Question of the Day
Tuesday, November 10, 2026
A 52-year-old woman with severe persistent asthma comes to the physician for follow-up. Despite adherence to high-dose inhaled corticosteroid plus a long-acting beta-agonist and a leukotriene receptor antagonist, she has frequent daytime symptoms and has required three courses of oral prednisone in the past year. She has a history of allergic rhinitis. Her serum total IgE is elevated, and skin testing demonstrates sensitization to perennial aeroallergens including dust mite. Her blood eosinophil count is 90/mm3. Spirometry shows an FEV1 of 62% of predicted.
Which of the following is the most appropriate additional therapy?
Answer: E. Add omalizumab
The correct answer is E (Add omalizumab). She has severe allergic asthma uncontrolled on high-dose inhaled corticosteroid plus LABA and a leukotriene receptor antagonist, with repeated oral steroid bursts, elevated total IgE, and documented sensitization to a perennial aeroallergen. These are the eligibility criteria for omalizumab, an anti-IgE monoclonal antibody that reduces exacerbations and oral corticosteroid use in allergic asthma.
Why not A (Add daily low-dose oral prednisone): Maintenance oral corticosteroids cause substantial cumulative toxicity and are a last resort after biologic options.
Why not B (Add mepolizumab): Anti-IL-5 therapy is for eosinophilic asthma, generally requiring a blood eosinophil count of at least 150/mm3; hers is 90/mm3.
Why not C (Add roflumilast): Roflumilast is a phosphodiesterase-4 inhibitor used in COPD with chronic bronchitis and frequent exacerbations, not asthma.
Why not D (Add theophylline): Theophylline adds little efficacy, has a narrow therapeutic index, and is not recommended in current asthma guidelines.
Clinical Pearl: Match the biologic to the phenotype: anti-IgE for allergic asthma with elevated IgE and perennial sensitization; anti-IL-5 or anti-IL-5R for eosinophils of 150 to 300/mm3 or more.
Just show me the answer
Answer: E. Add omalizumab
The correct answer is E (Add omalizumab). She has severe allergic asthma uncontrolled on high-dose inhaled corticosteroid plus LABA and a leukotriene receptor antagonist, with repeated oral steroid bursts, elevated total IgE, and documented sensitization to a perennial aeroallergen. These are the eligibility criteria for omalizumab, an anti-IgE monoclonal antibody that reduces exacerbations and oral corticosteroid use in allergic asthma.
Why not A (Add daily low-dose oral prednisone): Maintenance oral corticosteroids cause substantial cumulative toxicity and are a last resort after biologic options.
Why not B (Add mepolizumab): Anti-IL-5 therapy is for eosinophilic asthma, generally requiring a blood eosinophil count of at least 150/mm3; hers is 90/mm3.
Why not C (Add roflumilast): Roflumilast is a phosphodiesterase-4 inhibitor used in COPD with chronic bronchitis and frequent exacerbations, not asthma.
Why not D (Add theophylline): Theophylline adds little efficacy, has a narrow therapeutic index, and is not recommended in current asthma guidelines.
Clinical Pearl: Match the biologic to the phenotype: anti-IgE for allergic asthma with elevated IgE and perennial sensitization; anti-IL-5 or anti-IL-5R for eosinophils of 150 to 300/mm3 or more.
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