The relationship between allergen immunotherapy and omalizumab for treating asthma

Abstract

Allergen-specific immunotherapy (AIT) is considered the only treatment capable of modifying the natural history of allergic respiratory disorders. The possible adverse events related to AIT have, until now, limited its use to mild and controlled asthma. The pre-administration or concomitant treatment of AIT and omalizumab (an anti-IgE humanized antibody), recommended for the treatment of severe allergic asthma, could be useful in reducing the adverse events due to AIT and to allow its use in patients with more severe or uncontrolled asthma. AIT/omalizumab combination has been explored in a few trials on asthma patients and also in other allergic disorders, such as rhinitis, hymenoptera systemic reaction and food allergy with significant results. We are at the beginning a new era where phenotype/endotype-based treatment will be associated with drug mass therapy and/or nonpharmacological phenotype/endotype-driven treatment to optimize disease control and/or to make the use of other treatments safer.

Keywords:

• asthma
• IgE
• omalizumab
• outcomes
• specific immunotherapy

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Asthma drugs can effectively control the disease symptoms in a great percentage of patients, but they do not affect the natural history of the disease.

• Despite the moderate and low quality of evidence, allergen-specific immunotherapy (AIT) is considered the only real curative modality in allergic asthma.

• Omalizumab is the first biotechnological drug used for treating allergy-related asthma.

• The concomitant treatment with AIT and omalizumab has been proved to be useful in reducing the adverse event due to AIT and to allow use of AIT in patients with incompletely controlled asthma.

• Clinical trials exploring the effect of omalizumab before or concomitant with AIT administration reported an improvement as regards reduction of symptom severity and asthma control.

• The impact of combining AIT and omalizumab on health-related quality of life needs to be further explored in order to show a significant improvement from patients’ perspective.

• The net balance of omalizumab plus AIT approach must consider both the costs of treatments and the costs avoided such as those associated with treating systemic allergic reactions and asthma exacerbations.

• The evidence for the combination of omalizumab and allergen immunotherapy is low, especially in severe asthma, and it is still not labeled as a pretreatment to improve tolerance of allergen immunotherapy, although it may be valuable in this indication.

• Until now, omalizumab is added to AIT not only in severe asthma but also in venom immunotherapy and food allergy. More studies are necessary to investigate this combination treatment in terms of efficacy, safety and specific pathophysiological mechanisms.