Correspondence
Omalizumab for Asthma
N Engl J Med 2006; 355:1281-1282September 21, 2006
- Article
To the Editor:
Strunk and Bloomberg (June 22 issue)1 discuss omalizumab for the treatment of asthma associated with high serum IgE levels. We provided care for a man who received omalizumab and in whom the Churg–Strauss syndrome subsequently developed.
Our patient was a 55-year-old man with a history of asthma who presented with acute onset of numbness and tingling in his extremities. A neurologic examination was notable for hyporeflexia. The patient had a purpuric rash on both lower extremities. A pulmonary examination was unremarkable. The white-cell count was 23.1×103 per microliter with 47% eosinophils. Skin biopsy revealed a leukocytoclastic vasculitis with an eosinophilic infiltrate (Figure 1Figure 1
Photomicrograph of Skin-Biopsy Sample Showing Inflammation of Small Blood Vessels and Prominent Perivascular Infiltration with Eosinophils (Arrows) (Hematoxylin and Eosin).). The patient was treated with intravenous methylprednisolone. His symptoms improved, treatment was changed to oral prednisone, and he was discharged several days later. Cyclophosphamide was added to outpatient therapy.Our review of the literature yielded many articles discussing the association between leukotriene-receptor antagonists2-4 and the Churg–Strauss syndrome but none associating this disease with omalizumab. To our knowledge, this is the first description of a temporal association between the use of this drug and the development of the Churg–Strauss syndrome.
4 ReferencesDavid E. Winchester, M.D.
Ashok Jacob, M.D.
Tom Murphy, M.D.
University of Virginia Health System, Charlottesville, VA 22908-06961
Strunk RC ,Bloomberg GR . Omalizumab for asthma. N Engl J Med 2006;354:2689-2695
Full Text | Web of Science | Medline2
Wechsler ME ,Garpestad E ,Flier SR , et al. Pulmonary infiltrates, eosinophilia, and cardiomyopathy following corticosteroid withdrawal in patients with asthma receiving zafirlukast. JAMA 1998;279:455-457
CrossRef | Web of Science | Medline3
Stirling RG ,Chung KF . Leukotriene antagonists and Churg-Strauss syndrome: the smoking gun. Thorax 1999;54:865-866
CrossRef | Web of Science | Medline4
Kobayashi S ,Ishizuka S ,Tamura N ,Takaya M ,Kaneda K ,Hashimoto H . Churg-Strauss syndrome (CSS) in a patient receiving pranlukast. Clin Rheumatol 2003;22:491-492
CrossRef | Web of Science | Medline
To the Editor:
The efficacy and safety of omalizumab for severe asthma have been reviewed.1,2 We report two unexpected consequences of omalizumab among 16 patients with allergic asthma treated for at least 6 months. The first patient had allergic asthma, aspirin intolerance, and stabilized nasal polyposis. He received 10 mg of prednisolone per day, 2000 μg of fluticasone per day, and a long-acting β2 agonist. With omalizumab (300 mg every 2 weeks), his asthma was brought under control (regimen at 6 months: 500 μg of fluticasone per day and 100 μg of salmeterol per day), but the patient reported a recurrence of obstructive nasal polyposis.
The second patient had uncontrolled severe allergic asthma treated with 2000 μg of fluticasone per day and 200 μg of salmeterol per day. She received eight short courses of systemic corticosteroids per year. Omalizumab (250 mg every 2 weeks) was initiated in January 2006. After 3 months, her asthma was controlled. Six weeks later, she was found to have subacute adrenal insufficiency. Exhaustive questioning revealed that the patient had received two intramuscular injections of 80 mg of triamcinolone acetonide, the last one in November 2005.
The possibility of paradoxical complications of successful treatment with omalizumab, induced by the rapid reduction of glucocorticoids, must be considered.
André-Bernard Tonnel, M.D.
Isabelle Tillie-Leblond, M.D., Ph.D.
Calmette University Hospital of Lille, 59037 Lille, France
ab-tonnel@chru-lille.fr Drs. Tonnel and Tillie-Leblond report having received consulting fees from GlaxoSmithKline, AstraZeneca, Novartis, and Boehringer Ingelheim, and consulting fees from Merck Sharp & Dohme.
2 References1
Busse W ,Corren J ,Lanier BQ , et al. Omalizumab, anti-IgE recombinant humanized monoclonal antibody, for the treatment of severe allergic asthma. J Allergy Clin Immunol 2001;108:184-190
CrossRef | Web of Science | Medline2
Berger W ,Gupta N ,McAlary M ,Fowler-Taylor A . Evaluation of long-term safety of the anti-IgE antibody, omalizumab, in children with allergic asthma. Ann Allergy Asthma Immunol 2003;91:182-188
CrossRef | Web of Science | Medline
- Citing Articles (20)
Citing Articles
1
J. Sanchez, R. Ramirez, S. Diez, S. Sus, A. Echenique, M. Olivarez, R. Cardona. (2012) Omalizumab beyond asthma. Allergologia et Immunopathologia
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Ricardo Tan, Jonathan Corren. (2011) Omalizumab in the treatment of asthma. Expert Review of Respiratory Medicine 5:6, 747-756
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C. Francès, N. Kluger, M.-S. Doutre. (2011) Vasculitis cutáneas y cutaneosistémicas. EMC - Dermatología 45:4, 1-20
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Christian Pagnoux, Loïc Guillevin. (2010) Churg–Strauss syndrome: evidence for disease subtypes?. Current Opinion in Rheumatology 22:1, 21-28
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Maria Francesca Spina, Antonio Miadonna. (2009) Role of omalizumab and steroids in Churg-Strauss syndrome. Journal of Allergy and Clinical Immunology 124:3, 600-601
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M. Cazzola, M. Mura, A. Segreti, M. A. Mattei, P. Rogliani. (2009) Eosinophilic pneumonia in an asthmatic patient treated with omalizumab therapy: forme-fruste of Churg-Strauss syndrome?. Allergy 64:9, 1389-1390
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Renato A. Sinico, Paolo Bottero. (2009) Churg–Strauss angiitis. Best Practice & Research Clinical Rheumatology 23:3, 355-366
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Jean-Emmanuel Kahn, Olivier Blétry, Loïc Guillevin. (2008) Hypereosinophilic syndromes. Best Practice & Research Clinical Rheumatology 22:5, 863-882
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Xavier Puéchal, Philippe Rivereau, François Vinchon. (2008) Churg–Strauss syndrome associated with omalizumab. European Journal of Internal Medicine 19:5, 364-366
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Anne-Marie Ruppert, Daniela Stanciu, Nicolas Deroide, Frédéric de Blay. (2008) Reply. Journal of Allergy and Clinical Immunology 122:1, 217-218
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Pedro Giavina-Bianchi, Mara Giavina-Bianchi, Rosana Agondi, Jorge Kalil. (2008) Omalizumab and Churg-Strauss syndrome. Journal of Allergy and Clinical Immunology 122:1, 217
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Thomas A Luger, Martin Steinhoff. 2008. Experimental therapeutic strategies for thetreatment of atopic dermatitis. , 247-260.
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Anne-Marie Ruppert, Gerlinde Averous, Daniela Stanciu, Nicolas Deroide, Sophie Riehm, Vincent Poindron, Gabrielle Pauli, Christian Debry, Frédéric de Blay. (2008) Development of Churg-Strauss syndrome with controlled asthma during omalizumab treatment. Journal of Allergy and Clinical Immunology 121:1, 253-254
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Pedro Giavina-Bianchi, Rosana Agondi, Jorge Kalil. (2008) One Year Administration of Anti-IgE to a Patient with Churg-Strauss Syndrome. International Archives of Allergy and Immunology 146:2, 176-176
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Chetan Mukhtyar, Antoni Chan, Raashid Luqmani. (2007) Update on the use of biologics in primary systemic vasculitides. Expert Review of Clinical Immunology 3:6, 901-911
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Oliver Noga, Meike Probst, Gerald Hanf. (2007) Reply. Journal of Allergy and Clinical Immunology 119:5, 1279-1280
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Pedro Giavina-Bianchi, Mara Giavina-Bianchi, Rosana Agondi, Jorge Kalil. (2007) Three months' administration of anti-IgE to a patient with Churg-Strauss syndrome. Journal of Allergy and Clinical Immunology 119:5, 1279
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(2007) Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiology and Drug Safety 16:4, i-xii
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Christian Pagnoux, Philippe Guilpain, Loïc Guillevin. (2007) Churg–Strauss syndrome. Current Opinion in Rheumatology 19:1, 25-32
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Tomoki ORIGUCHI, Kunihiro ICHINOSE, Mami TAMAI, Hideki NAKAMURA, Atsushi KAWAKAMI, Katsumi EGUCHI. (2007) Progress in pathogenesis and therapy of vasculitis syndrome. Japanese Journal of Clinical Immunology 30:6, 432-443
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