Off-Label Uses of Omalizumab

A case report of food-dependent exercise-induced anaphylaxis (FDEIA) treated with omalizumab

Food-dependent exercise-induced anaphylaxis (FDEIA) is a rare and complex clinical condition in which allergic reactions are triggered by specific foods combined with physical activity, even though the food allergen and exercise are tolerated individually. Wheat is the most common culprit food leading to wheat dependent exercise induced anaphylaxis (WDEIA). Management of FDEIA is challenging due to the unpredictability of attacks and the lack of approved prophylactic medications. This report presents a case of successful symptom control in a young woman with WDEIA through the addition of omalizumab to the treatment regimen. To our knowledge, this is the first reported case of food-dependent exercise-induced anaphylaxis (FDEIA) treated with omalizumab as the primary indication. We also summarize the pathophysiology, diagnosis and treatment of FDEIA. The need for heightened awareness and innovative therapeutic approaches is crucial for those affected by FDEIA.

Omalizumab for Treatment of Anti-GD2 Antibody-related Urticaria

Outcomes for high-risk neuroblastoma have improved with the addition of antidisialoganglioside (GD2) antibody-mediated immunotherapy to multimodality therapy. Urticaria is an expected side effect of anti-GD2 immunotherapy. Rarely, despite maximal use of antihistamines and H2 receptor antagonists, refractory urticaria can result in impaired quality of life, and delays or discontinuation of immunotherapy. The anti-IgE monoclonal antibody, omalizumab, is approved for the treatment of asthma and chronic spontaneous urticaria. We successfully managed grade 3, naxitamab-related urticaria refractory to standard management in 2 patients using omalizumab, allowing for continued anti-GD2 immunotherapy. Omalizumab did not impact antitumor activity or immunogenicity of naxitamab.

Mast cell stabilizers: from pathogenic roles to targeting therapies

Mast cells (MCs) are bone-marrow-derived haematopoietic cells that are widely distributed in human tissues. When activated, they will release tryptase, histamine and other mediators that play major roles in a diverse array of diseases/disorders, including allergies, inflammation, cardiovascular diseases, autoimmune diseases, cancers and even death. The multiple pathological effects of MCs have made their stabilizers a research hotspot for the treatment of related diseases. To date, the clinically available MC stabilizers are limited. Considering the rapidly increasing incidence rate and widespread prevalence of MC-related diseases, a comprehensive reference is needed for the clinicians or researchers to identify and choose efficacious MC stabilizers. This review analyzes the mechanism of MC activation, and summarizes the progress made so far in the development of MC stabilizers. MC stabilizers are classified by the action mechanism here, including acting on cell surface receptors, disturbing signal transduction pathways and interfering exocytosis systems. Particular emphasis is placed on the clinical applications and the future development direction of MC stabilizers.

Omalizumab for the reduction of allergic reactions to foods: a narrative review

The frequency of food allergies varies between 2% and 10%, depending on characteristics including age, region, race, and method of diagnosis self-reported by patients or oral food challenges (OFCs). The most common allergies reported are tree nuts (1.2%), milk (1.9%), peanuts (2.2%), and shellfish (1.3%). Omalizumab injection has now been approved by the FDA for the treatment of immunoglobulin E-mediated food allergies in specific adults and children aged one year or older. This medication reduces the risk of allergic reactions (Type I), which can include anaphylaxis, when an individual accidentally encounters one or more food allergens. Omalizumab functions by binding to IgE and altering IgE-mediated pathways, which lessens IgE's capacity to cause allergic reactions. Promising outcomes from clinical trials and case studies include lowered anaphylactic risk and enhanced tolerance to allergens. Omalizumab, however, may have adverse effects; thus, close observation is required. Overall, this review sheds light on the efficacy, safety, and clinical implications of omalizumab, highlighting its potential as a useful intervention for IgE-mediated food allergies.

Anti-immunoglobulin E provides an additional therapy to conventional steroids for Kimura's disease

Kimura's disease (KD) is a chronic inflammatory disease characterized by painless subcutaneous head and neck swelling, eosinophilia, and elevated serum immunoglobulin (Ig) E levels. There are various therapies, including surgery, radiation, systemic steroids, and immune suppressants, but their efficacy remains moderate due to the high recurrence rate. Biologics, like monoclonal antibodies, have shown tremendous effectiveness for chronic inflammatory diseases. Omalizumab is a monoclonal antibody against IgE and has not been approved for KD so far. We describe two refractory KD cases that responded to a small dose of steroids plus omalizumab. Additionally, we reviewed another 13 KD cases that were treated with biologics, including omalizumab, rituximab, dupilumab, and mepolizumab. The results indicate that biologics provide an alternative treatment strategy for KD.

Omalizumab therapy of bullous pemphigoid

This is an editorial comment on a paper by Chebani, et al that reports on a retrospective, multicentre study of omalizumab in bullous pemphigoid.

Systemic pain relief after omalizumab injection in patient with hypermobile Ehlers-Danlos syndrome: A case report

Omalizumab may be a beneficial adjunct treatment option for hEDS patients require to improve pain control, ability to perform ADLs and functionality and social engagement, and most importantly, quality of life.

Management of vernal keratoconjunctivitis: Navigating a changing treatment landscape

Vernal keratoconjunctivitis (VKC) is a chronic, progressive, and potentially sight-threatening form of ocular inflammatory disease that primarily affects children and young adults. Prevalence varies by region, ranging from <2 per 10,000 in the United States to as high as 1,100 per 10,000 in parts of Africa. The rarity of VKC in developed countries can make differential diagnosis challenging, and treatment is often delayed until the disease is advanced, and symptoms are significantly impacting patients' quality of life. Although once viewed primarily as an immunoglobulin E-mediated condition, approximately 50% of patients with VKC do not exhibit allergic sensitization. It is now recognized that the immunopathology of VKC involves multiple inflammatory pathways that lead to the signs, symptoms, and conjunctival eosinophilic and fibroproliferative lesions that are a hallmark of the disease. We examine the evolution of our understanding of the immunopathology of VKC, the expanding VKC treatment armamentarium, the clinical implications of emerging treatment approaches, and future directions for VKC research and practice.

Effectiveness and safety of omalizumab in patients with allergic bronchopulmonary aspergillosis with or without allergic rhinitis: a retrospective chart review

BACKGROUND

Omalizumab is a valuable alternative treatment for allergic bronchopulmonary aspergillosis (ABPA). The effectiveness and safety of this medication have not been confirmed. The main purpose of this study was to evaluate the effectiveness and safety of omalizumab for ABPA.

METHODS

This study involved a retrospective chart review. The main indicators used were asthma control test (ACT) scores, lung function parameters, doses of corticosteroids, acute exacerbation, hospitalization rates, total serum immunoglobulin E (IgE) levels, and blood eosinophil counts. Related adverse events were also reviewed to evaluate the safety of omalizumab.

RESULTS

Fourteen patients with ABPA were included, of whom 10 (71%) concurrently had allergic rhinitis (AR). There were improvements in the mean percentages of the forced vital capacity, percentages of the forced expiratory volume in 1 s, and ACT score after omalizumab administration (p < 0.05, p < 0.01, and p < 0.01, respectively). After the initiation of omalizumab administration, the median corticosteroid dose, acute exacerbation rate, hospitalization rate, and mean blood eosinophil count decreased when compared with the baseline values (p < 0.05, p < 0.05, p < 0.01, and p < 0.05, respectively). A reduction in the total serum IgE level was observed in patients with ABPA without AR compared with that in patients with AR (p < 0.05). One patient reported a concurrent skin rash, which spontaneously resolved without medication.

CONCLUSION

It is safe and effective to prescribe omalizumab to patients with ABPA, irrespective of whether they have AR. Dose adjustment of omalizumab is safe after disease control. The total serum IgE level might be a predictor of the effectiveness of omalizumab in patients without AR.

Targeting type 2 inflammation in bullous pemphigoid: current and emerging therapeutic approaches

Bullous pemphigoid (BP) is one of the most common autoimmune bullous diseases and mainly affects an elderly population with multi-morbidity. Due to the frailty of many BP patients, existing treatment options are limited. The blisters associated with BP result from IgG and IgE autoantibodies binding to the central components of hemidesmosome, BP180, and BP230, stimulating a destructive inflammatory process. The known characteristic features of BP, such as intense pruritus, urticarial prodrome, peripheral eosinophilia, elevated IgE, as well as recent expanding evidence from in vitro and in vivo studies implicate type 2 inflammation as an important driver of BP pathogenesis. Type 2 inflammation is an inflammatory pathway involving a subset of CD4+ T cells that secrete IL-4, IL-5, and IL-13, IgE-secreting B cells, and granulocytes, such as eosinophils, mast cells, and basophils. It is believed that effectors in type 2 inflammation may serve as novel and effective treatment targets for BP. This review focuses on recent understandings of BP pathogenesis with a particular emphasis on the role of type 2 inflammation. We summarize current clinical evidence of using rituximab (B-cell depletion), omalizumab (anti-IgE antibody), and dupilumab (anti-IL-4/13 antibody) in the treatment of BP. The latest advances in emerging targeted therapeutic approaches for BP treatment are also discussed.

Dupilumab in chronic rhinosinusitis with nasal polyposis: current status, challenges, and future perspectives

INTRODUCTION

Chronic sinusitis with nasal polyposis (CRSwNP) is a common heterogeneous disease that mainly manifests as chronic inflammation of the sinus mucosa. The effect of conventional treatments for CRSwNP, such as oral corticosteroids, intranasal corticosteroids (INCS) and polypectomy, is not always obvious, and postoperative recurrence is common in some CRSwNP patients. In recent years, some biologics have been shown to be very effective in treating refractory CRSwNP, of which dupilumab has attracted much attention as the first monoclonal drug approved to treat nasal polyps.

AREAS COVERED

In this review, we discuss the research status of dupilumab in treatment of CRSwNP and how dupilumab differs from other treatment methods.

EXPERT OPINION

The European Union and United States have approved dupilumab as the first biological agent for treatment of CRSwNP. Dupilumab can improve symptoms of nasal congestion or obstruction, nasal secretion, and olfactory loss in patients with CRSwNP. It can also improve a patient's health-related quality of life (HR-QoL) and reduce the need for systemic corticosteroids and nasal polyp surgery. While subcutaneous injection of dupilumab is a novel method for treating CRSwNP, it is still necessary to reasonably evaluate which patients might benefit most from biological therapy.

Case Report: Off-label treatment of idiopathic hypereosinophilic syndrome with Omalizumab

Idiopathic hypereosinophilic syndrome (IHES) is a rare disease characterized by causeless persistent hypereosinophilia and eosinophilia-associated end-organ damage. Current treatment modalities don't meet the needs due to adverse events of steroids as first-line therapy and the limited efficacy of second-line treatments, underscoring the need for new therapeutic strategies. Here we presented two cases of IHES with different clinical manifestations that were both refractory to corticosteroids. Patient #1 experienced rashes, cough, pneumonia, and steroid-induced side effects. Patient #2 had severe gastrointestinal symptoms attributed to hypereosinophilia. They both had high levels of serum IgE, didn't respond well to second-line treatments of interferon-α (IFN-α) and imatinib, and Mepolizumab was not accessible. We then innovatively switched to Omalizumab, an anti-IgE monoclonal antibody approved for allergic asthma and chronic idiopathic urticaria. Patient #1 was treated with Omalizumab 600 mg per month for 20 months; his absolute eosinophil count (AEC) decreased significantly and has stabilized at around 1.0×10⁹/L for 17 months, with complete relief from erythra and cough. Patient #2 recovered promptly from severe diarrhea with a sharp drop in AEC after 3 months of treatment with omalizumab at 600 mg per month. Therefore, we concluded that Omalizumab may be a seminal therapeutic strategy for IHES patients who are refractory to corticosteroids, whether as long-term management of AEC or as an urgent intervention to address severe symptoms caused by eosinophilia.

Allergen immunotherapy: progress and future outlook

INTRODUCTION

Allergy, the immunological hypersensitivity to innocuous environmental compounds, is a global health problem. The disease triggers, allergens, are mostly proteins contained in various natural sources such as plant pollen, animal dander, dust mites, foods, fungi and insect venoms. Allergies can manifest with a wide range of symptoms in various organs, and be anything from just tedious to life-threatening. A majority of all allergy patients are self-treated with symptom-relieving medicines, while allergen immunotherapy (AIT) is the only causative treatment option.

AREAS COVERED

This review will aim to give an overview of the state-of-the-art allergy management, including the use of new biologics and the application of biomarkers, and a special emphasis and discussion on current research trends in the field of AIT.

EXPERT OPINION

Conventional AIT has proven effective, but the years-long treatment compromises patient compliance. Moreover, AIT is typically not offered in food allergy. Hence, there is a need for new, effective and safe AIT methods. Novel routes of administration (e.g. oral and intralymphatic), hypoallergenic AIT products and more effective adjuvants holds great promise. Most recently, the development of allergen-specific monoclonal antibodies for passive immunotherapy may also allow treatment of patients currently not treated or treatable.

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.

Drug delivery targets and strategies to address mast cell diseases

INTRODUCTION

Current and developing mast cell therapeutics are reliant on small molecule drugs and biologics, but few are truly selective for mast cells. Most have cellular and disease-specific limitations that require innovation to overcome longstanding challenges to selectively targeting and modulating mast cell behavior. This review is designed to serve as a frame of reference for new approaches that utilize nanotechnology or combine different drugs to increase mast cell selectivity and therapeutic efficacy.

AREAS COVERED

Mast cell diseases include allergy and related conditions as well as malignancies. Here, we discuss the targets of existing and developing therapies used to treat these disease pathologies, classifying them into cell surface, intracellular, and extracellular categories. For each target discussed, we discuss drugs that are either the current standard of care, under development, or have indications for potential use. Finally, we discuss how novel technologies and tools can be used to take existing therapeutics to a new level of selectivity and potency against mast cells.

EXPERT OPINION

There are many broadly and very few selectively targeted therapeutics for mast cells in allergy and malignant disease. Combining existing targeting strategies with technology like nanoparticles will provide novel platforms to treat mast cell disease more selectively.

Boxed Warnings and Off-Label Use of Allergy Medications: Risks, Benefits, and Shared Decision Making

The Food and Drug Administration is tasked with evaluating the efficacy and safety of a drug. Despite having a regimented appraisal process in place, safety evidence can emerge during clinical trials as well as from observations and studies conducted after the drug has been on the market, which might require a boxed warning. The boxed warning is the most severe warning that the Food and Drug Administration can give to an approved drug. It is commonly referred to as a Black Box Warning because it is outlined in the package insert by a thick black box to garner the attention of prescribers and patients. There are currently more than 400 medications that have boxed warnings, and the information addressing major risks associated with a particular drug may, appropriately or inappropriately, influence patient and clinician decision making. Health care professionals must use the best evidence and clinical judgment in determining whether to prescribe medications with these warnings. Use of an approved drug at dosages or for indications other than what it was originally licensed for is referred to as "off-label" and is legal, commonplace, and may be evidence-based. All drugs may expose patients to possible harm, so prescribers have an obligation to discuss the best available evidence regarding benefits and harms so that patients can participate in shared decision making.

An Analysis of Biologic Therapies in Patients With Asthma and Chronic Rhinosinusitis

Background Asthma, Allergic rhinitis (AR), Chronic Obstructive Pulmonary Disease (COPD), Eczema, and Chronic Rhinosinusitis with Sinonasal Polyposis (CRSwNP) are illnesses often characterized by type 2 (T2) inflammation, wherein T helper (Th) cells release pro-inflammatory cytokines such as IL (interleukin)-4, IL-5, IL-9, and IL-13. This response may also promote the production of IgE and an increase in/activation of serum eosinophils. In the aforementioned type 2 inflammatory diseases, this immune response can cause excess mucous production, inflammation of the airways, other atopic responses when patients are exposed to certain environmental allergic triggers. Relatively new biologic monoclonal antibody therapies such as dupilumab (blocks IL-4 and IL-13), benralizumab (blocks IL-5), mepolizumab (blocks IL-5), and omalizumab (blocks IgE Fc/fragment of crystallization region) offer novel therapeutic targets that more specifically and directly block type 2 inflammatory responses. Methods To examine the effect of monoclonal antibody biologic therapies on patient indicators of type 2 inflammation, a retrospective analysis of 193 patients on biologic therapy was conducted, and these patients were compared to 48 control patients with type 2 inflammatory diseases who did not initiate biologic therapy. Total Lund-MacKay radiographic score, FEV1 (forced expiratory volume in the first second), FEF25-75 (forced expiratory flow from 25-75% of the forced vital capacity curve), annualized pulmonary exacerbations, oral corticosteroid dose, and serum eosinophils were recorded at baseline (zero months), and at three, six, nine, and twelve months after initiation of biologic therapy. Least squares mean data and the percent change from the baseline of least squares mean for the biologic and control groups were compared. Results Omalizumab was the most common biologic therapy prescribed. Control patients were younger than patients who initiated biologic therapy. Patients on biologic therapy had statistically significant reductions in Lund-MacKay score, improvements in FEV1 and FEF25-75, reductions in serum IgE levels, and reductions in serum Eosinophils. Patients on biologic therapy also had statistically significant reductions in annualized pulmonary exacerbations and oral corticosteroid dose compared to controls. Conclusions Patients with a variety of type 2 inflammatory conditions appear to have significant improvements in lung function, radiographic sinusitis, and serum markers of type 2 inflammation after initiation of biologic therapy versus controls. These therapeutic medications appear to significantly improve type 2 inflammatory disease course in patients who can tolerate these medications.

Eosinophilic Otitis Media: Modern Aspects of Pathogenesis, Clinical Features, Diagnosis and Treatment

Eosinophilic otitis media (EOM) is an inflammatory chronic disease of the middle ear, characterized by the presence of a particularly viscous effusion with a high content of protein toxins of eosinophilic origin in the middle ear cavity. The pathology has relationship with bronchial asthma, allergic rhinitis and chronic rhinosinusitis with nasal polyps. EOM is characterized by a sluggish course, a tendency to relapse, which can lead to a gradual hearing decrease up to complete deafness. In this paper, we reviewed the international literature with special attention to pathogenesis and treatment management.

Update on omalizumab in allergen immunotherapy

PURPOSE OF REVIEW

To review the most relevant studies in the advancing field of omalizumab in allergen immunotherapy.

RECENT FINDINGS

Omalizumab has been used in combination with inhalant, venom, and food allergen immunotherapy. These studies suggest that omalizumab can decrease the time required to reach maintenance dosing and adverse events. However, severe adverse events do still occur. Limited long-term data suggests that there is a risk for increased reactivity after stopping omalizumab.

SUMMARY

Omalizumab in conjunction with immunotherapy has shown promising results for the treatment of allergic rhinitis, venom hypersensitivity, and food allergy, especially in the reduction of adverse events. Larger randomized, placebo-controlled trials are needed to better understand optimal dosing and duration, cost--benefit analysis, ideal patients, and long-term benefits. This combination therapy has the potential to improve treatment, particularly for high-risk patients.

Allergic Aspects of IgG4-Related Disease: Implications for Pathogenesis and Therapy

IgG4-related disease (IgG4-RD) is a rare systemic fibroinflammatory disease frequently associated with allergy. The pathogenesis of IgG4-RD is poorly understood, and effective therapies are limited. However, IgG4-RD appears to involve some of the same pathogenic mechanisms observed in allergic disease, such as T helper 2 (Th2) and regulatory T cell (Treg) activation, IgG4 and IgE hypersecretion, and blood/tissue eosinophilia. In addition, IgG4-RD tissue fibrosis appears to involve activation of basophils and mast cells and their release of alarmins and cytokines. In this article, we review allergy-like features of IgG4-RD and highlight targeted therapies for allergy that have potential in treating patients with IgG4-RD.

Omalizumab as an adjuvant in food allergen immunotherapy

PURPOSE OF REVIEW

To review the most relevant studies in the rapidly advancing field of omalizumab as an adjunct to food allergen oral immunotherapy (OIT).

RECENT FINDINGS

Clinical trials have primarily focused on milk, peanut, and multiallergen OIT combined with omalizumab. These studies suggest that omalizumab in addition to OIT can decrease the time required to reach maintenance OIT dosing and adverse events; however, serious adverse events did still occur. There is limited long-term data but available information suggests that individuals are at risk for increased reactivity after stopping omalizumab, and many discontinued treatment. There has been diversity in study designs, dosing, and populations.

SUMMARY

The use of anti-IgE antibody as an adjunct to food allergen OIT has been an expanding area of research with several additional trials underway. Significant progress has been made in the past decades but further studies are needed to optimize protocols, improve safety and efficacy, and identify patients who will have the greatest benefit.

Past, present, and future of anti-IgE biologics

About 20 years after the identification of immunoglobulin E (IgE) and its key role in allergic hypersensitivity reactions against normally harmless substances, scientists have started inventing strategies to block its pathophysiological activity in 1986. The initial concept of specific IgE targeting through the use of anti-IgE antibodies has gained a lot of momentum and within a few years independent research groups have reported successful generation of first murine monoclonal anti-IgE antibodies. Subsequent generation of optimized chimeric and humanized versions of these antibodies has paved the way for the development of therapeutic anti-IgE biologicals as we know them today. With omalizumab, there is currently still only one therapeutic anti-IgE antibody approved for the treatment of allergic conditions. Since its application is limited to the treatment of moderate-to-severe persistent asthma and chronic spontaneous urticaria, major efforts have been undertaken to develop alternative anti-IgE biologicals that could potentially be used in a broader spectrum of allergic diseases. Several new drug candidates have been generated and are currently assessed in pre-clinical studies or clinical trials. In this review, we highlight the molecular properties of past and present anti-IgE biologicals and suggest concepts that might improve treatment efficacy of future drug candidates.

Emerging Causes of Drug-Induced Anaphylaxis: A Review of Anaphylaxis-Associated Reports in the FDA Adverse Event Reporting System (FAERS)

BACKGROUND

Drug-induced anaphylaxis is a well-known adverse drug reaction for some drug classes, but emerging drug causes of anaphylaxis and novel mechanisms may contribute in unrecognized ways.

OBJECTIVE

We sought to determine the top drugs reported in association with anaphylaxis and anaphylaxis followed by death in the Food and Drug Administration Adverse Event Reporting System (FAERS).

METHODS

We reviewed the publicly available FAERS database from 1999 to 2019. Using search terms "anaphylactic shock" or "anaphylactic reaction" and sorting cases by generic drug names, we counted and trended reports to FAERS in which a drug was associated with anaphylaxis or anaphylaxis followed by death.

RESULTS

From 1999 to 2019, there were 17,506,002 adverse drug events reported in FAERS, of which 47,496 (0.27%) were reported as anaphylaxis. Excluding patients without age, sex, or country data, respectively, the median age of patients in reports of anaphylaxis was 52 (interquartile range: 28), 62.71% were female, and 13,899 of 34,381 (40.43%) reports were from the United States. There were 2984 of 47,496 (6.28%) reports of anaphylaxis followed by death. Top drug classes associated with anaphylaxis in FAERS were antibiotics, monoclonal antibodies (mAbs), nonsteroidal anti-inflammatory drugs, and acetaminophen. Top drug classes associated with anaphylaxis deaths were antibiotics, radiocontrast agents, and intraoperative agents. Linear regression demonstrated reports of anaphylaxis to mAbs increasing at an average rate of 0.77% of total anaphylaxis reports per year (95% confidence interval: 0.65, 0.88) from 2.00% in 1999 to 17.37% in 2019, faster than any other drug class.

CONCLUSION

Antibiotics were highly reported for anaphylaxis overall and anaphylaxis followed by death. Increasing reports were noted for anaphylaxis to mAb therapies.

Dramatic improvement of bullous pemphigoid with omalizumab in an elderly patient

A 70-year-old man with a history of hypertension was evaluated in our dermatology department due to the appearance of a clinical picture compatible with bullous pemphigoid that was confirmed histologically. The lack of response to topical and systemic immunosuppressive treatment resulted in omalizumab being prescribed in a multidisciplinary committee based on the clinical and analytical findings and the patient's refusal to be treated with rituximab. The evaluation at 3 months showed the absence of blisters on the clinical examination. No associated adverse effects were observed. In the following 3 months the patient was administered medication at home in the absence of an anaphylactic reaction and with prior training by the nursing staff of the Hospital Pharmacy Service. After 6 months the medication was suspended with no relapses for 6 months since the last dose. Omalizumab, an anti-IgE monoclonal drug which has a good safety profile with minimum adverse side effects should be considered when there is a contraindication to the use of intravenous therapies (eg, immunoglobulins, rituximab) or prolonged immunosuppressive treatment (eg, methotrexate, azathioprine).

Vernal Keratoconjunctivitis: A Case of Anti-IgE Treatment with Short-Lasting Remission

Vernal keratoconjunctivitis (VKC) is a persistent, severe allergic eye disease, mainly occurring in children, that can lead to severe ocular complications including visual loss. The underlying etiology and pathophysiology of VKC remain unclear. Common therapies include topical antihistamines and mast cell stabilizers that are effective in mild-to-moderate forms of VKC but are often ineffective in severe forms that require topical or systemic corticosteroids. Dependence on steroids is common with potential adverse effects both local, as increased intraocular pressure, glaucoma, infection and cataract, as well as systemic ones, as reduction in child growth velocity. Alternative therapies are immunosuppressive drugs, like cyclosporine A and tacrolimus, that usually are effective but may also cause adverse effects. A promising therapeutic option is omalizumab, a recombinant anti-IgE humanized monoclonal antibody, currently used as add-on therapy for moderate to severe uncontrolled allergic asthma and chronic spontaneous urticaria. Here, we report the short-time duration of effective relief of symptoms after the prolonged use of omalizumab in a patient affected by refractory VKC. However, in our case any apparent beneficial effect was short lasting, and we propose that the duration of the disease and the concomitant long-term use of steroids leads to iatrogenic damage; thus, the disease becomes refractory to anti-IgE treatment.

Roles of omalizumab in various allergic diseases

IgE and mast cells play a pivotal role in various allergic diseases, including asthma, allergic rhinitis, and urticaria. Treatment with omalizumab, a monoclonal anti-IgE antibody, has significantly improved control of these allergic diseases and introduced a new era for the management of severe allergic conditions. About 10 years of experience with omalizumab treatment for severe allergic asthma confirmed its effectiveness and safety, reducing symptoms, frequency of reliever use, and severe exacerbations in patients with intractable conditions. Omalizumab is particularly useful in childhood asthma, where atopic conditions often determine clinical courses of asthma. Recently, omalizumab is approved for the treatment of chronic spontaneous urticaria (CSU) with the fixed dose of 300 mg. Although the mechanisms underlying the actions of omalizumab in CSU are not fully clarified, nearly 90% of patients with CSU showed a complete or a partial response to omalizumab treatment. Furthermore, omalizumab is just approved for the treatment of severe Japanese cedar pollinosis (JC) based on the successful results of an add-on study of omalizumab for inadequately controlled severe pollinosis despite antihistamines and nasal corticosteroids. For proper use of omalizumab to treat severe JC, co-administration of antihistamines is necessary, while patients should meet the criteria including strong sensitization to Japanese cedar pollen (≥class 3) and poor control under standard treatment. In the management of severe allergic diseases using omalizumab, issues including cost and concerns about relapse after its discontinuation should be overcome. At the same time, possibilities for application to other intractable allergic diseases should be considered.

Immunoglobulin E (IgE)-Mediated Food Allergy in Children: Epidemiology, Pathogenesis, Diagnosis, Prevention, and Management

A food allergy is an immunoglobulin E (IgE)-mediated hypersensitive reaction to food, which consists in the appearance of allergic symptoms; it can vary from common urticaria to even fatal anaphylaxis. The prevalence of food allergies has been increasing in the past twenty years and it represents a major public health problem in industrialized countries. The mechanism that leads to food allergies is the lack of immunologic and clinical tolerance to food allergens. The diagnosis of IgE-mediated food allergies is based on the combined use of a detailed medical history, in-vivo, and in-vitro research of specific IgE, the elimination diet, and the double-blind placebo-controlled food challenge. The only currently available treatment for allergies is the strict elimination diet. This type of attitude, which we could define as “passive”, does not overcome the risk of accidental reactions due to involuntary intake of the culprit food. For food allergy management, an “active” approach is urgently needed, such as specific allergen immunotherapy, which is currently under development and only used for research purposes. This article aims to give an updated review of IgE-mediated food allergies in pediatric populations in terms of epidemiology, pathogenesis, prevention, diagnosis, and management.

Food allergy-From food avoidance to active treatment

The prevalence of food allergy (FA) has increased too rapidly, possibly due to environmental factors. The guidelines recommend strict allergen avoidance, but FA is still the main cause of anaphylaxis in all age groups. Immunotherapy is the only treatment able to change the course of allergic disease, and oral immunotherapy (OIT) is the more effective route in FA. However, it carries the risk of adverse reactions, including anaphylaxis. To improve OIT safety, adjuvant therapy with the immunoglobulin E (IgE) monoclonal antibody omalizumab has been extensively used. Results suggest particular benefit in patients with high risk of fatal anaphylaxis. An alternative approach is to use omalizumab instead of OIT to prevent severe allergic reactions upon accidental exposure. This paper reviews current evidence regarding IgE-mediated FA, focusing on natural tolerance and food sensitization acquisition, and on avoidance measures and their limitations.

Omalizumab in children with severe allergic disease: a case series

Background

Currently, severe allergic asthma and food allergy in children represent an important public health problem with medical, psychosocial and economic impacts. Omalizumab is a humanized monoclonal anti-IgE antibody, approved for refractory allergic asthma and chronic urticaria. It has been widely used in clinical practice as add-on therapy in patients with severe uncontrolled allergic asthma. In recent years there has seen the emergence of an allergic epidemic with increasing food allergy, which represents the main cause of anaphylaxis in children. The standard of care for food allergy is strictly dietary allergen avoidance and emergency treatment, but recent clinical trials have suggested that omalizumab may have a role to play as an adjuvant to oral immunotherapy (OIT). We present a case series of patients treated at our institution with omalizumab for severe allergic asthma and food allergy.

Methods

Patients received omalizumab according to a standard reference nomogram after failing standard therapies. In children with comorbid severe food allergy, omalizumab was administered in conjunction with an oral immunotherapy protocol.

Results

Omalizumab was effective in controlling symptoms of allergic asthma, allergic rhinitis and rhinosinusitis, but not eosinophilic esophagitis, while aiding successful oral desensitization of comorbid severe food allergies.

Conclusions

Omalizumab appears to be an excellent therapeutic option in children with inadequately controlled severe allergic asthma, allergic rhinitis and rhinosinusitis, with or without food allergy.

Biological therapies for atopic dermatitis: An update

Severe atopic dermatitis, which affects both adults and children, is a debilitating disorder with a significant decline of patients' quality of life. Although aetiopathogenic factors are currently a topic of study and interpretation, the main features of atopic eczema are skin barrier disturbance and immune dysregulation. Severe refractory disease that fails to improve with conventional therapy may benefit from biologic therapy. Progress in understanding immunopathology of atopic dermatitis have allowed identification of therapeutic molecular targets in the field of biological therapy. We reviewed the different biological treatments with a focus on novel targeted agents: Systemic immunotherapy (Omalizumab, Dupilumab, Lebrikizumab, Tralokinumab, Nemolizumab, Ustekinumab, Fezakinumab, Tezepelumab, Apremilast, allergen specific immunotherapy), and topical agents (Tofacitinib, Crisaborole).

Two decades with omalizumab: what we still have to learn

From its availability for clinical use nearly two decades ago for severe asthma, omalizumab has gained strong evidence of efficacy and safety in the treatment of severe asthma not controlled by standard-of-care therapy. It has been acknowledged by Global Initiative on Asthma guidelines as add-on therapy against severe uncontrolled asthma. Thanks to controlled trials supporting its efficacy, omalizumab has also been licensed for the treatment of chronic spontaneous urticaria. The optimal duration of treatment in either disease has not been established. Despite its high price, omalizumab appears to be cost-effective in severe uncontrolled asthma as well as in chronic urticaria. The literature suggests a wide range of applications for omalizumab in various disorders regardless of allergic or non-allergic pathophysiology.

The Influence of Age on the Relationship Between Allergic Rhinitis and Otitis Media

PURPOSE OF REVIEW

To examine the relationship between otitis media, allergic rhinitis, and age.

RECENT FINDINGS

Otitis media and allergic rhinitis are prevalent conditions with a controversial relationship. Some data suggest that these entities are significantly associated, either through allergic rhinitis inducing Eustachian tube dysfunction or through allergic pathophysiology simultaneously occurring intranasally and in the ear. Other studies, however, have refuted this relationship. For example, treatment with antihistamines does not reliably improve OME, making causation and association challenging to establish. Age may have an effect on the nature of the relationship between allergic rhinitis and otitis media, by impacting both the individual conditions and their association. Epidemiological, immunological, and adenoidal studies have suggested that differences occur with age, and this review encapsulates the related data and publications. We begin by evaluating how allergic rhinitis and otitis media each are affected by age, then evaluate the role that age may have in the relationship between the two conditions. Adult and pediatric literature are evaluated so as to include the full impact of age across patients' lifespan. Age induces changes in immunity, patterns of inflammation, and susceptibility to both allergic rhinitis and otitis media with effusion. Age may also be an effect modifier which impacts the nature of the relationship between these two conditions. The influence of age on the association between these highly prevalent conditions remains a topic of active study.

Omalizumab for Severe Asthma: Beyond Allergic Asthma

Different subsets of asthma patients may be recognized according to the exposure trigger and the frequency and severity of clinical signs and symptoms. Regarding the exposure trigger, generally asthma can be classified as allergic (or atopic) and nonallergic (or nonatopic). Allergic and nonallergic asthma are distinguished by the presence or absence of clinical allergic reaction and in vitro IgE response to specific aeroallergens. The mechanisms of allergic asthma have been extensively studied with major advances in the last two decades. Nonallergic asthma is characterized by its apparent independence from allergen exposure and sensitization and a higher degree of severity, but little is known regarding the underlying mechanisms. Clinically, allergic and nonallergic asthma are virtually indistinguishable in exacerbations, although exacerbation following allergen exposure is typical of allergic asthma. Although they both show several distinct clinical phenotypes and different biomarkers, there are no ideal biomarkers to stratify asthma phenotypes and guide therapy in clinical practice. Nevertheless, some biomarkers may be helpful to select subsets of atopic patients which might benefit from biologic agents, such as omalizumab. Patients with severe asthma, uncontrolled besides optimal treatment, notwithstanding nonatopic, may also benefit from omalizumab therapy, although currently there are no randomized double-blind placebo controlled clinical trials to support this suggestion. However, omalizumab discontinuation according to each patient's response to therapy and pharmacoeconomical analysis are questions that remain to be answered.

The effect of omalizumab treatment on severe allergic asthma and allergic comorbidities: real-life experience from the Czech Anti-IgE Registry

Introduction

Omalizumab is indicated for the treatment of severe allergic asthma (SAA) and chronic spontaneous urticaria, although a number of studies have confirmed the effectiveness of this therapy also for other IgE-mediated diseases.

Aim

To assess the impact of anti-IgE therapy on SAA and comorbid IgE-mediated allergic diseases in patients treated with omalizumab for SAA enrolled in the CAR (Czech Anti-IgE Registry).

Material and methods

Three hundred and ten patients with SAA treated with omalizumab were enrolled in the CAR. Two hundred and twenty-nine individuals were evaluated after 12 months of omalizumab treatment for asthma control test (ACT), examination of fractional exhaled nitric oxide (FENO), forced expiratory volume in 1 s (FEV₁), the use of systemic corticosteroids, side effects of treatment and clinical effect of omalizumab on allergic comorbidities (allergic rhinitis, chronic urticaria, atopic dermatitis and food allergy).

Results

After 12 months of treatment with omalizumab, patients experienced a significant improvement of ACT and FEV₁, reduction of FENO, use of systemic corticosteroids for asthma exacerbations and dose of maintenance oral corticosteroid therapy. The positive effect of treatment with omalizumab was observed in 82.2% of patients with allergic rhinitis, in 85.7% of patients with chronic urticaria, in 82.1% of patients with atopic dermatitis, and in 67.3% of patients with food allergy.

Conclusions

In the CAR registry, patients with SAA treated with omalizumab showed a significant positive effect of anti-IgE therapy not only on the asthma control, but also on allergic comorbidities.

Ragweed Pollen Allergy: Burden, Characteristics, and Management of an Imported Allergen Source in Europe

Ambrosia artemisiifolia, also known as common or short ragweed, is an invasive annual flowering herbaceous plant that has its origin in North America. Nowadays, ragweed can be found in many areas worldwide. Ragweed pollen is known for its high potential to cause type I allergic reactions in late summer and autumn and represents a major health problem in America and several countries in Europe. Climate change and urbanization, as well as long distance transport capacity, enhance the spread of ragweed pollen. Therefore ragweed is becoming domestic in non-invaded areas which in turn will increase the sensitization rate. So far 11 ragweed allergens have been described and, according to IgE reactivity, Amb a 1 and Amb a 11 seem to be major allergens. Sensitization rates of the other allergens vary between 10 and 50%. Most of the allergens have already been recombinantly produced, but most of them have not been characterized regarding their allergenic activity, therefore no conclusion on the clinical relevance of all the allergens can be made, which is important and necessary for an accurate diagnosis. Pharmacotherapy is the most common treatment for ragweed pollen allergy but fails to impact on the course of allergy. Allergen-specific immunotherapy (AIT) is the only causative and disease-modifying treatment of allergy with long-lasting effects, but currently it is based on the administration of ragweed pollen extract or Amb a 1 only. In order to improve ragweed pollen AIT, new strategies are required with higher efficacy and safety.

Non-surgical management of chronic rhinosinusitis with nasal polyps based on clinical-cytological grading: a precision medicine-based approach

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a common inflammatory disorder that strongly impacts patients' quality of life. CRSwNP is still a challenge for ENT specialists due to its unknown pathogenesis, difficult control and frequent relapse. We tested the hypothesis that a new standardised therapeutic approach based on individual clinical-cytological grading (CCG), may improve control of the disease and prevent the needing for surgery. We analysed 204 patients suffering from bilateral CRSwNP, 145 patients of whom regularly assumed therapy, respecting the planned check-up, and were considered cases; 59 patients were not assuming therapy as indicated and were considered as controls. After five years of standardised treatment, 15 of 145 (10.5%) improved endoscopic staging, 61 of 145 (42%) did not change their endoscopic staging, and 69 of 145 (47.5%) were worse. In the control group, 49 of 59 (83%) were worse by at least two stages (p < 0.05). Patients and controls were stratified basing on clinical and cytological grading as mild, moderate and severe. After patient stratification, in the mild group (n = 27) 92% patients had a constant trend, with no worsening and no need for surgery over a 5-year period, whereas in the mild CCG control group 1 of 59 (1.6%) required surgery (p < 0.05). In moderate GCC (n = 83), 44% of patients did not modify or improve endoscopic staging and 3.6% needed surgery, compared to 13.6% of controls with moderate GCC (p < 0.05). In severe CCG (n = 35), even though no patients achieved significant amelioration of endoscopic grading, 40% of patients were considered as "clinically controlled" and 5.7% of patients underwent surgery, but the percentage was significantly higher (49%) in the control group significant (p = 0.0000). Finally, statistical analyses revealed a clear trend that polyp size increased at a faster rate in the control group than in the treatment group and for each subgroup (low, moderate and severe). The present study suggests a new approach in the management of CRS according to clinical cytological grading that allows defining the grade of CRSwNP severity and to adapt the intensity of treatment. This approach limited the use of systemic corticosteroids to only moderate-severe CRSwNP with a low corticosteroid dosage in comparison with those previously suggested. Our protocol seems to improve the adherence by patients, control of disease and the need for surgery in the long-term.

ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies: an infectious diseases perspective (Soluble immune effector molecules [II]: agents targeting interleukins, immunoglobulins and complement factors)

BACKGROUND

The present review is part of the ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies.

AIMS

To review, from an Infectious Diseases perspective, the safety profile of agents targeting interleukins, immunoglobulins and complement factors and to suggest preventive recommendations.

SOURCES

Computer-based MEDLINE searches with MeSH terms pertaining to each agent or therapeutic family.

CONTENT

Patients receiving interleukin-1 (IL-1) -targeted (anakinra, canakinumab or rilonacept) or IL-5-targeted (mepolizumab) agents have a moderate risk of infection and no specific prevention strategies are recommended. The use of IL-6/IL-6 receptor-targeted agents (tocilizumab and siltuximab) is associated with a risk increase similar to that observed with anti-tumour necrosis factor-α agents. IL-12/23-targeted agents (ustekinumab) do not seem to pose a meaningful risk of infection, although screening for latent tuberculosis infection may be considered and antiviral prophylaxis should be given to hepatitis B surface antigen-positive patients. Therapy with IL-17-targeted agents (secukinumab, brodalumab and ixekizumab) may result in the development of mild-to-moderate mucocutaneous candidiasis. Pre-treatment screening for Strongyloides stercoralis and other geohelminths should be considered in patients who come from areas where these are endemic who are receiving IgE-targeted agents (omalizumab). C5-targeted agents (eculizumab) are associated with a markedly increased risk of infection due to encapsulated bacteria, particularly Neisseria spp. Meningococcal vaccination and chemoprophylaxis must be administered 2-4 weeks before initiating eculizumab. Patients with high-risk behaviours and their partners should also be screened for gonococcal infection.

IMPLICATIONS

Preventive strategies are particularly encouraged to minimize the occurrence of neisserial infection associated with eculizumab.

How to manage anaphylaxis in primary care

Anaphylaxis is defined as a severe life-threatening generalized or systemic hypersensitivity reaction characterized by rapidly developing airway and/or circulation problems. It presents with very different combinations of symptoms and apparently mild signs and can progress to fatal anaphylactic shock unpredictably. The difficulty in recognizing anaphylaxis is due, in part, to the variability of diagnostic criteria, which in turn leads to a delay in administration of appropriate treatment, thus increasing the risk of death. The use of validated clinical criteria can facilitate the diagnosis of anaphylaxis. Intramuscular epinephrine (adrenaline) is the medication of choice for the emergency treatment of anaphylaxis. Administration of corticosteroids and H1-antihistamines should not delay the administration of epinephrine, and the management of a patient with anaphylaxis should not end with the acute episode. Long-term management of anaphylaxis should include avoidance of triggers, following confirmation by an allergology study. Etiologic factors suspected in the emergency department often differ from the real causes of anaphylaxis. Evaluation of patients with a history of anaphylaxis should also include an assessment of personal data, such as age and comorbidities, which may increase the risk of severe reactions. Special attention should also be paid to co-factors, as these may easily confound the cause of the anaphylaxis. Patients experiencing anaphylaxis should administer epinephrine as soon as possible. Education (including the use of Internet and social media), written personalized emergency action plans, and self-injectable epinephrine have proven useful for the treatment of further anaphylaxis episodes.

An overview on safety of monoclonal antibodies

PURPOSE OF REVIEW

Biological agents have been a treatment option for many chronic immune-mediated diseases as well as oncological conditions. The issue of infusion reactions is of particular importance and at least in some cases related to the immunogenicity of these drugs with the production of antidrug antibodies. Infectious diseases are a well described side-effect of certain biological agents, even if, at least regarding the biological agents used for the treatment of allergic diseases and immune-mediated diseases, the risk has been reduced. Biological agents clearly impact the physiological functions of the immune system also those connected to immunosurveillance against cancers. This review discusses the safety profile to the main biological agents currently in use in allergic and chronic immune-mediated diseases.

RECENT FINDINGS

By reducing chronic inflammation in immune-mediated diseases, biological agents decrease mortality, cardiovascular events without increasing significantly the risk of cancer. In addition, specific clinical procedure enables the identification of potentially reactive patients and the prevention of acute severe reactions. Overall, the ratio between therapeutic and side-effects is clearly in favor of the former.

SUMMARY

The safety profile of biological agents is, just as much as their efficacy, one of the fundamental criteria justifying their clinical broad use.

Systemic Treatment of Adult Atopic Dermatitis: A Review

Atopic dermatitis (AD) is a common chronic inflammatory skin disease that predominantly affects children. However, it can persist in adulthood and/or start at older ages. Due to its chronic nature and frequently occurring relapses, AD has a substantial effect on patients' quality of life, often requiring long-term systemic treatment, especially in adult patients, who are more frequently refractory to adequate topical treatment with mid- to high-potent corticosteroids and/or calcineurin inhibitors. Therefore, treatment with systemic therapies is often needed to take control of the disease, prevent exacerbations and improve quality of life. However, data regarding systemic treatment effectiveness and long-term safety in adult patients with AD are insufficient. Indeed, standardized international guidelines are lacking, and the treatment approach widely differs among diverse countries. This review focuses on the use of systemic treatments in adult AD patients analyzing published literature.