Adverse Reactions to Biologic Medications Used in Allergy and Immunology Diseases

Abstract

Purpose of ReviewThe use of biologic therapies has risen exponentially over recent years, allowing for unprecedented disease control within numerous areas of Allergy/Immunology. With this expanded use, awareness and understanding of adverse reactions to biologic agents have also increased. Recent Findings Multiple biologic adverse reaction phenotypes have been described, but significant overlap in clinical features across phenotypes exists. Given considerable phenotypic overlap, a targeted testing approach may not always be clear, and more recent classifications focus on management decision making using tools of diagnostic challenges and rapid drug desensitizations, guiding clinicians in developing a management plan when the exact underlying mechanism is not clearly known. With increased clinical experience with omalizumab, mepolizumab, reslizumab, benralizumab, dupilumab, tezepelumab, rituximab, and TNF-inhibitors, there is a growing appreciation to the spectrum and particularities of adverse reactions to these agents which are outlined in this review. Summary Our understanding of the clinical presentation and management of adverse reactions to biologic medications encountered in Allergy/Immunology has grown. Opportunities remain to further define optimal diagnostic and management strategies for these reactions.

Delayed Hyperpigmented Injection Site Reactions Due to Chronic Dupilumab Use

“…Injection site reactions are common with biologic agents and are among the most common adverse events reported with dupilumab, occurring in approximately 15-18% of patients [ 13 , 14 ]. Typical injection site reactions to biologic agents are characterized by local site swelling, erythema, and pain that often resolve within 48 hours of injection [ 5 ]. Our patient had an abrupt onset of asymptomatic eczematous injection site reactions with residual hyperpigmented patches that started approximately one year after the initiation of dupilumab.…”

“…Dupilumab is a monoclonal antibody that inhibits interleukin 4 (IL-4) receptor alpha and is highly effective in reducing nasal polyp burden, preventing recurrent sinus surgery, and reducing sinus infections in patients with severe CRSwNP, particularly those with AERD [2][3][4]. The most common adverse reactions from dupilumab use include temporary injection site reactions, ocular surface reactions, and transient eosinophilia [5]. In rare cases, inflammatory arthritis/enthesitis may also occur [6].…”

Ofatumumab Desensitization Protocol: A Case of Refractory Immune Thrombocytopenic Purpura

“…Hypersensitivity reactions to biologics have been increasing in frequency over time, likely due in part to their growing therapeutic use [ 8 ]. Since the first biologic medication was approved by the FDA in 1986, the indications for biologic therapies have expanded exponentially [ 9 ]. The clinical utility of biologics now spans a broad spectrum of medical specialties, from hematology and oncology to rheumatology, pulmonology, dermatology, and allergy [ 8 ].…”

“…While most drugs are chemicals composed of small molecules, most biologics are large, complex proteins with tertiary polypeptide structures. Biologics are also broken down into peptides in the body like any protein, whereas other drugs undergo renal or hepatic metabolism [ 9 ]. Unlike other drugs that sometimes require metabolic activation after administration, biologics do not contain prodrugs [ 10 ].…”

Implementation of an Accelerated Infusion Protocol (90-Minute Infusion) of Rituximab and Its Safety in Patients With Autoimmune Rheumatic Diseases at a Tertiary Veterans Affairs Center

“…IRRs to RTX occur at an incidence rate of up to 77% with the first infusion and are markedly less common after the initial infusion, as reported by the manufacturer [5][6][7][8]. Over time, several schemes have been proposed to classify hypersensitivity reactions associated with monoclonal antibody treatments [9][10][11][12]. The most described ones and their incidences include the following [12,13].…”