Xolair for Chronic Urticaria and Asthma

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Xolair (omalizumab) is a injectable medicine which is given every 2-4 week under the skin. It was approved by FDA in 2003 for management of chronic moderate to severe allergic asthma. It has been recently approved by FDA to be used in treatment of chronic hives in patients who don’t respond to antihistamines.

Xolair in Urticaria

Many patients with chronic urticarial appear to respond to usual doses of allergy medications like Claritin, Allegra, Zyrtec, desloratidine or levocetirizine. There are patients who need up to 4 times the usual doses of these antihistamines, or need H2 blockers like cimetidine or ranitidine or leukotriene inhibitors like Singulair or Accolate.

Despite trying these medications, some patients will continue to experience hives. Prior to the availability of Xolair, patient received variety of medications including antidepressants like doxepin, inflammatory or immunosuppressive drugs like corticosteroid, dapsone, cyclosporine and mycophenolate. There is a long list of medications and non-medication therapies available to treat urticarial many of them have been tried in few patients only. Sometimes these drugs help but patients experience difficulty to manage side effects.

What To Expect

Availability of Xolair for urticarial has improved the lives of many patients. It improves hives by 40-50% of the patients. Some patients may see relief as early as week one. 40-50% patients become hive free in 4-12 weeks.

Side Effects of Xolair

There have been a lot of experience with Xolair in asthma treatment with more than 75,000 doses being given. More than 1,000 patients with chronic hives have also received Xolair. As the drug was approved for hives in 2014, more patients will use the drug and find it useful.

Major side effect is anaphylaxis which occurs in less than 0.5% of the patients. Most reactions occur after the first few injections, occasionally afterwards. Because of the risk of these reactions, the drug is only given in a healthcare facility. Patient need to wait for 2-3 hours in the office after the 1st injection and 1-2 hours after subsequent injections.

When to Use Xolair in Chronic Hives

Xolair is used in chronic urticarial patients where nothing else works or patient are experiencing side effect with the treatment regimen.

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Immune system consist of two major components:

1. Innate Immunity
2. Adaptive Immunity

The term adaptive immunity is used to refer to part of immune system when one comes across foreign protein or a virus, bacteria and fungi.

Apart from looking at immune system as innate or adaptive immunity, we can think of immune system as composed of various cells and proteins. Each component performs a special task aimed at recognizing foreign material and reacting to it.

The major components of immune system are:

• B-lymphocytes
• T-lymphocytes
• NK cells
• Phagocytes
• Complement

Of more than 150 immunodeficiency disorders recognized so far, antibody account for 65%, phagocyte defect 10%, complement deficiency 5%, and rest 15-20% are due to combined cellular and antibody defects.

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What is Immune System?

Immune system is a part of the body that is involved in defending against foreign material (antigens) i.e. bacteria, viruses, fungi of all kind, allergens, as well as keeping in check unwanted cells or tissues like cancer or transplanted tissue like donor kidney, liver, heart etc.

If one or more pieces of immune system are missing due to whatever reason, patient will experience severe, repeated, persistent and unusual infections. Patients will often say “I am sick all the time” to summarize their conditions. Apart from infections, patients with defective immune experience bread and butter allergy issues as well as higher risk of cancers. They tend to experience autoimmune disorder more often i.e. lupus, rheumatoid arthritis, I.T.P., inflammatory bowel disease etc. You should suspect immunodeficiency if you are experiencing a lot of infections.

How Frequent are Primary Immune Deficiency?

There are more than 200 individual disorders affecting as few as one patient to thousands of patients. Selective IgA immunodeficiency, most common of primary immunodeficiency affects 1 in 500-700 people worldwide. Approximately 0.5 million in U.S. have this disorder.

Most people are aware of HIV infections or AIDS (Acquired Immunodeficiency Disease) but not primary immunodeficiency. Primary immunodeficiency cases are found worldwide and can affect anyone. Many are inherited but not all.

How Can We Help?

Allergists and immunologists are trained to diagnose and find help with the treatment of some relatively benign disorders to life threatening diseases, which may require bone marrow transplant. If diagnosed early, these patients can have healthy lives.

Treatment Options

Depending upon what component of immune system is missing or defective, here are some of the treatment options available:

• Patient who are predisposed to infection with pneumocystis carinii will benefit from bactrim prophylaxis. Many patients will repeat pulmonary and sinus infections need prophylactic antibiotics.
• Intravenous and subcutaneous immunoglobulin therapy in patients with low or non functioning IgG. However, patient with low IgA and low IgM don’t benefit from replacement therapy.
• Many patients benefit from bone marrow transplant, gene therapy and replacement deficient protein i.e. PEG-ADA in patients with AD Adeficiency.
• There may be no treatment available to fix the problem i.e. patients with complement defects may benefit from early diagnose and treatment of infections.

Most importantly, finding what is wrong with the patient can put an end to frustrating search and allow healing to begin.