Effect of Dupilumab (Anti-IL4Rα) on the Host-Microbe Interface in Atopic Dermatitis
Condition: Atopic Dermatitis (AD)
MeSH terms: Dermatitis, Atopic; Dermatitis; Eczema
Intervention: Dupilumab; Placebo
Intervention description: Dupilumab, an interleukin (IL)-4 receptor alpha (IL-4Rα) antagonist, is indicated for the treatment of adult patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. (FDA approved on March 28, 2017.); Placebo will contain the identical formulation as the dupilumab formulation without the active mAb and will be given by exactly the same route and schedule through Day 28.
Intervention MeSH terms: Antibodies, Monoclonal
Phase: Phase 4
Study type: Interventional
Primary purpose: Treatment
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Care Provider, Investigator)
Enrollment: 72.0
Sex: All
Minimum age: 18 Years
Maximum age: 75 Years
Healthy volunteers: No
Keywords: randomized double-masked (blind) placebo-controlled trial; T helper 2 (Th2) effect; cutaneous microbial community; skin barrier

Summary:

      The purpose of this study is to understand the effect that T helper 2 (Th2) blockade has on
      well-described pathophysiological features of Atopic Dermatitis (AD), for example: barrier,
      epidermal activation, dysbiosis and epidermal lipids.
    

Eligibility criteria:

        Inclusion Criteria:

          -  Must be able to understand and provide informed consent

          -  Chronic AD, (according to the Atopic Dermatitis Research Network [ADRN] Standard
             Diagnostic Criteria), that has been present for at least 3 years before the Screening
             Visit

          -  EASI score ≥12 at the Screening Visit and ≥16 at the Treatment Initiation Visit

          -  Investigator Global Assessment (IGA) score ≥3 (on the 0-4 IGA scale) at the Screening
             and Treatment Initiation Visits

          -  ≥10% body surface area of AD involvement at the Screening and Treatment Initiation
             Visits

          -  Must have active lesions (minimum of 3 of at least 4x4 cm^2 each on the upper or lower
             extremities, excluding the palms of the hands and soles of the feet) at the Screening
             and Treatment Initiation Visits

          -  Documented recent history (within 6 months before the Screening Visit) of inadequate
             response to outpatient treatment with topical corticosteroids of medium to high
             potency (± topical calcineurin inhibitors as appropriate), or for whom topical
             treatments are otherwise inadvisable

          -  Must agree to apply a stable dose of a topical emollient (moisturizer) at least twice
             daily for at least 7 days before the Treatment Initiation Visit, and must confirm
             application at the Treatment Initiation Visit

          -  Individuals with asthma must adhere to asthma controller medication(s) for the
             duration of the study including the open-label and follow-up portions

          -  Females of childbearing potential must have a negative pregnancy test at the Screening
             and Treatment Initiation Visits

          -  Females with reproductive potential* and sexually active must agree to use FDA
             approved methods of birth control for the duration of the study, including during the
             open-label and follow-up portions of the study:

             --FDA approved methods of birth control include hormonal contraceptives, intrauterine
             device, double barrier contraception (i.e., condom plus diaphragm), or male partner
             with documented vasectomy.

             ---*Menopause is defined as at least 12 consecutive months without menses; if in
             question, a follicle stimulating hormone of ≥25 U/mL must be documented. Hysterectomy,
             bilateral oophorectomy, or bilateral tubal ligation must be documented, as applicable;
             if documented, women with these conditions are not required to use additional
             contraception.

          -  Males who are sexually active must agree to use an acceptable method of birth control
             (e.g. barrier methods with vaginal spermicide, surgical sterilization or surgically
             sterilized partner), or have a female partner practicing an approved birth control
             method for females as described in Inclusion Criterion above.

          -  Willing and able to comply with all clinic visits and study-related procedures

          -  Able to understand and complete study-related questionnaires

        Exclusion Criteria:

          -  Inability or unwillingness of an individual to give written informed consent or comply
             with study protocol

          -  Known systemic hypersensitivity to any of the excipients of the dupilumab or placebo
             study products

          -  Known or suspected immunosuppression, including history of invasive opportunistic
             infections (e.g., tuberculosis, histoplasmosis, listeriosis, coccidioidomycosis,
             pneumocystosis, aspergillosis) despite infection resolution, or otherwise recurrent
             immune-compromised status, as judged by the investigator

          -  Known history of human immunodeficiency virus (HIV) infection

          -  Ocular disorder that, in the opinion of the investigator, could adversely affect the
             individual's risk for study participation. Examples include, but are not limited to,
             individuals with a history of or active case of:

               -  herpes keratitis,

               -  Sjogren's Syndrome,

               -  keratoconjunctivitis sicca or Dry Eye Syndrome that requires daily use of
                  supplemental lubrication, or

               -  ocular condition(s) requiring the regular use of ocular corticosteroids or
                  cyclosporine.

          -  Parasitic infection, except for vaginal trichomoniasis, within 12 months of the
             Treatment Initiation Visit, or high risk for contracting parasitic infections (e.g.,
             living in or traveling to endemic areas)

          -  Presence of skin comorbidities that may interfere with study assessments

          -  History of malignancy within 5 years before the Treatment Initiation Visit except
             completely treated in situ carcinoma of the cervix, and completely treated and
             resolved non-metastatic squamous or basal cell carcinoma of the skin or melanoma in
             situ

          -  History of non-malignant lymphoproliferative disorders

          -  History of alcohol or drug abuse within 2 years before the Screening Visit

          -  Severe concomitant illness(es) that, in the investigator's judgment, would adversely
             affect the individual's participation in the study. Examples include, but are not
             limited to, individuals with short life expectancy, uncontrolled diabetes (HbA1c ≥9%),
             cardiovascular conditions (e.g., stage III or IV cardiac failure according to the New
             York Heart Association classification), severe renal conditions (e.g., individuals on
             dialysis), hepato-biliary conditions (e.g., Child-Pugh class B or C), neurological
             conditions (e.g., demyelinating diseases), active major autoimmune diseases (e.g.,
             lupus, inflammatory bowel disease, rheumatoid arthritis, etc.), other severe
             endocrinological, gastrointestinal, metabolic, pulmonary, or lymphatic diseases.

          -  Any other medical or psychological condition including relevant laboratory
             abnormalities at screening that, in the opinion of the investigator, suggests a new
             and/or insufficiently understood disease, may present an unreasonable risk to the
             study participant as a result of his/her participation in this clinical trial, may
             make individual's participation unreliable, or may interfere with study assessments.
             This includes hypersensitivity to local anesthetics (e.g., lidocaine or Novocain),
             bleeding disorders, treatment with anticoagulants or other conditions that make the
             biopsy procedure inadvisable.

          -  Planned major surgical procedure during the screening period or study treatment (i.e.
             Screening through Day 112)

          -  Member of the investigational team or his/her immediate family

          -  Pregnant or breast-feeding women, or women planning to become pregnant or breastfeed
             during the study including the open-label and follow up portions of the study

          -  Individuals unwilling to use adequate birth control, if of reproductive potential and
             sexually active. Adequate birth control is defined as agreement to consistently
             practice an approved method of contraception for the duration of the study, including
             the open-label and follow up portions of the study.

          -  History of keloid formation

          -  History of serious life-threatening reaction to latex, tape, or adhesives

          -  Prior treatment with dupilumab

          -  Individuals with asthma who have required use of a systemic corticosteroid within 3
             months prior to the Treatment Initiation Visit or who require a dose greater than 880
             mcg/day of fluticasone propionate or equivalent inhaled corticosteroid to maintain
             asthma control

          -  Treatment with biologics as follows:

               -  Any cell-depleting agents, including but not limited to rituximab, within 6
                  months before the Treatment Initiation Visit, or until lymphocyte and CD 19+
                  lymphocyte count returns to normal, whichever is longer

               -  Infliximab, adalimumab, golimumab, certolizumab pegol, abatacept, etanercept,
                  anakinra within 16 weeks before the Treatment Initiation Visit for any
                  indication, or

               -  Other biologics within 5 half-lives (if known) or 16 weeks before the Treatment
                  Initiation Visit, whichever is longer

          -  Treatment with a live (attenuated) vaccine within 12 weeks before the Treatment
             Initiation Visit or planning to receive a live vaccine during the study (through Day
             182)

          -  Use of an investigational drug within 8 weeks or within 5 half-lives (if known),
             whichever is longer, before the Treatment Initiation Visit

          -  Chronic or acute infection requiring treatment with systemic antibiotics, antivirals,
             antiparasitics, antiprotozoals, or antifungals within 4 weeks before the Treatment
             Initiation Visit, or superficial skin infections within 1 week before the Treatment
             Initiation Visit

          -  The following treatments within 4 weeks before the Treatment Initiation Visit, or any
             condition that, in the opinion of the investigator, will likely require such
             treatment(s) during the screening period and study treatment (i.e., Screening through
             Day 112):

               -  Systemic corticosteroids

               -  Immunosuppressive/immunomodulating drugs (e.g., cyclosporine,
                  mycophenolate-mofetil, IFN-γ, Janus kinase inhibitors, azathioprine, or
                  methotrexate)

          -  Use of phototherapy (such as narrow band ultraviolet B [NBUVB], ultraviolet B [UVB],
             ultraviolet A1 [UVA1], psoralen + UVA [PUVA]) or a tanning booth/parlor within 4 weeks
             of the Treatment Initiation Visit

          -  Treatment with bleach bath within 3 weeks before the Treatment Initiation Visit

          -  Use of a chlorinated hot tub within 3 weeks before the Treatment Initiation Visit

          -  Treatment with topical corticosteroids, phosphodiesterase inhibitors (crisaborole), or
             calcineurin inhibitors (tacrolimus or pimecrolimus) within 1 week before the Treatment
             Initiation Visit

          -  Initiation of treatment of AD with prescription moisturizers or moisturizers
             containing ceramide, hyaluronic acid, urea, or filaggrin during the screening period
             (participants may continue using stable doses of such moisturizers if initiated before
             the Screening Visit)

          -  Planned or anticipated use of any prohibited medications or procedures during the
             screening period and study treatment (i.e., Screening through Day 112)