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Wise et al.

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improves compliance and benefits for INCS, and likely all patient-administered pharmacotherapy. • Harm: Pharmacotherapy other than systemic steroids—minimal harm with rare mild adverse events such as drowsiness. No serious adverse events reported in the studies reviewed. Systemic corticosteroids have significant side effects. • Cost: Generally low cost for pharmacotherapy. • Benefits-Harm Assessment: There is a benefit over placebo for asthma treatment, though no significant benefit is seen over standard asthma pharmacotherapy. Risks of routine use of systemic corticosteroids generally outweighs the benefits, though short courses for acute indications (eg, asthma exacerbation) have a favorable likelihood of benefit relative to harm. • Value Judgments: Pharmacotherapy for AR may also benefit asthma symptoms and objective parameters of pulmonary function in patients with coexisting asthma and AR, however, the benefit for asthma should be considered a positive side effect rather than an indication for use as there appears to be limited benefit compared to standard asthma therapy. • Policy Level: Use of pharmacotherapy other than systemic steroids: Recommended use for optimal control of AR, with potential additional benefit for coexistent asthma, though not recommended for primary intent of asthma treatment. Use of systemic corticosteroid: Not recommended for routine use in AR with comorbid asthma due to unfavorable risk-benefit profile, though certain situations may indicate a short course (eg, acute asthma exacerbation). Biologics: omalizumab.— Omalizumab is an anti-IgE mAb that binds free IgE, preventing interactions with high-affinity IgE receptors and resulting in receptor down regulation on inflammatory cells. 1815 Omalizumab has demonstrated effectiveness separately for asthma as well as AR. 1393,1815-1818 Despite a number of studies evaluating omalizumab in AR or asthma, 1815,1819 there is only 1 double-blind RCT which specifically evaluates the efficacy of omalizumab in patients with concomitant moderate-to-severe asthma and persistent AR. 1820 Additionally, another study evaluates omalizumab as an adjunct to SCIT, 1403 with both studies showing a reduction in symptoms as well as an improvement in QOL measures (Table X.A.4-4). The 2010 ARIA update makes a conditional recommendation of using a mAb against IgE, such as omalizumab for treatment of asthma in patients with both AR and asthma, where there is a clear IgE-dependent allergic component and failure of other maximal therapy. 1167 Additional biologics, including anti IL5, anti-IL4, and IL-4 receptor mAbs, are currently in varying stages of development/ emergence with positive findings for the treatment of asthma and other atopic diseases. Additional evaluation is needed to further evaluate their role for the treatment of coexistent AR and asthma. (See section IX.B.7. Management – Pharmacotherapy – Biologics for additional information on this topic.)

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Biologics recommendations for the treatment of AR with coexisting asthma.

Int Forum Allergy Rhinol . Author manuscript; available in PMC 2020 June 10.