Omalizumab for Asthma
http://www.100md.com
《新英格兰医药杂志》
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 23.1x103 per microliter with 47% eosinophils. Skin biopsy revealed a leukocytoclastic vasculitis with an eosinophilic infiltrate (Figure 1). 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.
Figure 1. Photomicrograph of Skin-Biopsy Sample Showing Inflammation of Small Blood Vessels and Prominent Perivascular Infiltration with Eosinophils (Arrows) (Hematoxylin and Eosin).
Our review of the literature yielded many articles discussing the association between leukotriene-receptor antagonists2,3,4 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.
David E. Winchester, M.D.
Ashok Jacob, M.D.
Tom Murphy, M.D.
University of Virginia Health System
Charlottesville, VA 22908-0696
References
Strunk RC, Bloomberg GR. Omalizumab for asthma. N Engl J Med 2006;354:2689-2695.
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.
Stirling RG, Chung KF. Leukotriene antagonists and Churg-Strauss syndrome: the smoking gun. Thorax 1999;54:865-866.
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.
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 2 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.
References
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.
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.
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 23.1x103 per microliter with 47% eosinophils. Skin biopsy revealed a leukocytoclastic vasculitis with an eosinophilic infiltrate (Figure 1). 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.
Figure 1. Photomicrograph of Skin-Biopsy Sample Showing Inflammation of Small Blood Vessels and Prominent Perivascular Infiltration with Eosinophils (Arrows) (Hematoxylin and Eosin).
Our review of the literature yielded many articles discussing the association between leukotriene-receptor antagonists2,3,4 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.
David E. Winchester, M.D.
Ashok Jacob, M.D.
Tom Murphy, M.D.
University of Virginia Health System
Charlottesville, VA 22908-0696
References
Strunk RC, Bloomberg GR. Omalizumab for asthma. N Engl J Med 2006;354:2689-2695.
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.
Stirling RG, Chung KF. Leukotriene antagonists and Churg-Strauss syndrome: the smoking gun. Thorax 1999;54:865-866.
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.
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 2 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.
References
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.
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.