A 58-year-old lady, nurse by profession, residing in the United States, presented to us in the second half of 2019. Her history was remarkable for systemic hypertension, dyslipidemia, and chronic persistent asthma. She denied any history of smoking or tobacco product use. She did not have any environmental or professional exposure to agents triggering her asthma. Her asthmatic symptoms dated back to late adolescence and had progressed in severity since then, with significant worsening over the last 3 years. She was steroid dependent for the last 15 months. Despite being on a maintenance dose of 10 mg of prednisolone per day, she used to experience nocturnal symptoms and needed salbutamol inhalations on an average 3-4 times a week. She used to get exacerbations once a month needing hiking up of prednisolone dose to 40 mg per day for 5-7 days. Her detailed evaluation was done in the United States. Her spirometry showed persistent obstructive ventilatory defect. Her compliance to medications was ascertained, inhaler technique was supervised, and medications were optimised. Thyroid abnormalities, gastroesophageal reflux, allergic rhinitis, and vocal cord dysfunction were ruled out by appropriate evaluations. She was obese (BMI 33) with no snoring or excessive daytime sleepiness measured by the Epworth scale. Cardiac function as measured by ECG and 2D ECHO were normal. CT chest showed no parenchymal shadows, bronchiectasis, or mucoid impaction. She had no features of anxiety or depression ascertained during a formal psychology evaluation. Her IgE levels were <10 mg/mL on multiple occasions in the United States as well as during her current evaluation. She was considered for therapy with biological agents (omalizumab) but therapy with this agent was not instituted as her IgE levels were below the range approved for therapy. She was having significant steroid adverse effects including truncal obesity and osteopenia.
With this background, she presented to our outpatient department. Her blood counts revealed a normal total leucocyte count (7700 per cubic mm) with 6 percent eosinophils. Renal functions, hepatic functions, serum electrolytes, fasting lipid profile, and thyroid functions were normal. She was evaluated at the difficult asthma clinic where her compliance to medications was ascertained, inhaler technique was supervised, and medications were optimised (budesonide 1600 mcg per day, tiotropium 18 mcg per day, addition of montelukast-levocetirizine combination, and sustained release theophylline). The reports of evaluations done in the United States were crosschecked. Her spirometry (Figure 1) showed persistent obstructive ventilatory defect (postbronchodilator FEV1 74% predicted). Serum IgE levels repeated at our institution revealed a value of 7.5 IU/mL. She had inadequate response at one month of our therapy with exacerbations needing escalation of systemic steroids. Considering the burden of her disease, adverse drug effects, and its impact on her life, she was given the option of off label omalizumab therapy which she readily accepted after detailed briefing regarding the uncertainty in efficacy. She was initiated on omalizumab 150 mg subcutaneously once monthly, while continuing her baseline drugs. She began to get subjective improvement in her nocturnal symptoms after the second dose and tapering of prednisolone was attempted after the second dose. She was totally off systemic steroids by the sixth month of therapy and her rescue use of beta 2 agonists reduced to one per week on an average. A total of 9 doses of omalizumab were given. The improvement in steroid dose, asthma symptoms, and early morning PEFR are shown in Table 1. She had only 2 exacerbations needing hiking up of steroids during these nine months of therapy as opposed to 7 in the 6 months prior to omalizumab initiation (Figure 2). Her asthma control improved significantly (baseline ACT score of 13 improving to 22 at the end of 9 months). Her postbronchodilator FEV1 improved by 3% over the 9 months of therapy. She remains under reasonable control with 800 mcg per day of budesonide, tiotropium, sustained release theophylline, and montelukast. She plans to return to the United States in the next 2 months.