OMALIZUMAB Drug Interactions: What You Need to Know
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Drug Interactions (FDA Label)
INTERACTIONS No formal drug interaction studies have been performed with omalizumab products. In patients with asthma, CRSwNP, and IgE-mediated food allergy the concomitant use of omalizumab products and allergen immunotherapy has not been evaluated . In patients with CSU, the use of omalizumab products in combination with immunosuppressive therapies has not been studied. No formal drug interaction studies have been performed. ( 7 )
Contraindications
Omalizumab-igec is contraindicated in patients with severe hypersensitivity reaction to omalizumab products or any ingredient of Omalizumab-igec [see Warnings and Precautions (5.1) ] . Severe hypersensitivity reaction to omalizumab productsor any ingredient of Omalizumab-igec ( 4 , 5.1 )
Related Warnings
AND PRECAUTIONS Anaphylaxis: Initiate Omalizumab-igec therapy in a healthcare setting prepared to manage anaphylaxis which can be life-threatening and observe patients for an appropriate period of time after administration. ( 5.1 ) Malignancy: Malignancies have been observed in clinical studies. ( 5.2 )
Acute Asthma
Symptoms: Do not use for the treatment of acute bronchospasm or status asthmaticus. ( 5.3 )
Corticosteroid
Reduction: Do not abruptly discontinue corticosteroids upon initiation of Omalizumab-igec therapy. ( 5.4 )
Eosinophilic
Conditions: Be alert to eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, and/or neuropathy, especially upon reduction of oral corticosteroids. ( 5.5 ) Fever, Arthralgia, and Rash: Stop Omalizumab-igec if patients develop signs and symptoms similar to serum sickness. ( 5.6 )
Potential Medication Error
Related to Emergency Treatment of Anaphylaxis: Omalizumab-igec should not be used for emergency treatment of allergic reactions, including anaphylaxis. ( 5.9 )
5.1 Anaphylaxis Anaphylaxis has been reported to occur after administration of omalizumab products in premarketing clinical trials and in postmarketing spontaneous reports <span class="opacity-50 text-xs">[see Boxed Warning and Adverse Reactions (6.2) ]</span> . Signs and symptoms in these reported cases have included bronchospasm, hypotension, syncope, urticaria, and/or angioedema of the throat or tongue. Some of these events have been life-threatening. In premarketing clinical trials in patients with asthma, anaphylaxis was reported in 3 of 3,507 (0.1%) patients. Anaphylaxis occurred with the first dose of omalizumab in two patients and with the fourth dose in one patient. The time to onset of anaphylaxis was 90 minutes after administration in two patients and 2 hours after administration in one patient. A case-control study in asthma patients showed that, among omalizumab users, patients with a history of anaphylaxis to foods, medications, or other causes were at increased risk of anaphylaxis associated with omalizumab products, compared to those with no prior history of anaphylaxis <span class="opacity-50 text-xs">[see Adverse Reactions (6.1) ]</span> . In postmarketing spontaneous reports, the frequency of anaphylaxis attributed to omalizumab use was estimated to be at least 0.2% of patients based on an estimated exposure of 57,300 patients from June 2003 through December 2006. Anaphylaxis has occurred as early as after the first dose of omalizumab, but also has occurred beyond one year after beginning regularly scheduled treatment.
Approximately
60% to 70% of anaphylaxis cases have been reported to occur within the first three doses of omalizumab, with additional cases occurring sporadically beyond the third dose.
Initiate
Omalizumab-igec only in a healthcare setting equipped to manage anaphylaxis, which can be life-threatening. Observe patients closely for an appropriate period of time after administration of Omalizumab-igec, taking into account the time to onset of anaphylaxis seen in premarketing clinical trials and postmarketing spontaneous reports [see Adverse Reactions (6.1 , 6.2) ] . Inform patients of the signs and symptoms of anaphylaxis, and instruct them to seek immediate medical care should signs or symptoms occur.
Once
Omalizumab-igec therapy has been established, administration of Omalizumab-igec prefilled syringe outside of a healthcare setting by a patient or a caregiver may be appropriate for selected patients. Patient selection, determined by the healthcare provider in consultation with the patient, should take into account the pattern of anaphylaxis events seen in premarketing clinical trials and postmarketing spontaneous reports, as well as individual patient risk factors (e.g., prior history of anaphylaxis), ability to recognize signs and symptoms of anaphylaxis, and ability to perform subcutaneous injections with Omalizumab-igec prefilled syringe or autoinjector with proper technique according to the prescribed dosing regimen and Instructions for Use [see Dosage and Administration (2.6) , Adverse Reactions (6.1 , 6.2) ].
Discontinue
Omalizumab-igec in patients who experience a severe hypersensitivity reaction [see Contraindications (4) ] .
5.2 Malignancy Malignant neoplasms were observed in 20 of 4,127 (0.5%) omalizumab-treated patients compared with 5 of 2,236 (0.2%) control patients in clinical studies of adults and adolescents ≥12 years of age with asthma and other allergic disorders. The observed malignancies in omalizumab-treated patients were a variety of types, with breast, non-melanoma skin, prostate, melanoma, and parotid occurring more than once, and five other types occurring once each. The majority of patients were observed for less than 1 year. The impact of longer exposure to omalizumab products or use in patients at higher risk for malignancy (e.g., elderly, current smokers) is not known. In a subsequent observational study of 5,007 omalizumab-treated and 2,829 non-omalizumab- treated adolescent and adult patients with moderate to severe persistent asthma and a positive skin test reaction or in vitro reactivity to a perennial aeroallergen, patients were followed for up to 5 years. In this study, the incidence rates of primary malignancies (per 1,000 patient years) were similar among omalizumab-treated (12.3) and non-omalizumab-treated patients (13.0) <span class="opacity-50 text-xs">[see Adverse Reactions (6.1) ]</span> . However, study limitations preclude definitively ruling out a malignancy risk with omalizumab products. Study limitations include: the observational study design, the bias introduced by allowing enrollment of patients previously exposed to omalizumab (88%), enrollment of patients (56%) while a history of cancer or a premalignant condition were study exclusion criteria, and the high study discontinuation rate (44%).
5.3 Acute Asthma Symptoms and Deteriorating Disease Omalizumab products have not been shown to alleviate asthma exacerbations acutely. Do not use Omalizumab-igec to treat acute bronchospasm or status asthmaticus. Patients should seek medical advice if their asthma remains uncontrolled or worsens after initiation of treatment with Omalizumab-igec.
5.4 Corticosteroid Reduction Do not discontinue systemic or inhaled corticosteroids abruptly upon initiation of Omalizumab-igec therapy for asthma or CRSwNP. Decrease corticosteroids gradually under the direct supervision of a physician. In CSU patients, the use of omalizumab products in combination with corticosteroids has not been evaluated.
5.5 Eosinophilic Conditions In rare cases, patients with asthma on therapy with omalizumab products may present with serious systemic eosinophilia sometimes presenting with clinical features of vasculitis consistent with Churg-Strauss syndrome, a condition which is often treated with systemic corticosteroid therapy. These events usually, but not always, have been associated with the reduction of oral corticosteroid therapy. Physicians should be alert to eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, and/or neuropathy presenting in their patients. A causal association between omalizumab products and these underlying conditions has not been established.
5.6 Fever, Arthralgia, and Rash In post-approval use, some patients have experienced a constellation of signs and symptoms including arthritis/arthralgia, rash, fever, and lymphadenopathy with an onset 1 to 5 days after the first or subsequent injections of omalizumab products. These signs and symptoms have recurred after additional doses in some patients. Although circulating immune complexes or a skin biopsy consistent with a Type III reaction were not seen with these cases, these signs and symptoms are similar to those seen in patients with serum sickness. Physicians should stop Omalizumab-igec if a patient develops this constellation of signs and symptoms <span class="opacity-50 text-xs">[see Adverse Reactions (6.2) ]</span> .
5.7 Parasitic (Helminth)
Infection
Monitor patients at high risk of geohelminth infection while on Omalizumab-igec therapy. Insufficient data are available to determine the length of monitoring required for geohelminth infections after stopping omalizumab products treatment. In a one-year clinical trial conducted in Brazil in adult and adolescent patients at high risk for geohelminthic infections (roundworm, hookworm, whipworm, threadworm), 53% (36/68) of omalizumab-treated patients experienced an infection, as diagnosed by standard stool examination, compared to 42% (29/69) of placebo controls. The point estimate of the odds ratio for infection was 1.96, with a 95% confidence interval (0.88, 4.36) indicating that in this study a patient who had an infection was anywhere from 0.88 to 4.36 times as likely to have received omalizumab than a patient who did not have an infection. Response to appropriate anti-geohelminth treatment of infection as measured by stool egg counts was not different between treatment groups.