Dupixent - summary of medicine characteristics

1. NAME OF THE MEDICINAL PRODUCT

Dupixent 300 mg solution for injection in pre-filled syringe

Dupixent 300 mg solution for injection in pre-filled pen

2. QUALITATIVE AND QUANTITATIVE COMPOSITION

Dupilumab 300 mg solution for injection in pre-filled syringe

Each single-use pre-filled syringe contains 300 mg of dupilumab in 2 ml solution (150 mg/ml).

Dupilumab 300 mg solution for injection in pre-filled pen

Each single-use pre-filled pen contains 300 mg of dupilumab in 2 ml solution (150 mg/ml).

Dupilumab is a fully human monoclonal antibody against interleukin (IL)-4 receptor alpha that inhibits IL-4/IL-13 signalling, produced in Chinese Hamster Ovary (CHO) cells by recombinant DNA technology.

For the full list of excipients, see section 6.1.

3. PHARMACEUTICAL FORM

Solution for injection (injection)

Clear to slightly opalescent, colourless to pale yellow sterile solution, which is free from visible particulates, with a pH of approximately 5.9.

4. CLINICAL PARTICULARS4.1 Therapeutic indications

Atopic dermatitis

Adults and adolescents

Dupixent is indicated for the treatment of moderate-to-severe atopic dermatitis in adults and adolescents 12 years and older who are candidates for systemic therapy.

Children 6 to 11 years of age

Dupixent is indicated for the treatment of severe atopic dermatitis in children 6 to 11 years old who are candidates for systemic therapy.

Asthma

Dupixent is indicated in adults and adolescents 12 years and older as add-on maintenance treatment for severe asthma with type 2 inflammation characterised by raised blood eosinophils and/or raised fraction of exhaled nitric oxide (FeNO), see section 5.1, who are inadequately controlled with high dose ICS plus another medicinal product for maintenance treatment.

Chronic rhinosinusitis with nasal polyposis (CRSwNP)

Dupixent is indicated as an add-on therapy with intranasal corticosteroids for the treatment of adults with severe CRSwNP for whom therapy with systemic corticosteroids and/or surgery do not provide adequate disease control.

4.2 Posology and method of administration

Treatment should be initiated by healthcare professionals experienced in the diagnosis and treatment of conditions for which dupilumab is indicated (see section 4.1).

Posology

Atopic Dermatitis

Adults

The recommended dose of dupilumab for adult patients is an initial dose of 600 mg (two 300 mg injections), followed by 300 mg given every other week administered as subcutaneous injection.

Adolescents (12 to 17 years of age)

The recommended dose of dupilumab for adolescent patients 12 to 17 years of age is specified in

• Table 1.

Table 1: Dose of dupilumab for subcutaneous administration in adolescent patients 12 to 17 years of age with atopic dermatitis

Body Weight of Patient	Initial Dose	Subsequent Doses (every other week)
less than 60 kg	400 mg (two 200 mg injections)	200 mg
60 kg or more	600 mg (two 300 mg injections)	300 mg

Children 6 to 11 years of age

The recommended dose of dupilumab for children 6 to 11 years of age is specified in Table 2.

Table 2: Dose of dupilumab for subcutaneous administration in children 6 to 11 years of age with atopic dermatitis

Body Weight of Patient	Initial Dose	Subsequent Doses
15 kg to less than 60 kg	300 mg (one 300 mg injection) on Day 1, followed by 300 mg on Day 15	300 mg every 4 weeks (Q4W), starting 4 weeks after Day 15 dose
60 kg or more	600 mg (two 300 mg injections)	300 mg every other week (Q2W)

The dose may be increased to 200 mg Q2W in patients with body weight of 15 kg to less than 60 kg based on physician’s as­sessment.

Dupilumab can be used with or without topical corticosteroids. Topical calcineurin inhibitors may be used, but should be reserved for problem areas only, such as the face, neck, intertriginous and genital areas.

Consideration should be given to discontinuing treatment in patients who have shown no response after 16 weeks of treatment for atopic dermatitis. Some patients with initial partial response may subsequently improve with continued treatment beyond 16 weeks. If dupilumab treatment interruption becomes necessary, patients can still be successfully re-treated.

Asthma

The recommended dose of dupilumab for adults and adolescents (12 years of age and older) is:

• • For patients with severe asthma and who are on oral corticosteroids or for patients with severe asthma and co-morbid moderate-to-severe atopic dermatitis or adults with co-morbid severe chronic rhinosinusitis with nasal polyposis, an initial dose of 600 mg (two 300 mg injections), followed by 300 mg every other week administered as subcutaneous injection.
• • For all other patients, an initial dose of 400 mg (two 200 mg injections), followed by 200 mg every other week administered as subcutaneous injection.

Patients receiving concomitant oral corticosteroids may reduce their steroid dose once clinical improvement with dupilumab has occurred (see section 5.1). Steroid reductions should be accomplished gradually (see section 4.4).

Dupilumab is intended for long-term treatment. The need for continued therapy should be considered at least on an annual basis as determined by physician assessment of the patient’s level of asthma control.

Chronic rhinosinusitis with nasal polyposis (CRSwNP)

The recommended dose of dupilumab for adult patients is an initial dose of 300 mg followed by 300 mg given every other week.

Dupilumab is intended for long-term treatment. Consideration should be given to discontinuing treatment in patients who have shown no response after 24 weeks of treatment for CRSwNP. Some patients with initial partial response may subsequently improve with continued treatment beyond 24 weeks.

Missed dose

If a dose is missed, administer the dose as soon as possible. Thereafter, resume dosing at the regular scheduled time.

Special populations

Elderly (> 65 years)

No dose adjustment is recommended for elderly patients (see section 5.2).

Renal impairment

No dose adjustment is needed in patients with mild or moderate renal impairment. Very limited data are available in patients with severe renal impairment (see section 5.2).

Hepatic impairment

No data are available in patients with hepatic impairment (see section 5.2).

Body weight

No dose adjustment for body weight is recommended for patients with asthma 12 years of age and older or in adults with atopic dermatitis or CRSwNP (see section 5.2).

For patients 12 to 17 years of age with atopic dermatitis, the recommended every other week dose is 200 mg (< 60 kg) or 300 mg (> 60 kg).

For patients 6 to 11 years of age with atopic dermatitis, the recommended doses are 300 mg Q4W with the possibility to increase to 200 mg Q2W (15 kg to < 60 kg), and 300 mg Q2W (> 60 kg).

Paediatric patients

The safety and efficacy of dupilumab in children with atopic dermatitis below the age of 6 years have not been established. The safety and efficacy of dupilumab in children with a body weight < 15 kg have not been established (see section 5.2). No data are available.

The safety and efficacy of dupilumab in children with severe asthma below the age of 12 years have not been established (see section 5.2). No data are available.

CRSwNP does not normally occur in children. The safety and efficacy in children with CRSwNP below the age of 18 years have not been established (see section 5.2). No data are available.

Method of administration

Subcutaneous use

The dupilumab pre-filled pen is not intended for use in children below 12 years of age. For children 6 to 11 years of age with atopic dermatitis, the dupilumab pre-filled syringe is the presentation appropriate for administration to this population.

Dupilumab is administered by subcutaneous injection into the thigh or abdomen, except for the 5 cm around the navel. If somebody else administers the injection, the upper arm can also be used.

For the initial 600 mg dose, two 300 mg injections should be administered consecutively in different injection sites.

It is recommended to rotate the injection site with each injection. Dupilumab should not be injected into skin that is tender, damaged or has bruises or scars.

A patient may self-inject dupilumab or the patient's caregiver may administer dupilumab if their healthcare professional determines that this is appropriate. Proper training should be provided to patients and/or caregivers on the preparation and administration of dupilumab prior to use according to the Instructions for Use (IFU) section in the package leaflet.

4.3 Contraindications

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

4.4 Special warnings and precautions for use

Dupilumab should not be used to treat acute asthma symptoms or acute exacerbations. Dupilumab should not be used to treat acute bronchospasm or status asthmaticus.

Systemic, topical, or inhaled corticosteroids should not be discontinued abruptly upon initiation of therapy with dupilumab. Reductions in corticosteroid dose, if appropriate, should be gradual and performed under the direct supervision of a physician. Reduction in corticosteroid dose may be associated with systemic withdrawal symptoms and/or unmask conditions previously suppressed by systemic corticosteroid therapy.

Biomarkers of type 2 inflammation may be suppressed by systemic corticosteroid use. This should be taken into consideration to determine type 2 status in patients taking oral corticosteroids (see section 5.1).

Traceability

In order to improve the traceability of biological medicinal products, the name and the batch number of the administered product should be clearly recorded.

Hypersensitivity

If a systemic hypersensitivity reaction (immediate or delayed) occurs, administration of dupilumab should be discontinued immediately and appropriate therapy initiated. Cases of anaphylactic reaction, angioedema, and serum sickness/serum sickness-like reaction have been reported. Anaphylactic reactions and angioedema have occurred from minutes to up to seven days after the dupilumab injection (section 4.8).

Eosinophilic conditions

Cases of eosinophilic pneumonia and cases of vasculitis consistent with eosinophilic granulomatosis with polyangiitis (EGPA) have been reported with dupilumab in adult patients who participated in the asthma development program. Cases of vasculitis consistent with EGPA have been reported with dupilumab and placebo in adult patients with co-morbid asthma in the CRSwNP development program. Physicians should be alert to vasculitic rash, worsening pulmonary symptoms, cardiac complications, and/or neuropathy presenting in their patients with eosinophilia. Patients being treated for asthma may present with serious systemic eosinophilia sometimes presenting with clinical features of eosinophilic pneumonia or vasculitis consistent with eosinophilic granulomatosis with polyangiitis, conditions which are often treated with systemic corticosteroid therapy. These events usually, but not always, may be associated with the reduction of oral corticosteroid therapy.

Helminth infection

Patients with known helminth infections were excluded from participation in clinical studies. Dupilumab may influence the immune response against helminth infections by inhibiting IL-4/IL-13 signaling. Patients with pre-existing helminth infections should be treated before initiating dupilumab. If patients become infected while receiving treatment with dupilumab and do not respond to antihelminth treatment, treatment with dupilumab should be discontinued until infection resolves.

Conjunctivitis and keratitis related events

Conjunctivitis and keratitis related events have been reported with dupilumab, predominantly in atopic dermatitis patients. Some patients reported visual disturbances (e.g. blurred vision) associated with conjunctivitis or keratitis (section 4.8).

Patients should be advised to report new onset or worsening eye symptoms to their healthcare provider. Patients treated with dupilumab who develop conjunctivitis that does not resolve following standard treatment or signs and symptoms suggestive of keratitis should undergo ophthalmological examination, as appropriate (section 4.8).

Atopic dermatitis or CRSwNP patients with comorbid asthma

Patients on dupilumab for moderate-to-severe atopic dermatitis or severe CRSwNP who also have co-morbid asthma should not adjust or stop their asthma treatments without consultation with their physicians. Patients with comorbid asthma should be monitored carefully following discontinuation of dupilumab.

Vaccinations

Live and live attenuated vaccines should not be given concurrently with dupilumab as clinical safety and efficacy has not been established. Immune responses to TdaP vaccine and meningococcal polysaccharide vaccine were assessed, see section 4.5. It is recommended that patients should be brought up to date with live and live attenuated immunisations in agreement with current immunisation guidelines prior to treatment with dupilumab.

Sodium content

This medicinal product contains less than 1 mmol sodium (23 mg) per 300 mg dose, i.e. essentially “sodium-free”.

4.5 Interaction with other medicinal products and other forms of interaction

Immune responses to vaccination were assessed in a study in which patients with atopic dermatitis were treated once weekly for 16 weeks with 300 mg of dupilumab. After 12 weeks of dupilumab administration, patients were vaccinated with a Tdap vaccine (T cell-dependent), and a meningococcal polysaccharide vaccine (T cell-independent) and immune responses were assessed 4 weeks later.

Antibody responses to both tetanus vaccine and meningococcal polysaccharide vaccine were similar in dupilumab-treated and placebo-treated patients. No adverse interactions between either of the non-live vaccines and dupilumab were noted in the study.

Therefore, patients receiving dupilumab may receive concurrent inactivated or non-live vaccinations. For information on live vaccines see section 4.4.

In a clinical study of AD patients, the effects of dupilumab on the pharmacokinetics (PK) of CYP substrates were evaluated. The data gathered from this study did not indicate clinically relevant effects of dupilumab on CYP1A2, CYP3A, CYP2C19, CYP2D6, or CYP2C9 activity.

An effect of dupilumab on the PK of co-administered medications is not expected. Based on the population analysis, commonly co-administered medications had no effect on dupilumab pharmacokinetics on patients with moderate to severe asthma.

4.6 Fertility, pregnancy and lactation

Pregnancy

There are limited amount of data from the use of dupilumab in pregnant women. Animal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity (see section 5.3).

Dupilumab should be used during pregnancy only if the potential benefit justifies the potential risk to the foetus.

Breast-feeding

It is unknown whether dupilumab is excreted in human milk or absorbed systemically after ingestion. A decision must be made whether to discontinue breast-feeding or to discontinue dupilumab therapy taking into account the benefit of breast feeding for the child and the benefit of therapy for the woman.

Fertility

Animal studies showed no impairment of fertility (see section 5.3).

4.7 Effects on ability to drive and use machines

Dupilumab has no or negligible influence on the ability to drive or operate machinery.

4.8 Undesirable effects

Summary of the safety , profile

The most common adverse reactions in controlled clinical studies of dupilumab in atopic dermatitis, asthma, and CRSwNP were injection site reactions (includes erythema, oedema, pruritus, pain, and swelling), conjunctivitis, arthralgia, oral herpes, and eosinophilia. Rare cases of serum sickness, serum sickness-like reaction, anaphylactic reaction, and ulcerative keratitis have been reported (see section 4.4).

In the monotherapy atopic dermatitis adult studies, the proportion of patients who discontinued treatment due to adverse events was 1.9 % of the placebo group, 1.9 % of the dupilumab 300 mg Q2W group, 1.5 % of the dupilumab 300 mg QW group. In the concomitant TCS adult study, the proportion of patients who discontinued treatment due to adverse events was 7.6 % of the placebo + TCS group, 1.8 % of the dupilumab 300 mg Q2W + TCS group, and 2.9 % of the dupilumab 300 mg QW + TCS group.

In DRI12544 and QUEST asthma studies, the proportion of patients who discontinued treatment due to adverse events was 4.3% of the placebo group, 3.2% of the dupilumab 200 mg Q2W group, and 6.1% of the dupilumab 300 mg Q2W group.

In SINUS-24 and SINUS-52 CRSwNP studies, the proportion of patients who discontinued treatment due to adverse events was 2.0% of the dupilumab 300 mg Q2W group and 4.6% of the placebo group.

Tabulated list of adverse reactions

Dupilumab was studied in 12 randomised, placebo-controlled trials, including atopic dermatitis, asthma, and CRSwNP patients. The pivotal controlled studies involved 4,206 patients receiving dupilumab and 2,326 patients receiving placebo during the controlled period.

Listed in Table 3 are adverse reactions observed in atopic dermatitis, asthma, and CRSwNP clinical trials and/or postmarketing setting presented by system organ class and frequency, using the following categories: very common (> 1/10); common (> 1/100 to < 1/10); uncommon (> 1/1,000 to < 1/100); rare (> 1/10,000 to < 1/1,000); very rare (< 1/10,000).

Table 3: List of adverse reactions

Med I) RA System Organ Class	Frequency	Adverse Reaction
Infections and infestations	Common	Conjunctivitis* Oral herpes*
Blood and lymphatic system disorders	Common	Eosinophilia
Immune system disorders	Rare Uncommon	Serum sickness reaction Serum sickness-like reaction Anaphylactic reaction Angioedema
Eye disorders	Common Uncommon Rare	Conjunctivitis allergic* Eye pruritus** Blepharitis** Keratitis* Dry eye** Ulcerative keratitis**
Skin and subcutaneous tissue disorders	Uncommon	Facial rash

Musculoskeletal and connective tissue disorders	Common	Arthralgia
General disorders and administration site conditions	Common	Injection site reactions (includes erythema, oedema, pruritus, pain, and swelling)

*Eye disorders and oral herpes occurred predominately in atopic dermatitis studies.

'The frequencies for eye pruritus, blepharitis, and dry eye were common and ulcerative keratitis was uncommon in atopic dermatitis studies.

Description of selected adverse reactions in atopic dermatitis, asthma, and CRSwNP indications

Hypersensitivity

Cases of anaphylactic reaction, angioedema, and serum sickness/serum sickness-like reaction have been reported following administration of dupilumab (see section 4.4).

Conjunctivitis and keratitis related events

Conjunctivitis and keratitis occurred more frequently in atopic dermatitis patients who received dupilumab compared to placebo in atopic dermatitis studies. Most patients with conjunctivitis or keratitis recovered or were recovering during the treatment period. In the long-term OLE atopic dermatitis study (AD-1225) at 3 years, the respective rates of conjunctivitis and keratitis remained similar to those in the dupilumab arm in the placebo controlled atopic dermatitis studies. Among asthma patients frequency of conjunctivitis and keratitis was low and similar between dupilumab and placebo. Among CRSwNP patients the frequency of conjunctivitis was higher in dupilumab than placebo, though lower than that observed in atopic dermatitis patients. There were no cases of keratitis reported in the CRSwNP development program (see section 4.4).

Eczema herpeticum

Eczema herpeticum was reported in < 1% of the dupilumab groups and in < 1 % of the placebo group in the 16-week atopic dermatitis monotherapy adult studies. In the 52-week atopic dermatitis dupilumab + TCS adult study, eczema herpeticum was reported in 0.2 % of the dupilumab + TCS group and 1.9 % of the placebo + TCS group. These rates remained stable at 3 years in the long-term OLE study (AD-1225).

Eosinophilia

Dupilumab-treated patients had a greater mean initial increase from baseline in eosinophil count compared to patients treated with placebo. Eosinophil counts declined to near baseline levels during study treatment and returned to baseline during the asthma open-label extension safety study (TRAVERSE). The mean blood eosinophil levels decreased to below baseline by week 20 and was maintained up to 3 years in the long-term OLE study (AD-1225).

Treatment-emergent eosinophilia (> 5,000 cells/mcL) was reported in < 2 % of dupilumab-treated patients and < 0.5 % in placebo-treated patients (see section 4.4).

Infections

In the 16-week atopic dermatitis monotherapy clinical adult studies, serious infections were reported in 1.0 % of patients treated with placebo and 0.5 % of patients treated with dupilumab. In the 52-week atopic dermatitis CHRONOS adult study, serious infections were reported in 0.6 % of patients treated with placebo and 0.2 % of patients treated with dupilumab. The rates of serious infections remained stable at 3 years in the long-term OLE study (AD-1225).

No increase was observed in the overall incidence of infections with dupilumab compared to placebo in the safety pool for asthma clinical studies. In the 24-week safety pool, serious infections were reported in 1.0% of patients treated with dupilumab and 1.1% of patients treated with placebo. In the 52-week QUEST study, serious infections were reported in 1.3% of patients treated with dupilumab and 1.4% of patients treated with placebo.

No increase was observed in the overall incidence of infections with dupilumab compared to placebo in the safety pool for CRSwNP clinical studies. In the 52-week SINUS-52 study, serious infections were reported in 1.3 % of patients treated with dupilumab and 1.3 % of patients treated with placebo.

Immunogenicity

As with all therapeutic proteins, there is a potential for immunogenicity with dupilumab.

Anti-Drug-Antibodies (ADA) responses were not generally associated with impact on dupilumab exposure, safety, or efficacy.

Approximately 5 % of patients with atopic dermatitis, asthma, or CRSwNP who received dupilumab 300 mg Q2W for 52 weeks developed ADA to dupilumab; approximately 2 % exhibited persistent ADA responses and approximately 2 % had neutralizing antibodies. Similar results were observed in paediatric patients (6 to 11 years of age) with atopic dermatitis who received dupilumab 200 mg Q2W or 300 mg Q4W for 16 weeks. Similar ADA responses were observed in adult patients with atopic dermatitis treated with dupilumab for up to 3 years in the long-term OLE study (AD-1225).

Approximately 16 % of adolescent patients with atopic dermatitis who received dupilumab 300 mg or 200 mg Q2W for 16 weeks developed antibodies to dupilumab; approximately 3 % exhibited persistent ADA responses, and approximately 5 % had neutralizing antibodies.

Approximately 9 % of patients with asthma who received dupilumab 200 mg Q2W for 52 weeks developed antibodies to dupilumab; approximately 4 % exhibited persistent ADA responses and approximately 4 % had neutralizing antibodies.

Regardless of age or population, approximately 2 to 4 % of patients in the placebo groups were positive for antibodies to dupilumab; approximately 2 % exhibited persistent ADA response and approximately 1 % had neutralizing antibodies.

Less than 1 % of patients who received dupilumab at approved dosing regimens exhibited high titer ADA responses associated with reduced exposure and efficacy. In addition, there was one patient with serum sickness and one with serum sickness-like reaction (< 0.1 %) associated with high ADA titers (see section 4.4).

Paediatric population

Atopic Dermatitis

Adolescents 12 to 17 years of age

The safety of dupilumab was assessed in a study of 250 patients 12 to 17 years of age with moderate-to-severe atopic dermatitis (AD-1526). The safety profile of dupilumab in these patients followed through week 16 was similar to the safety profile from studies in adults with atopic dermatitis.

Asthma

A total of 107 adolescents aged 12 to 17 years with asthma were enrolled in the 52 week QUEST study. The safety profile observed was similar to that seen in adults.

The long-term safety of dupilumab was assessed in 89 adolescent patients who were enrolled in an open-label extension study in moderate-to-severe asthma (TRAVERSE). In this study, patients were followed for up to 96 weeks. The safety profile of dupilumab in TRAVERSE was consistent with the safety profile observed in pivotal asthma studies for up to 52 weeks of treatment.

Long-term safety

Atopic Dermatitis

The safety profile of dupilumab + TCS (CHRONOS) in adult atopic dermatitis patients) through week 52 was consistent with the safety profile observed at week 16. The long-term safety of dupilumab was assessed in an open-label extension study in patients 6 to 17 years of age with moderate-to-severe atopic dermatitis (AD-1434). The safety profile of dupilumab in patients followed through week 52 was similar to the safety profile observed at week 16 in the AD-1526 and AD-1652 studies. The longterm safety profile of dupilumab observed in children and adolescents was consistent with that seen in adults with atopic dermatitis.

In a phase 3, multicentre, open label extension (OLE) study (AD-1225), the long-term safety of repeat doses of dupilumab was assessed in 2,677 adults with moderate-to-severe AD exposed to 300 mg weekly dosing (99.7 %), including 347 who completed at least 148 weeks of the study. The long-term safety profile observed in this study up to 3 years was generally consistent with the safety profile of dupilumab observed in controlled studies.

Asthma

The safety profile of dupilumab in the 96 weeks long term safety study (TRAVERSE) was consistent with the safety profile observed in pivotal asthma studies for up to 52 weeks of treatment.

CRSwNP

The safety profile of dupilumab in adults with CRSwNP through week 52 was consistent with the safety profile observed at week 24.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the national reporting system listed in Appendix V.

4.9 Overdose

There is no specific treatment for dupilumab overdose. In the event of overdosage, monitor the patient for any signs or symptoms of adverse reactions and institute appropriate symptomatic treatment immediately.

5. PHARMACOLOGICAL PROPERTIES5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Other dermatological preparations, agents for dermatitis, excluding corticosteroids, ATC code: D11AH05

Mechanism of action

Dupilumab is a recombinant human IgG4 monoclonal antibody that inhibits interleukin-4 and interleukin-13 signaling. Dupilumab inhibits IL-4 signaling via the Type I receptor (IL-4Ra/yc), and both IL-4 and IL-13 signaling through the Type II receptor (IL-4Ra/IL-13Ra). IL-4 and IL-13 are major drivers of human type 2 inflammatory disease, such as atopic dermatitis, asthma, and CRSwNP. Blocking the IL-4/IL-13 pathway with dupilumab in patients decreases many of the mediators of type 2 inflammation.

Pharmacodynamic effects

In atopic dermatitis clinical trials, treatment with dupilumab was associated with decreases from baseline in concentrations of type 2 immunity biomarkers, such as thymus and activation-regulated chemokine (TARC/CCL17), total serum IgE and allergen-specific IgE in serum. A reduction of lactate dehydrogenase (LDH), a biomarker associated with AD disease activity and severity, was observed with dupilumab treatment in adults and adolescents with atopic dermatitis.

In asthma clinical trials, dupilumab treatment markedly decreased FeNO and circulating concentrations of eotaxin-3, total IgE, allergen specific IgE, TARC, and periostin in asthma subjects relative to placebo. These reductions in type 2 inflammatory biomarkers were comparable for the 200 mg Q2W and 300 mg Q2W regimens. These markers were near maximal suppression after 2 weeks of treatment, except for IgE which declined more slowly. These effects were sustained throughout treatment.

Clinical efficacy and safety in atopic dermatitis

Adults with atopic dermatitis

The efficacy and safety of dupilumab as monotherapy and with concomitant topical corticosteroids were evaluated in three pivotal randomised, double-blind, placebo-controlled studies (SOLO 1, SOLO 2, and CHRONOS) in 2,119 patients 18 years of age and older with moderate to severe atopic dermatitis (AD) defined by Investigator’s Glo­bal Assessment (IGA) score > 3, an Eczema Area and Severity Index (EASI) score > 16, and a minimum body surface area (BSA) involvement of > 10 %. Eligible patients enrolled into the three studies had previous inadequate response to topical medication.

In all three studies, patients received 1) an initial dose of 600 mg dupilumab (two 300 mg injections) on day 1, followed by 300 mg once every two weeks (Q2W); 2) an initial dose of 600 mg dupilumab on day 1, followed by 300 mg once weekly (QW); or 3) matching placebo. Dupilumab was administered by subcutaneous (SC) injection in all studies. If needed to control intolerable symptoms of atopic dermatitis, patients were permitted to receive rescue treatment (which included higher potency topical steroids or systemic immunosuppressants) at the discretion of the investigator. Patients who received rescue treatment were considered non-responders.

SOLO 1 enrolled 671 patients (224 to placebo, 224 to dupilumab 300 mg Q2W, and 223 to dupilumab 300 mg QW) and had a treatment period of 16 weeks.

SOLO 2 enrolled 708 patients (236 to placebo, 233 to dupilumab 300 mg Q2W, and 239 to dupilumab 300 mg QW) and had a treatment period of 16 weeks.

CHRONOS enrolled 740 patients (315 to placebo + topical corticosteroid (TCS), 106 to dupilumab 300 mg Q2W + TCS, and 319 to dupilumab 300 mg QW + TCS) and had a treatment period of 52 weeks. Patients received dupilumab or placebo with concomitant use of TCS starting at baseline using a standardized regimen. Patients were also permitted to use topical calcineurin inhibitors (TCI).

Endpoints

In all three pivotal studies, the co-primary endpoints were the proportion of patients with IGA 0 or 1 (“clear” or “almost clear”) with a reduction of > 2 points on a 0–4 IGA scale and the proportion of patients with improvement of at least 75 % in EASI (EASI-75) from baseline to week 16. Other evaluated outcomes included the proportion of patients with improvement of at least 50 % and 90 % in EASI (EASI-50 and EASI-90, respectively), reduction in itch as measured by the peak pruritus Numerical Rating Scale (NRS), and percent change in the SCORing Atopic Dermatitis (SCORAD) scale from baseline to week 16. Additional secondary endpoints included mean change from baseline to week 16 in the Patient Oriented Eczema Measure (POEM), Dermatology Life Quality Index (DLQI), and Hospital Anxiety and Depression Scale (HADS) scores. In CHRONOS, efficacy was also evaluated at week 52.

Baseline Characteristics

In the monotherapy studies (SOLO 1 and SOLO 2), across all treatment groups, the mean age was 38.3, the mean weight was 76.9 kg, 42.1 % were female, 68.1 % were white, 21.8 % were Asian, and 6.8 % were black. In these studies, 51.6 % of patients had a baseline IGA score of 3 (moderate AD), 48.3 % of patients had a baseline IGA of 4 (severe AD) and 32.4 % of patients had received prior systemic immunosuppressants. The baseline mean EASI score was 33.0, the baseline weekly averaged pruritus NRS was 7.4, the baseline mean SCORAD score was 67.8, the baseline mean POEM score was 20.5, the baseline mean DLQI was 15.0, and the baseline mean HADS total score was 13.3.

In the concomitant TCS study (CHRONOS), across all treatment groups, the mean age was 37.1, the mean weight was 74.5 kg, 39.7 % were female, 66.2 % were white, 27.2 % were Asian, and 4.6 % were black. In this study, 53.1 % of patients had a baseline IGA score of 3 and 46.9 % of patients had a baseline IGA of 4 and 33.6 % of patients received prior systemic immunosuppressants. The baseline mean EASI score was 32.5, the baseline weekly pruritus NRS was 7.3, the baseline mean SCORAD score was 66.4, the baseline mean POEM score was 20.1, the baseline mean DLQI was 14.5, and the baseline mean HADS total score was 12.7.

Clinical Response

16-Week Monotherapy Studies (SOLO 1 and SOLO 2)

In SOLO 1 and SOLO 2, from baseline to week 16, a significantly greater proportion of patients randomized to dupilumab achieved an IGA 0 or 1 response, EASI-75, and/or an improvement of >4 points on the pruritus NRS compared to placebo (see Table 4).

A significantly greater proportion of patients randomized to dupilumab achieved a rapid improvement in the pruritus NRS compared to placebo (defined as > 4-point improvement as early as week 2;

p < 0.01) and the proportion of patients responding on the pruritus NRS continued to increase through the treatment period. The improvement in pruritus NRS occurred in conjunction with the improvement of objective signs of atopic dermatitis.

Figure 1 and Figure 2 show the mean percent change from baseline in EASI and the mean percent change from baseline in NRS, respectively up to week 16.

Table 4: Efficacy results of dupilumab monotherapy at week 16 (FAS)

	SOLO 1 (FAS)a			SOLO 2 (FAS)a
	Placebo	Dupilumab 300 mg Q2W	Dupilumab 300 mg QW	Placebo	Dupilumab 300 mg Q2W	Dupilumab 300 mg QW
Patients randomised	224	224	223	236	233	239
IGA0orlb, % responders0	10.3 %	37.9 %e	37.2 %e	8.5 %	36.1 %e	36.4 %°
EASI-50, % responders0	24.6 %	68.8 %e	61.0%°	22.0 %	65.2 %e	61.1 %°
EASI-75, % responders0	14.7 %	51.3 %°	52.5 %°	11.9%	44.2 %°	48.1 %°
EASI-90, % responders0	7.6 %	35.7%°	33.2%°	7.2 %	30.0 %°	30.5 %°
EASI, LS mean % change from baseline (+/-SE)	–37.6 % (3.28)	–72.3 %° (2.63)	–72.0 %° (2.56)	–30.9 % (2.97)	–67.1 %° (2.52)	–69.1 %° (2.49)
SCORAD, LS mean % change from	–29.0 % (3.21)	–57.7 %e (2.11)	–57.0 %e (2.11)	–19.7 % (2.52)	–51.1 %e (2.02)	–53.5 %e (2.03)

	SOLO 1 (FAS)a			SOLO 2 (FAS)a
	Placebo	Dupilumab 300 mg Q2W	Dupilumab 300 mg QW	Placebo	Dupilumab 300 mg Q2W	Dupilumab 300 mg QW
baseline (+/-SE)
Pruritus NRS, LS mean % change from baseline (+/-SE)	–26.1 % (3.02)	–51.0 %e (2.50)	–48.9 %e (2.60)	–15.4% (2.98)	–44.3 %e (2.28)	–48.3 %e (2.35)
Number of patients with baseline pruritus NRS score > 4	212	213	201	221	225	228
Pruritus NRS (>4-point improvement) , % respondersc- d	12.3 %	40.8 %e	40.3 %e	9.5%	36.0 %e	39.0 %e

LS = least squares; SE= standard error

aFull analysis set (FAS) includes all patients randomized.

bResponder was defined as a patient with IGA 0 or 1 (“clear” or “almost clear”) with a reduction

of > 2 points on a 0–4 IGA scale.

cPatients who received rescue treatment or with missing data were considered as non-responders.

da significantly greater proportion of patients on dupilumab had improvement in pruritus NRS of > 4 points compared to placebo at week 2 (p < 0.01).

ep-value < 0.0001

Figure 1: Mean percent change from baseline in EASI in SOLO 1 aand SOLO 2 a(FAS) b

SOLO 1

SOLO 2

LS = least squares

aIn the primary analyses of the efficacy endpoints, patients who received rescue treatment or with missing data were considered non-responders.

bFull analysis set (FAS) includes all patients randomized.

Figure 2: Mean percent change from baseline in NRS in SOLO 1 aand SOLO 2 a(FAS) b

SOLO 1

SOLO 2

LS = least squares

aIn the primary analyses of the efficacy endpoints, patients who received rescue treatment or with missing data were considered non-responders

bFull analysis set (FAS) includes all patients randomized.

Treatment effects in subgroups (weight, age, gender, race, and background treatment, including immunosuppressants) in SOLO 1 and SOLO 2 were consistent with the results in the overall study population.

52-Week Concomitant TCSStudy (CHRONOS)

In CHRONOS, a significantly greater proportion of patients randomized to dupilumab 300 mg Q2W + TCS achieved an IGA 0 or 1 response, EASI-75, and/or an improvement of >4 points on the pruritis NRS from baseline to week 16 and week 52 compared to placebo + TCS (see Table 5).

A significantly greater proportion of patients randomized to dupilumab + TCS achieved a rapid improvement in the pruritus NRS compared to placebo + TCS (defined as >4-point improvement as early as week 2; p < 0.05) and the proportion of patients responding on the pruritus NRS continued to increase through the treatment period. The improvement in pruritus NRS occurred in conjunction with the improvement of objective signs of atopic dermatitis.

Figure 3 and Figure 4 show the mean percent change from baseline in EASI and the mean percent change from baseline in NRS, respectively, up to week 52 in CHRONOS.

Table 5: Efficacy results of dupilumab with concomitant TCS aat Week 16 and Week 52 in CHRONOS

	Week 16 (FAS)b			Week 52 (FAS Week 52)b
	Placebo + TCS	Dupilumab 300 mg Q2W + TCS	Dupilumab 300 mg QW + TCS	Placebo + TCS	Dupilumab 300 mg Q2W + TCS	Dupilumab 300 mg QW + TCS
Patients randomized	315	106	319	264	89	270
IGA 0 or Ie, % responders'1	12.4%	38.7 %f	39.2 %f	12.5 %	36.0 %f	40.0 %f
EASI-50, % responders'1	37.5 %	80.2 %f	78.1 %f	29.9 %	78.7 %f	70.0 %f
EASI-75, % responders'1	23.2%	68.9 %f	63.9 %f	21.6 %	65.2 %f	64.1 %f
EASI-90, % responders'1	11.1 %	39.6 %f	43.3 %f	15.5 %	50.6 %f	50.7 %f
EASI, LS mean % change from baseline (+/-SE)	–48.4 % (3.82)	–80.5 %f (6.34)	–81.5 %f (5.78)	–60.9 % (4.29)	–84.9 %g (6.73)	–87.8 %11 (6.19)
SCORAD, LS mean % change from baseline (+/-SE)	–36.2 % (1.66)	–63.9 %f (2.52)	–65.9 %f (1–49)	–47.3 % (2.18)	–69.7 %f (3.06)	–70.4 %f (1–72)
Pruritus NRS, LS mean % change from baseline (+/-SE)	–30.3 % (2.36)	–56.6 %f (3.95)	–57.1 %f (2.H)	–31.7% (3.95)	–57.0 %1 (6.17)	–56.5 %f (3.26)
Number of patients with baseline pruritus NRS score > 4	299	102	295	249	86	249
Pruritus NRS (> 4-point improvement) , % responders'1, e	19.7 %	58.8 %f	50.8 %f	12.9 %	51.2 %f	39.0 %f

LS = least squares; SE = standard error

aAll patients were on background topical corticosteroids therapy and patients were permitted to use topical calcineurin inhibitors.

• bFull analysis set (FAS) includes all patients randomized. FAS week 52 includes all patients randomized at least one year before the cutoff date of the primary analysis.

• cResponder was defined as a patient with IGA 0 or 1 (“clear” or “almost clear”) with a reduction of

• > 2 points on a 0–4 IGA scale.

dPatients who received rescue treatment or with missing data were considered as non-responders.

• ea significantly greater proportion of patients on dupilumab had improvement in pruritus NRS of > 4 points compared to placebo at week 2 (p < 0.05).

fp-value < 0.0001

gp-value = 0.0015

hp-value = 0.0003

ip-value = 0.0005

Figure 3: Mean percent change from baseline in EASI in CHRONOS a(FAS Week 52) b

CHRONOS

Dupixent 300 mg Q2W + TCS, primary analysis (N=89)

Placebo + TCS, primary analysis (N=264)

LS = least squares

aIn the primary analyses of the efficacy endpoints, patients who received rescue treatment or with missing data were considered non-responders.

bFAS week 52 includes all patients randomized at least one year before the cutoff date of the primary analysis.

Figure 4: Mean percent change from baseline in NRS in CHRONOS a(FAS Week 52) b

aIn the primary analyses of the efficacy endpoints, patients who received rescue treatment or with missing data were considered non-responders.

bFAS week 52 includes all patients randomized at least one year before the cutoff date of the primary analysis.

Treatment effects in subgroups (weight, age, gender, race, and background treatment, including immunosuppressants) in CHRONOS were consistent with the results in the overall study population.

Clinical Response in Patients Not Adequately Controlled with, Intolerant to, or for whom Ciclosporin Treatment was Inadvisable (CAFE study)

CAFE study evaluated the efficacy of dupilumab compared to placebo during a 16-week treatment period, administered with concomitant TCS, in adult patients with AD who are not adequately controlled with, or are intolerant to, oral ciclosporin, or when this treatment is currently contraindicated or not medically advisable.

A total of 325 patients were enrolled, with 210 patients who were previously exposed to ciclosporin and 115 patients who have never been exposed to ciclosporin because ciclosporin treatment was medically inadvisable. The mean age was 38.4 years, 38.8 % were female, the baseline mean EASI score was 33.1, the mean BSA was 55.7, the baseline weekly average pruritis NRS was 6.4, the baseline mean SCORAD score was 67.2, and the baseline mean DLQI was 13.8.

The primary endpoint was the proportion of patients with EASI-75 at week 16.

Primary and secondary endpoints for the 16 week CAFE study are summarized in table 6.

Table 6: Results of the primary and secondary endpoints in CAFE study

	Placebo + TCS	Dupilumab 300 mg Q2W + TCS	Dupilumab 300 mg QW+TCS
Patients randomised	108	107	110
EASI-75, % responders	29.6 %	62.6 %	59.1 %
EASI, LS mean % change from baseline (+/- SE)	–46.6 (2.76)	–79.8 (2.59)	–78.2 (2.55)
Pruritus NRS, LS mean % change from baseline (+/- SE)	–25.4 % (3.39)	–53.9 % (3.14)	–51.7% (3.09)
SCORAD, LS mean % change from baseline (+/- SE)	–29.5 % (2.55)	–62.4 % (2.48)	–58.3 % (2.45)
DLQI, LS mean change from baseline (SE)	–4.5 (0.49)	–9.5 (0.46)	–8.8 (0.45)

(all p-values <0.0001)

In the subgroup of patients resembling the CAFE study population within the 52 week CHRONOS study, 69.6 % of dupilumab 300 mg Q2W-treated patients reached EASI-75 vs 18.0 % placebo-treated patients at week 16, and 52.4 % of dupilumab 300 mg Q2W-treated vs 18.6 % placebo-treated at week 52. In this subset, the percent change of pruritus NRS from baseline was –51.4 % vs –30.2 % at week 16 and –54.8 % vs –30.9 % at week 52, for the dupilumab 300 mg Q2W and placebo groups respectively.

Maintenance and Durability of Response (SOLO CONTINUE study)

To evaluate maintenance and durability of response, subjects treated with dupilumab for 16 weeks in SOLO 1 and SOLO 2 studies who achieved IGA 0 or 1 or EASI-75 were re-randomized in SOLO CONTINUE study to an additional 36-week treatment of dupilumab or placebo, for a cumulative 52-week study treatment. Endpoints were assessed at weeks 51 or 52.

The co-primary endpoints were the difference between baseline (week 0) and week 36 in percent change in EASI from SOLO 1 and SOLO 2 studies baseline and percentage of patients with EASI-75 at week 36 in patients with EASI-75 at baseline.

Patients who continued on the same dose regimen received in the SOLO 1 and SOLO 2 studies (300 mg Q2W or 300 mg QW) showed the optimal effect in maintaining clinical response while efficacy for other dose regimens diminished in a dose-dependent manner.

Primary and secondary endpoints for the 52 week SOLO CONTINUE study are summarized in table 7.

Table 7: Results of the primary and secondary endpoints in SOLO CONTINUE study

	Placebo	Du	pilumab 300 mg
	N=83	Q8W N=84	Q4W N=86	Q2W/QW N=169
Co-Primary Endpoints
LS mean change (SE) between baseline and week 36 in percent change in EASI Score from Parent Study baseline	21.7 (3.13)	r o*** o.o (2.43)	3.8 (2.28)	0.1 (1.74)
Percent of patients with E ASI-75 at week 36 for patients with EASI-75 at baseline, n (%)	24/79 (30.4 %)	45/82* (54.9 %)	49/84** (58.3 %)	116/162*** (71.6 %)
Key Secondary Endpoints
Percent of patients whose IGA response at week 36 was maintained within 1 point of baseline in the subset of patients with IGA (0,1) at baseline, n (%)	18/63 (28.6)	32/641 (50.0)	41/66** (62.1)	89/126*** (70.6)
Percent of patients with IGA (0,1) at week 36 in the subset of patients with IGA (0,1) at baseline, n (%)	9/63 (14.3)	21/641 (32.8)	29/66** (43.9)	68/126*** (54.0)
Percent of patients whose peak pruritus NRS increased by > 3 points from baseline to week 35 in the subset of patients with peak pruritus NRS < 7 at baseline, n (%)	56/80 (70.0)	45/81 (55.6)	41/831 (49.4)	57/168*** (33.9)

1P< 0.05, *P< 0.01, **P< 0.001, ***P< 0.0001

In SOLO CONTINUE, a trend for increased treatment-emergent ADA positivity with increased dosing intervals was observed. Treatment-emergent ADA: QW: 1.2 %; Q2W: 4.3 %; Q4W: 6.0 %; Q8W: 11.7 %. ADA responses lasting more than 12 weeks: QW: 0.0 %; Q2W: 1.4 %; Q4W: 0.0 %; Q8W: 2.6 %.

Quality of Life/Patient-Reported Outcomes in Atopic Dermatitis

In both monotherapy studies (SOLO 1 and SOLO 2), both dupilumab 300 mg Q2W and 300 mg QW groups significantly improved patient-reported symptoms and the impact of AD on sleep and health-related quality of life as measured by POEM and DLQI total scores, respectively, at 16 weeks compared to placebo. A significantly larger proportion of patients administered dupilumab groups had clinically meaningful reductions in POEM and DLQI total score (each defined as > 4 points improvement) from baseline to week 16 compared to placebo group. In addition, anxiety and depression symptoms as measured by the HADS total score were significantly reduced in the dupilumab groups compared to placebo at 16 weeks. In a subset of patients with HADS-anxiety or HADS-depression subscale scores > 8 at baseline (the cut-off value for anxiety or depression), a larger proportion of patients in the dupilumab groups achieved HADS-anxiety and HADS-depression scores < 8 at week 16 compared to placebo (See Table 8).

Table 8: Additional secondary endpoint results of dupilumab monotherapy at Week 16

	Monotherapy
	SOLO 1 at Week 16			SOLO 2 at Week 16
	Placebo	Dupilumab 300 mg Q2W	Dupilumab 300 mg QW	Placebo	Dupilumab 300 mg Q2W	Dupilumab 300 mg QW
Patients randomized	224	224	223	236	233	239
DLQI, LS mean change from baseline (SE)	–5.3 (0.50)	–9.3a (0.40)	–9.0a (0.40)	–3.6 (0.50)	–9.3a (0.38)	–9.5a (0.39)
POEM, LS mean change from baseline (SE)	–5.1 (0.67)	–11.6a (0.49)	–11.0a (0.50)	–3.3 (0.55)	–10. T (0.49)	–11.3a (0.52)
EIADS, LS mean change from baseline (SE)	–3.0 (0.65)	–5.2b (0.54)	–5.2b (0.51)	–0.8 (0.44)	–5.1a (0.39)	–5.8a (0.38)
Number of patients with DLQI >4 at baseline	213	209	209	225	223	234
DLQI (> 4-point improvement), % responders	30.5 %	64.1 %a	58.4 %a	27.6 %	73.1 %a	62.0 %a
Number of patients with POEM >4 at baseline	223	222	222	234	233	239
POEM (> 4-point improvement), % responders	26.9 %	67.6 %a	63.1 %a	24.4 %	71.7 %a	64.0 %a
Number of patients with HADS-anxiety > 8 or HAD S-depression > 8 at baseline	97	100	102	115	129	136
Patients achieving HADS-anxiety and HADS-depression score < 8, %	12.4 %	41.0 %a	36.3 %b	6.1 %	39.5 %a	41.2 %a

LS = least squares; SE = standard error ap-value < 0.0001 bp-value < 0.001

In the concomitant TCS study (CHRONOS), dupilumab 300 mg Q2W + TCS and dupilumab 300 mg QW + TCS improved patient-reported symptoms and the impact of AD on sleep and health-related quality of life as measured by POEM and DLQI total scores, respectively, at 52 weeks compared to placebo + TCS. A larger proportion of patients administered dupilumab 300 mg Q2W + TCS and 300 mg QW + TCS had clinically meaningful reductions in POEM and DLQI total score (each defined as > 4-point improvement) from baseline to week 52 compared to the placebo + TCS. In addition, dupilumab 300 mg Q2W + TCS and 300 mg QW + TCS reduced anxiety and depression as measured by the HADS total score at 52 weeks compared to placebo + TCS. In a post-hoc analysis in a subset of patients with HADS-anxiety or HADS-depression subscale scores > 8 at baseline (the cut-off value for anxiety or depression), a larger proportion of patients in the dupilumab 300 mg Q2W + TCS and 300 mg QW + TCS groups achieved HADS-anxiety and HADS-depression scores < 8 at week 52 compared to placebo + TCS (See Table 9).

Table 9: Other secondary endpoint results of dupilumab with concomitant TCS at Week 16 and Week 52 in CHRONOS

	Concomitant Use of TCS
	CHRONOS at Week 16			CHRONOS at Week 52
	Placebo	Dupilumab 300 mg Q2W + TCS	Dupilumab 300 mg QW + TCS	Placebo +TCS	Dupilumab 300 mg Q2W + TCS	Dupilumab 300 mg QW + TCS
Patients randomized	315	106	319	264	89	270
DLQI, LS mean change from baseline (SE)	–5.8 (0.34)	–10.0a (0.50)	–10.7a (0.31)	–7.2 (0.40)	–11.4a (0.57)	–11.la (0.36)
POEM, LS mean change from baseline (SE)	–5.3 (0.41)	–12.7a (0.64)	–12.9a (0.37)	–7.0 (0.57)	–14.2a (0.78)	–13.2a (0.45)
EIADS, LS mean change from baseline (SE)	–4.0 (0.37)	–4.9 (0.58)	–5.4e (0.35)	–3.8 (0.47)	–5.5e (0.71)	–5.9b (0.42)
Number of patients with DLQI>4at baseline	300	100	311	254	85	264
DLQI (> 4-point improvement), % responders	43.0%	81.0 %a	74.3 %a	30.3 %	80.0 %a	63.3 %a
Number of patients with POEM >4 at baseline	312	106	318	261	89	269
POEM (> 4-point improvement), % responders	36.9 %	77.4 %a	77.4 %a	26.1 %	76.4 %a	64.7 %a
Number of patients with HADS-anxiety >8 or HADS-depression > 8 at baseline	148	59	154	133	53	138
Patients achieving HADS-anxiety	26.4 %	47.5 %c	47.4 %b	18.0 %	43.4 %b	44.9 %a

and HADS-depression < 8, %

LS = least squares; SE = standard error ap-value < 0.0001 bp-value < 0.001

cp-value < 0.05

Adolescents with atopic dermatitis (12 to 17 years of age)

The efficacy and safety of dupilumab monotherapy in adolescent patients was evaluated in a multicentre, randomised, double-blind, placebo-controlled study (AD-1526) in 251 adolescent patients 12 to 17 years of age with moderate-to-severe atopic dermatitis (AD) defined by Investigator’s Glo­bal Assessment (IGA) score > 3 in the overall assessment of AD lesions on a severity scale of 0 to 4, an Eczema Area and Severity Index (EASI) score > 16 on a scale of 0 to 72, and a minimum body surface area (BSA) involvement of >10 %. Eligible patients enrolled into this study had previous inadequate response to topical medication.

Patients received 1) an initial dose of 400 mg dupilumab (two 200 mg injections) on day 1, followed by 200 mg once every other week (Q2W) for patients with baseline weight of < 60 kg or an initial dose of 600 mg dupilumab (two 300 mg injections) on day 1, followed by 300 mg Q2W for patients with baseline weight of > 60 kg; 2) an initial dose of 600 mg dupilumab (two 300 mg injections) on day 1, followed by 300 mg every 4 weeks (Q4W) regardless of baseline body weight; or 3) matching placebo. Dupilumab was administered by subcutaneous (SC) injection. If needed to control intolerable symptoms, patients were permitted to receive rescue treatment at the discretion of the investigator. Patients who received rescue treatment were considered nonresponders.

In this study, the mean age was 14.5 years, the median weight was 59.4 kg, 41.0 % were female, 62.5 % were White, 15.1 % were Asian, and 12.0 % were Black. At baseline 46.2 % of patients had a baseline IGA score of 3 (moderate AD), 53.8 % of patients had a baseline IGA of 4 (severe AD), the mean BSA involvement was 56.5 %, and 42.4 % of patients had received prior systemic immunosuppressants. Also at baseline the mean Eczema Area and Severity Index (EASI) score was 35.5, the baseline weekly averaged pruritus Numerical Rating Scale (NRS) was 7.6, the baseline mean SCORing Atopic Dermatitis (SCORAD) score was 70.3, the baseline mean Patient Oriented Eczema Measure (POEM) score was 21.0, and the baseline mean Children Dermatology Life Quality Index (CDLQI) was 13.6. Overall, 92.0 % of patients had at least one co-morbid allergic condition; 65.6 % had allergic rhinitis, 53.6 % had asthma, and 60.8 % had food allergies. The co-primary endpoint was the proportion of patients with IGA 0 or 1 (“clear” or “almost clear”) least a 2-point improvement and the proportion of patients with EASI-75 (improvement of at least 75 % in EASI), from baseline to week 16. Other evaluated outcomes included the proportion of subjects with EASI-50 or EASI-90 (improvement of at least 50 % or 90 % in EASI from baseline respectively), reduction in itch as measured by the peak pruritus NRS, and percent change in the SCORAD scale from baseline to week 16. Additional secondary endpoints included mean change from baseline to week 16 in the POEM and CDLQI scores.

Clinical Response

The efficacy results at week 16 for adolescent atopic dermatitis study are presented in Table 10.

Table 10: Efficacy results of dupilumab in the adolescent atopic dermatitis study at Week 16 (FAS )

	AD-1526(FAS)a
	Placebo	Dupilumab 200 mg (<60 kg) and 300 mg (>60 kg) Q2W
Patients randomised	85a	82a
IGA 0 or lb, % responders0	2.4 %	24.4 %
E ASI-50, % responders0	12.9 %	61.0 %
EASI-75, % responders0	8.2 %	41.5 %
E ASI-90, % responders0	2.4 %	23.2 %
EASI, LS mean % change from baseline (+/-SE)	–23.6 % (5.49)	–65.9 % (3.99)
SCORAD, LS mean % change from baseline (+/- SE)	–17.6% (3.76)	–51.6% (3.23)
Pruritus NRS, LS mean % change from baseline (+/- SE)	–19.0 % (4.09)	–47.9 % (3.43)
Pruritus NRS (^4-point improvement), % responders0	4.8 %	36.6 %
BSA LS mean % change from baseline (+/- SE)	–11.7% (2.72)	–30.1 % (2.34)
CDLQI, LS mean change from baseline (+/-SE)	–5.1 (0.62)	–8.5 (0.50)
CDLQI, (> 6-point improvement), % responders	19.7 %	60.6 %
POEM, LS mean change from baseline (+/- SE)	–3.8 (0.96)	–10.1 (0.76)
POEM, (> 6-point improvement), % responders	9.5 %	63.4 %

a Full Analysis Set (FAS) includes all patients randomised.

bResponder was defined as a subject with IGA 0 or 1 (“clear” or “almost clear”) with a reduction of > 2 points

on a 0–4 IGA scale.

c Patients who received rescue treatment or with missing data were considered as non-responders (58.8 % and 20.7 % in the placebo and dupilumab arms, respectively).

All p-values < 0.0001

A larger percentage of patients randomised to placebo needed rescue treatment (topical corticosteroids, systemic corticosteroids, or systemic non-steroidal immunosuppressants) as compared to the dupilumab group (58.8 % and 20.7 %, respectively).

A significantly greater proportion of patients randomised to dupilumab achieved a rapid improvement in the pruritus NRS compared to placebo (defined as >4-point improvement as early as week 4;

nominal p< 0.001) and the proportion of patients responding on the pruritus NRS continued to increase through the treatment period (see Figure 5). The improvement in pruritus NRS occurred in conjunction with the improvement of objective signs of atopic dermatitis.

Figure 5: Proportion of adolescent patients with > 4-point improvement on the pruritus NRS in AD-1526 study 3(FAS) b

a In the primary analyses of the efficacy endpoints, subjects who received rescue treatment or with missing data were considered non-responders.

bFull Analysis Set (FAS) includes all subjects randomised.

The dupilumab group significantly improved patient-reported symptoms, the impact of AD on sleep and health-related quality of life as measured by POEM, SCORAD, and CDLQI scores at 16 weeks compared to placebo.

The long-term efficacy of dupilumab in adolescent patients with moderate-to-severe AD who had participated in previous clinical trials of dupilumab was assessed in open-label extension study (AD-1434). Efficacy data from this study suggests that clinical benefit provided at week 16 was sustained through week 52.

Paediatrics (6 to 11 years of age)

The efficacy and safety of dupilumab in paediatric patients concomitantly with TCS was evaluated in a multicentre, randomised, double-blind, placebo-controlled study (AD-1652) in 367 subjects 6 to 11 years of age, with AD defined by an IGA score of 4 (scale of 0 to 4), an EASI score > 21 (scale of 0 to 72), and a minimum BSA involvement of > 15 %. Eligible patients enrolled into this trial had previous inadequate response to topical medication. Enrollment was stratified by baseline weight (< 30 kg; > 30 kg).

Patients in the dupilumab Q2W + TCS group with baseline weight of < 30 kg received an initial dose of 200 mg on Day 1, followed by 100 mg Q2W from week 2 to week 14, and patients with baseline weight of > 30 kg received an initial dose of 400 mg on Day 1, followed by 200 mg Q2W from week 2 to week 14. Patients in the dupilumab Q4W + TCS group received an initial dose of 600 mg on Day 1, followed by 300 mg Q4W from week 4 to week 12, regardless of weight. Patients were permitted to receive rescue treatment at the discretion of the investigator. Patients who received rescue treatment were considered non-responders.

In this study, the mean age was 8.5 years, the median weight was 29.8 kg, 50.1 % of patients were female, 69.2 % were White, 16.9 % were Black, and 7.6 % were Asian. At baseline, the mean BSA involvement was 57.6 %, and 16.9 % had received prior systemic non-steroidal immunosuppressants. Also, at baseline the mean EASI score was 37.9, and the weekly average of daily worst itch score was 7.8 on a scale of 0–10, the baseline mean SCORAD score was 73.6, the baseline POEM score was 20.9, and the baseline mean CDLQI was 15.1. Overall, 91.7 % of subjects had at least one co-morbid allergic condition; 64.4 % had food allergies, 62.7 % had other allergies, 60.2 % had allergic rhinitis, and 46.7 % had asthma.

The co-primary endpoint was the proportion of patients with IGA 0 or 1 (“clear” or “almost clear”) at least a 2-point improvement and the proportion of patients with EASI-75 (improvement of at least 75 % in EASI), from baseline to week 16. Other evaluated outcomes included the proportion of patients with EASI-50 and EASI-90 (improvement of at least 50 % and 90 % in EASI from baseline, respectively), percent change in EASI score from baseline to week 16, and reduction in itch as measured by the peak pruritus NRS (> 4-point improvement). Additional secondary endpoints included mean change from baseline to week 16 in the POEM and CDLQI scores.

Clinical Response

Table 11 presents the results by baseline weight strata for the approved dose regimens.

Table 11: Efficacy Results of Dupilumab with Concomitant TCS in AD-1652 at Week 16 (FAS)a

	Dupilumab 300 mg Q4Wd + TCS	Placebo +TCS	Dupilumab 200 mg Q2We + TCS	Placebo + TCS
	(N=122)	(N=123)	(N=59)	(N=62)
	>15 kg	>15 kg	>30 kg	>30 kg
IGA 0 or lb, % responders0	32.8 %	11.4%	39.0 %	9.7 %
EASI-50, % responders0	91.0%	43.1 %	86.4 %	43.5 %
EASI-75, % responders0	69.7 %	26.8 %	74.6 %	25.8 %
EASI-90, % responders0	41.8%	7.3 %	35.6 %	8.1 %
EASI, LS mean % change from baseline (+/-SE)	–82.1 % (2.37)	–48.6 % (2.46)	–80.4 % (3.61)	–48.3 % (3.63)
SCORAD, LS mean % change from baseline (+/- SE)	–62.4 % (2.13)	–29.8 % (2.26)	–62.7 % (3.14)	–30.7 % (3.28)
Pruritus NRS, LS mean % change from baseline (+/- SE)	–54.6 % (2.89)	–25.9% (2.90)	–58.2 % (4.01)	–25.0% (3.95)
Pruritus NRS (>4-point improvement). % responders0	50.8 %	12.3 %	61.4%	12.9 %
BSA LS mean change from baseline (+/- SE)	–40.5 (1.65)	–21.7 (1–72)	–38.4 (2.47)	–19.8 (2.50)
CDLQI, LS mean change from baseline (+/-SE)	–10.6 (0.47)	–6.4 (0.51)	–9.8 (0.63)	–5.6 (0.66)
CDLQI, (> 6-point improvement). % responders	77.3 %	38.8 %	80.8 %	35.8 %
POEM, LS mean change from baseline (+/- SE)	–13.6 (0.65)	–5.3 (0.69)	–13.6 (0.90)	–4.7 (0.91)
POEM, (> 6-point improvement), % responders	81.7 %	32.0 %	79.3 %	31.1 %

Full Analysis Set (FAS) includes all patients randomised.

b Responder was defined as a patient with an IGA 0 or 1 (“clear” or “almost clear”).

c Patients who received rescue treatment or with missing data were considered as non-responders.

d At Day 1, patients received 600 mg of dupilumab (see section 5.2).

e At Day 1, patients received 400 mg (baseline weight > 30 kg) of dupilumab.

A greater proportion of patients randomised to dupilumab + TCS achieved an improvement in the peak pruritus NRS compared to placebo + TCS (defined as >4-point improvement at week 4). See Figure 6.

Figure 6: Proportion of Paediatric Subjects with >4-point Improvement on the Peak Pruritus NRS in AD-1652 a (FAS) b

Weeks

a In the primary analyses of the efficacy endpoints, patients who received rescue treatment or with missing data were considered non-responders.

b Full Analysis Set (FAS) includes all patients randomised.

c At Day 1, patients received 600 mg of dupilumab (see section 5.2)

dAt Day 1, patients received 400 mg (baseline weight > 30 kg) of dupilumab

The dupilumab groups significantly improved patient-reported symptoms, the impact of AD on sleep and health-related quality of life as measured by POEM, SCORAD, and CDLQI scores at 16 weeks compared to placebo.

The long-term efficacy and safety of dupilumab + TCS in paediatric patients with moderate to severe atopic dermatitis who had participated in the previous clinical trials of dupilumab + TCS was assessed in an open-label extension study (AD-1434). Efficacy data from this trial suggests that clinical benefit provided at week 16 was sustained through week 52. Some patients receiving dupilumab 300 mg Q4W + TCS showed further clinical benefit when escalated to dupilumab 200 mg Q2W + TCS. The safety profile of dupilumab in patients followed through week 52 was similar to the safety profile observed at week 16 in the AD-1526 and AD-1652 studies.

Clinical efficacy and safety in asthma

The asthma development program included three randomised, double-blind, placebo-controlled, parallel-group, multi-centre studies (DRI12544, QUEST, and VENTURE) of 24 to 52 weeks in treatment duration which enrolled a total of 2,888 patients (12 years of age and older). Patients were enrolled without requiring a minimum baseline blood eosinophil or other type 2 inflammatory biomarker (e.g. FeNO or IgE) level. Asthma treatment guidelines define type 2 inflammation as eosinophilia > 150 cells/mcL and/or FeNO > 20 ppb. In DRI12544 and QUEST, the pre-specified subgroup analyses included blood eosinophils > 150 and > 300 cells/mcL, FeNO > 25 and > 50 ppb.

DRI12544 was a 24-week dose-ranging study which included 776 patients (18 years of age and older). Dupilumab compared with placebo was evaluated in adult patients with moderate to severe asthma on a medium-to-high dose inhaled corticosteroid and a long acting beta agonist. The primary endpoint was change from baseline to week 12 in FEV1 (L). Annualized rate of severe asthma exacerbation events during the 24-week placebo controlled treatment period was also determined. Results were evaluated in the overall population (unrestricted by minimum baseline eosinophils or other type 2 inflammatory biomarkers) and subgroups based on baseline blood eosinophil count.

QUEST was a 52-week confirmatory study which included 1,902 patients (12 years of age and older). Dupilumab compared with placebo was evaluated in 107 adolescent and 1,795 adult patients with persistent asthma on a medium-to-high dose inhaled corticosteroid (ICS) and a second controller medication. Patients requiring a third controller were allowed to participate in this trial. Patients were randomised to receive either 200 mg (N=631) or 300 mg (N=633) Dupixent every other week (or matching placebo for either 200 mg (N = 317) or 300 mg (N= 321) every other week) following an initial dose of 400 mg, 600 mg or placebo respectively. The primary endpoints were the annualized rate of severe exacerbation events during the 52-week placebo controlled period and change from baseline in pre-bronchodilator FEV1 at week 12 in the overall population (unrestricted by minimum baseline eosinophils or other type 2 inflammatory biomarkers) and subgroups based on baseline blood eosinophils count and FeNO.

VENTURE was a 24-week oral corticosteroid-reduction study in 210 patients with asthma unrestricted by baseline type 2 biomarker levels who required daily oral corticosteroids in addition to regular use of high dose inhaled corticosteroids plus an additional controller. After optimizing the OCS dose during the screening period, patients received 300 mg dupilumab (n=103) or placebo (n=107) once every other week for 24 weeks following an initial dose of 600 mg or placebo. Patients continued to receive their existing asthma medicine during the study; however their OCS dose was reduced every 4 weeks during the OCS reduction phase (week 4–20), as long as asthma control was maintained. The primary endpoint was the percent reduction in oral corticosteroid dose assessed in the overall population, based on a comparison of the oral corticosteroid dose at weeks 20 to 24 that maintained asthma control with the previously optimized (at baseline) oral corticosteroid do­se.

The demographics and baseline characteristics of these 3 studies are provided in Table 12 below.

Table 12: Demographics and Baseline Characteristics of Asthma Trials

Parameter	DRI12544 (n = 776)	QUEST (n = 1902)	VENTURE (n=210)
Mean age (years) (SD)	48.6(13.0)	47.9(15.3)	51.3 (12.6)
% Female	63.1	62.9	60.5
% White	78.2	82.9	93.8
Duration of Asthma (years), mean ± SD	22.03 (15.42)	20.94(15.36)	19.95 (13.90)
Never smoked, (%)	77.4	80.7	80.5
Mean exacerbations in previous year ± SD	2.17(2.14)	2.09 (2.15)	2.09 (2.16)
High dose ICS use (%)a	49.5	51.5	88.6
Pre-dose FEVi (L) at baseline ± SD	1.84 (0.54)	1.78 (0.60)	1.58(0.57)
Mean percent predicted FEVi at baseline (%)(± SD)	60.77(10.72)	58.43 (13.52)	52.18(15.18)
% Reversibility (± SD)	26.85 (15.43)	26.29 (21.73)	19.47 (23.25)
Mean ACQ-5 score (± SD)	2.74 (0.81)	2.76 (0.77)	2.50(1.16)
Mean AQLQ score (± SD)	4.02(1.09)	4.29(1.05)	4.35(1.17)
Atopic Medical History % Overall (AD %, NP %, AR %)	72.9 (8.0, 10.6,61.7)	77.7 (10.3, 12.7, 68.6)	72.4 (7.6, 21.0, 55.7)
MeanFeNO ppb (± SD)	39.10(35.09)	34.97 (32.85)	37.61 (31.38)
% patients with FeNO ppb >25 >50	49.9 21.6	49.6 20.5	54.3 25.2
Mean total IgE lU/ml (± SD)	435.05 (753.88)	432.40 (746.66)	430.58(775.96)
Mean baseline Eosinophil count (± SD) cells/mcL	350 (430)	360 (370)	350 (310)

% patients with EOS > 150 cells/mcL > 300 cells/mcL

77.8 41.9

71.4 43.7

71.4 42.4

ICS = inhaled corticosteroid; FEV1 = Forced expiratory volume in 1 second; ACQ-5 = Asthma Control Questionnaire-5; AQLQ = Asthma Quality of Life Questionnaire; AD = atopic dermatitis; NP = nasal polyposis;

AR = allergic rhinitis; FeNO = fraction of exhaled nitric oxide; EOS = blood eosinophil aThe population in dupilumab asthma trials included patients on medium and high dose ICS. The medium ICS dose was defined as equal to 500 mcg fluticasone or equivalent per day.

Exacerbations

In the overall population in DRI12544 and QUEST subjects receiving either dupilumab 200 mg or 300 mg every other week had significant reductions in the rate of severe asthma exacerbations compared to placebo. There were greater reductions in exacerbations in subjects with higher baseline levels of type 2 inflammatory biomarkers such as blood eosinophils or FeNO (Table 13 and Table 14).

Table 13: Rate of Severe Exacerbations in DRI12544 and QUEST (Baseline Blood Eosinophil

Levels > 150 and > 300 cells/mcL)

Treatment	Baseline Blood EOS
	>150 cells/mcL				>300 cells/mcL
	Exacerbations per Year			% Reduction	Exacerbations		per Year	% Reduction
	N	Rate (95% CI)	Rate Ratio (95%CI)		N	Rate (95% CI)	Rate Ratio (95%CI)
AU Severe Exacerbations
DRI12544 study
Dupilumab 200 mg Q2W	120	0.29 (0.16, 0.53)	0.28a (0.14,0.55)	72%	65	0.30 (0.13,0.68)	0.29c (0.11,0.76)	71 %
Dupilumab 300 mg Q2W	129	0.28 (0.16, 0.50)	0.27b (0.14,0.52)	73 %	64	0.20 (0.08, 0.52)	0.19d (0.07, 0.56)	81 %
Placebo	127	1.05 (0.69, 1.60)			68	1.04 (0.57, 1.90)
QUEST study
Dupilumab 200 mg Q2W	437	0.45 (0.37, 0.54)	0.44e (0.34,0.58)	56%	264	0.37 (0.29, 0.48)	0.34e (0.24,0.48)	66%
Placebo	232	1.01 (0.81, 1.25)			148	1.08 (0.85, 1.38)
Dupilumab 300 mg Q2W	452	0.43 (0.36, 0.53)	0.40e (0.31,0.53)	60%	277	0.40 (0.32,0.51)	O.33e (0.23,0.45)	67%
Placebo	237	1.08 (0.88, 1.33)			142	1.24 (0.97, 1.57)

ap-value = 0.0003, bp-value = 0.0001, cp-value = 0.0116, dp-value = 0.0024, ep-value < 0.0001

Table 14 . Rate of Severe Exacerbations in QUEST Defined by Baseline FeNO Subgroups

Treatment	Exacerbations		per Year	Percent Reduction
	N	Rate (95% CI)	Rate Ratio (95%CI)
FeNO > 25 ppb
Dupilumab 200 mg Q2W	299	0.35 (0.27, 0.45)	0.35 (0.25, 0.50)a	65%
Placebo	162	1.00 (0.78, 1.30)
Dupilumab 300 mg Q2W	310	0.43 (0.35, 0.54)	0.39 (0.28, 0.54)a	61 %
Placebo	172	1.12(0.88, 1.43)
FeNO > 50 ppb
Dupilumab 200 mg Q2W	119	0.33 (0.22,0.48)	0.31 (0.18, 0.52)a	69 %
Placebo	71	1.057 (0.72, 1.55)
Dupilumab 300 mg Q2W	124	0.39 (0.27,0.558)	0.31 (0.19, 0.49)a	69 %
Placebo	75	1.27 (0.90, 1.80)

ap-value < 0.0001

In the pooled analysis of DRI12544 and QUEST, hospitalizations and/or emergency room visits due to severe exacerbations were reduced by 25.5 % and 46.9 % with dupilumab 200 mg or 300 mg every other week, respectively.

Lung Function

Clinically significant increases in pre-bronchodilator FEV1 were observed at week 12 for DRI12544 and QUEST. There were greater improvements in FEV1 in the subjects with higher baseline levels of type 2 inflammatory biomarkers such as blood eosinophils or FeNO (Table 15 and Table 16).

Significant improvements in FEV1 were observed as early as week 2 following the first dose of dupilumab for both the 200 mg and 300 mg dose strengths and were maintained through week 24 (DRI12544) and week 52 in QUEST (see Figure 7).

Figure 7: Mean Change from Baseline in Pre-Bronchodilator FEV 1 (L) Over Time (Baseline Eosinophils > 150 and > 300 cells/mcL and FeNO > 25 ppb) in QUEST

QUEST: FeNO > 25 ppb

QUEST: Blood Eosinophils > 150 cells/mcL

QUEST: Blood Eosinophils > 300 cells/mcL

Table 15: Mean Change from Baseline in Pre-Bronchodilator FEV 1 at Week 12 in DRI12544 and

QUEST (Baseline Blood Eosinophil Levels > 150 and > 300 cells/mcL) ________

Treatment	Baseline Blood EOS
	> 150 cells/mcL			> 300 cells/mcL
	N	LS Mean A From baseline L (%)	LS Mean Difference vs. placebo (95% CI)	N	LS mean A From baseline L (%)	LS Mean Difference vs. placebo (95% CI)
DRI12544 study
Dupilumab 200 mg Q2W	120	0.32(18.25)	0.23a (0.13,0.33)	65	0.43 (25.9)	0.26c (0.11,0.40)
Dupilumab 300 mg Q2W	129	0.26(17.1)	0.18b (0.08, 0.27)	64	0.39(25.8)	0.21d (0.06, 0.36)
Placebo	127	0.09 (4.36)		68	0.18(10.2)
QUEST study
Dupilumab 200 mg Q2W	437	0.36 (23.6)	0.17e (0.11,0.23)	264	0.43 (29.0)	0.21e (0.13, 0.29)
Placebo	232	0.18(12.4)		148	0.21 (15.6)
Dupilumab 300 mg Q2W	452	0.37 (25.3)	0.15e (0.09, 0.21)	277	0.47(32.5)	0.24e (0.16, 0.32)
Placebo	237	0.22 (14.2)		142	0.22 (14.4)

ap-value < 0.0001, bp-value = 0.0004, cp-value = 0.0008, dp-value = 0.0063, ep-value < 0.0001

Table 16: Mean Change from Baseline in Pre-Bronchodilator FEV 1 at Week 12 and Week 52 in

QUEST by Baseline FeNO Subgroups

Treatment		At Week 12		At Week 52
	N	LS Mean A From baseline L (%)	LS Mean Difference vs. placebo (95% ci)	LS Mean A From baseline L (%)	LS Mean Difference vs. placebo (95% CI)
FeNO > 25 ppb
Dupilumab 200 mg Q2W	288	0.44 (29.0 %)	0.23 (0.15, 0.31)a	0.49 (31.6%)	0.30(0.22,0.39)a
Placebo	157	0.21 (14.1 %)		0.18(13.2%)
Dupilumab 300 mg Q2W	295	0.45 (29.8 %)	0.24 (0.16, 0.31)a	0.45 (30.5 %)	0.23 (0.15,0.31)a
Placebo	167	0.21 (13.7%)		0.22(13.6%)
FeNO > 50 ppb
Dupilumab 200 mg Q2W	114	0.53 (33.5 %)	0.30(0.17, 0.44)a	0.59 (36.4 %)	0.38 (0.24, 0.53)a
Placebo	69	0.23 (14.9%)		0.21 (14.6 %)
Dupilumab 300 mg Q2W	113	0.59 (37.6 %)	0.39 (0.26, 0.52)a	0.55 (35.8 %)	0.30 (0.16, 0.44)a
Placebo	73	0.19 (13.0 %)		0.25 (13.6 %)

ap-value < 0.0001

Quality of Life/Patient-Reported Outcomes in Asthma

Pre-specified secondary endpoint of ACQ-5 and AQLQ(S) responder rates were analysed at 24 weeks (DRI12544 and VENTURE) and at 52 weeks (QUEST). The responder rate was defined as an improvement in score of 0.5 or more (scale range 0–6 for ACQ-5 and 1–7 for AQLQ(S)).

Improvements in ACQ-5 and AQLQ(S) were observed as early as week 2 and maintained for 24 weeks in DRI12544 study and 52 weeks in QUEST study. Similar results were observed in VENTURE. The ACQ-5 and AQLQ(S) responder rate results in patients with elevated baseline biomarkers of type 2 inflammation in QUEST at week 52 are presented in Table 17.

Table 17: ACQ-5 and AQLQ(S) Responder Rates at Week 52 in QUEST

PRO	Treatment	EOS >150 cells/mcL		EOS > 300 cells/mcL		FeNO > 25 ppb
		N	Responder rate %	N	Responder rate (%)	N	Responder rate (%)
ACQ-5	Dupilumab 200 mg Q2W	395	72.9	239	74.5	262	74.4
	Placebo	201	64.2	124	66.9	141	65.2
	Dupilumab 300 mg Q2W	408	70.1	248	71.0	277	75.8
	Placebo	217	64.5	129	64.3	159	64.2
AQLQ(S)	Dupilumab 200 mg Q2W	395	66.6	239	71.1	262	67.6
	Placebo	201	53.2	124	54.8	141	54.6
	Dupilumab 300 mg Q2W	408	62.0	248	64.5	277	65.3
	Placebo	217	53.9	129	55.0	159	58.5

Oral Corticosteroid Reduction Study (VENTURE)

VENTURE evaluated the effect of dupilumab on reducing the use of maintenance oral corticosteroids. Baseline characteristics are presented in Table 12. All patients were on oral corticosteroids for at least 6 months prior to the study initiation. The baseline mean oral corticosteroid use was 11.75 mg in the placebo group and 10.75 mg in the group receiving dupilumab.

In this 24-week trial, asthma exacerbations (defined as a temporary increase in oral corticosteroid dose for at least 3 days) were reduced by 59 % in subjects receiving dupilumab compared with those receiving placebo (annualized rate 0.65 and 1.60 for the dupilumab and placebo group, respectively; rate ratio 0.41 [95% CI 0.26, 0.63]) and improvement in pre-bronchodilator FEV1 from baseline to week 24 was greater in subjects receiving dupilumab compared with those receiving placebo (LS mean difference for dupilumab versus placebo of 0.22 L [95% CI: 0.09 to 0.34 L]). Effects on lung function, on oral steroid and exacerbation reduction were similar irrespective of baseline levels of type 2 inflammatory biomarkers (e.g. blood eosinophils, FeNO). The ACQ-5 and AQLQ(S) were also assessed in VENTURE and showed improvements similar to those in QUEST.

The results for VENTURE by baseline biomarkers are presented in the Table 18.

Table 18 : Effect of dupilumab on OCS dose reduction, VENTURE (Baseline Blood Eosinophil

Levels > 150 and > 300 cells/mcL and FeNO > 25 ppb)

	Baseline Blood EOS >150 cells/mcL		Baseline Blood EOS > 300 cells/mcL		FeNO > 25 ppb
	Dupilumab 300 mg Q2W N=81	Placebo N=69	Dupilumab 300 mg Q2W N=48	Placebo N=41	Dupilumab 300 mg Q2W N=57	Placebo N=57
Primary endpoint (week 24)
Percent reduction in OCS from baseline
Mean overall percent reduction from baseline (%) Difference (% [95% CI]) (Dupilumab vs. placebo)	75.91 29.39b (15.67, 43.12)	46.51	79.54 36.83b (18.94, 54.71)	42.71	77.46 34.53b (19.08, 49.97)	42.93
Median % reduction in daily OCS dose from baseline	100	50	100	50	100	50
Percent reduction from baseline 100%% > 90 % > 75 % > 50 % >0 % No reduction or any increase in OCS dose, or dropped out of study	54.3 58.0 72.8 82.7 87.7 12.3	33.3 34.8 44.9 55.1 66.7 33.3	60.4 66.7 77.1 85.4 85.4 14.6	31.7 34.1 41.5 53.7 63.4 36.6	52.6 54.4 73.7 86.0 89.5 10.5	28.1 29.8 36.8 50.9 66.7 33.3
Secondary endpoint (week 24)a
Proportion of patients achieving a reduction of OCS dose to < 5 mg/day	77	44	84	40	79	34
Odds ratio (95% CI)	4.29c (2.04, 9.04)		8.04d (2.71, 23.82)		7.21b (2.69, 19.28)

aModel estimates by logistic regression bp-value < 0.0001 cp-value = 0.0001 dp-value = 0.0002

Long-term extension trial (TRAVERSE)

The long-term safety of dupilumab in 2,193 adults and 89 adolescents with moderate-to-severe asthma, including 185 adults with oral corticosteroid-dependent asthma, who had participated in previous clinical trials of dupilumab (DRI12544, QUEST, and VENTURE), was assessed in the open-label extension study (TRAVERSE) (see section 4.8). Efficacy was measured as a secondary endpoint, was similar to results observed in the pivotal studies and was sustained up to 96 weeks. In the adults with oral-corticosteroid-dependent asthma, there was sustained reduction in exacerbations and improvement in lung function up to 96 weeks, despite decrease or discontinuation of oral corticosteroid do­se.

Clinical efficacy in chronic rhinosinusitis with nasal polyposis (CRSwNP)

The chronic rhinosinusitis with nasal polyposis (CRSwNP) development program included two randomised, double-blind, parallel-group, multicentre, placebo-controlled studies (SINUS-24 and SINUS-52) in 724 patients aged 18 years and older on background intranasal corticosteroids (INCS). These studies included patients with severe CRSwNP despite prior sino-nasal surgery or treatment with, or who were ineligible to receive, systemic corticosteroids in the past 2 years. Rescue with systemic corticosteroids or surgery was allowed during the studies at the investigator’s dis­cretion. In SINUS-24, a total of 276 patients were randomised to receive either 300 mg dupilumab (N=143) or

placebo (N=133) every other week for 24 weeks. In SINUS-52, 448 patients were randomised to receive either 300 mg dupilumab (N=150) every other week for 52 weeks, 300 mg dupilumab (N=145) every other week until week 24 followed by 300 mg dupilumab every 4 weeks until week 52, or placebo (N=153). All patients had evidence of sinus opacification on the Lund MacKay (LMK) sinus CT scan and 73 % to 90 % of patients had opacification of all sinuses. Patients were stratified based on their histories of prior surgery and co-morbid asthma/nonsteroidal anti-inflammatory drug exacerbated respiratory disease (NSAID-ERD).

The co-primary efficacy endpoints were change from baseline to week 24 in bilateral endoscopic nasal polyps score (NPS) as graded by central blinded readers, and change from baseline to week 24 in nasal congestion/ob­struction score averaged over 28 days (NC), as determined by patients using a daily diary. For NPS, polyps on each side of the nose were graded on a categorical scale (0=no polyps; 1=small polyps in the middle meatus not reaching below the inferior border of the middle turbinate; 2=polyps reaching below the lower border of the middle turbinate; 3=large polyps reaching the lower border of the inferior turbinate or polyps medial to the middle turbinate; 4=large polyps causing complete obstruction of the inferior nasal cavity). The total score was the sum of the right and left scores. Nasal congestion was rated daily by the subjects on a 0 to 3 categorical severity scale (0=no symptoms; 1=mild symptoms; 2=moderate symptoms; 3=severe symptoms).

In both studies, key secondary end-points at week 24 included change from baseline in: LMK sinus CT scan score, total symptoms score (TSS), University of Pennsylvania smell identification test (UPSIT), daily loss of smell, and 22-item Sino-Nasal Outcome Test (SNOT-22). In the pool of the two studies, the reduction in the proportion of patients rescued with systemic corticosteroid and/or sino-nasal surgery as well as the improvement in FEV1 in the asthma subgroup were evaluated. Additional secondary endpoints included 6-item Asthma Control Questionnaire (ACQ-6) in the co-morbid asthma subgroup.

The demographics and baseline characteristics of these 2 studies are provided in Table 19 below.

Table 19:     Demographics and Baseline Characteristics of CRSwNP Studies

Parameter	SINUS-24 (N=276)	SINUS-52 (N=448)
Mean age (years) (SD)	50.49 (13.39)	51.95 (12.45)
% Male	57.2	62.3
Mean CRSwNP duration (years)(SD)	11.11 (9.16)	10.94 (9.63)
Patients with > 1 prior surgery (%)	71.7	58.3
Patients with systemic corticosteroid use in the previous 2 years (%)	64.9	80.1
Mean Bilateral endoscopic NPS3(SD), range 0–8	5.75 (1.28)	6.10(1.21)
Mean Nasal congestion (NC) score3 (SD) range 0–3	2.35 (0.57)	2.43 (0.59)
Mean LMK sinus CT total score3(SD), range 0–24	19.03 (4.44)	17.96 (3.76)
Mean Smell test (UPSIT) score3 (SD), range 0 40	14.56 (8.48)	13.61 (8.02)
Mean loss of smell score3 (AM), (SD) range 0–3	2.71 (0.54)	2.75 (0.52)
Mean SNOT-22 total score3 (SD), range 0–110	49.40 (20.20)	51.86 (20.90)
Mean Rhinosinusitis severity scale3 (VAS), (SD) 0–10 cm	7.68 (2.05)	8.00 (2.08)
Mean blood eosinophils (cells/mcL)(SD)	437 (333)	431 (353)
Mean total IgE lU/ml (SD)	211.97 (275.73)	239.84 (341.53)
Atopic (type 2 inflammatory disease) Medical History % Overall	75.4 %	82.4 %
Asthma (%)	58.3	59.6
Mean FEVi (L)(SD)	2.69 (0.96)	2.57(0.83)
Mean FEVi percent predicted (%)(SD)	85.30 (20.23)	83.39 (17.72)
Mean ACQ-6 score3 (SD)	1.62 (1.14)	1.58 (1.09)

| NSAID-ERD (%)                                       |     30.4     |        26.8        |

aHigher scores indicate greater disease severity except UPSIT where higher scores indicate lower disease severity; SD=standard deviation; AM = morning; NPS = nasal polyps score; UPSIT = University of Pennsylvania smell identification test; SNOT-22 = 22-item Sino-Nasal Outcome Test; VAS = visual analogue scale; FEV1 = Forced expiratory volume in 1 second; ACQ-6 = Asthma Control Questionnaire-6; NSAID-ERD= aspirin/nonste­roidal anti-inflammatory drug exacerbated respiratory disease

Clinical Response (SINUS-24 and SINUS-52)

The results for primary and secondary endpoints in CRSwNP studies are presented in the Table 20.

Table 20: Results of the Primary and Secondary Endpoints in CRSwNP trials

	SINUS –24					SINUS –52
	Placebo (n=133)		Dupilumab 300mg Q2W (n=143)		LS mean difference vs. Placebo (95%CI)	Placebo (n=153)		Dupilumab 300mg Q2W (n=295)		LS mean difference vs. Placebo (95%CI)
Primary Endpoints at Week 24
Scores	Baseline mean	LS mean change	Baseline mean	LS mean change		Baseline mean	LS mean change	Baseline mean	LS mean change
NPS	5.86	0.17	5.64	–1.89	–2.06 (-2.43,–1.69)	5.96	0.10	6.18	–1.71	–1.80 (-2.10, –1.51)
NC	2.45	–0.45	2.26	–1.34	–0.89 (-1.07,–0.71)	2.38	–0.38	2.46	–1.25	–0.87 (-1.03, –0.71)
Key Secondary Endpoints at Week 24
Scores	Baseline mean	LS mean change	Baseline mean	LS mean change		Baseline mean	LS mean change	Baseline mean	LS mean change
LMK sinus CT scan score	19.55	–0.74	18.55	–8.18	–7.44 (-8.35,–6.53)	17.65	–0.09	18.12	–5.21	–5.13 (-5.80, –4.46)
Total symptom score	7.28	–1.17	6.82	–3.77	–2.61 (-3.04, –2.17)	7.08	–1.00	7.30	–3.45	–2.44 (-2.87, –2.02)
UPSIT	14.44	0.70	14.68	11.26	10.56 (8.79, 12.34)	13.78	–0.81	13.53	9.71	10.52 (8.98, 12.07)
Loss of smell	2.73	–0.29	2.70	–1.41	–1.12 (-1.31,–0.93)	2.72	–0.23	2.77	–1.21	–0.98 (-1.15, –0.81)
SNOT-22	50.87	–9.31	48.0	–30.43	–21.12 (-25.17,–17.06)	53.48	–10.40	51.02	–27.77	–17.36 (-20.87, –13.85)
VAS	7.96	–1.34	7.42	–4.54	–3.20 (-3.79, –2.60)	7.98	–1.39	8.01	–4.32	–2.93 (-3.45, –2.40)

A reduction in score indicates improvement, except UPSIT where an increase indicates improvement.

Total symptom score is a composite severity score consisting of the sum of daily symptoms of NC, loss of smell, and anterior/posterior rhinorrhoea.

NC = nasal congestion, NPS = nasal polyposis score; LMK = Lund-MacKay total CT score; UPSIT = University of Pennsylvania smell identification test; SNOT-22 = 22-item Sino-Nasal Outcome Test; TSS = total symptom score; VAS = visual analogue scale for rhinosinusitis

(all p-values < 0.0001, nominal for VAS)

The results of SINUS-52 study at week 52 are presented in Table 21.

Table 21: Results of the efficacy at week 52 in SINUS-52 study

	Placebo (n=153)		Dupilumab 300mg Q2W (n=150)		LS mean difference vs. Placebo (95%CI)	Dupilumab 300mg Q2W-Q4W (n=145)		LS mean difference vs. Placebo (95%CI)
	Baseline mean	LS mean change	Baseline mean	LS mean change		Baseline mean	LS mean change
NPS	5.96	0.15	6.07	–2.24	–2.40 (-2.77, –2.02)	6.29	–2.06	–2.21 (-2.59, –1.83)
NC	2.38	–0.37	2.48	–1.35	–0.98 (-1.17,–0.79)	2.44	–1.48	–1.10 (-1.29, –0.91)
LMK sinus CT scan score	17.65	0.11	18.42	–6.83	–6.94 (-7.87,–6.01)	17.81	–5.60	–5.71 (-6.64, –4.77)
Total symptom score	7.08	–0.94	7.31	–3.79	–2.85 (-3.35,–2.35)	7.28	–4.16	–3.22 (-3.73, –2.72)
UPSIT	13.78	–0.77	13.46	9.53	10.30 (8.50, 12.10)	13.60	9.99	10.76 (8.95, 12.57)
Loss of Smell	2.72	–0.19	2.81	–1.29	–1.10 (-1.31,–0.89)	2.73	–1.49	–1.30 (-1.51, –1.09)
SNOT-22	53.48	–8.88	50.16	–29.84	–20.96 (-25.03,–16.89)	51.89	–30.52	–21.65 (-25.71, –17.58)
VAS	7.98	–0.93	8.24	–4.74	–3.81 (-4.46, –3.17)	7.78	–4.39	–3.46 (-4.10, –2.81)

A reduction in score indicates improvement, except UPSIT where an increase indicates improvement.

Total symptom score is a composite severity score consisting of the sum of daily symptoms of NC, loss of smell, and anterior/posterior rhinorrhoea.

NC = nasal congestion, NPS = nasal polyposis score; LMK = Lund-MacKay total CT score; UPSIT = University of Pennsylvania smell identification test; SNOT-22 = 22-item Sino-Nasal Outcome Test; TSS = total symptom score; VAS = visual analogue scale for rhinosinusitis (all p-values < 0.0001)

Statistically significant and clinically meaningful efficacy was observed in SINUS-24 with regard to improvement in bilateral endoscopic NPS score at week 24. In the post-treatment period when patients were off dupilumab, the treatment effect diminished over time (see Figure 8a). Similar results were also seen in SINUS-52 at both week 24 and week 52 with a progressive improvement over time (see Figure 8b).

Figure 8. LS mean change from baseline in bilateral nasal polyps score (NPS) in SINUS-24 and SINUS-52 – ITT population.

In both studies, significant improvements in NC and daily loss of smell severity were observed as early as the first assessment at week 4. The LS mean difference for NC at week 4 in the dupilumab group versus placebo was –0.41 (95% CI: –0.52, –0.30) in SINUS-24 and –0.37 (95% CI: –0.46, –0.27) in SINUS-52. The LS mean difference for loss of smell at week 4 in the dupilumab group versus placebo was –0.34 (95% CI: –0.44, –0.25) in SINUS-24 and –0.31 (95% CI: –0.41, –0.22) in SINUS-52. A reduction in the proportion of patients with anosmia was observed in SINUS-24 and SINUS-52. At baseline, 74 % to 79 % of patients had anosmia, which was reduced to 24 % in SINUS-24 and 30 % in SINUS-52 at week 24, compared to no change in placebo. Improvement in nasal peak inspiratory flow (NPIF) was observed in SINUS-24 and SINUS-52 at week 24. The LS mean difference in the dupilumab group versus placebo was 40.4 L/min (95% CI: 30.4, 50.4) and 36.6 L/min (95% CI: 28.0, 45.3), respectively.

Among the patients with rhinosinusitis VAS score > 7 at baseline, a higher percentage of patients achieved VAS < 7 in the dupilumab group compared with the placebo group (83.3 % versus 39.4 % in SINUS-24 and 75.0 % versus 39.3 % in SINUS-52) at week 24.

In the pre-specified multiplicity-adjusted pooled analysis of two studies, treatment with dupilumab resulted in significant reduction of systemic corticosteroid use and need for sino-nasal surgery versus placebo (HR of 0.24; 95% CI: 0.17, 0.35) (see Figure 9). The proportion of patients who required systemic corticosteroids was reduced by 74 % (HR of 0.26; 95% CI: 0.18, 0.38). The total number of systemic corticosteroid courses per year was reduced by 75 % (RR of 0.25; 95% CI: 0.17, 0.37). The mean individual annualised prescribed total dose of systemic corticosteroids (in mg) during the treatment period was 71 % lower in the pooled dupilumab group compared with the pooled placebo group (60.5 [531.3] mg versus 209.5 [497.2] mg, respectively). The proportion of patients who required surgery was reduced by 83 % (HR of 0.17; 95% CI: 0.07, 0.46).

Figure 9. Kaplan Meier Curve for time to first systemic corticosteroid use and/or sino-nasal surgery during treatment period – ITT population [SINUS-24 and SINUS-52 pooled]

The effects of dupilumab on the primary endpoints of NPS and nasal congestion and the key secondary endpoint of LMK sinus CT scan score were consistent in patients with prior surgery and without prior surgery.

In patients with co-morbid asthma, significant improvements in FEV1 and ACQ-6 were observed at week 24 irrespective of baseline blood eosinophils levels. The pooled LS Mean change from baseline in FEV1 at week 24 for dupilumab 300 mg Q2W was 0.14 vs –0.07 L for placebo, for a difference of 0.21 L (95% CI: 0.13, 0.29). In addition, improvements in FEV1 were noted from the first post-baseline assessment, at week 8 in SINUS-24 and week 4 in SINUS-52. Improvements in ACQ-6 in patients with co-morbid asthma were observed in both studies. A response was defined as an improvement in score of 0.5 or more. The LS mean difference in the dupilumab group versus placebo at week 24 was –0.76 (95% CI: –1.00 to –0.51) in SINUS-24 and –0.94 (95% CI: –1.19, –0.69) in SINUS-52.

The ACQ-6 responder rate for dupilumab 300 mg Q2W for SINUS-24 at week 24 was 56 % versus 28 % in placebo (odds ratio 3.17; 95% CI: 1.65, 6.09). The ACQ-6 responder rate for dupilumab 300 mg Q2W for SINUS-52 was 46 % versus 14 % placebo at week 52 (odds ratio 7.02; 95% CI: 3.10, 15.90).

In patients with NSAID-ERD, the effects of dupilumab on the primary endpoints of NPS and NC and the key secondary endpoint of LMK sinus CT scan score were consistent with that observed in the overall CRSwNP population.

Paediatric population

Atopic dermatitis

The safety and efficacy of dupilumab have been established in 12 to 17 years old with moderate-to-severe atopic dermatitis in study AD-1526 which included 251 adolescents. The safety and efficacy of dupilumab have been established in 6 to 11 years old with severe atopic dermatitis in study AD-1652 which included 367 paediatric patients. Use is supported by study AD-1434 which enrolled patients who had completed AD-1526 (136 moderate and 64 severe at the time of enrolment in study AD-1434) and patients who had completed study AD-1652 (110 moderate and 72 severe at the time of enrolment in in study AD-1434). The safety and efficacy were generally consistent between children 6 to 11 years old, adolescent, and adult patients with atopic dermatitis (see section 4.8). Safety and efficacy in paediatric patients < 6 years of age with atopic dermatitis have not been established.

Asthma

A total of 107 adolescents aged 12 to 17 years with moderate to severe asthma were enrolled in QUEST study and received either 200 mg (N=21) or 300 mg (N=18) dupilumab (or matching placebo either 200 mg [N=34] or 300 mg [N=34]) every other week. Efficacy with respect to severe asthma exacerbations and lung function was observed in both adolescents and adults. For both the 200 mg and 300 mg every other week doses, significant improvements in FEV1 (LS mean change from baseline at eek 12) were observed (0.36 L and 0.27 L, respectively). For the 200 mg every other week dose, patients had a reduction in the rate of severe exacerbations that was consistent with adults. Safety and efficacy in paediatric patients (< 12 years of age) with severe asthma have not been established. The adverse event profile in adolescents was generally similar to the adults.

A total of 89 adolescents aged 12 to 17 years with moderate-to-severe asthma were enrolled in the open label long-term study (TRAVERSE). In this study, efficacy was measured as a secondary endpoint, was similar to results observed in the pivotal studies and was sustained up to 96 weeks.

The European Medicines Agency has deferred the obligation to submit the results of studies with dupilumab in one or more subset of the paediatric population in atopic dermatitis and asthma (see section 4.2 for information on paediatric use). The European Medicines Agency has waived the obligation to submit the results of studies with dupilumab in all subsets of the paediatric population in the treatment of nasal polyposis (see section 4.2 for information on paediatric use).

5.2 Pharmacokinetic properties

The pharmacokinetics of dupilumab is similar in patients with atopic dermatitis, asthma, and CRSwNP.

Absorption

After a single subcutaneous (SC) dose of 75–600 mg dupilumab to adults, median times to maximum concentration in serum (tmax) were 3–7 days. The absolute bioavailability of dupilumab following a SC dose is similar between AD, asthma, and CRSwNP patients, ranging between 61 % and 64 %, as determined by a population pharmacokinetics (PK) analysis.

Steady-state concentrations were achieved by week 16 following the administration of 600 mg starting dose and 300 mg dose every other week or 300 mg dose every other week without a loading dose.

Across clinical trials, the mean ±SD steady-state trough concentrations ranged from 69.2±36.9 mcg/ml to 80.2±35.3 mcg/ml for 300 mg dose and from 29.2±18.7 to 36.5±22.2 mcg/ml for 200 mg dose administered every other week to adults.

Distribution

A volume of distribution for dupilumab of approximately 4.6 L was estimated by population PK analysis, indicating that dupilumab is distributed primarily in the vascular system.

Biotransformation

Specific metabolism studies were not conducted because dupilumab is a protein. Dupilumab is expected to degrade to small peptides and individual amino acids.

Elimination

Dupilumab elimination is mediated by parallel linear and nonlinear pathways. At higher concentrations, dupilumab elimination is primarily through a non-saturable proteolytic pathway, while at lower concentrations, the non-linear saturable IL-4R a target-mediated elimination predominates. After the last steady state dose, the median time for dupilumab concentrations to decrease below the lower limit of detection, estimated by population PK analysis, was 6–7 weeks for the 300 mg Q4W regimen, 9 weeks for the 200 mg Q2W regimen, 10–11 weeks for the 300 mg Q2W regimen, and 13 weeks for the 300 mg QW regimen.

Linearity/non-linearity

Due to nonlinear clearance, dupilumab exposure, as measured by area under the concentration-time curve, increases with dose in a greater than proportional manner following single SC doses from 75600 mg.

Special populations

Gender

Gender was not found to be associated with any clinically meaningful impact on the systemic exposure of dupilumab determined by population PK analysis.

Elderly

Of the 1,472 patients with atopic dermatitis exposed to dupilumab in a phase 2 dose-ranging study or phase 3 placebo-controlled studies, a total of 67 were 65 years or older. Although no differences in safety or efficacy were observed between older and younger adult atopic dermatitis patients, the number of patients aged 65 and over is not sufficient to determine whether they respond differently from younger patients.

Age was not found to be associated with any clinically meaningful impact on the systemic exposure of dupilumab determined by population PK analysis. However, there were only 61 patients over 65 years of age included in this analysis.

Of the 1,977 patients with asthma exposed to dupilumab, a total of 240 patients were 65 years or older and 39 patients were 75 years or older. Efficacy and safety in this age group were similar to the overall study population.

There were only 79 patients older than 65 years with CRSwNP exposed to dupilumab among them 11 patients were 75 years and older.

Race

Race was not found to be associated with any clinically meaningful impact on the systemic exposure of dupilumab by population PK analysis.

Hepatic impairment

Dupilumab, as a monoclonal antibody, is not expected to undergo significant hepatic elimination. No clinical studies have been conducted to evaluate the effect of hepatic impairment on the pharmacokinetics of dupilumab.

Renal impairment

Dupilumab, as a monoclonal antibody, is not expected to undergo significant renal elimination. No clinical studies have been conducted to evaluate the effect of renal impairment on the pharmacokinetics of dupilumab. Population PK analysis did not identify mild or moderate renal impairment as having a clinically meaningful influence on the systemic exposure of dupilumab. Very limited data are available in patients with severe renal impairment.

Body Weight

Dupilumab trough concentrations were lower in subjects with higher body weight with no meaningful impact on efficacy. There were only 6 patients exposed to dupilumab with body weight >130 kg in CRSwNP clinical studies.

Paediatric population

Atopic dermatitis

The pharmacokinetics of dupilumab in paediatric patients (< 6 years of age) or body weight < 15 kg with atopic dermatitis has not been studied.

For adolescents 12 to 17 years of age with atopic dermatitis receiving every other week dosing (Q2W) with either 200 mg (< 60 kg) or 300 mg (> 60 kg), the mean ±SD steady state trough concentration of dupilumab was 54.5±27.0 mcg/ml.

For children 6 to 11 years of age with atopic dermatitis receiving every four week dosing (Q4W) with 300 mg (> 15 kg) in AD-1652, the mean ± SD steady-state trough concentration was 76.3±37.2 mcg/ml. At week 16 in AD-1434 in children 6 to 11 years of age who initiated every four week dosing (Q4W) with 300 mg (> 15 kg), and whose dose was increased to every other week dosing (Q2W) with 200 mg (> 15 to < 60 kg) or 300 mg (> 60 kg), the mean±SD steady-state trough concentration was 108±53.8 mcg/ml. For children 6 to 11 years of age receiving 300 mg Q4W, initial doses of 300 mg on Days 1 and 15 produce similar steady-state exposure as an initial dose of 600 mg on Day 1, based on PK simulations

Asthma

A total of 107 adolescents aged 12 to 17 years with asthma were enrolled in QUEST study. The mean ±SD steady-state trough concentrations of dupilumab were 107±51.6 mcg/ml and 46.7±26.9 mcg/ml, respectively, for 300 mg or 200 mg administered every other week. No age-related pharmacokinetic difference was observed in adolescent patients after correction for body weight.

CRSwNP

CRSwNP does not normally occur in children. The pharmacokinetics of dupilumab in paediatric patients (< 18 years of age) with CRSwNP has not been studied.

5.3 Preclinical safety data

Non-clinical data reveal no special hazard for humans based on conventional studies of repeated dose toxicity (including safety pharmacology endpoints) and toxicity to reproduction and development.

The mutagenic potential of dupilumab has not been evaluated; however monoclonal antibodies are not expected to alter DNA or chromosomes.

Carcinogenicity studies have not been conducted with dupilumab. An evaluation of the available evidence related to IL-4Ra inhibition and animal toxicology data with surrogate antibodies does not suggest an increased carcinogenic potential for dupilumab.

During a reproductive toxicology study conducted in monkeys, using a surrogate antibody specific to the monkey IL-4Ra, no fetal abnormalities were observed at dosages that saturate the IL-4Ra.

An enhanced pre- and post-natal developmental study revealed no adverse effects in maternal animals or their offspring up to 6 months post-partum/post-birth.

Fertility studies conducted in male and female mice using a surrogate antibody against IL-4Ra showed no impairment of fertility (see section 4.6).

6. PHARMACEUTICAL PARTICULARS6.1 List of excipients

arginine hydrochloride histidine

polysorbate 80 (E433)

sodium acetate trihydrate

glacial acetic acid (E260)

sucrose

water for injections

6.2 Incompatibilities

In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.

6.3 Shelf life

3 years.

If necessary, pre-filled syringes or pre-filled pens may be kept at room temperature up to 25°C for a maximum of 14 days. Do not store above 25°C. If the carton needs to be removed permanently from refrigerator, the date of removal may be recorded on the outer carton. After removal from the refrigerator, Dupixent must be used within 14 days or discarded.

6.4 Special precautions for storage

Store in a refrigerator (2°C – 8°C).

Do not freeze.

Store in the original carton in order to protect from light.

6.5 Nature and contents of container

Dupixent 300 mg solution for injection in pre-filled syringe

2 ml solution in a siliconised type-1 clear glass pre-filled syringe with or without needle shield, with a fixed 27 gauge 12.7 mm (*A inch), thin wall stainless steel staked needle.

Pack size:

• • 1 pre-filled syringe
• • 2 pre-filled syringes
• • Multipack containing 3 (3 packs of 1) pre-filled syringes
• • Multipack containing 6 (3 packs of 2) pre-filled syringes

Dupixent 300 mg solution for injection in pre-filled pen

2 ml solution in a siliconised type-1 clear glass syringe in a pre-filled pen, with a fixed 27 gauge 12.7 mm (*A inch), thin wall stainless steel staked needle.

Pack size:

• • 1 pre-filled pen
• • 2 pre-filled pens
• • 3 pre-filled pens
• • 6 pre-filled pens

Not all pack sizes may be marketed.

6.6 Special precautions for disposal and other handling

The instructions for the preparation and administration of Dupixent in a pre-filled syringe or in a prefilled pen are given in the package leaflet.

The solution should be clear to slightly opalescent, colourless to pale yellow. If the solution is cloudy, discoloured or contains visible particulate matter, the solution should not be used.

After removing the 300 mg pre-filled syringe or pre-filled pen from the refrigerator, it should be allowed to reach room temperature up to 25°C by waiting for 45 min before injecting Dupixent.

The pre-filled syringe or the pre-filled pen should not be exposed to heat or direct sunlight and should not be shaken.

Any unused medicinal product or waste material should be disposed of in accordance with local requirements. After use, place the pre-filled syringe or the pre-filled pen into a puncture-resistant container and discard as required by local regulations. Do not recycle the container. Keep the container out of sight and reach of children.

7. MARKETING AUTHORISATION HOLDER

sanofi-aventis groupe

54, rue La Boétie

75008 Paris

France

8. MARKETING AUTHORISATION NUMBER(S)

EU/1/17/1229/001

EU/1/17/1229/002

EU/1/17/1229/003

EU/1/17/1229/004

EU/1/17/1229/005

EU/1/17/1229/006

EU/1/17/1229/007

EU/1/17/1229/008

EU/1/17/1229/017

EU/1/17/1229/018

EU/1/17/1229/019

EU/1/17/1229/020

9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

Date of first authorisation: 26 September 2017