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Intervention Review

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Anti-IgE therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis

  1. Kana R Jat1,*,
  2. Dinesh K Walia2,
  3. Anju Khairwa3

Editorial Group: Cochrane Cystic Fibrosis and Genetic Disorders Group

Published Online: 17 SEP 2013

Assessed as up-to-date: 11 SEP 2013

DOI: 10.1002/14651858.CD010288.pub2


How to Cite

Jat KR, Walia DK, Khairwa A. Anti-IgE therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD010288. DOI: 10.1002/14651858.CD010288.pub2.

Author Information

  1. 1

    All India Institute of Medical Sciences, Department of Pediatrics, New Delhi, Delhi, India

  2. 2

    Govt. Medical College and Hospital (GMCH), Department of Community Medicine, Chandigarh, Chandigarh UT, India

  3. 3

    Postgraduate Institute of Medical Education and Research (PGIMER), Department of Pathology, Chandigarh, Chandigarh UT, India

*Kana R Jat, Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, Delhi, 110029, India. drkanaram@gmail.com. drkanaram@yahoo.co.in.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 17 SEP 2013

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This is not the most recent version of the article. View current version (04 NOV 2015)

 
Characteristics of included studies [ordered by study ID]
Novartis 2008

MethodsDouble-blind randomized parallel assignment placebo-controlled study.

Multicentre: Belgium, Germany, Italy, Netherlands, and United Kingdom.


ParticipantsInclusion Criteria:

  • diagnosis of CF complicated by ABPA;
  • oral corticosteroid use for ABPA flare;
  • age ≥ 12 years (except for Italy; ≥ 18 years), both male and female;
  • total serum IgE levels ≥ 500 IU/mL;
  • their FEV1 at baseline was no lower than 90% of their previous best FEV1 as measured at screening and their FEV1 was >40% of predicted or >30% of predicted;
  • Female patients could only be included if they were using adequate methods of contraception, were proven to be surgically sterilized or post-menopausal;
  • All patients (or parents for minors) had to be able to communicate well with the investigator and to have understood and signed the written informed consent prior to inclusion.


Exclusion Criteria:

  • history of cancer in the last 10 years;
  • history of severe allergic reactions;
  • pregnant and lactating women;
  • prior use of omalizumab (Xolair®);
  • lung or other transplant;
  • participation in any clinical trial within 4 weeks prior to initial dosing or longer if required by local regulations, and for any other limitation of participation based on local regulations;
  • haemoglobin levels below 10.0 g/dl at screening;
  • history of immunodeficiency diseases;
  • significant illness other than CF/ABPA within 2 weeks prior to initial dosing;
  • a past medical history of clinically significant ECG abnormalities.
  • patients who were known to be positive for chronic atypical Mycobacteria and Burkholderia cepacia including subspecies;
  • history of elevated liver enzymes (3x ULN) or active liver disease, or patients who have experienced liver toxicity with other drugs;
  • elevated liver enzymes (3x ULN) at screening;
  • patients treated with contraindicated drugs as listed in the Itraconazole SPC, ie cisapride, pimozide, quinidine or dofetilide;
  • history or active condition of congestive heart failure or evidence of ventricular dysfunction;
  • history of hypersensitivity to itraconazole and/or oral corticosteroid tablets (or any excipients).


Intervention group: 9 patients (5 females) patients; mean (SD) age was 21 (4.1) years.

Placebo group: 5 patients (4 females) patients; mean (SD) age was 28 (9.5) years.


InterventionsExperimental arm:

omalizumab (Xolair®) subcutaneous injections into the upper arm in the area of the deltoid or to the thigh of 600 mg daily for 6 months in the double-blind phase of the study along with itraconazole 2x daily, while receiving oral corticosteroids, with a maximum daily dose of 400 mg.

Placebo arm:

placebo subcutaneous injections into the upper arm in the area of the deltoid or to the thigh blinded to match experimental arm dosing regimen daily for 6 months in the double-blind phase of the study along with itraconazole 2xe daily, while receiving oral corticosteroids, with a maximum daily dose of 400 mg.


OutcomesPrimary outcome measures:

  • change from baseline in the percentage of participants requiring rescue with corticosteroids (Time frame: 6 months of blinded treatment);
  • time to deviation from the protocol prescribed steroid tapering regimen (Time frame: 6 months of blinded treatment).


Secondary outcome measures:

  • change in ABPA exacerbation rates during double-blind treatment period and open-label treatment period (Time frame: 6 months, 12 months);
  • change in FEV1 from baseline (Time frame: 3 months, 6 months);
  • time to steroid-free state (Time frame: 12 months);
  • change from baseline in average oral corticosteroid use (Time frame: 6 months, 12 months);
  • percentage of participants responding to omalizumab, as defined by a reduction in oral corticosteroid dose use of 50% or more as compared to baseline (Time frame: 6 months, 12 months).
  • number of steps needed to reduce the steroid dose to zero (or to 5 mg or less) following 6 months of treatment
  • immunogenicity (anti-omalizumab antibodies)
  • PK/PD: total omalizumab levels, free & total IgE


NotesStudy was started in Novermber 2008 and was terminated in July 2010 after enrolling just 14 participants. Reason for premature termination was not available.

Participants who completed the double-blinded phase of the study, entered an open-label treatment period of 6 months and continued the same regimen of omalizumab as in the double-blinded phase. No placebo was used in the open-label period.

Sponsors and Collaborators: Novartis Pharmaceuticals.


Risk of bias

BiasAuthors' judgementSupport for judgement

Adequate sequence generationUnclear riskNo information available.

Allocation concealmentUnclear riskNo information available.

Blinding
All outcomes
Low riskStudy was double blind where patient, caregiver, investigator, and outcomes assessor were masked to treatment assignment.

Incomplete outcome data addressed
All outcomes
High riskOf the 9 patients enrolled in the intervention group only 4 completed the double-blind phase of the study (5 dropped out: 1 due to adverse events; 1 due to lack of efficacy; and 3 due to administrative problems); of the 5 patients in the placebo group only 3 patients completed this phase (2 dropped out: both due to administrative problems).

Free of selective reportingHigh riskData related to all outcome measures were not reported on the website, not even for those patients who completed trial before its termination.

Free of other biasHigh riskEarly termination of trial.

 
Table 1. Adverse effects in included trial

Adverse events (AEs)Omalizumab group

N = 9, n (%)
Placebo group

N = 5, n (%)

Non-serious adverse events (AEs)

Patients with AE(s)9 (100)5 (100)

Infective pulmonary exacerbation of cystic fibrosis7 (78)4 (80)

Cough4 (44)1 (20)

Headache4 (44)1 (20)

Pyrexia3 (33)2 (40)

Hemoptysis (blood in sputum)4 (44)0

Injection site swelling4 (44)0

Injection site warmth4 (44)0

Injection site erythema (redness)3 (33)0

Hypokalemia2 (22)0

Nasopharyngitis2 (22)0

Sputum increased1 (11)1 (20)

Bronchopulmonary aspergillosis allergic2 (22)0

Rhonchi (noisy expiratory breathing sound)1 (11)1 (20)

Non-cardiac chest pain1 (11)1 (20)

Vomiting01 (20)

Serious adverse events (SAEs)

Patients with any Serious adverse event (SAE)6 (67)1 (20)

Infective pulmonary exacerbation of cystic fibrosis5 (56)1 (20)

Allergic Bronchopulmonary Aspergillosis2 (22)0

Distal intestinal obstruction syndrome1 (11)0

Hemoptysis1 (11)0

Rhonchi1 (11)0