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I have a patient that I am contemplating starting Xolair therapy for chronic idiopathic urticaria indication. He takes Propranolol 10 mg twice daily for blood pressure management. Is beta blocker management contraindicated with Xolair therapy due to risk of anaphylaxis? Would you recommend an alternative blood pressure vs holding the dose 48 hours before monthly injections vs no change in beta blocker therapy?


The product insert lists only one contraindication: "Severe hypersensitivity reaction to Xolair or any ingredient of Xolair. "

Your suggestion about whether an alternative anti-hypertensive agent (also avoiding ACE inhibitors) could be used to replace Propanolol seems very reasonable. If this is not possible, then there is no clear correct option. You could ask the provider who is treating the patient's hypertension about the risks of holding the dose of Propanolol as you propose, though this approach seems very cumbersome and since some omalizumab reactions are delayed, the withholding period may need to be extended to include the post-injection period.

In the initial Joint Task Force report, the rate of omalizumab-associated anaphylaxis in patients with asthma was low at 0.09% and 61% of reactions occurred within two hours of the first three doses. The Joint Task Force's 2011 follow-up report found an additional 77 cases of anaphylaxis. They noted that if the Joint Task Force guidelines for observation were followed, 77% of these reactions would have occurred in a supervised medical facility.

A 2019 meta-analysis of omalizumab efficacy and safety in patients with chronic spontaneous urticaria reported that anaphylaxis occurred in three out of 1314 patients, which translates to a rate of 0.2.%

Given these findings, a frank discussion with the patient of the data, weighing the risks and benefits should be performed as part of the informed consent process.

Cox L, Platts-Mills TA, Finegold I, et al. American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma and Immunology Joint Task Force Report on omalizumab-associated anaphylaxis. J Allergy Clin Immunol. 2007;120:1373e1377.

Cox L, Lieberman P, Wallace D, et al. American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma & Immunology Omalizumab-Associated Anaphylaxis Joint Task Force follow-up report. J Allergy Clin Immunol. 2011;128:210e212.

Tharp MD, Bernstein JA, Kavati A. Benefits and Harms of Omalizumab Treatment in Adolescent and Adult Patients with Chronic Idiopathic (Spontaneous) Urticaria. JAMA Dermatol. 2019;155(1):29-38.

I hope this information helps you with your patient.

Jacqueline A. Pongracic, MD, FAAAAI

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