Add-on therapy in severe asthma in HIV+ patients
Question:
5/31/2018
I have a patient with AIDS and severe persistent asthma, poorly controlled on combination high dose ICS/LABA, LAMA, LTRA, antihistamines, nasal corticosteroids, daily albuterol and frequent prednisone courses. What would you consider as add on therapy? Patient's T cell count~300, WBC 2.8 with AEC of 400, total IGE of 349 as well as perennial and seasonal sensitization. With the low T cell count, would he mount a good response to inhalant immunotherapy or would it be better to consider anti-IgE or anti-eosinophil therapy such as omalizumab, mepolizumab, etc?
Answer:
This is a complex question and I think you need to keep several factors in mind.
First, is AIT safe and effective in HIV+ patients? There is limited data on the safety and efficacy of AIT in HIV+ patients. A recent small study examined efficacy and safety of grass SLIT in HIV+ patients and suggested it was well tolerated and efficacious. That being said, for the patient you describe, I would be concerned about initiating AIT in the context of poorly controlled severe asthma with daily symptoms and frequent exacerbations.
With regards to biologic therapies such as omalizumab or the anti-IL5 agents in patients who are HIV+, Dr. Dennis Ledford responded to a previous ask the expert question with the following:
"I am not aware of any negative effect of omalizumab or decreased IgE and the clinical course of HIV infection. There is in vitro experimental evidence that mast cells may be a reservoir of virus and the susceptibility of mast cells to HIV are reduced by omalizumab (Sundstrum). Thus, one might argue there is a benefit in reducing IgE which reduces CXCR4 and IgE and high affinity IgE-receptor interaction, resulting in less susceptibility of mast cells to HIV. I am not aware that there is any evidence of a clinical benefit of omalizumab or lower IgE blood levels and HIV progression. There is evidence that an increase in serum IgE is associated with a worse outcome but this does not verify that lowering IgE has a therapeutic value."
With regard to potential efficacy of omalizumab for your patient, I was only able to find a case report regarding efficacy of omalizumab for chronic urticaria in an HIV+ patient. I searched for literature related to the use of anti-IL5 agents in HIV+ patients and was unable to find any information.
Taken together, there is some in vitro evidence that supports considering omalizumab in this case.
1. Iemoli, E. et al. "Sublingual allergen immunotherapy in HIV-positive patients." Allergy 71 (2016): 412-415.
2. Sundstrom, J. Bruce, et al. "IgE-FceRI interactions determine HIV coreceptor usage and susceptibility to infection during ontogeny of mast cells." The Journal of Immunology 182.10 (2009): 6401-6409.
3. Israël-Biet, Dominique, et al. "Elevation of IgE in HIV-infected subjects: a marker of poor prognosis." Journal of Allergy and Clinical Immunology 89.1 (1992): 68-75.
4. Wright, David N., et al. "Serum IgE and human immunodeficiency virus (HIV) infection." Journal of Allergy and Clinical Immunology 85.2 (1990): 445-452.
5. Viganó, Alessandra, et al. "Elevation of IgE in HIV-infected children and its correlation with the progression of disease." Journal of Allergy and Clinical Immunology 95.2 (1995): 627-632.
6. Iemoli, E et al. "Successful Omalizumab treatment in HIV positive patient with chronic spontaneous urticaria: a case report." Eur Ann Allergy Clin Immunology 49(2) (2017): 88-91.
I hope this information is helpful to you.
Regards,
Daniel Jackson, MD, FAAAAI