Biologic Treatment Considerations for Asthma During the COVID-19 Pandemic and the Upcoming Flu Season - Episode 8

Patient Factors That Determine the Use of Omalizumab in Asthma

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Stanley Goldstein, MD: Shahzad, you mentioned that we have biologics approved down to the age of six, and in allergic asthma, we have omalizumab approved down to the age of six. It’s indicated for those patients who have a perennial allergen, continue to be uncontrolled on inhaled corticosteroids and may be taking another controller, and obviously they’re showing a decrease in exacerbations.

The question always comes up, we see patients who have allergic asthma and non-allergic asthma. Omalizumab has been present for the last 18 years. It was approved in the early 2000s, and it was the only standalone biologic for many years up until maybe five or six years ago, when the eosinophilic phenotypic asthma biologics became available. We know that there were both allergic and non-allergic asthma patients being treated with a biologic indicated for, so to speak, allergic asthma.

What’s the data on that? It’s interesting. There was a recent study, probably not so recent anymore, maybe two to three years ago, called the PROSPERO study, which was a prospective look in a real-world situation, looking at patients who were treated with omalizumab. In order to be in that study, patients had to be approved for omalizumab, and they looked at 48 weeks of patients who had a response. Response could have been improvement in lung function, decrease in exacerbations, or a decrease in their Asthma Control Test scores. Actually, 80% of patients had a response to omalizumab.

The interesting thing about that is that within those patient populations, they found patients who were used out of the specific total IgE that omalizumab is approved for. Right now, it’s approved in the United States for 12 and above, for those patients who have a total IgE of 30 up until 700, and there’s a grid which helps you decide what dosage to use of omalizumab. But we know in the prospective study, PROSPERO, they had patients who fell out of those total IgE, with either low IgE, under 30, or high IgE, above 700, and these patients also showed a response.

There’s this question, can you have a non-allergic asthmatic respond to omalizumab? There was a Spanish study called FENOMA which did look at specific patient population, allergic and non-allergic, and they also found there was a significant number of patients in that study which did not have allergic asthma. Obviously, we have choices now, and that’s why we have allergic asthma being treated with omalizumab, and then we have non-allergic asthma being treated with the other patient populations.

Giselle Mosnaim, MD, MS: for the omalizumab, if a patient also has chronic idiopathic urticaria, omalizumab is a very nice choice because then you can treat both the asthma and the chronic idiopathic urticaria. More recently, the omalizumab, after the first four doses in the office, the patient can now self-administer it at home. With COVID, it’s nice that we can have patients self-administer these medications at home. All of the biologics that we are discussing today that are in subcutaneous form, can now be delivered at home. Xolair still needs to be delivered in the office for the first four doses, and if that goes well, then it can be transitioned to home. The reslizumab is intravenous, so that cannot be delivered at home. But the home delivery has been a huge help with COVID, so that’s a big advantage in terms of options. So that’s a big factor that I talk about with patients, is dosing, their comfort level with the dosing. We do a visit in the office with the patient and a nurse to make sure that they are comfortable with self-administration. For the omalizumab or for some of the others, we’re going to get into it with dupilumab, some of the things that you need to do in terms of storing the medication, if you need to allow it to come to a certain temperature before administration. Some of these issues are important in shared decision-making.

Transcript Edited for Clarity