Treatment with a Combination of Omalizumab and Specific Immunotherapy for Severe Anaphylaxis after a Wasp Sting

Abstract

Hymenoptera venom anaphylaxis after bee or wasp sting is a common problem that affects about 1.2 percent to 3.5 percent of the general population. Venom-specific immunotherapy (VIT) is an established mode of treatment for immunoglobulin (Ig) E-mediated Hymenoptera venom allergy. However, VIT may often be associated with immediate anaphylaxis which can lead to treatment withdrawal. Several cases published in recent years suggest that omalizumab, used as add-on therapy may be able to prevent anaphylaxis during VIT. We report the case of a 30-year-old woman, suffering from mild persistent asthma, who had a history of severe anaphylactic reactions after yellow jacket sting, and after eating peanuts, contact with guinea pig hair, and i.v. administration of dexamethasone natrium phosphate. Initial specific immunotherapy had to be stopped due to severe anaphylaxis (hypotension, dyspnea, and angioedema). The immunotherapy was reintroduced accompanied by the anti-immunoglobulin (Ig) E monoclonal antibody omalizumab. Subcutaneous omalizumab 150 mg was initiated 4 weeks after the anaphylaxis incident and 1 day before the resumption of VIT. Rush treatment was uneventful, and the usual cumulative dose of 111.1 microg was successfully reached. The combination of omalizumab and VIT is a valid option of therapy for these patients and could reduce asthma and food allergy symptoms.

Overcoming severe adverse reactions to venom immunotherapy using anti‐IgE antibodies in combination with a high maintenance dose

“…Meanwhile, a number case reports have been published that report the use of omalizumab in Hymenoptera venom allergic patients on VIT . Treatment protocols using omalizumab in patients not tolerating VIT vary widely, and a standard regimen is not yet available; corresponding outcomes are inconsistent.…”

“…In some patients, omalizumab was found to prevent side‐effects of VIT. This prevention, however, required an ongoing omalizumab therapy . If the omalizumab dose was reduced, systemic reactions promptly recurred …”

Dose-dependence of protection from systemic reactions to venom immunotherapy by omalizumab

“…In previous reports, the minimal effective dose of omalizumab to protect from systemic reactions to VIT was 150 mg [10], thus the search of the protective dose should start from 150 mg, with increase to 300 mg and, possibly, to 450 mg in case of incomplete protection. The most appropriate combination therapy including also corticosteroids and antihistamines is not yet established and needs be investigated.…”

The use of omalizumab in allergen immunotherapy

“…While there have been no randomized controlled trials evaluating the addition of omalizumab to venom IT, several case reports and small patient series have been published on the use of omalizumab with venom IT, using a variety of treatment protocols with regard to both venom IT and omalizumab dosing . While some case reports have not shown benefit, most have suggested that the addition of pre‐treatment and/or maintenance omalizumab decreased the risk of systemic reactions during venom IT in high‐risk patients, including some individuals with mastocytosis …”