Q:

9/10/2019
Have patient with known venom anaphylaxis who is having reactions to her venom IT. Have looked at Xolair/venom protocols out there, however am looking for any data if someone has done this without rush or ultra rush IT. I have been unable to find any protocols using Xolair for standard weekly build-up. Any guidance would be appreciated as the patient needs the shots.

A:

The advantage of using omalizumab during rush immunotherapy is that it can be used for a much shorter period of time, with a significant cost savings. The following article describes the use of omalizumab in a situation similar to what you are describing:

Clin Exp Allergy. 2017 Dec;47(12):1631-1639.
Overcoming severe adverse reactions to venom immunotherapy using anti-IgE antibodies in combination with a high maintenance dose.
Stretz E, Oppel EM, Räwer HC, Chatelain R, Mastnik S, Przybilla B, Ruëff F.
Klinik und Poliklinik für Dermatologie und Allergologie, Ludwig-Maximilians-Universität, München, Germany.
Abstract
BACKGROUND: An omalizumab treatment and a high maintenance venom dose may both help to prevent recurrent systemic allergic reactions (SAR) to venom immunotherapy (VIT). The effectiveness of this combination therapy, however, is unclear.
OBJECTIVE: We wanted to explore the possibility whether a temporary treatment with the anti-IgE antibody omalizumab combined with a VIT using an elevated maintenance dose of >100 μg venom may establish a permanent tolerance of maintenance VIT.
METHODS: For this retrospective case series, we scoured our institutional data base for patients who had had an insect venom allergy, and in whom it had not been possible to continue VIT because of repeated unstoppable SAR during maintenance VIT. Patients were divided into those who had received the combination therapy (omalizumab group) and those who had not received omalizumab because its costs could not be covered (controls). Guided by the total IgE level and by body weight, omalizumab had been given subcutaneously 5, 3 and 1 weeks before VIT had been restarted. Three to 6 months after an elevated maintenance dose (200-300 μg venom) had been reached, omalizumab had been stopped.
RESULTS: Between 2006 and 2011, 15 patients had qualified for an off-label use of omalizumab: 10 patients had received the combination therapy, and 5 patients had remained without such a therapy. The combination therapy leads to a durable tolerance of VIT in all patients even after omalizumab had been discontinued (median of follow-up time 5.8 years, IQR 2.7-8.6 years). Sting challenge tests were tolerated by all of the re-stung omalizumab patients (n = 8). In all controls, VIT had to be stopped permanently due to repeated SARs (P < .001 vs omalizumab group).
CONCLUSIONS AND CLINICAL RELEVANCE: Combining a temporary omalizumab therapy with an elevated maintenance dose seems a promising approach to achieve a tolerance of treatment in patients with a recurrent SAR to VIT.

I hope this information is of help to you and your patient.

Regards,
Eric Macy, MD, MS, FAAAAI

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