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Omalizumab induces aspirin tolerance in allergic and nonallergic N-ERD patients

Published: October 19, 2021

Nonsteroidal anti-inflammatory drug (NSAID) exacerbated respiratory disease (N-ERD) comprises the triad of chronic rhinosinusitis with nasal polyps (CRSwNP), allergic asthma, and intolerance to nonsteroidal anti-inflammatory drugs. N-ERD is a very burdensome chronic type 2 inflammation in upper and lower airways that represents many therapeutic challenges. IgE, which is highly elevated in nasal mucosa in N-ERD, is thought to play a central role in its pathogenesis by activating mast cells and further intensifying type 2 immunity. Omalizumab is a humanized anti-IgE monoclonal antibody approved for the treatment of allergic asthma and nasal polyposis. The effect of anti-immunoglobulin E therapy on prevention of aspirin-induced hypersensitivity especially in N-ERD patients without concomitant allergies has not been addressed so far.

Quint T. et al performed a prospective single center trial published in The Journal of Allergy and Clinical Immunology: In Practice to evaluate overall omalizumab-induced aspirin tolerability in N-ERD patients by performing aspirin challenge testing before and after 6 months of omalizumab therapy. In addition, the impact of anti-IgE therapy on nasal polyposis, asthma, eosinophilia, and serum and tissue IgE levels was evaluated, taking allergic and nonallergic patients into special consideration.

Out of 33 patients, 56% developed complete aspirin tolerance or tolerated higher dosages (18%) after 24 weeks of omalizumab treatment. Polyp size and disease-specific symptoms, such as rhinorrhea, nasal blockage/discharge, ear fulness, facial pressure, clearly improved in all patients irrespective of aspirin tolerance after 6 months. While lung function data demonstrated only mild improvements during therapy, asthma symptoms improved in all patients. Of note, the improvement of symptoms and induction of aspirin tolerance occurred in both allergic and nonallergic patients. Whereas clinical effectiveness of omalizumab was accompanied by an increase in mean total serum IgE as well as a decrease in eosinophilic activation in all patients, the authors found a significant reduction in the number of tissue eosinophils only in allergic patients.

This is the first prospective study to demonstrate successful omalizumab-induced aspirin tolerance in N-ERD patients independent of their allergic sensitization status. Omalizumab demonstrated overall clinical effectiveness also in N-ERD patients who remain aspirin intolerant under treatment and can therefore be an overall promising treatment option in N-ERD patients.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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