Omalizumab Add-on Offers Benefit in Allergen Immunotherapy
A recent review paper published in Current Opinion in Allergy and Clinical Immunology suggests that when used in conjunction with allergen immunotherapy, the biologic omalizumab (Xolair) can enhance effectiveness and reduce adverse reactions.
“The use of allergen immunotherapy has been restricted by the possibility of adverse reactions and poor adhesion due to a range of reasons, one of them being the inconvenience caused by the time it takes,” said lead author Jennifer A. Dantzer, MD, MHS, assistant professor of pediatrics, Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland in an interview with Medscape Medical News. “For these reasons, I think having an add-on treatment that would improve safety, improve effectiveness, and speed up the time to sensitization is needed.”
The review also revealed that there are many unanswered questions with respect to optimal dosing duration, patient selection and the long-term benefits of using omalizumab, an antigen against IgE.
Dantzer stated that Omalizumab is a possibility to use in combination with inhalant and venom, as well as an immunotherapy for food allergies. Patients who are at highest risk of having reactions to allergen immunotherapy would be the most obvious group of patients who could get the most benefit from omalizumab as an additional treatment for allergy immunotherapy, she added.
Dantzer said that injectable omalizumab is one of the major obstacles for omalizumab usage. She suggested that the delivery route could pose a problem since certain people don’t want to receive shots every 2–4 weeks.
Dantzer stated that doctors might be interested in the benefits of allergy immunotherapy for patients currently taking omalizumab due to medical reasons.
“I believe we’ve seen it can have some promising results in the treatment of allergic rhinitis as well as allergy and food allergies,” said Dantzer. It is not approved for use as an add-on treatment to allergen immunotherapy but clinicians could consider the results we have found when they have a patient already on the medication, such as for asthma, their hives or considering starting it (omalizumab).
Jay M. Portnoy, MD, Section of Allergy Asthma, Allergy & Immunology and medical director of Telemedicine, Children’s Mercy Hospital, Kansas City, Missouri, described the review as a sufficient overview of the information available about the use of omalizumab for the treatment of oral or injectable immunotherapy. Portnoy was not involved with the review.
“Basically administration decreases the chance of developing reactions during the build-up phase of injection immunotherapy and can permit the oral desensitization to certain foods more quickly and safely,” said Portnoy. “The limitations, which are spelled out, are that the effect is only effective as long as the drug is given. When omalizumab is removed and the symptoms are reactivated.”
“Another factor that wasn’t emphasized is that omalizumab can be very expensive, and therefore no health insurance plan will cover the cost to be used in this manner,” said Portnoy. The use of this adjuvant therapy is likely to remain a test subject until the patient is extremely wealthy.
Joseph T. Inglefield III MD is a doctor who is board-certified in allergy immunology and director of Hickory Allergy Asthma Clinic, Hickory (North Carolina) The doctor noted that the review was a thorough review.
“It reviews all the studies using Xolair (omalizumab) in combination with various forms of allergen immunotherapy including oral and subcutaneous regimens,” said Inglefield. “In general, the use of it in conjunction with these different schedules improves outcomes in terms of the relief of symptoms and tolerance to food items that cause severe reactions. It’s not surprising that it could aid in accelerating the rate of relief and decreasing reactions, both mild or severe.
Inglefield The researcher, who isn’t among the review authors, noted in a number of studies that the withdrawal of the combination therapy omalizumab resulted in more reactions.
Portnoy and Inglefield both agreed that the high price of omalizumab is likely to limit its use. However, Inglefield said he would still consider subcutaneous immunotherapy using Omalizumab if it was less expensive.
“Basically the premedication of steroids and antihistamines allows us to give multiple injections about every 15 minutes to achieve tolerance to allergens that are provided,” said Inglefield. “I would definitely like to use Xolair as a premedication, but it is not approved for this and it’s expensive. The insurance companies won’t cover reimbursement.
Inglefield, Portnoy and Dantzer have not disclosed any relevant financial relationships.
Curr Opin Immunol. Published December 20,21 issue. Abstract
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