Omalizumab can serve as a bridge to immunotherapy in severe asthma

Author: M. Sandhu, M.D.; V. Dimov, M.D., Allergist/Immunologist and Assistant Professor at University of Chicago
Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at LSU (Shreveport) Department of Allergy and Immunology

A 14-year-old African American male is referred to the allergy clinic with a severe persistent asthma that is poorly controlled on maximum dose inhaled corticosteroids and a long acting beta-agonist. The patient required oral steroids on 4 separate occasions in the past 2 years.

Past medical history (PMH)

Severe persistent asthma, allergic rhinitis.


Advair 500/50 one inhalation BID, Singulair 10 mg po daily, albuterol prn, Rhinocort daily, loratidine 10 mg po daily.

Physical examination

Skin: no rashes, keratosis, excoriations, or lichenifications.
HEENT: pale boggy turbinates (B).
Chest: slightly decreased air entry (B).
CVS: Clear S1S2.
Abdomen: Soft, NT, ND, +BS.
Extremities: no c/c/e.

What diagnostic tests would you suggest?

His FEV1 values ranged widely from as low as 55% to as high as 89% predicted with the higher FEV1 measurements representing recent oral steroid administration. The average FEV1 excluding those values due to oral steroid administration was 68% predicted. The average ACT score was 21.6

What happened?

Our patient was started on omalizumab and his condition stabilized. Allergen immunotherapy was added 5 months later. The patient was initially built up on immunotherapy followed by monthly maintenance doses. The total overlap period of immunotherapy and omalizumab was 19 months.

The average FEV1 during the 19 month overlap phase was 86% predicted and average ACT score was 23.8. During this time the patient had no ER visits, oral steroid doses or adverse reactions to immunotherapy.

What happened next?

Omalizumab was discontinued after 2 years. The patient has been maintained on immunotherapy alone since that time and has maintained this benefit with an average FEV1 of 103%. His average ACT score has been 23.5, with no oral steroid use. Because of overall improvement, his ICS were tapered from high to medium dose. Currently, the patient’s regimen consists of a medium dose inhaled steroid with a long acting beta- agonist, montelukast, and monthly maintenance immunotherapy.

Final diagnosis

Use of Omalizumab as a bridge to immunotherapy in severe asthma.


Asthma is the most common chronic respiratory disease, affecting up to 10% of adults and 30% of children (JACI, 2011). Allergen immunotherapy was introduced by Leonard Noon 100 years ago and is the only disease-modifying treatment for allergic individuals (Allergy, 2012).

Both allergen immunotherapy (IT) and omalizumab (anti-IgE antibody) are used to treat persistent perennial allergic asthma. Allergen immunotherapy can lead to long lasting improvement with a typical regimen lasting a set time period of 3-5 years. More severe asthmatic patients are at greater risk for serious and potentially life threatening reactions with allergen immunotherapy. Omalizumab treats perennial allergic asthma, acts synergistically with allergen immunotherapy and reduces anaphylactic reactions associated with immunotherapy. Allergic asthma improvements associated with omalizumab are generally present only while on therapy, and thus therapy may continue indefinitely. Our use of omalizumab is as a bridge to immunotherapy making immunotherapy more effective and safer in high risk severe asthmatics.

Severe asthma - differential diagnosis and management (click to enlarge the image).


Response to omalizumab after 16 weeks is a predictor of continuing persistent response to omalizumab in asthmatics. Allergy 2011.
Immunotherapy can reduce asthma symptoms and it is possibly as effective as inhaled steroids - Cochrane, 2010.

Published: 03/19/2010
Updated: 01/19/2012

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