From the Journals

Omalizumab proves effective for severe pediatric atopic dermatitis



A new study has found that omalizumab (Xolair) reduced severity and improved quality of life in pediatric patients with severe atopic dermatitis.

Atopic dermatitis diagnosis with pills and pen Michail_Petrov-96/Thinkstock

“Future work with an even larger sample size, a longer duration, and higher-affinity versions of omalizumab would clarify the precise role of anti-IgE therapy and its ideal target population,” wrote Susan Chan, MD, of Guy’s and St. Thomas’ NHS Foundation Trust in London and her coauthors. The study was published in JAMA Pediatrics.

To determine the benefits of omalizumab in reducing immunoglobulin E levels and thereby treating severe childhood eczema, the researchers launched the Atopic Dermatitis Anti-IgE Pediatric Trial (ADAPT). This randomized clinical trial recruited 62 patients between the ages of 4 and 19 years with severe eczema, which was defined as a score over 40 on the objective Scoring Atopic Dermatitis (SCORAD) index. They received 24 weeks of treatment with either omalizumab (n = 30) or placebo (n = 32) followed by 24 weeks of follow-up. Participants had a mean age of 10.3 years.

After 24 weeks, the adjusted mean difference in objective SCORAD index between the two groups was –6.9 (95% confidence interval, –12.2 to –1.5; P = .01) and significantly favored omalizumab therapy. The adjusted mean difference for the Eczema Area and Severity Index (–6.7; 95% CI, –13.2 to –0.1) also favored omalizumab. In regard to quality of life, after 24 weeks the Children’s Dermatology Life Quality Index/Dermatology Life Quality Index favored the omalizumab group with an adjusted mean difference of –3.5 (95% CI, –6.4 to –0.5).

In an accompanying editorial, Ann Chen Wu, MD, of Harvard Medical School in Boston noted that the results of the study from Chan et al. were promising but “more questions need to be answered before the drug can be used to treat atopic dermatitis in clinical practice” (JAMA Pediatr. 2019 Nov. 25. doi: 10.1001/jamapediatrics.2019.4509).

Her initial concern was price; she acknowledged that “omalizumab is a costly intervention” but said atopic dermatitis is also costly, raising the question as to whether the high costs of both justify treatment. In addition, omalizumab as treatment can come with both benefits and harms. Severe atopic dermatitis can decrease quality of life and, though omalizumab appears to be safe, there are adverse effects and logistical burdens to overcome.

More than anything, she recognized the need to prioritize, wondering what level of atopic dermatitis patients would truly benefit from this level of treatment. “Is using a $100,000-per-year medication for an itchy condition an overtreatment,” she asked, “or a lifesaver?”

The study was funded by the National Institute for Health Research Efficacy and Mechanism Evaluation Programme and Guy’s and St. Thomas’ Charity. The authors had numerous financial disclosures, including receiving grants from the NIHR EME Programme and Guy’s and St. Thomas’ Charity along with active and placebo drugs from Novartis for use in the study. Dr. Wu reported receiving a grant from GlaxoSmithKline.

SOURCE: Chan S et al. JAMA Pediatr. 2019 Nov 25. doi: 10.1001/jamapediatrics.2019.4476.

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