Concurrent use of omalizumab and dupilumab in a 47-year-old woman with chronic spontaneous urticaria and atopic dermatitis

Design

Case presentation

A 47-year-old woman with a history of multiple allergies and itchy skin presented with a 4-month history of hives after unsuccessful treatment with high-dose antihistamines (fexofenadine 360 mg twice daily) and prednisolone (25 mg daily). The patient reported a Dermatology Life Quality Index (DLQI) score of 25 out of 30, an Urticaria Activity Score in the past 7 days (UAS7) of 35 out of 42, and an Urticaria Control Test (UCT) score of 2 out of 16. She was initiated on omalizumab 300 mg every 4 weeks for chronic spontaneous urticaria (CSU) and prednisone was withdrawn over 3 weeks. After 4 weeks, the patient failed to experience efficacy from omalizumab, prompting a change to a shorter, 2-week treatment interval with the addition of prednisolone 25 mg daily and topical corticosteroids. At 3 months, the patient reported satisfactory effects of omalizumab 300 mg every 2 weeks without the use of prednisolone.

However, omalizumab efficacy ultimately dwindled, despite a dose increase to 450 mg every 3 weeks and the addition of prednisone 12.5 mg daily for skin pain. The patient was diagnosed with concurrent atopic dermatitis (AD) and initiated on dupilumab 600 mg followed by 300 mg every 2 weeks. Dupilumab was taken concurrently with omalizumab 300 mg every 4 weeks and fexofenadine 360 mg twice daily. The patient was also allowed the use of topical corticosteroids and was given prednisolone 12.5 mg with withdrawal over 10 days to bridge dupilumab with omalizumab injections. 

Study Author Conclusions

At the time dupilumab was added to omalizumab, the patient had a DLQI score of 29, UAS7 of 21, and UCT of 0. AD severity was also assessed, using validated tools. The patient had a SCOring Atopic Dermatitis (SCORAD) score of 57.7 out of 103, an Eczema Area and Severity Index (EASI) score of 14.8 out of 72, and a Patient Oriented Eczema Measure (POEM) score of 20 out of 28. Work Productivity and Activity Impairment (WPAI) score was 100% absent from work, the patient usually working full time and with very limited impairment of daily activities.

At follow-up after 12 months, she reported marked improvement of both CSU and AD supported by significant improvement in symptom scores with a DLQI score of 3, UAS of 7, UCT of 12, SCORAD of 19.9, EASI of 2.6, and POEM of 6. The patient had resumed work, full-time, with no absence because of symptoms. Apart from a mild and short itch the day after the dupilumab injection, no side effects of treatment were reported. As of June 2021, the patient reported almost an immediate onset of itch if antihistamines were not taken, indicating the need for continuous treatment.

Case Report: Combination of Omalizumab and Dupilumab for Recalcitrant Bullous Pemphigoid

Design

Case presentation

A 70-year-old male with a history of recurrent skin lesions was diagnosed with bullous pemphigoid (BP). The patient responded poorly to conventional treatment with high-potency corticosteroids and dapsone. Oral corticosteroids were avoided due to various uncontrolled metabolic conditions (e.g., obesity, diabetes, and arterial hypertension). Methotrexate and mycophenolate mofetil treatment was also attempted, which led to issues regarding tolerance and efficacy, respectively.

As a result, omalizumab 300 mg subcutaneously every 4 weeks was initiated in addition to mycophenolate mofetil and high-potency topical corticosteroids. After two months of omalizumab, the pruritus Visual Analog Scale (VAS) showed major improvement from 9/10 points to 2/10 points, along with significant reductions in the ELISA-BP180 values. However, the patient continued to experience itching from lesions which led to add-on therapy with dupilumab as one 600 mg subcutaneously initial dose followed by a 300 mg subcutaneously dose every other week. Three months later, the patient was cleared of pruritus with complete healing of the lesions. The patient was able to discontinue partial treatment after 7 and 10-month follow-ups showing complete remission and remained stable on a combination of omalizumab and dupilumab.

Study Author Conclusions

Combination of biologic therapy for severe persistent asthma

Design

Case presentation

A 61-year-old female presented for severe persistent allergic and eosinophilic asthma, allergic bronchopulmonary aspergillosis requiring chronic prednisone, allergic rhinitis, recurrent pneumonia and sinusitis, and severe atopic dermatitis. Despite maximal medical therapy and receiving omalizumab (after which oral steroids were successfully weaned), she experienced persistent, severe, refractory atopic dermatitis. Therefore, she received dual biologic therapy of dupilumab in addition to omalizumab, ultimately leading to the improvement of symptoms. She did not report exacerbation of symptoms while being on dual biologic therapy, and both asthma and atopic dermatitis were well controlled on high-dose fluticasone/salmeterol and montelukast, even after completely discontinuing the oral steroids.

There were no safety concerns or adverse events of concomitant biologic therapies reported in this case report.

Study Author Conclusions

Patients with very severe asthma may require aggressive therapy that targets multiple relevant biologic pathways. The potential benefit of treating these patients with multiple targeted agents should be considered and studied for efficacy, cost-effectiveness, and safety.