I saw this 50 y/o man with a label of remote asthma who had quit smoking in 1980 for cough, wheezing and dyspnea. He gave a good Hx for asthma and had an FEV1 of 58% with FVC: 65%, normal TLC and normal DLCO. I started treatment and a few months later on ICS his FEV1 had come up to 69% but he still had a significant cough. In searching for triggers (e.g. GERD) and other conditions (e.g. ABPA) I found an IgE level of 927 (upper limit 158). Since he was still wheezing I gave him some prednisone and continued the ICS. His FEV1 is now 73% and he feels better. His IgE is now 655.
Would you bother following the IgE at all?
Since he still has a persistent (mild) defect, would you give him any more systemic steroids?
Have you had a good experience with Xolair?
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Did you rule out (clinically or otherwise) ABPA? I agree that if it was ABPA you would still give steroids, but at least you could then think about identifying the source of exposure so that it can potentially be avoided.
No, doesn't look like ABPA... no bronchiectasis, negative Aspergillus preciptins, not enough criteria for ABPA. Looks like asthma and high IgE.
I had good "success stories" with Xolair... I would not follow IgE level, and I would not give more systemic steroids. He has at least moderate persistent asthma from what you described. I would start Xolair (Problem is getting people approved/insurance coverage).
The other problem is that he is 124 kg and with an IgE level of 655 he falls in the "do no give Xolair" dosing category.
Smoking history, 50 yrs old, non-atopic. Try zileuton before Xolair, he should show fev improvement, something not seen with Xolair.
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