By Dr. Paul Ehrlich
Back when we wrote our book Asthma Allergies Children: a parent’s guide, Dr. Chiaramonte and I both expressed our exasperation over the dismal state of treatment for chronic urticaria—the fancy name for hives—by recalling our training. Larry remembered, “My teacher at Johns Hopkins said, ‘I’d rather have a tiger come into my office than a patient with chronic hives.’”
My version was from my fellowship at Walter Reed Army Hospital. We learned that 80 percent of the cases we would evaluate would never reveal a cause. My professor, Colonel Richard Evans, told us, “For those of you who are going into practice and will treat urticaria I would suggest having an office with two doors to the outside. You’ll need one door for your patient to enter and the other for you to sneak out.” His point was that many cases defy diagnosis, it often takes a while before the right treatment is determined, and patients are rarely satisfied with it.
That book was published in 2010 and it’s still very good—I give copies to my patients and young doctors who spend month-long rotations in the practice, although some bits need updating (that’s at least part of the mission of this website). I was particularly struck by this paragraph:
A case recently came to our attention of a chronic asthmatic who had the good fortune (financially as well as medically, because the stuff costs $1,000 a month) to use Xolair. It helped not only with his asthma, but with his cold-induced urticaria. We can only speculate that this anti-IgE drug is functioning in the skin as well as the lungs. It makes sense to us, because cold can induce asthma in twitchy lungs. We doubt that this off-label use of Xolair will be transformed into an on-label use any time soon, not at current prices. p.110, 2010 edition
Here it is eight years later and we hardly use omalizumab for asthma in my practice but we use it for urticaria all the time. More important, we hardly hear from our patients in the intervals between their shots, where once we would have heard from the same patients all the time. Chronic urticaria like its cousin atopic dermatitis, or eczema, is a cause of active suffering day to day. Quality-of-life scores are much lower than for chronic diseases such as diabetes. Not only are the skin conditions intensely uncomfortable, they are disfiguring. Many years ago I had a 14-year-old girl patient who was hospitalized for suicidal depression because of her hives. It was a formative experience for me as an allergist.
A key milestone was a 2013 article in the New England Journal of Medicine that found dramatic improvements from omalizumab. There were the usual hurdles of further studies and insurance reimbursement along the way, but here we are in 2018 and omalizumab is pretty much standard of care. Genentech is also generous for those patients who struggle with the cost.
Omalizumab is so effective in treating hives that I find it bewildering to encounter physicians who still don’t use it. One prominent dermatologist I know still clings to the cycles of more steroids, topical and systemic, antihistamines, baths, and emollients. It should surprise me, but it doesn’t. In his book How Doctors Think, Dr. Jerome Groopman cites Douglas Watson, former president and CEO of Novartis (which helped develop omalizumab) to the effect that research shows that most physicians regularly prescribe around two dozen drugs, most of which they learned about during their training, although their training may have taken place many years earlier.
Along the way this anti-IgE drug has had its share of public relations and medical problems. There was alarm over a statistical association with cancer, although I am convinced it was just data noise. There are those who are allergic to the drug itself, complete with instances of anaphylaxis. That’s one advantage to giving shots in a clinical setting—the tools and the personnel are on hand to treat adverse events. The FDA has also raised concerns of risks to blood vessels supplying the brain and heart.
Regardless, my patients are happy with their Xolair–costs, inconvenience, and all because of the profound relief they have achieved. And if they’re happy, I’m happy. I even got rid of the back door to my consulting room.
(Note: we received no financial or other consideration from Genentech and Novartis for publishing this piece. It is based entirely on Dr. Ehrlich’s appreciation of a drug that has produced tremendous benefits for his patients.)