Effectiveness and Safety of Immunosuppressants and Biological Therapy for Chronic Spontaneous Urticaria: A Network Meta-Analysis

Abstract

Chronic spontaneous urticaria (CSU) is the most common phenotype of chronic urticaria. We compared treatment effects and safety profiles of the medications in patients with CSU. We searched PubMed, MEDLINE, and Web of Science for randomized control trials (RCTs), from 1 January 2000 to 31 July 2021, which evaluated omalizumab and immunosuppressants. Network meta-analyses (NMAs) were performed with a frequentist approach. Outcome assessments considered the efficacy (Dermatology Life Quality Index (DLQI) and weekly urticaria activity score (UAS7)) and tolerability profiles with evaluations of study quality, inconsistencies, and heterogeneity. We identified 14 studies which we included in our direct and indirect quantitative analyses. Omalizumab demonstrated better efficacy in DLQI and UAS7 outcomes compared to a placebo, and UAS7 assessments also demonstrated better outcomes compared to cyclosporine. Alongside this, omalizumab demonstrated relatively lower incidences of safety concerns compared to the other immunosuppressants. Cyclosporin was also associated with higher odds of adverse events than other treatment options. Our findings indicate that omalizumab resulted in greater improvements in terms of the DLQI and UAS7 with good tolerability in CSU patients compared to the other immunosuppressants.

A global perspective on stepping down chronic spontaneous urticaria treatment: Results of the Urticaria Centers of Reference and Excellence SDown‐CSU study

“…Omalizumab is the first and currently the only approved monoclonal antibody for the treatment of CSU. In CSU, omalizumab shows good long‐term efficacy and safety 14–17 . More than 80% of participants indicated that there is no limitation for the duration of omalizumab treatment in their country, suggesting that step down decisions are mainly based on the assessment of disease control achieved by treatment.…”

“…In CSU, omalizumab shows good long‐term efficacy and safety. 14 , 15 , 16 , 17 More than 80% of participants indicated that there is no limitation for the duration of omalizumab treatment in their country, suggesting that step down decisions are mainly based on the assessment of disease control achieved by treatment. Almost all of the participants indicated that they assess control status of the patients within 6 months of omalizumab treatment and 95% make stepping down decisions within 6 months from the first controlled status in patients with completely controlled disease.…”

Mapping the intellectual structure of the research of omalizumab in chronic spontaneous urticaria: A bibliometric analysis

“…In response, novel therapies, such as mAbs and immunosuppressive agents (eg, cyclosporine, methotrexate, azathioprine, hydroxychloroquine), have been developed over the past 2 decades to improve symptom management and enhance patients' quality of life. 43 , 45 …”

An Overview of Methotrexate Indications in Skin Diseases

“…The effect of MTX on adenosine and its capacity to inhibit cytokines, leucocyte chemotaxis, and free radicals leads to the improvement of skin lesions from chronic urticaria. A recent meta-analysis, based on data published in the literature between 2000 and 2021, which studied the effectiveness of immunosuppressive therapy in patients with refractory chronic urticaria, highlighted the fact that the therapeutic action of MTX proved to be weaker in patients with chronic urticaria compared to placebo [42,43]. The current recommendation in urticaria does not detail the dose, nor duration treatment, with MTX.…”