Which Food Allergy Patients Will Benefit Most From Omalizumab?

Data presented at the recent American Academy of Allergy, Asthma & Immunology annual meeting showed that routine injections of omalizumab (Xolair) slashed the severity of allergic reactions to peanuts and other foods — such as milk, eggs, and wheat — in adults and children as young as 1 year.

In this exclusive MedPage Today video, Bruce J. Lanser, MD, MPH, director of the Pediatric Food Allergy Program at National Jewish Health, discusses the nuances behind deciding which patients might be the best candidates for this novel treatment.

Following is a transcript of his remarks:

Almost overnight, we’ve gone from having very few options in terms of treatment or management for pediatric and adult food allergies, and now with this approval, it’s a huge game changer that we have a medicine that will protect folks from an allergic reaction to the things that they’re allergic to. And it is absolutely going to be a huge shift in terms of what we do as food allergists.

A lot of patients called on the day it was approved, the week following, because they were excited about it. They wanted the opportunity and they wanted to take advantage of that protection that it can offer. And so being prepared to answer those questions and talk about what is the benefit of it potentially, what are the, I think limited, but potential side effects or risks. And the biggest question that I’ve gotten or heard, really, from other providers is, well, who’s a good candidate? And I think that is kind of a nuanced issue that we will, I think, tease out over time.

There’s almost nobody who isn’t potentially a good candidate, so long as they have IgE [immunoglobulin E]-mediated or Type 1 allergic reactions to food, if that is the diagnosis. And so assuming that you have the right diagnosis for your patient. Younger kids who are afraid of shots, they might not be great candidates, but surprisingly in the trial, young kids did very well and they tolerated it better than some of the older kids did. So needle phobia would be one very real issue to kind of overcome.

There’s some folks who might not need it either because their threshold of reaction — or the amount that they can tolerate before triggers of reaction — is so high. They may have only one food, which isn’t necessarily an exclusion, but certain foods are relatively easy to avoid and [have] low risk for an accidental exposure, and so why would you necessarily go through this monthly or twice-monthly treatment to prevent something that’s very, very rare?

And overall yes, fatalities are certainly fortunately very rare. Anaphylaxis is not common, but it does occur. And allergic reactions, of course, not involving anaphylaxis, are even more common. So if you can prevent those, that is a huge reduction in time spent in the ER [emergency room], costs to these families, time away from work or school, and certainly worry and anxiety.

And so the key factors that are the drivers to say, who do I think should get this treatment? There’s a group of teenagers who have milk or egg allergy where avoiding those foods is nearly impossible and they try their hardest, and once or twice a year or more, they have a reaction despite every best effort. For some adults, fish and shellfish can be very difficult to avoid, and they can have frequent reactions to those. That might be a good reason for some folks. Multiple foods where you’re avoiding seeds and nuts and many other things. Seeds are hard to avoid, you can’t see them, they’re difficult to distinguish. The whole sesame labeling controversy that has developed since January 1st has shown that that’s not an easy food to avoid. And so that could be one reason. But the other very real, but not as tangible, is the stress and anxiety and the families who are really debilitated by fear. And no matter how real that risk is, that can be a reason to let them be able to start living their life.

I think it is absolutely ready for primetime and for the real world. It’s just the nuance of who’s going to benefit the most or who is a good candidate per se, varies, I think. And that’s something you tease out over time. There’s not a study that could necessarily tell you that in this case, it’s just a level of detail that you gain with experience.

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