Current status of therapy with omalizumab in children

Biologics and severe asthma in children

PURPOSE OF REVIEW

Severe asthma can carry significant morbidity and mortality for patients, and it places a burden on families and the healthcare system. Biologic agents have revolutionized the care of patients with severe asthma in recent years. Evidence surrounding some of these therapies is limited in the pediatric population, but recent studies show that they significantly improve asthma care when used appropriately. In this review, we discuss the biologic therapies currently approved to treat severe asthma in school-age children and adolescents.

RECENT FINDINGS

Randomized controlled trials have been published in support of biologics in children and/or adolescents. These therapies have been shown to reduce the annual rate of severe asthma exacerbations by at least 40-50%, and some up to about 70%. Improvements in asthma control, lung function, oral corticosteroid use, and quality of life have also been demonstrated, although these vary by agent. Furthermore, these therapies have reassuring safety profiles in pediatric patients.

SUMMARY

With three biologic agents approved for children ages 6-11 years and five approved for adolescents ages >12 years, it can be challenging to select one. The therapy should be chosen after careful consideration of the patient's asthma phenotype and biomarkers. Additional pediatric-specific clinical trials would be helpful in developing evidence-based guidelines on biologic therapies in this population.

Effects of omalizumab on allergic conjunctivitis

PURPOSE

To evaluate the effect of subcutaneous omalizumab therapy on the allergic conjunctivitis symptoms of patients being treated for asthma.

METHODS

A total of 84 eyes of 42 patients who were receiving subcutaneous omalizumab therapy for asthma and complained of allergic conjunctivitis symptoms underwent complete ophthalmic examination. All of the patients were graded according to signs and symptoms and duration of symptoms, evaluated using an ocular severity index (SI) and quality of life questionnaires. Immunoglobulin E (IgE) levels and both initial and final %FEV₁ (forced expiratory volume in the first second) values were also evaluated. p values < 0.05 were accepted as statistically significant.

RESULTS

The study included 36 women (85.7%) and 6 men (14.3%) with a mean age of 54.5 ± 10.8 years. The mean duration of omalizumab therapy was 46 ± 30.9 months. There were statistically significant changes between initial and final values for ocular SI, quality of life, subjective symptom frequency and severity and %FEV1. Final values of SI, quality of life, and symptom severity and frequency were statistically significantly lower compared to initial values, while final %FEV₁ was statistically significantly higher compared to initial value (p < 0.001).

CONCLUSION

Omalizumab therapy for asthma had a favorable effect on the patients' allergic conjunctivitis symptoms and decreased parameters related to ocular disease severity, improved quality of life and increased %FEV₁values.

TRIAL REGISTRATION NUMBER

2019/5-5, Trial Registration Date: 28/03/2019, Retrospectively registered.

Anti-IgE for the Treatment of Chronic Urticaria

Urticaria and angioedema are very common. Management of chronic urticaria subtypes, which usually persist for many years, is challenging. Recent years have demonstrated that targeting IgE with antibodies provides a safe and efficient treatment approach. Whilst several anti-IgE antibodies have been developed, omalizumab is currently the only one approved for use. International and national guidelines recommend its use after failure of antihistamines at standard and increased dose. Whilst not yet approved, many new anti-IgE approaches are currently being investigated in pre-clinical studies or clinical trials. This non-systematic focused review summarizes current knowledge of omalizumab and other anti-IgE biologics in chronic urticaria using data extracted from PubMed, Google Scholar and clinical trial databases, clinicaltrials.gov and clinicaltrials.eu. For adults, there is good evidence from randomized clinical trials and real-world data that symptomatic treatment with omalizumab is efficacious and safe in chronic spontaneous urticaria (CSU), whereas evidence in chronic inducible urticaria (CINDU) and special populations is limited. Easy-to-use tools to identify non-responders and predict the required duration of treatment have not been established yet. Phase 2 b results of ligelizumab have not only demonstrated efficacy and safety but also superiority to omalizumab. Indeed, there is preliminary evidence that omalizumab non- or partial responders benefit from ligelizumab. Whereas further development of quilizumab was discontinued, other approaches, eg UB-221 or DARPins are under investigation. Anti-IgE treatment with omalizumab represents a landmark in the treatment of chronic urticaria, with and without angioedema, and there is light on the horizon suggesting success may come with various next-generation anti-IgE approaches.

Active smoking effect in allergic rhinitis

Background

Tobacco smoke has been described as causing increased prevalence of rhinitis symptoms and decreased atopy. Furthermore, these nasal symptoms and quality of life in smokers with Allergic Rhinitis (AR) were not significantly different to non-smokers. As a result of this duality, a comparison study between the quality of life and inflammatory markers of atopy among active smokers and non-smokers having AR was put forward.

Material and methods

Cross-sectional study in adult smokers and non-smokers, with a clinical diagnosis of AR and positive Skin Prick Test (SPT). Smoking status was confirmed by salivary cotinine measurements. Functional respiratory evaluation was performed, and quality of life between groups was compared using Mini-RQLQ questionnaire. Immunological markers in serum and nasal washes (IgE, IL-4, IL 5, IL 13, IL 17, IL 33) were evaluated, while samples from a third group of passive smokers was incorporated for serological comparison exclusively. The statistical analysis included Student T test, x2, Mann Whitney U (Anova 2-way), and Kruskal Wallis for 3 groups analysis. Values of P < 0.05 were considered significant.

Results

Twenty-two patients per group with similar demographics and allergen sensitivity were studied. Regarding inflammatory markers, a reduction of IL 33 in the serum of smokers (P < 0.001) was the only statistically significant different parameter revealed, showing a remarkable trend in nasal lavage. Salivary cotinine levels were absolutely different (P < 0.0001), but pulmonary function evaluations were not statistically significant after multiple adjusting. There were no significant differences in quality of life parameters.

Conclusions

In our study of AR, active smokers do not demonstrate impaired nasal related quality of life or impact on atopic inflammatory parameters, compared to non-smokers. Reduced levels of IL33 could explain a lack of symptoms alerting smokers of the harmful consequences of smoking.

Successful prevention of severe allergic transfusion reactions with omalizumab

BACKGROUND

Allergic transfusion reactions (ATRs) are a common adverse reaction to transfusion therapy and can be potentially fatal. Washing blood products is the most effective strategy for preventing ATRs; however, washed products, especially platelets, are not available at many blood centers.

STUDY DESIGN AND METHODS

A 29-year-old female patient with an advanced myelodysplastic/myeloproliferative neoplasm, unclassifiable, developed severe ATRs after four platelet transfusions in a week. She showed no response to premedication with histamines and steroids and still had severe ATRs with the next three platelet transfusions. A laboratory workup revealed that her IgA level was slightly decreased, while her haptoglobin level was normal. Anti-IgA testing was not available. The patient decided to undergo allogeneic peripheral blood stem cell (PBSC) transplantation. As the onset of symptoms ATR, which were similar to Type 1 hypersensitivity reactions mediated by IgE antibodies, occurred immediately after transfusion and omalizumab is a humanized monoclonal anti-IgE, we elected to offer off-label use of omalizumab before administering the conditioning regimen.

RESULTS

Omalizumab was injected subcutaneously at a dose of 150 mg. Surprisingly, transfusion reactions fully resolved within 24 hours. No serious side effects were noticed. Another 150 mg of omalizumab was administered 1 day before PBSC infusion. The patient remained asymptomatic without any signs of ATRs throughout the whole period of transplantation. Seven months after transplantation, the patient was in complete remission without overt complications.

CONCLUSION

This case suggests that omalizumab is a promising new alternative treatment for the prevention of severe ATRs.

Anti-IgE treatment in allergic rhinitis

OBJECTIVES

To review the efficacy of anti-IgE therapy in allergic rhinitis (AR).

METHODS

Literature search was performed using the PubMed and Proquest Central databases at Kırıkkale University Library.

RESULTS

Although the skin prick testing in patients suffering from AR is positive (indicating that antigen-specific Immunoglobulin E has been produced), there is no association with overall circulating IgE levels. Correlation was lacking between circulating IgE level and either skin prick tests or laboratory testing for specific IgE. Omalizumab binds to uncomplexed IgE in man more avidly than does Fc-epsilon. The effect of omalizumab is to lower the level of IgE and downgrade production of FceRI receptors (which bind IgE) in mast cells and basophils, causing less mast cell recruitment and responsivity and thus diminishing eosinophilic infiltration and activation. Anti-IgE therapy through omalizumab may shorten the lifetime of mast cells and causes dendritic cells to downgrade their production of FcεRI. There are reports indicating benefit from omalizumab in managing food allergies, nasal polyp formation, essential anaphylaxis, AR, venom allergy and eczema. Omalizumab acts to lessen circulating IgE levels, whilst reducing production of FceRI by mast cells and basophils. The fact that omalizumab influences how eosinophils respond may be down to disruption of the antigen-IgE-mast cell interactions, with mast cells being recruited at lower levels and thus chemotactic eosinophilic recruitment via cytokines being greatly reduced. Omalizumab has the effect in cases of perennial AR of blocking the increased eosinophilic recruitment and tissue infiltration initiated by seasonal antigens. Likewise, in omalizumab-treated cases, circulating unbound IgE levels showed significant decreases. For patients with perennial AR, the average daily nasal severity score was significantly reduced where omalizumab was administered, compared to placebo.

CONCLUSION

Omalizumab has efficacy in ameliorating symptoms and reduces the necessity for additional medication in both seasonal and perennial allergic rhinitis.

Omalizumab and mepolizumab in the landscape of biological therapy for severe asthma in children: how to choose?

Severe asthma has a substantial epidemiological impact on children and biological treatments can be an option to take into account, as they target specific molecules and pathways involved in its pathogenesis. Modern medicine is continuously and progressively oriented towards tailored treatments designed specifically for the pathology patterns observed in individual patients and identified as endotypes with associated biomarkers. In this regard, biologic treatments in asthma are one of the best examples. Among the biological drugs currently available, omalizumab is the one with the greatest amount of data on efficacy and safety, and the one we have more real-life clinical experience with. However, mepolizumab will likely be accessible soon globally for clinical use. Moreover, research on biological drugs for the treatment of severe asthma is expanding rapidly, with some molecules currently used in adult patients that could be registered also for pediatric use and new molecules that could be available in the future. On the other hand, due to this potential abundance of therapeutic options, new criteria could become necessary to guide clinicians through an evidence-based choice between omalizumab and these new drugs. For the same reason, more data collected specifically from pediatric clinical trials are necessary. In this review we aim to analyze the factors that could help clinicians make their choice and to highlight the unmet need for a more evidence-based choice.

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.

Biological Modulators in Eosinophilic Diseases

Eosinophils can regulate local and systemic inflammation, and their presence in higher numbers appears to play an important role in the pathology of various atopic and inflammatory diseases. Eosinophil maturation, recruitment, and survival depend on several cytokine regulators, including interleukin (IL)-5, IL-4, and IL-13 as well as growth factors such as GM-CSF. Over the last decade, the approach to treating eosinophilic diseases has changed greatly. A number of biologic modulators have been developed to target eosinophilic inflammatory pathways, and their usage has resulted in variable clinical improvement in the treatment of eosinophilic-associated conditions. Novel targeted therapies that are safe and effective for treating these disorders are being investigated. This review summarizes the clinical use of biologic agents that have been studied in clinical trials or approved for treating eosinophilic diseases.

Risk and safety requirements for diagnostic and therapeutic procedures in allergology: World Allergy Organization Statement

One of the major concerns in the practice of allergy is related to the safety of procedures for the diagnosis and treatment of allergic disease. Management (diagnosis and treatment) of hypersensitivity disorders involves often intentional exposure to potentially allergenic substances (during skin testing), deliberate induction in the office of allergic symptoms to offending compounds (provocation tests) or intentional application of potentially dangerous substances (allergy vaccine) to sensitized patients. These situations may be associated with a significant risk of unwanted, excessive or even dangerous reactions, which in many instances cannot be completely avoided. However, adverse reactions can be minimized or even avoided if a physician is fully aware of potential risk and is prepared to appropriately handle the situation. Information on the risk of diagnostic and therapeutic procedures in allergic diseases has been accumulated in the medical literature for decades; however, except for allergen specific immunotherapy, it has never been presented in a systematic fashion. Up to now no single document addressed the risk of the most commonly used medical procedures in the allergy office nor attempted to present general requirements necessary to assure the safety of these procedures. Following review of available literature a group of allergy experts within the World Allergy Organization (WAO), representing various continents and areas of allergy expertise, presents this report on risk associated with diagnostic and therapeutic procedures in allergology and proposes a consensus on safety requirements for performing procedures in allergy offices. Optimal safety measures including appropriate location, type and required time of supervision, availability of safety equipment, access to specialized emergency services, etc. for various procedures have been recommended. This document should be useful for allergists with already established practices and experience as well as to other specialists taking care of patients with allergies.

Omalizumab in children

Omalizumab is a recombinant humanized monoclonal antibody that reduces levels of circulating immunoglobulin E (IgE) and expression of IgE high-affinity receptors on mast cells and basophils, interrupting the subsequent allergic inflammatory cascade. Current indications for treatment with omalizumab in pediatric patients are clearly defined and are confined to moderate-to-severe uncontrolled allergic asthma and chronic spontaneous urticaria (CSU). Any other prescription can only be off label. Data available from clinical trials conducted in children suggest that omalizumab is clinically effective and generally well tolerated. Given its mechanism of action, recent reports have suggested its possible clinical use in other IgE-mediated disorders, such as allergic rhinitis, food allergy, and anaphylaxis. In recent years, several studies have also investigated the possible applications of omalizumab in a number of non IgE-mediated diseases. The aim of the present review is to assess all applications of omalizumab as therapy in the pediatric population. The approved indications--allergic asthma and CSU--are reviewed. Moreover, further potential applications of omalizumab are discussed in both IgE-mediated and non-IgE-mediated diseases.

Allergic airway diseases in childhood: an update

Complex multifactorial diseases such as allergic rhinitis and asthma are not only becoming an increasing burden to healthcare systems, but especially affect the life quality of children and families suffering from their allergic symptoms. Also physicians are challenged by the multifaceted diseases as their work involves not only the often difficult decisions on case-adapted diagnostics, treatment, and monitoring, but also possible preventive measures. This review gives an outline of the latest scientific developments related to the etiology, diagnosis, and management of allergic airway diseases in childhood, as well as prenatal and early life risk factors and strategies for prevention.

mRNA transcript therapy

mRNA is the central molecule of all forms of life. It is generally accepted that current life on Earth descended from an RNA world. mRNA, after its first therapeutic description in 1992, has recently come into increased focus as a method to deliver genetic information. The recent solution to the two main difficulties in using mRNA as a therapeutic, immune stimulation and potency, has provided the basis for a wide range of applications. While mRNA-based cancer immunotherapies have been in clinical trials for a few years, novel approaches; including, in vivo delivery of mRNA to replace or supplement proteins, mRNA-based generation of pluripotent stem cells, or genome engineering using mRNA-encoded meganucleases are beginning to be realized. This review presents the current state of mRNA drug technologies and potential applications, as well as discussing the challenges and prospects in mRNA development and drug discovery.

Immune mechanisms and development of childhood asthma

Early life influences are crucial for the development of distinct childhood asthma phenotypes, which are currently included under the term asthma syndrome. Improved characterisation of different childhood asthma phenotypes will help to elucidate specific underlying immune mechanisms--namely, endotypes. Besides genetics, epigenetics and environmental factors have an effect on innate and adaptive immune regulatory networks. Crucial determining factors for complex immune regulation and barrier function include family history of atopy, respiratory infections, microbiome, and nutrition. Recent diagnostic approaches, including biomarkers, might offer a unique opportunity to improve definitions of asthma sub-phenotypes, prediction of outcome, and treatment options, by referring to the underlying pathophysiology. For prevention and patient-individualised medicine, a multifactorial approach incorporating deep phenotyping and mathematical models for analysis to extend our present knowledge is needed.