Therapy of antihistamine-resistant chronic spontaneous urticaria

Quantifying patient preferences for treatments for refractory chronic spontaneous urticaria

Background

In recent years, it has become increasingly common to incorporate the patient perspective into drug development and regulatory decision making.

Objective

This study aimed to measure and quantify patient preferences (priorities and trade-offs) for attributes that characterize current and emerging refractory chronic spontaneous urticaria (rCSU) treatments.

Methods

Adult patients with self-reported rCSU symptoms completed an online discrete choice experiment survey. The survey included 10 questions that asked respondents to choose between 2 hypothetical rCSU treatment profiles having similar attributes with varying levels. The attributes included the following: chance of control of symptoms, time to symptom control, return of symptoms after discontinuation of therapy (complete remission), allergic reaction, risk of kidney dysfunction (usually reversible), and mode and frequency of administration. Relative attribute importance and maximum acceptable risks were calculated.

Results

A total of 213 subjects with a mean age of 51 years completed the survey. Efficacy (symptom control) and mode of administration were the 2 most important attributes to treatment choice, followed by risk of kidney dysfunction and time to achieve symptom control. Complete remission of symptoms and risk of allergic reaction were identified as least important. With regard to mode of administration, topical treatment was the most preferred option and infusion therapy was least preferred. Respondents who were presented with a scenario of refractory and severe chronic spontaneous urticaria were willing to accept increased risk of reversible kidney dysfunction in exchange for improvement in symptom control or complete remission. Respondents were willing to accept infusion over topical treatment if there was significant increase in treatment efficacy.

Conclusion

These study results can be used to inform development and evaluation of future rCSU therapies by product developers and regulatory authorities, respectively.

Fisetin alleviates chronic urticaria by inhibiting mast cell activation via MRGPRX2

OBJECTIVES

The activation of mast cell (MC) plays an important part in the pathogenesis of chronic urticaria (CU), and the expression of MRGPRX2 (Mas-related G-protein coupled receptor X2) and the circulating levels of SP (substance P) in skin MC of CU patients increased. Fisetin is a natural flavonoid with anti-inflammatory and antiallergic pharmacological effects. This study aimed to investigate the inhibitory effect of fisetin on CU via MRGPRX2 and its possible molecular mechanisms.

METHODS

OVA/SP co-stimulated and SP-stimulated CU like murine models were used to evaluate the effect of fisetin on CU. MRGPRX2/HEK293 cells and LAD2 cells were used to perform the antagonism effect of fisetin on MC via MRGPRX2.

KEY FINDINGS

The results indicated that fisetin prevented urticaria-like symptoms in murine CU models, and inhibited MCs activation by suppressing calcium mobilization and degranulation of cytokines and chemokines via binding to MRGPRX2. The bioinformatics analysis showed that fisetin might have an interaction relationship with Akt in CU. The western blotting experiments showed that fisetin downregulated the phosphorylation levels of Akt, P38, NF-κB, and PLCγ in C48/80 activated LAD2 cells.

CONCLUSIONS

Fisetin alleviates CU progression by inhibiting mast cell activation via MRGPRX2, which may be a novel therapeutic candidate for CU.

Comparing four immunosuppressive agents for chronic spontaneous urticaria-A network meta-analysis

BACKGROUND

Immunosuppression is an integral part of treating chronic spontaneous urticaria (CSU), but there is no literature to evaluate the efficacy of multiple immunosuppressive agents.

OBJECTIVE

The comparison of the efficacy, safety, and incidence of adverse effects of four immunosuppressive medicines (tripterygium glycosides, methotrexate, cyclosporine A, and azathioprine) in combination with antihistamines in treating CSU provides a clinical reference and evidence-based medicine for treating CSU.

METHODS

PUBMED, The Cochrane Library, EMBASE, WANFANG, CNKI, CBM, and clinical trial registration platform were searched to collect relevant randomized controlled trials (RCT) and cohort studies of four immunosuppressive medicines combined with antihistamines for treating CSU. The primary outcomes were the efficacy of weekly urticaria activity score 7 (UAS7) and adverse effects.

RESULTS

This study pooled data from seven randomized clinical trials with 410 participants. The standardized mean differences for change in UAS7 were 0.10 (95% confidence interval (CI), 0.01 to 0.68) for cyclosporine A plus antihistamine; 0.03 (95% CI, 0.00 to 0.23) for azathioprine plus antihistamine; 0.52 (95% CI, 0.32 to 0.85) for tripterygium glycosides plus antihistamine; and 1.54 (95% CI, 0.64 to 3.67) for methotrexate plus antihistamine. There were no significant differences in side effects between these medicines in the limited number of trials and clinical samples.

CONCLUSION

Our results indicate that cyclosporine A combined with antihistamine resulted in greater improvements regarding the UAS7 in CSU patients and that tripterygium glycosides are also effective in treating CSU.

Omalizumab treatment in adolescents with chronic spontaneous urticaria: Efficacy and safety

BACKGROUND

Omalizumab is useful as an add-on treatment in patients unresponsive to high doses of second-generation antihistamines. This study aimed to evaluate the efficacy and safety of omalizumab treatment in adolescents with refractory chronic spontaneous urticaria (CSU).

METHODS

CSU patients aged 12-18 years old with the diagnosis of symptomatic CSU and unresponsive to classical treatment were included in the study. All patients had an urticaria-activity-score (UAS7) of ≥16 or and were treated with 300mg omalizumab every four weeks. The degree of response was classified into complete, partial and non-responders due to UAS7.

RESULTS

A total of 29 patients were evaluated. The median age and symptom onset age of the patients was 15.2 (IQR, 12.8-16.5) years and 14.0 (IQR, 11.8-15.9) years, respectively. The median duration of urticaria was eight (IQR, 4-24) months at admission. Eleven (37.9%) patients had angioedema and ten (34.5%) patients had concomitant allergic diseases. The median age at the beginning of treatment with omalizumab was 15.4 (IQR, 12.9-16.9) years. The median symptom duration was 12 (IQR, 6.5-27.5) months before the omalizumab treatment. Twenty-eight (96.5%) of the patients (89.6% complete, 6.9% partial) achieved response; however, one patient was a non-responder (3.5%). The adverse effect was observed in one (3.4%) patient as angioedema after the third dose. Twenty-three patients were followed up for a median of 18 (IQR, 13-27) months. Relapse was observed in three (13%) patients.

CONCLUSIONS

Omalizumab is considered as an effective and safe treatment for CSU in adolescents. Relapses mostly occur within the first year after the cessation of treatment.

Approach to the Patient with Hives

Urticaria is a common presenting problem to the primary care provider. Acute urticaria lasting less than 6 weeks may be associated with a drug or food allergens. Chronic urticaria lasting more than 6 weeks is often associated without a known underlying cause. Inducible stimuli causing hives should be excluded using specific provocation testing. Treatment follows a standardized algorithmic approach as outlined by the Joint Task Force Practice Parameter and/or International Urticaria guidelines. Patients not responsive to steps 1 or 2 should be referred to an urticaria specialist for further evaluation and treatment. The prognosis and outcome of urticaria is generally very favorable for most patients.

Omalizumab for urticaria treatment in clinical practice: a case series

Introduction

Omalizumab (Xolair) originally intended to reduce symptoms of moderate to severe asthma uncontrollable with steroids is the first monoclonal antibody approved for treatment of chronic spontaneous urticaria in 2014.

Aim

To evaluate response and potential side effects to omalizumab treatment in clinical practice.

Material and methods

Eleven patients (6 males and 5 females) were recruited into the study. All participants signed written informed consent before enrollment to the study. At the beginning they were receiving 300 mg of omalizumab in a subcutaneous injection every 4 weeks in an outpatient clinic. Five the clinical response was sufficient, the dose of omalizumab was decreased to 150 mg. We evaluated response to the treatment using the Urticaria Activity Score in the last 7 days and the Urticaria Control Test at certain time points.

Results

Nine out of 11 patients achieved complete syndrome resolution. Five patients achieved clinical remission after the first dose of omalizumab. Mean time to remission was 9.3 weeks. During the study, no side effects were observed.

Conclusions

Omalizumab appears to be a safe drug, which in a quick and effective way inducts remission in patients who have not responded to previous treatment.

Effectiveness of omalizumab in adolescent and adult patients with chronic idiopathic/spontaneous urticaria: a systematic review of 'real-world' evidence

INTRODUCTION

Chronic idiopathic/spontaneous urticaria (CIU/CSU) is a dermatological condition characterized by itchy wheals and/or angioedema of continuous or intermittent duration of ≥6 weeks with a high burden of disease and impact on quality of life. Omalizumab is a recombinant humanized monoclonal antibody that inhibits the binding of IgE to high affinity receptors, and is approved for the CIU/CSU indication. The objective of this systematic review was to evaluate and synthesize the evidence on the real-world effectiveness of omalizumab in CIU/CSU in daily clinical practice.

AREAS COVERED

This review of 84 observational effectiveness studies covers treatments (dosing, medication use), clinical outcomes (treatment response, disease activity, quality of life), and safety.

EXPERT OPINION

The clinical outcomes observed across studies underscore the real-world effectiveness of omalizumab in the management of CIU/CSU. Continued treatment may assist patients showing an initial response to achieve a complete treatment response. Response rates are aligned with observed changes in disease activity, symptom experience, and quality of life, and this across subtypes of CIU/CSU. The positive therapeutic profile is complemented by a positive safety profile. The real-world evidence summarized here points convincingly at the high degree of effectiveness of omalizumab in the treatment of CIU/CSU in daily clinical practice.