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Q:

3/31/2017
My colleagues and I have several patients that are currently on both allergen immunotherapy injections and omalizumab for allergic asthma. Typically, these patients are moderate to severe asthmatics initially started on omalizumab who did improve, but still had considerable symptoms. As far as I know, there is no data to support the concomitant use of omalizumab and immunotherapy for asthma. However, there is evidence that this combination does benefit patients with allergic rhinitis over monotherapy alone.

Several of our patients have been doing quite well over the past few years, but my colleagues and I have started to wonder when and how we can discontinue the omalizumab (of the two therapies, omalizumab might be the best candidate for discontinuation given its cost). We are concerned, as experts have warned, that patients will be at risk for systemic allergic reactions if we discontinue the anti-IgE therapy and maintain the current dose of allergen immunotherapy.

Do you have any advice for us as far as how to handle this? One thought was that you can decrease the dose by a dilution after you stop the omalizumab, and then gradually build the patient up over a few months to the typical maintenance dose.

A:

Thank you for the question. We sought the expert answer from Dr. Thomas Casale below.

Below are three references that in part address this issue. There have been no double-blind, placebo-controlled trials to examine the added efficacy and safety of omalizumab plus allergen immunotherapy. The Massanari study does show that pretreatment with omalizumab imparts safety to allergen immunotherapy in patients with asthma. The other two studies are open label studies not controlled but do show added safety and efficacy of the combination. My personal opinion is that the omalizumab should be given for 8 to 16 weeks to make sure that asthma is under reasonable control before starting allergen immunotherapy. There are no data to show if you can stop the omalizumab treatment once a patient reaches maintenance immunotherapy. Again, my opinion would be to continue both.

Key considerations for clinical trials of dietary interventions for primary prevention of allergy and asthma in children (pages 730–732) Bright I. Nwaru, Suvi M. Virtanen and Aziz Sheikh, Pediatric Allergy and Immunology 25 (2015) 817–837

Children with severe asthma can start allergen immunotherapy after controlling asthma with omalizumab: a case series from Poland, Iwona Stelmach1, Paweł Majak, Joanna Jerzyńska, Magdalena Bojo, Łukasz Cichalewski, Katarzyna Smejda, Arch Med Sci 2015; 11, 4: 901–904

Effect of pretreatment with omalizumab on the tolerability of specific immunotherapy in allergic asthma Marc Massanari, PharmD, Harold Nelson, MD, Thomas Casale, MD, William Busse, MD, Farid Kianifard, PhD, Gregory P. Geba, MD, MPH, and Robert K. Zeldin, MD. J Allergy Clin Immunol 2010;125:383-9.

We hope this helps.
Patricia McNally, MD, FAAAAI

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