventilator  Improved, with successful extubation  Improved 
Sequential respiratory support  Nasal oxygen  Nasal oxygen, non-invasive ventilation alternatively  Nasal oxygen 
Length of hospital stay (day)  28  25  66 

COPD: chronic obstructive pulmonary disease; T2: type 2; SMZ-TMP: sulfamethoxazole-trimethoprim; IvCS: intravenous corticosteroids; OCS: oral corticosteroids (prednisone); MP: methylprednisolone.

a

Reduction of IvCS was calculated on the percentage of mean doses of IvCS before 1st injection.

At diagnosis, the three elderly patients with severe COPD exacerbations were characterized with T2 phenotypes – one with elevated blood eosinophils, one with high serum IgE and rebounded eosinophils, and another with ACO and atopy (Table 1). There is a growing recognition that 20–40% of patients with COPD exhibit eosinophilic inflammation, indicating a T2 phenotype. This patient subset constantly experiences frequent exacerbations and responds favorably to corticosteroids.6,7 At the onset of the exacerbations, defining their phenotypes was challenging due to the inhibitory effect of corticosteroid use on blood eosinophils. Expectedly, new biomarkers are emerging, such as atopy and fractional exhaled nitric oxide, beyond eosinophils.8 Upon the corticosteroid withdrawal, all three patients were affiliated with episodic dyspnea, with eosinophil counts rebounded in cases 1 and 2, high levels of IgE found in cases 2 and 3. Due to their corticosteroid dependence and characteristics of T2 phenotypes, we firstly introduced dupilumab treatment after the peak of their severe exacerbations, to facilitate the rapid control of their symptoms and withdrawal of systemic corticosteroids, finally leading to successful outcomes. And no significant adverse effects were observed.

The mechanism of T2 inflammation in COPD has not been incompletely understood. While sharing certain similarities with asthma, anti-IL-5 (mepolizumab) or anti-IL-5 receptor (benralizumab) therapies targeting eosinophils have shown limited efficacy in COPD population, with no significant lung function improvement.9,10 This therapeutic discrepancy highlights the involvement of other components in T2 inflammatory cascade. Preclinical studies implicated IL-4 and IL-13, key divers of T2 inflammation, contributed to airway remodeling and lung parenchyma destruction in COPD, and also promoted the activation and trafficking of eosinophils to airways.11 By suppressing T2 inflammation in a broader way, anti-IL-4 receptor α antibody – dupilumab demonstrates superior clinical outcomes, including reduced exacerbations and improved lung function in COPD population with elevated blood eosinophils. As a fact, eosinophilic inflammation has been also observed in approximately 30% of exacerbations.12 Although the role of dupilumab in the acute management of exacerbation has not been evaluated, its efficacy in the maintenance phase suggests potential benefits. The use of dupilumab at severe exacerbations could help corticosteroid tapering in these elderly patients, thereby avoiding adverse effects like hyperglycemia, secondary infections, osteoporosis, and adrenal insufficiency.13

To our knowledge, our cases represented the first attempt to dupilumab use during COPD exacerbation, based on the comprehensive evaluation of T2 characteristics and clinical features. Dupilumab, as an add-on treatment, should be considered earlier, particularly in severe cases, rather than postpone to the stable phase, to manage symptoms better.

CRediT Authorship Contribution Statement

HC collected and analyzed the data, wrote and revised the manuscript. ZC helped the data analysis and prepared tables. HJ, QS, JB, LT and SJ shared responsibility for the diagnosis and treatment of three cases, and helped data interpretation. LW conducted the follow-up assessments of the cases. JJ reviewed the manuscript and provided critical discussions. JZ conducted the study, reviewed the manuscript and provided critical discussions. All authors have read and agreed to the final version of manuscript.

Declaration of Generative AI and AI-assisted Technologies in the Writing Process

None of the material was produced with the help of any artificial intelligence software or tool.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of Interests

The authors declare not to have any conflicts of interest that may be considered to influence directly or indirectly the content of the manuscript.

References
[1]
Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (2025 report).
(2005),
[2]
R.V.S. Tan, H.W.W. Aung, C. Flynn, N.J. Greening, C.E. Brightling.
Dupilumab in type 2 airway inflammation – a step forward in targeted therapy for COPD.
J Allergy Clin Immunol, 153 (2024), pp. 404-406
[3]
M.R. McCann, M.P. Kosloski, C. Xu, J.D. Davis, M.A. Kamal.
Dupilumab: mechanism of action, clinical, and translational science.
Clin Transl Sci, 17 (2024), pp. e13899
[4]
S.P. Bhatt, K.F. Rabe, N.A. Hanania, C.F. Vogelmeier, M. Bafadhel, S.A. Christenson, et al.
Dupilumab for COPD with blood eosinophil evidence of type 2 inflammation.
N Engl J Med, 390 (2024), pp. 2274-2283
[5]
S.P. Bhatt, K.F. Rabe, N.A. Hanania, C.F. Vogelmeier, J. Cole, M. Bafadhel, et al.
Dupilumab for COPD with type 2 inflammation indicated by eosinophil counts.
N Engl J Med, 389 (2023), pp. 205-214
[6]
K. Hasegawa, C.A. Camargo Jr..
Prevalence of blood eosinophilia in hospitalized patients with acute exacerbation of COPD.
Respirology, 21 (2016), pp. 761-764
[7]
M. Maniscalco, C. Candia, P. Ambrosino, A. Iovine, S. Fuschillo.
Chronic obstructive pulmonary disease's eosinophilic phenotype: clinical characteristics, biomarkers and biotherapy.
[8]
K. Oishi, K. Matsunaga, T. Shirai, K. Hirai, Y. Gon.
Role of type 2 inflammatory biomarkers in chronic obstructive pulmonary disease.
[9]
I.D. Pavord, P. Chanez, G.J. Criner, H.A.M. Kerstjens, S. Korn, N. Lugogo, et al.
Mepolizumab for eosinophilic chronic obstructive pulmonary disease.
N Engl J Med, 377 (2017), pp. 1613-1629
[10]
C.E. Brightling, E.R. Bleecker, R.A. Panettieri Jr., M. Bafadhel, D. She, C.K. Ward, et al.
Benralizumab for chronic obstructive pulmonary disease and sputum eosinophilia: a randomised, double-blind, placebo-controlled, phase 2a study.
Lancet Respir Med, 2 (2014), pp. 891-901
[11]
K.F. Rabe, S. Rennard, F.J. Martinez, B.R. Celli, D. Singh, A. Papi, et al.
Targeting type 2 inflammation and epithelial alarmins in chronic obstructive pulmonary disease: a biologics outlook.
Am J Respir Crit Care Med, 208 (2023), pp. 395-405
[12]
M. Bafadhel, S. McKenna, S. Terry, V. Mistry, C. Reid, P. Haldar, et al.
Acute exacerbations of chronic obstructive pulmonary disease: identification of biologic clusters and their biomarkers.
Am J Respir Crit Care Med, 184 (2011), pp. 662-671
[13]
D.E. Niewoehner, M.L. Erbland, R.H. Deupree, D. Collins, N.J. Gross, R.W. Light, et al.
Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. Department of Veterans Affairs Cooperative Study Group.
N Engl J Med, 340 (1999), pp. 1941-1947
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