Dupixent — Medica
Eosinophilic Esophagitis
Initial criteria
- age ≥ 1 year
- weight ≥ 15 kg
- diagnosis confirmed by endoscopic biopsy showing ≥ 15 intraepithelial eosinophils per high-power field
- no secondary cause of eosinophilic esophagitis (e.g., hypereosinophilic syndrome, eosinophilic granulomatosis with polyangiitis, food allergy)
- received at least 8 weeks of proton pump inhibitor therapy
- tried dietary modification OR provider determined patient not appropriate for dietary modification
- prescribed by or in consultation with allergist or gastroenterologist
Reauthorization criteria
- already received ≥ 6 months of Dupixent therapy
- experienced beneficial clinical response (reduced intraepithelial eosinophil count OR decreased dysphagia/pain on swallowing OR reduced frequency/severity of food impaction)
Approval duration
initial 6 months, renewal 1 year