Safety of biologics in severe asthmatic patients with SARS-CoV-2 infection: A prospective study

BACKGROUND

Asthma guidelines have recommended continuing treatment with biologics during coronavirus disease 2019 (COVID-19) pandemic. However, a continuation of treatment with biologics in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been little investigated.

OBJECTIVE

To assess the safety of biologics in patients with SARS-CoV-2 infection.

METHODS

A pilot, monocentric, prospective study. Patients aged 6 years old and older with severe asthma on treatment with biologics and confirmed SARS-CoV-2 infection were enrolled. Patients were followed-up with periodic calls at different time points up to 3 months to detect any adverse effect and its relationship with biologic treatment according to the Naranjo Adverse Probability Scale (NAPS). The severity of SARS-CoV-2 infection and clinical outcome were also assessed.

RESULTS

Overall, we included 21 patients (10 on therapy with omalizumab, 9 with dupilumab, and 2 with mepolizumab). Only a patient-reported two local adverse events. No other adverse event was reported. Twenty out of 21 patients had a mild COVID-19 course, and no adverse outcome was observed.

CONCLUSION

We showed that the scheduled dose of the biologic therapy can be administered safely on time in patients with SARS-CoV-2 infection, as the treatment did not result in adverse events or outcomes.

Omalizumab treatment in combination with any other biologics: Is it really a safe duo?

BACKGROUND

Chronic spontaneous urticaria (CSU) is a mast cell-mediated disease, which is sometimes associated with various inflammatory disorders. Omalizumab is a commonly used biological agent, which is a recombinant, humanized, monoclonal antibody against human immunoglobulin E. However, there are only few reports about the combination of omalizumab for CSU with any other biologics for accompanying inflammatory diseases in the literature. The aim of this study was to evaluate the patients whose treatment of omalizumab for CSU were combined with any other biologics for associated inflammatory disorders and to describe whether these combinations might have any safety concerns.

METHODS

We conducted a retrospective cohort study of adult patients with CSU treated with omalizumab concurrently using another biological agent for their other dermatological conditions.

RESULTS

Thirty-one patients, 19 women and 12 men, were evaluated. The mean age was 45.13 years. The median duration of omalizumab was 11 months. Biological agents which patients were treated other than omalizumab were as follows: adalimumab biosimilar (n = 3), ustekinumab (n = 4), secukinumab (n = 17) and ixekizumab (n = 7). The median duration of concurrent use of omalizumab and other biologics was 8 months. None of the drug combinations was stopped because of side effects.

CONCLUSION

This observational study demonstrated that omalizumab treatment for CSU in combination with any other biological agents for dermatological disorders appeared to be well tolerated without any major safety concerns.

Can omalizumab be an alternative treatment for non-atopic severe asthma? A real-life experience with omalizumab

Introduction

Omalizumab, a humanized monoclonal anti-IgE antibody, has largely demonstrated its efficacy in severe allergic asthma. There are limited data about the effectiveness of omalizumab in patients with non-atopic severe persistent asthma. In this study, we aimed to determine the effect of omalizumab in patients with non-atopic severe asthma and compare the data obtained with those in patients with allergic severe asthma.

Materials and Methods

This study was an observational, retrospective, tertiary single-center study that assessed and compared the clinical outcome of adult patients with severe asthma (165 atopic and 41 non-atopic) who have been on omalizumab for one year or longer between January 2008 and January 2020. Effectiveness was assessed by considering symptom scores (GINA symptom control score), daily systemic corticosteroids (SCS) dosage, blood eosinophil counts, pulmonary function, and number of severe exacerbations and hospitalizations within the last one year.

Result

Omalizumab exhibited significant improvement in the clinical status of non-atopic asthma patients as measured by GINA symptom score [decreased from 3.77 ± 0.63 to 1.36 ± 1.27 (p<0.001)], the number of emergency room visits for asthma [decreased from 11.25 ± 14.69 to 0.25 ± 0.55 (p<0.001)], and the number of hospitalizations [decreased from 1.17 ± 2.87 to 0.14 ± 0.36 (p= 0.036)]. These results were not significantly different from those obtained in allergic asthma patients. FEV1 improved significantly from 2.08 ± 0.86 to 2.14 ± 0.84 (p= 0.041) and oral corticosteroid doses decreased significantly from 1.67 ± 7.49 to 0.46 ± 2.74 (p= 0.015) in the only atopic group.

Conclusions

Omalizumab, which is a proven and effective treatment option for allergic asthma, may also be an efficacious alternative option in non-atopic severe asthma.

B Lineage Cells and IgE in Allergic Rhinitis and CRSwNP and the Role of Omalizumab Treatment

BACKGROUND

Allergic rhinitis (AR) and chronic rhinosinusitis (CRS) are two prevalent nasal diseases where both type 2 inflammation and immunoglobulin E (IgE) may play important roles. Although they can exist independently or comorbidly, subtle but important differences exist in immunopathogenesis.

OBJECTIVE

To summarize current knowledge of pathophysiological roles of B lineage cells and IgE in AR and CRS with nasal polyps (CRSwNP).

METHODS

Searched PubMed database, reviewed AR and CRSwNP-related literature, and discussed disease diagnosis, comorbidity, epidemiology, pathophysiology, and treatment. Similarities and differences in B-cell biology and IgE are compared in the 2 conditions.

RESULTS

Both AR and CRSwNP have evidence for pathological type 2 inflammation, B-cell activation and differentiation, and IgE production. However, distinctions exist in the clinical and serological profiles at diagnosis, as well as treatments utilized. B-cell activation in AR may more frequently be regulated in the germinal center of lymphoid follicles, whereas CRSwNP may occur via extrafollicular pathways although controversies remain in these initial activating events. Oligoclonal and antigen-specific IgE maybe predominate in AR, but polyclonal and antigen-nonspecific IgE may predominate in CRSwNP. Omalizumab has been shown efficacious in treating both AR and CRSwNP in multiple clinical trials but is the only Food and Drug Administration-approved anti-IgE biologic to treat CRSwNP or allergic asthma. Staphylococcus aureus frequently colonizes the nasal airway and has the ability to activate type two responses including B-cell responses although the extent to which it modulates AR and CRSwNP disease severity is being investigated.

CONCLUSION

This review highlights current knowledge of the roles of B cells and IgE in the pathogenesis of AR and CRSwNP and a small comparison between the 2 diseases. More systemic studies should be done to elevate the understanding of these diseases and their treatment.

Remibrutinib inhibits hives effector cells stimulated by serum from chronic urticaria patients independently of FcεR1 expression level and omalizumab clinical response

BACKGROUND

Despite advances in the treatment of chronic urticaria, in a significant percentage of the patients symptoms are not fully controlled with conventional approaches. New strategies under development include blocking intracellular mediators of mast cell and basophil activation.

OBJECTIVE

We aim to investigate the effects of the Bruton's tyrosine kinase (BTK) inhibitor remibrutinib on human blood basophils and CD34+ -derived mast cells activation induced by serum obtained from chronic urticaria patients.

METHODS

Twenty-two patients with chronic spontaneous urticaria (mean age 52 years, 27% women) and 22 patients with chronic inducible urticaria (46 years, 27% women) were included in the study together with a sex-matched control group. Patients were classified as responders or non-responders to anti-IgE therapy on the basis of their clinical data, FcεR1a expression on blood basophils and total IgE levels. Changes on CD63 expression-as an activation marker-, were used to evaluate in vitro the response of basophils and mast cells to serum exposure and the inhibitory effects of remibrutinib.

RESULTS

Remibrutinib inhibits degranulation induced by IgE cross-linking in mast cells and basophils and also the activation triggered by factors present in the sera of spontaneous and inducible chronic urticaria patients. Patient's serum induces a greater degranulation of effector cells than controls. Activation of mast cells and basophils by patient sera and remibrutinib effects were not related to omalizumab responsiveness.

CONCLUSION

Remibrutinib inhibits activation of human basophils and mast cells induced in vitro by exposure to the serum of chronic urticaria patients independently of their response to omalizumab.

Biologics for Nasal Polyps: Synthesizing Current Recommendations into a Practical Clinical Algorithm

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) has been traditionally managed with a combination of topical and systemic medical therapy as well as endoscopic sinus surgery. The emergence of biologic therapies that target specific aspects of the inflammatory cascade has ushered in a potentially new paradigm in the management options available for CRSwNP.

PURPOSE

To summarize the current literature and recommendations supporting the use of available biologic therapies for CRSwNP and to develop an algorithm to aid clinical decision-making regarding treatment selection.

METHODS

A review of available literature and studies that demonstrated the clinical efficacy of biologic agents for the treatment of CRSwNP informing current CRSwNP consensus algorithms.

RESULTS

Current biologic medications target immunoglobulin E, interleukins, or interleukin receptors implicated in the Th2 inflammatory cascade. Institution of biologic therapy is now an option for patients who have disease refractory to topical medical therapy and endoscopic sinus surgery, those who cannot tolerate surgery, or patients with other comorbid Th2 diseases. Response to treatment should be monitored at 4-6 months and 1 year after initiating therapy. Across multiple indirect comparisons, dupilumab appears to have the largest therapeutic benefit across multiple subjective and objective outcomes. The choice of therapeutic agent also depends on drug availability, patient tolerance, presence of comorbid illnesses, and cost.

CONCLUSIONS

Biologics are emerging as an important option in the management of patients with CRSwNP. While more data is required to fully inform indications, treatment selection, and health economics related to their use, biologics may offer robust symptom relief to patients who have failed other interventions.

Treatment of severe cow's milk allergy with omalizumab in an adult

BACKGROUND

The therapy of severe food allergy so far consists mainly of allergen abstinence and emergency treatment. The use of anti-IgE antibodies represents a promising therapy.

CASE REPORT

We report on a 22-year-old male with severe cow's milk allergy with multiple anaphylactic reactions, known since infancy and persisting into adulthood with sometimes severe immediate-type reactions on accidental ingestion. The prick test for native whole milk was positive, the CAP-FEIA was also positive for milk protein, mare's milk, whey, sheep's milk whey as well as Bos d4, Bos d5, and Bos d8 and blue cheese; total IgE was 1,265 kU/L. The patient's history included well-controlled bronchial asthma. An off-label therapy with omalizumab (3 × 150 mg/month SC) and cetirizine 10 mg once daily was initiated. Under this therapy, we performed a double-blind oral exposure test to cow's milk in the patient after long term. Thereby 14 mL could be tolerated. After consumption of 30 mL of cow's milk, urticaria, dyspnea, and angioedema occurred.

CONCLUSION

Under therapy with omalizumab, an increase of the tolerance to cow's milk was shown in our patient. As a consequence, reactions during accidental consumption could be prevented.

Impact of Omalizumab in Patients with Severe Uncontrolled Asthma and Possible Predictive Biomarkers of Response: A Real-Life Study

Most patients with asthma can control their symptoms with a basic standard of medical care and with maintenance and rescue medication. However, between 5% and 10% of asthmatics worldwide do not achieve control of their symptoms and have recurrent exacerbations and respiratory difficulties. The objective of the study was the real-life evaluation of the clinical improvement of patients with severe eosinophilic asthma treated with omalizumab, together with the search for biomarkers associated with the response. An observational retrospective cohort study was conducted that included patients with severe uncontrolled allergic asthma being treated with omalizumab. Three types of response were evaluated: lower use of oral corticosteroids, improvement in lung function, and reduction in exacerbations. A total of 110 patients under treatment with omalizumab were included, with a mean age of 48 ± 16 years. After 12 months had elapsed, significant reductions were found in the number of exacerbations, use of oral cortico-steroids and doses of inhaled corticosteroids (p < 0.001). Lung function and asthma control improved significantly (p < 0.001; p = 0.004) and eosinophil levels were significantly reduced (p = 0.004). Low scores in the Asthma Control Test were associated with the oral corticosteroid-saving effect; lower previous FEV1 levels and absence of chronic obstructive pulmonary disease (COPD) were related to improvement in lung function, and prior FEV1 values higher than 80% and absence of gastroesophageal reflux disease (GERD) with a reduction in exacerbations. The results of this study confirm the clinical benefit obtained after the introduction of omalizumab and the possible predictive biomarkers of response to the treatment.

Changes of Gut Microbiome in Adolescent Patients with Chronic Spontaneous Urticaria After Omalizumab Treatment

Purpose

Omalizumab is a humanized anti-immunoglobulin (Ig) E monoclonal antibody that is effective in treating some patients with chronic spontaneous urticaria (CSU) who do not respond to antihistamines. Gut microbiome plays a role in the pathogenesis of allergies and autoimmune diseases. Here, we investigated differences in the gut microbiome of adolescent CSU patients before and after omalizumab treatment, which has not been previously reported.

Patients and Methods

Ten adolescent CSU patients were given 300 mg omalizumab subcutaneously in three treatments at 4-week intervals. Urticaria Activity Score (UAS7) was applied to evaluate the efficacy of each omalizumab treatment during follow-up. Fecal samples were collected before and 12 weeks after the first treatment. Total DNA of the gut microbiota in all fecal samples were extracted. The 16S rRNA gene-targeted sequencing technology was used for the analysis of the diversity and distribution of gut microbiome, followed by bioinformatics analysis.

Results

UAS7 scores decreased significantly after each treatment compared with the baseline (all P < 0.0001). There were five well-controlled responders and five non-responders after three treatment sessions of omalizumab. The dominant bacteria phyla in all fecal samples were Firmicutes, Bacteroidetes, Proteobacteria, and Actinobacteria. Alpha diversity analysis showed no significant difference before and after treatment (P > 0.05), whereas beta diversity analysis revealed a significant difference in the bacterial abundance before and after treatment (P < 0.01). The relative abundance of Alphaproteobacteria and Betaproteobacteria at the class level and Burkholderia, Rhodococcus, and Sphingomonas at the genus level decreased significantly after treatment (linear discriminant analysis > 4, P < 0.05). The functional prediction results showed that the dioxin and xylene degradation pathways were more abundant before treatment.

Conclusion

Omalizumab is effective in treating CSU and the abundance of Alphaproteobacteria and Betaproteobacteria was reduced after treatment, which may help improve the treatment outcomes in adolescent CSU patients.

Dual biologic therapy for the treatment of rheumatic diseases and asthma: a case series

Objective

Combination biological therapies are being considered increasingly for patients with multiple co-morbidities requiring biologics. There are limited data available on this approach, and concerns remain about the possible risk of adverse events, particularly infection.

Methods

We present three patients on dual biologics for rheumatic disease and asthma. The biologic combinations used were etanercept and mepolizumab, infliximab and omalizumab, and etanercept and omalizumab. The time on combination biologic therapies ranged from 24 to 36 months. Patients were monitored for any serious adverse events.

Results

All three patients were able to tolerate combined biologic therapies, with no serious adverse events. All three patients gained improvement in their rheumatic and asthma disease control, with reduction in disease activity scores and reduction in steroid usage.

Conclusion

The decision to start dual biologic therapy should be considered carefully, on a case-by-case basis. The number of patients who are on combination biological therapy is small, and data are sparse. Real-world data are needed to examine the long-term benefits and risks of different forms of combination biologic therapies.

Differences between adult and pediatric chronic spontaneous urticaria from a cohort of 751 patients: Clinical features, associated conditions and indicators of treatment response

BACKGROUND

Chronic spontaneous urticaria (CSU) is a common disease both in the pediatric and in the adult population. However, there are differences between the two patient populations with respect to etiological factors, comorbidities, and treatment responses. Our aim was to determine differences between pediatric and adult CSU in terms of clinical characteristics, laboratory parameters, comorbidities, response to treatment, and indicators of response.

METHODS

A retrospective analysis of CSU patients was performed. Data regarding differences between pediatric and adult CSU patients were analyzed. Indicators of treatment response were determined separately in both pediatric and adult patients.

RESULTS

Of 751 CSU patients (162 pediatrics and 589 adults), female dominancy (48.8% vs. 69.6%) and rate of angioedema (19.1% vs. 59.8%) were lower, and disease duration (5 months vs. 12 months) was shorter in pediatric patients. Anti-TPO positivity (24.7% vs. 9%), elevated CRP (46.5% vs. 11.1%), eosinopenia (38.5% vs. 18.1%), and skin prick test positivity (39.3% vs. 28.8%) were significantly more frequent in adult patients. Response to antihistamines was higher in the pediatric group, and only 7% used omalizumab versus 20.8% in the adults. The comparisons were also performed between <12-year and ≥12-year patients and yielded similar results.

CONCLUSION

Pediatric CSU shows distinct characteristics such as lower incidence of angioedema and antithyroid antibodies, and it responds better to antihistamines. These suggest that CSU becomes more severe and refractory in adolescents and adults. Adolescent CSU shows features similar to adult CSU rather than pediatric CSU.

The "real-world" effectiveness and safety of omalizumab in patients with uncontrolled persistent allergic asthma in Slovakia: a subgroup analysis of the eXpeRience study

Introduction

Omalizumab was proven to be effective and safe in patients with moderate-to-severe allergic asthma. However, there is no direct evidence of the benefits of add-on omalizumab in real-life practice in the Slovakian population.

Aim

This subgroup analysis assessed the real-life effectiveness and safety of omalizumab in Slovakian patients with severe allergic asthma enrolled in the eXpeRience registry.

Material and methods

Patients who commenced omalizumab 15 weeks prior to inclusion were assessed for the physicians' global evaluation of treatment effectiveness (GETE), exacerbation rate, asthma symptoms, lung function, oral corticosteroid (OCS) use, rescue medication, hospitalizations, and school/work absenteeism at 16 weeks and 12 and 24 months.

Results

Of 204 patients, 159 (77.9%) completed 2-year follow-up. As per GETE, 69.5% of patients treated with omalizumab achieved excellent/good response at 16 (±1) weeks. The proportion of patients with no severe clinically significant asthma exacerbations increased from 17.3% at pre-treatment to 82.4% and 92.0% at months 12 and 24, respectively. Maintenance OCS use was reduced to 17.0% and 15.3% of patients at 12 and 24 months, respectively, compared with 34.7% at baseline (BL). From BL until month 24, asthma control test scores improved from 11.6 to 20.3; rescue medication use/week decreased from 5.5 to 1.6 days; mean total number of days of asthma-related medical healthcare use decreased from 7.7 to 0.3 days and missed workdays decreased from 16.8 to 0.3 days. No new safety signals were observed.

Conclusions

Add-on omalizumab was effective and well-tolerated in Slovakian patients, complementing the results observed in the overall population of eXpeRience.

Self-reactive IgE and anti-IgE therapy in autoimmune diseases

Growing evidence indicates the pathogenic role of autoreactive IgE in autoimmune diseases. Incidence of autoimmune and allergic diseases in the industrialized countries is consistently icreasing, thus leading to concerted efforts to comprehend the regulation of IgE-mediated mechanisms. The first reports of a presence of IgE autoantibodies in patients with autoimmune diseases have been published a long time ago, and it is now recognized that self-reactive IgE can mediate inflammatory response in bullous pemhigoid, systemic lupus erythematosus, chronic urticaria, and atopic dermatitis. The advances in understanding the pathomechanisms of these disorders brought to a successful use of anti-IgE strategies in their management. The present review discusses the current state of knowledge on the IgE-mediated autoimmunity and anti-IgE treatment, and pave the way for further exploration of the subject.

Specific IgE Response and Omalizumab Responsiveness in Severe Allergic Asthma

Objective

Omalizumab has demonstrated clinical efficacy in patients with severe allergic asthma sensitized to perennial allergens and/or severe pollinosis through inhibition of IgE-dependent allergic response. When considering the "one airway, one disease" concept, sensitization to pollen could predict responsiveness to omalizumab. This study aimed to assess whether the pretreatment specific IgE response could be a predictor of responsiveness to omalizumab in severe allergic asthma sensitized to perennial allergens.

Methods

In this retrospective study, 41 adult patients with severe allergic asthma sensitized to perennial allergens (27 females; mean age 59 years) who had completed 52-week omalizumab treatment were enrolled. The Global Evaluation of Treatment Effectiveness was performed, and demographic characteristics and the positive ratios of specific IgE responses classified into five subgroups (pollen, dust mite, house dust, mold, and animal dander) were compared between responders and non-responders. Multivariate logistic regression analyses were performed to identify predictors of responsiveness to omalizumab.

Results

Thirty-one patients (76%) were identified as responders. The number of sensitized aeroallergen subgroups and sensitization to pollens were significantly higher in responders than in non-responders (both p<0.05). Multivariate logistic regression analysis showed that sensitization to pollen (OR = 8.41, p = 0.02) was independently associated with the effectiveness of omalizumab.

Conclusion

Pretreatment serum pollen-specific IgE could be a predictor of responsiveness to omalizumab.

Dupilumab to induce tolerance to SLIT-Melocotón®

Summary

Introduction. Food allergy is an increasing problem for population and treatments inducing tolerance using sublingual immunotherapy is currently under study. Case presentation. Our aim as allergists is to achieve tolerance to sublingual allergen specific immunotherapy with sublingual immunotherapy (SLIT-peach). We present a case report consisting of a 40 year old woman with anaphylactic reactions after eating fruit and other plant-foods due to sensitization to nonspecific lipid transfer proteins (nsLTP). Her diagnose, LTP-syndrome. This protein is the main panallergen in our area and causes crossed reaction to multiple plant foods. The principal allergen in this syndrome is rPru p3, present in peach and most vegetables, fruits, nuts and grains. Serum specific IgE levels were performed using microarrays and positive for seven nsLTPs: rAra h9, rCor a8, nJug r3, rPru p3, rTri a 14, nArt v3 and rPla a3. Immediate reaction to SLIT in the fourth month of maintenance-dose led us to interrupt pru p3 immunotherapy. Immediate reaction to Omalizumab in the fourth dose in Hospital consisting in anaphylaxis prompted us to switch to Dupilumab. After four months with this monoclonal antibody we reintroduced sublingual immunotherapy with pru p3 SLIT-peach® achieving maintenance dose of four drops a day with no clinical reactions. SLIT-peach® in our patient is crucial for her due to her restricted diet, the severity of reactions and lack of quality of life measured by Europevall questionnaire. Conclusions in our case our aim is to achieve SLIT. We report a case of compassionate use with Dupilumab in a patient with multiple food allergy syndrome mediated by nsLTP. There are no cases reported for Dupilumab in this use.

Case report: Severe chronic spontaneous urticaria successfully treated with omalizumab and dupilumab

Urticaria is a disease triggered by mast cells and characterized by recurrent symptoms such as wheals and/or angioedema. Most patients benefit from treatment with antihistamines (AH) or, if not effective enough, from additional therapy with omalizumab, which leads to significant symptom relief. Here we present a patient with therapy-resistant chronic spontaneous urticaria treated with AH, omalizumab, and glucocorticosteroids. The subsequent recommended therapy according to the current guideline, cyclosporine A, was contraindicated in this patient. Therefore, therapy with dupilumab was initiated, resulting in a complete control of symptoms. In this case report, we present a case of successful dual therapy with omalizumab and dupilumab.

Prospective, monocentric, observational study of the long-term effectiveness of omalizumab in chronic urticaria

Omalizumab, a monoclonal antibody targeting IgE, has been approved in 2014 for the treatment of H1 antihistamine-refractory chronic urticaria. Data on long-term effectiveness and predictive factors for treatment response are currently limited. In this monocentric, prospective, observational study, 112 patients with chronic spontaneous urticaria (CSU) and 32 patients with chronic inducible urticaria (CIndU) were included. In addition to a rapid response, omalizumab also showed good effectiveness on both forms of chronic urticaria over 2 years. Low total IgE and elevated Yersinia IgA were identified as potential predictive markers for slower treatment responses in CSU. In conclusion, the present study highlights the efficacy of omalizumab for the treatment of chronic urticaria. With emerging new therapeutic options for chronic urticaria, further genetic as well as molecular markers are needed to establish patient-specific therapy selection.

IgG and IgE Autoantibodies to IgE Receptors in Chronic Spontaneous Urticaria and Their Role in the Response to Omalizumab

Background: Chronic spontaneous urticaria (CSU) is defined as the recurrence of unprovoked transient wheals and itch for more than 6 weeks. Currently, there is an unmet need concerning response prediction in CSU. The present study investigated biomarkers of type I and type IIb autoimmunity as potential predictors of response to omalizumab in CSU. Materials and methods: Differences in levels of IgG and IgE autoantibodies targeting the high- and low-affinity IgE receptors (FcεRI and FcεRII, respectively), as well as spontaneous and specifically triggered leukotriene C (LTC)4 release by basophils from the investigated subjects, were evaluated in 18 consecutive, prospectively enrolled CSU patients and 18 age- and sex-matched, healthy non-atopic controls. Results: The patients with CSU had higher levels of anti-FcεRI IgE (542 (386.25-776.5) vs. 375 (355-418), optical density (OD), p = 0.008), and IgG (297 (214.5-431.25) vs. 193.5 (118-275) OD, p = 0.004) autoantibodies relative to the controls. Simultaneous anti-FcεRI IgG and IgE positivity (i.e., both autoantibody levels above the respective cut-offs) was recorded only in late- and non-responders (3/8 and 1/2, respectively). Discussion: Significantly higher anti-FcεRI IgE autoantibody levels were found in the CSU patients as compared to the controls, supporting FcεRI as an autoallergic target of IgE (autoallergen) in the complex pathophysiological scenario of CSU. The co-occurrence of anti-FcεRI IgG and IgE autoantibodies was documented only in late- and non-responders, but not in early ones, crediting the co-existence of autoimmune and autoallergic mechanisms as a driver of late/poor response to omalizumab.

Treatment for food allergy: Current status and unmet needs

The treatment of food allergy has traditionally relied on avoidance of the offending food(s) and use of emergency medications in the event of accidental exposures. However, this long-standing paradigm is beginning to shift, as a variety of treatment approaches have been and are being developed. This report provides an overview of the past, present, and future landscape of interventional clinical trials for the treatment of food allergy. It focuses on specific issues related to participant characteristics, protocol design, and study end points in the key clinical trials in the literature and examine how differences between studies may impact the clinical significance of the study results. Recommendations are provided for the optimization of future trial designs and focus on specific unmet needs in this rapidly evolving field.

Clinical experience of a specialized urticaria outpatient clinic from a Portuguese UCARE

Summary

Background. Chronic urticaria (CU) is a frequent disease, with a prevalence of at least 1%. It is characterized by pruritic wheals, angioedema or both for a period longer than 6 weeks. Objective. Identify the demographic, clinical, laboratory and therapeutic profile of patients treated in a Portuguese Urticaria Center of Reference and Excellence (UCARE) and compare it with international series. Methods. Retrospective analysis of database of patients observed in a specialized urticaria outpatient clinic, from January 2017 through September 2019, of a UCARE center in Portugal. Demographic and clinical features, laboratory findings and pharmacological treatment were obtained from the records. Descriptive analyses were performed for all variables. Chi square and fisher's exact tests were applied to analyze the independence of variables and the fit of distribution. P less than 0.05 was considered significant. Results. During this period, 477 patients were observed, of whom 429 (90%) were diagnosed with chronic urticaria. Mean age (years) at the onset of symptoms was 43.7 (standard deviation (SD) 17.6, range 6-88) and at diagnosis 46.7 (SD 17.8, range 6-88) resulting in an average diagnostic delay of 3 years (range 0-25). Median follow-up period since first attendance in the specialized outpatient clinic was 1.7 years (interquartile range (IQR) 0.79, range 0.1-2.75) . Concerning the whole group of CU patients, 347 (81%) had chronic spontaneous urticaria (CSU) - 79% female, 39 (9%) had isolated chronic inducible urticaria (CIndU) and 43 (10%) had CSU with CIndU. Autologous serum skin test (ASST) was done in 76 patients (positive in 24 (32%)) and basophil activation test (BAT) was done in 38 (positive in 13 (34%)). At the moment of study, 204 (48%) of CU patients were medicated with a second-generation H1-antihistamine (sgAH) daily (first-line therapy), 99 (23%) with sgAH up to four times the standard dose (second-line therapy) and 126 (29%) with omalizumab (third-line therapy). Additionally, 7 (2%) patients were completing a short course of systemic corticosteroids for management of disease exacerbation. Disease control was achieved in 316 of CSU patients (81%). Conclusions. Referral to a specialized urticaria outpatient clinic is important for a proper assessment of the disease and adequately symptom control.

Role of clinical biomarkers in predicting the effectiveness of omalizumab

OBJECTIVE

To explore whether baseline clinical biomarkers and characteristics can be used to predict the responsiveness of omalizumab.

METHODS

We retrospectively analyzed a cohort of patients with severe asthma who received omalizumab treatment and collected their baseline data and relevant laboratory examination results along with case records of omalizumab treatment responsiveness after 16 weeks. We compared the differences in variables between the group of patients that responded to omalizumab therapy and the non-responder group, and then performed univariate and multivariate logistic regression. Finally, we analyzed the difference in response rate for subgroups by selecting cut-off values for the variables using Fisher's exact probability method.

RESULTS

This retrospective, single-center observational study enrolled 32 patients with severe asthma who were prescribed daily high-dose inhaled corticosteroids and long-acting β2 receptor agonists on long-acting muscarinic receptor antagonists with or without OCS. Data on age, sex, BMI, bronchial thermoplasty, FeNO, serum total IgE, FEV1, blood eosinophils, induced sputum eosinophils, blood basophils, and complications were not significantly different between the responder and non-responder groups. In the univariate and multivariate logistic regression, all the variants were not significant, and we were unable to build a regression model. We used normal high values and the mean or median of variables as cut-off values to create patient subgroups for the variables and found no significant difference in the omalizumab response rate between the subgroups.

CONCLUSION

The responsiveness of omalizumab is not associated with pretreatment clinical biomarkers, and these biomarkers should not be used to predict the responsiveness of omalizumab.

Current and future treatments for peanut allergy

Peanut allergy (PA) is a common, burdensome childhood disease that in most patients continues into adulthood and has historically been untreatable. However, peanut oral immunotherapy (POIT) is increasingly being incorporated into allergy practices, using both the first FDA-approved product, PTAH (previously AR101; Palforzia™, Aimmune Therapeutics), as well as store-bought peanut products. POIT in preschoolers continues to gain more acceptance as evidence accrues that it is a safe and feasible approach that may have distinct advantages. There are many new therapeutic interventions currently under study with a variety of different approaches and potential mechanisms. With respect to other forms of immunotherapy, none are currently approved, but the epicutaneous approach is the most well-studied and others are being actively investigated, including sublingual, subcutaneous, and intralymphatic. Biologics are gaining evidence both as adjunctive treatments to POIT and as monotherapy. Omalizumab is the most widely studied biologic for PA but others also have potential. Looking ahead to a future therapeutic landscape of choice, allergists will need to understand each patient's goal of treatment through shared decision-making and fully evaluate the risks, benefits, and alternatives of each new therapy.

Biological treatment for bullous pemphigoid

Background

Bullous pemphigoid (BP) is the most common autoimmune subepidermal bullous disease. Topical or systemic corticosteroids are often used as the first-line treatment. However, long-term corticosteroid use may lead to significant side effects. Therefore, various adjuvant immunosuppressant therapies are used as steroid-sparing agents, with accumulating reports of biological treatments for severely recalcitrant BP.

Objective

To describe the clinical and immunological features of a series of patients with recalcitrant BP treated with immunobiological therapies. To assess the efficacy and safety of their therapies.

Methods

Patients receiving biological treatment for BP from two centers were assessed. Here, we described the clinical, immunopathological, and immunofluorescence findings of adult patients with BP and analyzed the clinical response and adverse events associated with various biological therapies.

Results

We identified nine eligible patients treated with rituximab (seven), omalizumab (three), or dupilumab (one). The mean age at diagnosis was 60.4 years, the average BP duration before biologic initiation was 1.9 years, and the average previous treatment failure was 2.11 therapies. The mean follow-up period from the first biological treatment to the last visit was 29.3 months. Satisfactory response, defined as clinical improvement, was achieved in 78% (7) of the patients, and total BP clearance was achieved in 55% (5) of the patients at the last follow-up visit. Additional rituximab courses improved the disease outcomes. No adverse events were reported.

Conclusions

Efficient and safe novel therapies can be considered in recalcitrant steroid-dependent BP non-responsive to conventional immunosuppressant therapies.

Resistant Chronic Spontaneous Urticaria - A Case Series Narrative Review of Treatment Options

Background

Chronic spontaneous urticaria (CSU) can be extremely debilitating to the patient and challenging for the treating clinician. The National Institute of Health and Clinical Excellence (NICE) in the United Kingdom (UK) recommendation of omalizumab for patients who fail to respond to high-dose anti-histamines has improved treatment options and quality of life. However, there is still lack of clear guidelines for treatment of patients resistant to standard and anti-IgE therapies.

Methods

We discuss the therapeutic strategies employed among nine extremely resistant CSU cases and the heterogeneity between guidelines from different societies.

Results

Patients with anti-histamine-resistant urticaria either remained on omalizumab or started on immunosuppressive drugs (dapsone or ciclosporin) when they stopped responding to omalizumab. We used clinical assessment, skin biopsies (when available) and previous published reports to consider dapsone (for predominantly neutrophilic infiltration), or ciclosporin at doses between 2 and 4 mg/kg/day. One patient with ciclosporin-resistant urticaria responded to mycophenolate mofetil. Two patients remain on long-term omalizumab due to its relative safety and efficacy including 1 patient with underlying antibody deficiency where omalizumab was preferred over risks of using immunosuppressive medications.

Conclusions

These case studies bring to light the real-world difficulties in managing patients with resistant CSU and the need for generating the evidence base on alternative therapeutic options such as synergistic use of biologics and immunosuppressive drugs.

Efficacy of Different Dosing Regimens of IgE Targeted Biologic Omalizumab for Chronic Spontaneous Urticaria in Adult and Pediatric Populations: A Meta-Analysis

Chronic urticaria is a debilitating skin condition that is defined as itchy hives at least twice a week and lasting for six or more weeks, with or without angioedema. Chronic spontaneous urticaria (CSU) is a form of disease that is witnessed in two-thirds of those with chronic urticaria. This meta-analysis explores the efficacy of differential dosages of omalizumab for outcomes of weekly itching scores, weekly wheal scores, urticarial assessment score 7 (UAS7), and responder rates. Adhering to PRISMA Statement 2020 guidelines, a systematic search of PubMed/MEDLINE, Scopus, Embase, and Web of Science was conducted until 15 September 2022. A combination of the following keywords was used: omalizumab and chronic urticaria. Data comprising clinical trial ID, name, author/year, country, dosage and time of intervention, inclusion criteria, mean age, female gender, and racial grouping information were obtained. The meta-analytical outcomes were analyzed in RevMan 5.4. The risk-of-bias assessment was conducted using version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2). A total of 10 trials comprising 1705 patients with CSU were included. Notably, 1162 belonged to the intervention group, while 543 were controls. A total of 70.4% of the participants were female in the intervention group, while 65.6% of them were female in the control group. The overall mean age was 38.64 ± 10.66 years. Weekly itch score outcomes were most notable with 150 mg dosage (Cohen’s d = −2.6, 95% CI = −4.75, −0.46, p = 0.02). The weekly wheal score outcomes had the largest effect size with 300 mg dosage (Cohen’s d = −1.45, 95% CI = −2.2, −0.69, p = 0.0002). For UAS7 outcomes, the largest effect size was yielded with 150 mg dosage (Cohen’s d = −6.92, 95% CI: −10.38, −3.47, p < 0.0001). The response rate to omalizumab had a likelihood of being higher with 300 mg of intervention compared to placebo (OR = 8.65, 95% CI = 4.42, 16.93, p < 0.0001). Well-rounded urticarial symptom resolution was observed with 150 mg and 300 mg dosages of omalizumab. Improvement of UAS7 was more comparable with 150 mg dosage, whereas the chance of response to treatment was higher with 300 mg dosage. Our findings support omalizumab as an effective intervention for adult and pediatric populations that are resistant to many therapies, including high-dose H1-antihistamines.

Biologicals in Treatment of Chronic Urticaria: A Narrative Review

Chronic urticaria is a common inflammatory skin disease affecting around 0.5-1% of the world's population. The disease has a chronic indolent course which significantly affects the patient's quality of life. Urticaria pathogenesis involves cross-linking of immunoglobulin E (IgE) on mast cells causing degranulation which occurs by various pathways which leads to development of wheals and angioedema. The first-line treatment for chronic urticaria is non-sedating second-generation H1 antihistamines (AHs). After the advent of anti-IgE monoclonal antibody omalizumab, the response rate in resistant urticaria has improved significantly without any major adverse events. Other biologicals such as anti-IgE, anti-IL-5, anti-IL-1, anti-IL-17, and anti-CD20 monoclonal antibodies are under trial. These biologicals have better efficacy and safety profile as compared to conventional immunosuppressants. Even with the advances in the last decade, recurrence after stopping the therapy is common, and there is a need for better understanding of the pathogenesis and the drugs acting on the key pathways involved in urticaria. In this review, we provide the role of several biologicals in the treatment of chronic urticaria.

Clinical effect of omalizumab as an adjuvant treatment to rituximab in patient with refractory bullous pemphigoid

Patients with refractory bullous pemphigoid (BP) achieve remission after rituximab treatment but require high-dose systemic corticosteroids until the remission. The aim of this retrospective study was to examine the clinical efficacy of omalizumab as an adjuvant treatment to rituximab in patients with refractory BP. Patients with BP receiving treatment with either rituximab monotherapy or rituximab plus omalizumab were considered for the study. The total dose of corticosteroids received for 60 days after administration of rituximab, mortality and relapse rates, and median time to relapse were also investigated. Of 49 patients included in the study, 25 received rituximab monotherapy and 17 received the combination therapy with rituximab and omalizumab. The rituximab plus omalizumab group showed shorter time to disease control with minimal treatment (15 days vs. 67.5 days, p < 0.001) and lower corticosteroid dose for 60 days after administration of rituximab (698.4 mg vs. 1087.4 mg of methylprednisolone, p < 0.001) compared to the rituximab monotherapy group. The results of this study suggest that combination therapy with rituximab and omalizumab can achieve disease control status faster than the rituximab monotherapy, reducing the total dose of corticosteroids.

Monoclonal antibodies in the management of asthma: Dead ends, current status and future perspectives

Patients with moderate-to-severe asthma may now be treated using a variety of monoclonal antibodies that target key inflammatory cytokines involved in disease pathogenesis. Existing clinical data on anti-IgE, anti-IL-5 and other immunological pathways indicate these therapies to offer reduced exacerbation rates, improved lung function, greater asthma control and better quality of life. However, as several patients still do not achieve satisfactory clinical response with the antibodies available, many more biologics, aiming different immunological pathways, are under evaluation. This review summarizes recent data on existing and potential monoclonal antibodies in asthma. Recent advances have resulted in the registration of a new antibody targeting TSLP (tezepelumab), with others being under development. Some of the researched monoclonal antibodies (e.g. anti-IL-13 tralokinumab and lebrikizumab or anti-IL-17A secukinumab) have shown optimistic results in preliminary research; however, these have been discontinued in asthma clinical research. In addition, as available monoclonal antibody treatments have shown little benefit among patients with T₂-low asthma, research continues in this area, with several antibodies in development. This article summarizes the available pre-clinical and clinical data on new and emerging drugs for treating severe asthma, discusses discontinued treatments and outlines future directions in this area.

Response to Omalizumab as an Add-On Therapy in the Treatment of Allergic Asthma in Adult Chinese Patients-A Retrospective Study

(a) Background: Omalizumab is an anti-IgE humanized monoclonal antibody marketed in China for the conventional treatment of poorly controlled moderate-to-severe allergic asthma. Numerous clinical trials have demonstrated the effectiveness of omalizumab, but the data from studies in actual clinical treatment are still relatively limited. (b) Methods: Thirty-two patients with moderate-to-severe allergic asthma treated with omalizumab on the basis of ICS-LABA (inhaled corticosteroids/long-acting beta2-agonist) were selected. Clinical characteristics before and after treatment were collected to analyze the relationship between changes in serum total IgE levels and peripheral blood EOS (eosinophil) levels, FEV1 (forced expiratory volume in 1 second), PEF (peak expiratory flow), OCS (oral glucocorticoid) dosage, ATC (asthma control test) score, and the number of acute exacerbations and the treatment response, in order to observe the efficacy of omalizumab in addition to primary therapy, and to investigate whether baseline clinical characteristics such as serum total IgE and EOS levels could predict a treatment response. (c) Results: Using the ACT score as an evaluation, 68.75% of patients benefited from omalizumab treatment at the end of 16 weeks. The response group has a reduction in OCS dosage (p-values of 0.026 and 0.039), a significant reduction in ACT scores (both p < 0.001), and a reduction in the number of acute exacerbations (p = 0.034 and 0.025, respectively) after omalizumab treatment. The binary logistics analysis of factors affecting the effectiveness of omalizumab in the treatment of allergic asthma were total serum IgE and the presence of comorbidities (p-values of 0.039 and 0.046, respectively). (d) Conclusions: Combining omalizumab with ICS-LABA for 16 weeks significantly improves asthma symptoms in Chinese adults and can be used as an add-on treatment. In addition, high serum IgE levels and the presence of comorbidities were predictors of its therapeutic efficacy.

Biologics for chronic spontaneous urticaria: toward a personalized treatment

INTRODUCTION

Chronic spontaneous urticaria (CSU) is characterized by the recurrent occurrence of short-lived wheals with or without angioedema for more than 6 weeks. Although its pathogenesis is not completely defined, several mechanisms seem involved, including autoimmunity and autoallergy with complement and coagulation activation. Various biologics are currently available or under investigation to counteract different CSU pathomechanisms.

AREAS COVERED

The recent literature dealing with biologics in the treatment of CSU was screened and analyzed; the different treatments were divided into anti-IgE and other than anti-IgE biologics. The latter were subdivided according to their target mechanisms.

EXPERT OPINION

Biologic drugs exert their effects in a very precise and specific manner. A majority of patients (arguably those with type I disease) respond to anti-IgE treatment. Others, possibly with type IIa disease, show a slow response to anti-IgE drugs. Things are much more complicated in anti-IgE-refractory patients. Some respond well to nonspecific immune suppressors, such as corticosteroids and cyclosporin suggesting that an immune-mediated pathogenic mechanism, not involving the high-affinity IgE receptor, is probably active. Several ongoing studies are evaluating biologics and small molecules counteracting other pathomechanisms, including anti-receptor biologics, Bruton tyrosine kinase (BTK) inhibitors, mast cell targets, and specific cytokines.

Comparison between chronic spontaneous urticaria and chronic induced urticaria on the efficacy of omalizumab treatment: A systematic review and meta-analysis

This meta-analysis aimed to assess the efficacy of omalizumab in the treatment of refractory-to-antihistamines chronic induced urticaria (CIndU) in comparison with that of refractory-to-antihistamines chronic spontaneous urticaria (CSU). We retrieved interventional studies and observational studies on omalizumab efficacy to CIndU patients and efficacy comparison between CSU and CIndU both refractory to H1-antihistamines in electronic databases (accessed till May 2022). The odd ratio (OR) and 95% confidence interval (CI) was calculated with a random-effect model in this meta-analysis. The majority of patients with different CIndU subtypes gained complete or partial response and good safety after omalizumab treatment. A total of five studies with 355 CSU patients and 103 CIndU patients were included for the meta-analysis. There was no significant difference in the efficacy of omalizumab in the treatment of CSU and CIndU (OR -0.83, 95% CI [0.84, 2.21], P > 0.05). Based on the validity of omalizumab in the treatment of various CIndU subtypes and non-differential efficacy between CSU and CIndU, it is reasonable to list omalizumab as a third-line treatment of refractory CIndU.

Omalizumab as a corticosteroid-sparing agent in the treatment of bullous pemphigoid

Bullous pemphigoid (BP) is the most common autoimmune blistering skin disease, characterized by the development of autoantibodies against hemidesmosomal components BP180 and BP230. The mainstay of therapy is topical and systemic corticosteroids (CS) and immunosuppressors. As this pathology mainly involves the elderly, subjects often have numerous comorbidities that influence the clinical management. Omalizumab is a recombinant humanized monoclonal anti-IgE antibody which has recently emerged as a promising treatment for BP in patients for whom CS are contraindicated or conventional treatments have failed to control the disease. For this study, we selected five patients who presented with corticosteroid-dependent BP with a contraindication to the use of other immunosuppressive treatments. The objectives of our study were to evaluate the effectiveness of omalizumab in controlling BP and allowing to decrease the dosage of systemic CS, assessing the effects of omalizumab on the clinical manifestations and the titers of circulating anti-BP180 and BP230 antibodies, IgE and eosinophils. A reduction in the dose of systemic CS was possible in 100% of the patients and complete resolution of the clinical picture was seen in 100% for skin lesions and in 40% for pruritus. A reduction of circulating IgE was found in 40%, anti-BP180 and BP230 IgGs were decreased in 60% and eosinophils in 80%.

Omalizumab added to allergen immunotherapy increased the effect of therapy in patients with severe local allergic rhinitis

BACKGROUND

Allergen immunotherapy (AIT) is effective in patient with local allergic rhinitis (LAR). However, AIT may not always achieve the optimal treatment effect.

OBJECTIVE

To present short study with clinical cases of LAR combined therapy with sublingual immunotherapy (SLIT) and omalizumab in patients with house dust mite (HDM) allergy and compared it to therapy with omalizumab alone.

METHODS

Patients with severe LAR and hypersensitivity to HDMs were included. SLIT for HDMs was launched in a perennial protocol using SQ-HDM SLIT tablets with omalizumab. The total rhinitis symptom score (TRSS), total medication score (TMS) and combined total score (CTS) were assessed after one year.

RESULTS

After 12 months, significant improvements in all analyzed parameters in the patients on SLIT+ omalizumab therapy were observed: a reduction in the TRSS from 1.21 ± 0.33 to 0.6 ± 0.28 (p < .05), a reduction in the TMS from 2.25 ± 1.05 to 0.88 ± 0.31 (p < .05) and a reduction in the CTS from 3.46 ± 0.57 to 1.48 ± 0.51 (p < .05). This improvement in TRSS, TMS also in CTS was significantly greater than in the rest of the group with SLIT alone or omalizumab alone.

CONCLUSION

Omalizumab may be a valuable treatment that increases the effectiveness of immunotherapy in patients with severe LAR.

Pharmacokinetic equivalence of CT-P39 and reference omalizumab in healthy individuals: A randomised, double-blind, parallel-group, Phase 1 trial

BACKGROUND

CT-P39 is being developed as a biosimilar of reference omalizumab. This study aimed to assess the pharmacokinetic equivalence of CT-P39 to European Union-approved and United States-licensed reference omalizumab (EU- and US-omalizumab, respectively).

METHODS

This two-part, randomised, parallel-group, double-blind Phase 1 trial (NCT04018313) was conducted in healthy individuals with a total immunoglobulin E (IgE) level ≤100  international units (IU)/ml at screening. In part 2, described herein, participants were randomised (1:1:1) to receive a single 150 mg subcutaneous dose of CT-P39, EU-omalizumab, or US-omalizumab. The primary endpoint was pharmacokinetic equivalence in terms of area under the concentration-time curve (AUC) from time zero to the last quantifiable concentration (AUC_0-last ), AUC from time zero to infinity (AUC_0-inf ), and maximum serum concentration (C_max ). Equivalence was concluded if 90% confidence intervals (CIs) of the geometric least-squares means ratios were contained within the predefined 80%-125% equivalence margin. Additional pharmacokinetic parameters, pharmacodynamics, safety, and immunogenicity were also evaluated.

RESULTS

Overall, 146 participants were randomised (CT-P39, N = 47; EU-omalizumab, N = 49; US-omalizumab, N = 50). For all primary pharmacokinetic parameters, 90% CIs for pairwise treatment comparisons were within the 80%-125% equivalence margin, demonstrating pharmacokinetic equivalence. Decreases in free IgE and increases in total IgE serum concentrations were comparable across groups. CT-P39 was well tolerated. Safety endpoints were comparable across groups: there were no treatment-related serious adverse events, deaths, or discontinuations due to treatment-emergent adverse events.

CONCLUSIONS

CT-P39 was well tolerated and demonstrated pharmacokinetic equivalence with EU-omalizumab and US-omalizumab following administration of a single dose in healthy individuals.

Therapeutical Targets in Allergic Inflammation

From the discovery of IgE to the in-depth characterization of Th2 cells and ILC2, allergic inflammation has been extensively addressed to find potential therapeutical targets. To date, omalizumab, an anti-IgE monoclonal antibody, and dupilumab, an anti-IL-4 receptor α monoclonal antibody, represent two pillars of biologic therapy of allergic inflammation. Their increasing indications and long-term follow-up studies are shaping the many different faces of allergy. At the same time, their limitations are showing the intricate pathogenesis of allergic diseases.

Protocol design and synopsis: Omalizumab as Monotherapy and as Adjunct Therapy to Multiallergen OIT in Children and Adults with Food Allergy (OUtMATCH)

Background

Food allergy is common and causes substantial morbidity and even mortality. Safe and effective treatments for food allergy would therefore be highly desirable, especially for individuals with multiple food allergies.

Objectives

Our aim was to describe a phase 3 study on treatment of patients with multiple food allergies with omalizumab.

Methods

The study was developed as a collaboration between the Consortium for Food Allergy Research, the National Institute of Allergy and Infectious Diseases, and 2 industry sponsors (Genentech and Novartis).

Results

The study is currently under way, enrolling participants from age 1 year to age 55 years who are allergic to peanut and at least 2 other foods (including milk, egg, wheat, cashew, hazelnut, and walnut). The study is designed to address 3 major questions. First, stage 1 will study the potential value of omalizumab for the treatment of patients with peanut allergy and at least 2 other common food allergens. Second, stage 2 will directly compare treatment of patients with multifood allergies using omalizumab as monotherapy versus treatment with omalizumab-facilitated multiallergen oral immunotherapy in which omalizumab is used as an adjunctive treatment. Third, stage 3 will address the longer-term outcomes following these treatment approaches, including the introduction of dietary forms of the study foods to induce or maintain desensitization.

Conclusions

This phase 3 study will provide important information on the potential of omalizumab to treat patients with multiple food allergies.

Diagnosis and Management of Urticaria in Indian Settings: Skin Allergy Research Society's Guideline-2022

Urticaria is a common skin disorder. Chronic urticaria, i.e., the presence of symptoms for more than six weeks, is associated with a significant adverse impact on sleep, performance, quality of life, and financial status of the patients. Although several treatment options are available, the condition can be challenging to treat for many clinicians. Several updates have been published on the subject of urticaria and its management since the publication of an updated consensus statement in 2018 by Indian experts. The objective of this consensus statement is to summarize the updates and provide concise information, including classification, diagnosis, and management of urticaria. Understanding and elimination of the underlying eliciting trigger are essential in all possible cases. The goal of pharmacological treatment is to provide symptomatic relief. Second-generation nonsedating H1 antihistamine continue to be recommended as the first-line treatment, the dose of which can be increased up to four times in patients not responding satisfactorily, in the second step. The role of omalizumab, cyclosporine, H2 antihistamines, and other options is also discussed.

Regulatory T cells and immunoglobulin E: A new therapeutic link for autoimmunity?

Autoimmune diseases have a prevalence of approximately 7 to 9% and are classified as either organ-specific diseases, including type I diabetes, multiple sclerosis, inflammatory bowel disease and myasthenia gravis, or systemic diseases, including systemic lupus erythematosus, rheumatoid arthritis and Sjögren's syndrome. While many advancements have been made in understanding of the mechanisms of autoimmune disease, including the nature of self-tolerance and its breakdown, there remain unmet needs in terms of effective and highly targeted treatments. T regulatory cells (Tregs) are key mediators of peripheral tolerance and are implicated in many autoimmune diseases, either as a result of reduced numbers or altered function. Tregs may be broadly divided into those generated in the thymus (tTregs) and those generated in the periphery (pTregs). Tregs target many different immune cell subsets and tissues to suppress excessive inflammation and to support tissue repair and homeostasis: there is a fine balance between Treg cell stability and the plasticity that is required to adjust Tregs' regulatory purposes to particular immune responses. The central role of immunoglobulin E (IgE) in allergic disease is well recognized, and it is becoming increasingly apparent that this immunoglobulin also has a wider role encompassing other diseases including autoimmune disease. Anti-IgE treatment restores the capacity of plasmacytoid dendritic cells (pDCs) impaired by IgE- high-affinity IgE receptor (FcεR1) cross-linking to induce Tregs in vitro in atopic patients. The finding that anti-IgE therapy restores Treg cell homeostasis, and that this mechanism is associated with clinical improvement in asthma and chronic spontaneous urticaria suggests that anti-IgE therapy may also have a potential role in the treatment of autoimmune diseases in which Tregs are involved.

Is Omalizumab Related to Ear and Labyrinth Disorders? A Disproportionality Analysis Based on a Global Pharmacovigilance Database

Introduction: Asthma is a chronic disease, characterized by reversible airway obstruction, hypersensitivity reactions, and inflammation. Oral corticosteroids are an important treatment option for patients with severe or steroid-resistant asthma. Biologics for asthma are recommended in patients with severe asthma, owing to their steroid-sparing effect as well as their ability to reduce the severity and aggravation of uncontrolled asthma. Most clinical trials of omalizumab in patients with asthma have suggested its tolerability and safety. However, some studies reported eosinophilic comorbidities in the ear, nose, and throat during omalizumab treatment, particularly eosinophilic otitis media. This study examined the relationship between ear disorders and omalizumab compared with that of other biologics for asthma using a large real-world database. Materials and Methods: Individual case safety reports from the Uppsala Monitoring Centre Vigibase of biologics for asthma (omalizumab, mepolizumab, reslizumab, benralizumab, and dupilumab) up to 29 December 2019, were used. A disproportionality analysis was performed using the proportional reporting ratio (PRR), reporting odds ratio (ROR), and information components (IC). A hierarchy analysis used the Medical Dictionary for Regulatory Activities Terminology. A tree map was generated using R studio version 4.2. Results: In 32,618 omalizumab reports, 714 adverse events (AEs) were detected as signals. Among the 714 signals, seventeen AEs were detected as signals of omalizumab-related ear and labyrinth disorders in 394 reports. Only three AEs (ear pain, ear disorder, and ear discomfort) were detected from mepolizumab. No signal was detected from reslizumab, benralizumab, and dupilumab. Conclusions: Careful monitoring of ear disorders is recommended when omalizumab treatment is started, with decreased oral corticosteroid use in patients with severe asthma. Further studies are necessary to confirm the omalizumab-related signals.

Clinical and laboratory parameters associated with treatment response to third-line therapies in chronic refractory urticaria: a real world study from northern India

BACKGROUND

Current guidelines recommend omalizumab and cyclosporine for management of chronic spontaneous urticaria (CSU) refractory to anti-histamines.

AIMS AND OBJECTIVES

Identification of clinico-epidemiological characteristics predictive of treatment response with both modalities which will aid therapy selection.

METHODS

Clinical records of CSU patients receiving omalizumab and cyclosporine from 01/05/2016 to 31/12/2020 were reviewed retrospectively. Patients with a minimum follow up duration of 4 months were included in the analysis. Treatment response was defined as >90% recorded reduction in Urticaria Activity Score-7 (UAS7) as compared to baseline four months after treatment initiation.

RESULTS

Records of 1364 CSU patients were reviewed. Fifty-six patients who received omalizumab and 132 patients who received cyclosporine fulfilled the inclusion criteria. Treatment response was observed in 46/56 (82.1%) patients in omalizumab cohort and 106/132 (80.3%) patients in cyclosporine cohort (P=0.76). Factors significantly associated with response to omalizumab included high baseline serum Ig E levels (P=0.028), lesser disease duration (P=0.001) and absence of prior immunosuppressant use (P=0.024). Factors predictive of cyclosporine response included high baseline UAS7 (P=0.048), low baseline Ig E levels (P=0.047) and normal baseline D-dimer levels (P=0.027). Concomitant inducible urticaria, atopy and angioedema were associated with non-response in both groups (P≤0.05). Incidence of adverse events was slightly higher in cyclosporine group (28.7%) as compared to omalizumab group (19.5%) (P=0.19).

CONCLUSION

This study highlights several clinical parameters and laboratory markers that may be utilized to predict treatment response and aid in prognostication of patients with chronic spontaneous urticaria. This article is protected by copyright. All rights reserved.