Monitoring Advanced Therapies for CIndU in Clinical Practice

In "Monitoring Advanced Therapies for CIndU in Clinical Practice," the panel walks through the checkpoints that make clinicians comfortable prescribing.

Dr. Cotter notes that the panel has focused on omalizumab, dupilumab, and remibrutinib, with remibrutinib now approved for symptomatic dermographism. He asks what monitoring, required or not, helps clinicians feel confident using these agents.

Dr. Finklea explains that none of the three requires mandatory laboratory monitoring. For omalizumab, her clinic administers the first three injections in office and watches for signs of anaphylaxis. Afterward, patients can inject at home. She may prescribe an epinephrine auto-injector, especially for patients with asthma or a history of facial or airway angioedema.

For dupilumab, she monitors for ocular surface disease, injection-site reactions, and possible viral infections. For remibrutinib, she watches for bleeding, counsels patients ahead of invasive procedures, and screens for concomitant antithrombotics. She also checks for strong CYP3A4 inducers or inhibitors. For patients unsure of their supplements, she reviews anything that could affect coagulation.

She also confirms that patients starting remibrutinib do not have severe liver disease. The drug does not cause liver dysfunction, but severe hepatic impairment is a reason to avoid it. Dr. Cotter asks her to define severe. She clarifies that mild transaminase elevations, fatty liver disease, or transient changes from a viral illness are not the concern. She is referring to cirrhosis and severe hepatic damage.

Dr. Cotter then asks Dr. Trotter whether she prescribes epinephrine auto-injectors to every omalizumab patient. She does. The practice began early, when omalizumab was new, and continues because patients know about the risk even though it is small. Concern is greater in patients with prior anaphylaxis. She frames the prescription as precautionary, trains office staff on protocols, and finds that insurance coverage gives patients additional peace of mind.

The next episode in this series, "Personalizing Advanced Therapy Selection for CIndU Subtypes," features the panel matching patient phenotypes to therapy.