New Priorities: An Atopic 11-Year-Old Child on Dupilumab, With Multiple and Recurrent Food Anaphylaxis Requiring Intensive Care

Introduction In atopic dermatitis, dupilumab reduces IL-4 and IL-13, important cytokines that cause inflammation and dysregulation of the skin barrier. A downstream effect, through blockade of IL-4R alpha, is a reduction in IgE (and specific IgEs [sIgEs]). SIgEs can be used to aid decision making regarding suitability for oral food challenges. Omalizumab, an anti-IgE antibody, has a role in asthma and a promising future role in improving safety in food allergy. Dosing in food allergy is based on IgE levels. Case We present the case of an 11-year-old boy with a history of severe eczema, asthma requiring multiple preventers, and multiple food allergies. He had experienced 6 episodes of anaphylaxis by age 10 years, including 1 paediatric intensive care unit (PICU) admission, generally at small protein content/contamination doses. Dupilumab was commenced in 2023 for his severe eczema, with significant improvement. His asthma control also improved. IgE and sIgE levels to allergens decreased. Unfortunately, he went on to have a second PICU admission for anaphylaxis in 2024, although this was secondary to a large protein load. With data from the OUtMATCH study, our patient is a prime candidate for omalizumab, which improves safety in multi-food allergy while actively avoiding triggers. Conclusion We have a highly atopic child with eczema treated with dupilumab with reducing IgE, who continues to have life-threatening anaphylaxis and is under consideration for omalizumab. This case is representative of a conundrum that is likely to become common over the next decade, with overlapping cohorts with severe eczema, asthma, and food allergy, and growing evidence for the use of biologics. The challenging management for this patient will be discussed.