Swelling in woman with idiopathic angioedema eased with omalizumab

Medication is approved for allergic asthma, sinus infections, food allergies, hives

Steve Bryson, PhD avatar

by Steve Bryson, PhD |

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A 46-year-old woman with hard to treat idiopathic angioedema was successfully treated with the asthma and allergies medication omalizumab, which is sold as Xolair, according to a recent case study.

“In the context of isolated [angioedema], even after failure of up-dosed antihistaminic therapy, a trial with omalizumab is advised,” the researchers wrote in “Omalizumab for isolated idiopathic angioedema: A case report and short literature review,” which was published in the Journal of the German Society of Dermatology as a clinical letter.

Angioedema refers to severe swelling caused by fluid building up under the skin and/or in the mucus membranes. The swelling can be triggered by an allergic reaction or occur as a side effect of some medications. Genetic mutations or other health conditions may also lead to angioedema, but there is no apparent cause in some cases, where it’s called idiopathic angioedema.

Xolair is approved for allergic asthma, chronic sinus infections, some types of food allergies, and chronic spontaneous urticaria, a condition marked by recurrent hives that have no known cause. Omalizumab, its active ingredient, is being investigated for idiopathic angioedema.

Omalizumab blocks the interaction between immunoglobulin E (IgE), a type of antibody involved in allergic responses, and certain immune cell receptors. By doing so, it should prevent immune-mediated reactions and reduce allergy symptoms.

Previous Phase 3 trials involving people with chronic spontaneous urticaria, of whom up to 53% had angioedema, showed omalizumab could also ease angioedema symptoms. A small Phase 4 clinical trial also showed that six months of add-on treatment with omalizumab reduced disease activity in four of five treated idiopathic angioedema patients.

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Treating refractory idiopathic angioedema

Here, researchers in Italy described the successful use of omalizumab in a 46-year-old woman with recurrent idiopathic angioedema who began having swelling attacks of the eyelids and lips in 2016 that lasted between 36 to 48 hours, without signs of hives. She had no family history of similar episodes, didn’t carry angioedema-related genetic mutations, and her relevant blood tests were in the normal range. She’d also never used  angiotensin-converting enzyme (ACE) inhibitors, a class of blood pressure-lowering medications that are the most common cause of drug-induced angioedema.

The woman’s IgE blood levels were elevated, however. This was consistent with a history of swelling of the nasal membranes (rhinitis), mild allergic asthma, and atopy, or a tendency to develop allergic diseases, the researchers said. She also showed hypersensitivity to dust mites and cat allergens, but these weren’t linked to her angioedema attacks.

The woman was diagnosed with isolated idiopathic angioedema. Despite treatment, she remained refractory, meaning she didn’t respond to medications like oral antihistamines (up-dosed three times), tranexamic acid, montelukast, and prednisone.

In December 2020, she was started on 300 mg of omalizumab, which was administered as an injection under the skin every four weeks. The treatment’s effectiveness was assessed monthly using the angioedema quality of life tool (AE-QoL).

Her global and fear/shame AE-QoL scores improved substantially by April 2021. She had a swelling attack a few months later after an attempt to reduce the omalizumab dosage, as indicated by a worsening of AE-QoL scores.

In December 2022, the omalizumab treatment at the original dose was extended to every six weeks and she had no further attacks or side effects by the last follow-up in June 2023. She received 32 treatment cycles over 28 months, or more than two years.

“Our experience confirms the real-life effectiveness of omalizumab in a patient with isolated idiopathic [angioedema] refractory to antihistamines with a follow-up of 28 months,” the researchers wrote. “Additional research is needed to verify these results, identify the correct treatment dosage and protocol for such patients, and evaluate the possibility and timing of treatment tapering and discontinuation.”