A unique solution for severe asthma. Dr Talker Olga Pulmonary department. C ase Presentation, 10.2009: . 48 year old lady, teacher at school Married +7 s/p op. d/t scoliosis at age 17 No smoking history Family history of severe asthma Allergy to dust mites
A unique solution for severe asthma.Dr Talker OlgaPulmonary department
48 year old lady, teacher at school
s/p op. d/t scoliosis at age 17
No smoking history
Family history of severe asthma
Allergy to dust mites
Severe asthma with recurrent exacerbations, recurrent prolonged courses of oral steroids, prednisone 30-40 mg.
Normal CXR, normal ECHO, p-ANCA, c-ANCA- normal
High eosinophil count-1100
Stool examination- no parasites
PFT- obstructive pattern with FEV1- 60%
Treatment- Prednisone, Seretide 500, Foradil, Flixonase, Omepradex.
What is to be done?
Severe asthma- disease that requires high dose inhaled or near continuous oral glucocorticoid treatment to maintain asthma control.
Ongoing exposure to triggers
Alternative disorder that mimics asthma
Ongoing exposure to triggers:
allergens, irritants at patient’s home, school, work-laboratory animals, latex, glutaraldehide, toluene diisocyanate, flour, NSAID’s, beta-blockers.
Conditions that mimic asthma:
Vocal cord dysfunction( combination of inspiratory flow volume loop and laryngoscopy during symptoms), vocal cord paralysis, vocal cord lesions.
Central airway obstruction- tracheal strictures, tracheal copmpression by goiter, thracheal and proximal bronchial tumors, vascular rings( CT, bronchoscopy)
COPD- greater than 20 p.y. smoking history, family history of emphysema or alpha-1 antitrypsin deficiency, irreversible airflow obstruction and low diffusing capacity.
Bronchiectasis- copious productive cough, refractory to bronchodilator therapy, HRCT.
ABPA may develop patients with asthma d/t colonization of the airways with aspergillus and typically present with recurrent mucoid impaction and atelectasis, proximal bronchiectasis, skin test positive to aspergillus, elevated IgE (>1000 ng/ml).
Hypersensitivity pneumonitis- exposure to allergens- birds, barns, humidifiers, PFT- mixed obstructive and restrictive pattern, reduced DLCO, fleeting infiltrates.
Eosinophilia and respiratory sypmtoms: filariasis, trichinellosis, strongiloides infection- patients from endemic area, blood eosinophilia, elevated IgE, specific IgG to parasites, improvement with specific treatment.
Paranasal sinus disease, skin lesions, peripheral neuropathy, eosynophilia > 10% is common in Churg-Strauss s-me, p-ANCA positive.
Chronic eosinophilic pneumonia- fever, weight loss, night sweats, pulmonary infiltrates.
Endobronchialsarcoidosis- hylaradenopathy and interstitial opacities.
Cardiac disease- echocardiography.
Chronic rhinosinusitis, allergic rhinitis
Anxiety , depression.
IgE- 80 u/ml
Started Xolair- monoclonal anti-IgE antibody, 225 mg every two weeks
Prednisone tapering down
Receiving Xolair 225 mg every two weeks
PFT- FEV1- 75%
Holgate ST. QJM 1998
Omalizumab (~150 kD)
IgE (~190 kD)
(~490 kD- 530 kD)
Median free IgE (ng/mL)
Day 1 post-dose
Days (not to scale)
Day 0 = screening (n=93)
Source: Extension Study Report 8C
Humbert M, et al. Allergy 2005
* P = 0.04, ** P = 0.002, *** P = 0.038
†Change from baseline (least squares mean)
AQLQ = Asthma Quality of Life Questionnaire
Humbert M, et al. Allergy 2005
*For children older than 5 years, adolescents and adults†Receptor antagonist or synthesis inhibitor
ICS = inhaled corticosteroid; LABA = long-acting β2-agonist
GINA Workshop Report 2007
Omalizumab is effective add-on treatment in patients with moderate to severe allergic asthma and accompany by an acceptable safety profile.