Omalizumab proving to be effective in patients with normal IgE levels & refractory asthma,

BackgroundTo assess the response of Omalizumab in patients with normal IgE levels regards asthma control & quality of life MethodsA 38yr old female physician with childhood asthma from 5yrs, later developing into adulthood as severe uncontrolled asthma on high dose salmeterol/fluticasone 500mcg BD,anti-cholinergics,aminophylline,on nasal steroids & antihistamines for rhinitis control,antireflux measures with frequent need for  nebulizations & subcutaneous sympathomimetics during severe attacks with high doses of 80mg to 60 mg of oral steroids.There is H/o atopy, eczema, allergic rhinitis & asthma in family.Work up for ABPA, carcinoid & endocrinopathies was negative. H/o intubation thrice since2002& steroid reduction not possible.In 2006Methotrexate 20-25mg weekly  achieved a steroid reduction of up to 10mg/day after 6mths.In 2008 she developed methotrexate alveolitis by HRCT which was treated with iv methylprednisolone &  high oral steroids with resolution in  subsequent follow up CT after stopping MethotrexateResults Inspite of normal IgE levels & negative specific IgE to common aeroallergens Omalizumab started at a moderate dose of 225mg sc every 2weeks for 6months, showed a significant improvement in asthma control & rhinitis, no nocturnal symptoms, only once needed prn salbutamol, modest improvement in lung function, asthma control test scores up from 5 to 22 with half dose of oral steroids, eczema disappeared. After 6 months, omalizumab stopped due to economic reasons during which her symptoms recurred, to resolve again after a month when it was restarted  ConclusionThis beneficial effect of omalizumab may be attributed to either long-term steroid use suppressing IgE or to the production of local IgE complexes in the pulmonary system and local pulmonary steroid resistance .This expands the role of Omalizumab & modifies the indication from the use of the drug based on purely IgE levels as a parameter to patients symptoms and clinical improvement as an important factor.References1.Omalizumab (Xolair) in patients with steroid-resistant asthma:Lessons to be learnt ,Philip j.thompson,neil l.misso & john woods Respirology (2007) 12 (suppl.3),s29–s34. Ref No2.Benefits of omalizumab as add-on therapy in patients with severe persistent asthma who are inadequately controlled despite best available therapy (GINA 2002step 4 treatment)INNOVATE, M.Humbert,R.Beasley,J.Ayres, R.Slavin,J.H bert,J.Bousquet,Allergy 2005:60:309–316