Treatment of chronic spontaneous urticaria with an inadequate response to H1-antihistamines: an expert opinion

Abstract

Chronic spontaneous urticaria (CSU) is characterized by the sudden, continuous or intermittent appearance of pruritic wheals (hives), angioedema, or both for six weeks or more, with no known specific trigger. The international EAACI/GA 2 LEN/EDF/WAO urticaria guideline advises standard-dose, second-generation H 1 -antihistamines as firstline therapy. However, H 1 -antihistamine treatment leads to absence of symptoms in fewer than 50% of patients. Updosing of secondgeneration H 1 -antihistamines (up to fourfold) as recommended by the EAACI/GA 2 LEN/EDF/WAO urticaria guideline as second-line therapy, can improve response, but many patients remain symptomatic. Definitions of response are often subjective and a consensus is needed regarding appropriate treatment targets. There is also an unmet need for biomarkers to assess CSU severity and activity and to predict treatment response. The EAACI/GA 2 LEN/EDF/WAO urticaria guideline recommends addon omalizumab, ciclosporin A (CsA), or montelukast third-line treatment in patients with an inadequate response to high-dose H 1 -antihistamines. Omalizumab is currently the only licensed systemic biologic for use in CSU. Both omalizumab and CsA are effective third-line CSU treatments; montelukast appears to have lower efficacy in this setting. Omalizumab carries a label warning for anaphylaxis, although no cases of anaphylaxis were reported in the phase III trials of omalizumab in CSU and it is generally well tolerated in patients with CSU. Omalizumab arguably has a better safety profile than CsA.

Omalizumab in chronic urticaria: A comprehensive review

“…The real life studies report an 80% response rate to omalizumab 29,33 . However, in terms of evaluating the treatment response, it is not possible to compare the study results to each other due to the fact that standard methodologies were not employed 12 .…”

Guía clínica chilena de urticaria crónica espontánea

“…El tratamiento farmacológico se sustenta en el uso de anti-histamínicos (anti-H1) de 2ª generación, no obstante alrededor de 70% de los pacientes no logra mejoría completa 23 . Por este motivo se han estudiado y aprobado otro tipo de tratamientos para el manejo de UCE, como los fármacos inmunosupresores sistémicos y drogas biológicas.…”

“…En general no se recomienda el uso de corticoesteroides en UCE, sobre todo como terapia de largo plazo, debido a la gran cantidad de efectos adversos de estos fármacos 1,23 . Sin embargo, en situaciones puntuales, como una exacerbación del cuadro clínico se puede utilizar un pulso corto de prednisona en dosis de 20 a 50 mg al día, por no más de 10 días 23 .…”

The use of omalizumab for treatment‐refractory chronic spontaneous urticaria in a West Australian outpatient cohort

“…Chronic spontaneous urticaria (CSU) is defined as daily pruritic hives and/or angioedema for 6 weeks or more, without an identifiable trigger. The disease may be self‐limiting; however, in some cases, symptoms persist for years with a profound impact on patients’ quality of life . Treatments for CSU include antihistamines, leukotriene receptor antagonists and immunosuppressive drugs such as prednisolone and cyclosporin.…”

“…Treatments for CSU include antihistamines, leukotriene receptor antagonists and immunosuppressive drugs such as prednisolone and cyclosporin. Omalizumab is a recombinant humanised anti‐IgE monoclonal antibody that targets the Fc region of IgE, reducing levels of free IgE . Omalizumab was listed on the Pharmaceutical Benefits Scheme for the management of CSU in September of 2017.…”