What therapy is beneficial for a 19-year-old male with severe persistent asthma, treated with high-dose inhaled corticosteroids (ICS) and a long-acting inhaled beta agonist (LABA), with daily wheezing and perennial allergic rhinitis related to cockroach allergy?

From the Guidelines

For a 19-year-old male with severe persistent asthma who remains symptomatic despite high-dose inhaled corticosteroids and a long-acting beta agonist, adding an anti-IgE monoclonal antibody therapy such as omalizumab (Xolair) would be beneficial. This recommendation is based on the National Asthma Education and Prevention Program guidelines, which suggest considering omalizumab for patients with allergies, as seen in this case with perennial allergic rhinitis related to cockroach allergy 1. Omalizumab is specifically indicated for patients with allergic asthma who have demonstrated sensitization to perennial allergens and have inadequate control with standard controller medications.

The typical dosing ranges from 150-375 mg subcutaneously every 2-4 weeks, with the exact dose determined by the patient's weight and serum IgE levels 1. Treatment should be continued long-term as benefits may take several months to fully manifest. Additionally, the patient should continue his current regimen of high-dose ICS and LABA. Environmental control measures to reduce cockroach exposure are also essential, including regular pest control, sealing cracks and crevices, proper food storage, and regular cleaning.

Some key points to consider in the management of this patient include:

• The importance of adherence to current medications and environmental control measures
• The role of omalizumab in reducing exacerbations and improving symptom control in patients with allergic asthma
• The need for regular monitoring and potential step-down therapy if asthma control is achieved for at least three months 1
• The mechanism of action of omalizumab, which works by binding to circulating IgE antibodies, preventing them from attaching to mast cells and basophils, thereby inhibiting the allergic cascade that triggers asthma symptoms.

Overall, the addition of omalizumab to this patient's treatment regimen has the potential to significantly improve his asthma control and quality of life, and is a recommended step according to the National Asthma Education and Prevention Program guidelines.

From the FDA Drug Label

The safety and efficacy of XOLAIR were evaluated in three randomized, double-blind, placebo-controlled, multicenter trials. The trials enrolled patients 12 to 76 years old, with moderate to severe persistent (NHLBI criteria) asthma for at least one year, and a positive skin test reaction to a perennial aeroallergen In all trials, XOLAIR dosing was based on body weight and baseline serum total IgE concentration. In both Asthma Trials 1 and 2 the number of exacerbations per patient was reduced in patients treated with XOLAIR compared with placebo

Omalizumab (XOLAIR) may be beneficial for a 19-year-old male with severe persistent asthma, treated with high-dose inhaled corticosteroids (ICS) and a long-acting inhaled beta agonist (LABA), with daily wheezing and perennial allergic rhinitis related to cockroach allergy.

• The patient's age and asthma severity are within the range of patients studied in the clinical trials.
• The patient has a positive skin test reaction to a perennial aeroallergen (cockroach allergy), which is a criterion for XOLAIR treatment.
• XOLAIR has been shown to reduce the number of asthma exacerbations in patients with moderate to severe persistent asthma. 2 2

From the Research

Therapy for Severe Persistent Asthma with Allergic Rhinitis

The National Asthma Education and Prevention Program guidelines suggest that for a 19-year-old male with severe persistent asthma, treated with high-dose inhaled corticosteroids (ICS) and a long-acting inhaled beta agonist (LABA), experiencing daily wheezing and perennial allergic rhinitis related to cockroach allergy, the following therapies may be beneficial:

• Anti-IL-5 treatment, such as mepolizumab or benralizumab, which target IL-5 and the IL-5 receptor α, respectively, and have been established as effective for severe asthma 3
• Omalizumab, a humanized anti-IgE monoclonal antibody, which binds to free IgE and prevents its binding to specific receptors on the surface of cells, thus preventing the release of immune mediators, and has been shown to be effective in treating allergic asthma and rhinitis 4
• Intranasal corticosteroids (INCS), which have been shown to have a positive effect on asthma outcomes, particularly in combined allergic rhinitis and asthma syndrome (CARAS) 5
• Antihistamines (AHs), which have been shown to have a positive effect on asthma outcomes, particularly in terms of quality of life (QoL) and objective asthma outcomes (OAO) 6

Considerations for Therapy Selection

When selecting a therapy, the following factors should be considered:

• Blood eosinophil count, which is the best-established predictive biomarker of the efficacy of anti-IL-5 treatment 3
• Presence of comorbidities, such as perennial allergic rhinitis related to cockroach allergy
• Longitudinal safety of the therapy
• Interval of injection or administration of the therapy
• Patient's history of response to previous therapies, such as vanillin use several times a day