Omalizumab response correlates with reduced IFN ‐γ‐, IL ‐10‐ and IL ‐31‐secreting cells in chronic spontaneous urticaria

Effects of Omalizumab on Serum Levels of Substance P, Calcitonin Gene-Related Peptide, Neuropeptide Y, and Interleukin-31 in Patients with Chronic Spontaneous Urticaria

The mechanism of action of omalizumab in urticaria is still not literally known. This study examines the serum values of substance P (SP), calcitonin gene-related peptide (CGRP), neuropeptide Y (NPY), and interleukin-31 (IL-31) in patients using omalizumab. In this study, 30 patients with chronic spontaneous urticaria (CSU) who were going to be treated with omalizumab and 20 healthy volunteers took part. Demographic data, clinical data, and disease activity scores were noted. For serum SP, CGRP, NPY, and IL-31 values, 10 mL of blood were taken from the patients before starting the treatment, 3 months after the treatment, at the end of the 6th month, and from healthy volunteers all at once. The change in values measured at baseline, 3rd month, and 6th month was analyzed by the Friedman Test. The Mann-Whitney U test was used to compare the parameters obtained from the patients and control groups. The significance level was set at p=0.05. SP, CGRP, NPY, and IL-31 values were all statistically significantly lower in the CSU patient group compared to the control group. After treatment, the levels of SP and CGRP in the serum went up, and the levels of serum IL-31 went down. These changes were statistically significant. This study supports the view that omalizumab does not only affect IgE receptors but also affects mast cells through other mechanisms. According to our knowledge, this is the first study to show that omalizumab therapy and serum CGRP levels are related.

IL-31-Pruritus Interleukin: Serum Values and Clinical Impact in Chronic Spontaneous Urticaria-A Romanian Retrospective Study

(1) Background: This study aimed to evaluate the implications of interleukin-31 (IL-31) in the pathogenesis of chronic spontaneous urticaria (CSU) and to assess the differences that occur between its serum values compared to controls. Additionally, the serum IL-31 levels were measured alongside other clinical and paraclinical parameters that were identified in the patients to understand its immunological importance in this skin disease and to determine if it could potentially serve as a therapeutic target in CSU in the future. (2) Methods: The serum levels of IL-31 were estimated in 50 patients diagnosed with CSU according to the accepted international guidelines. Additionally, 38 controls who had not experienced any episodes of urticaria during their lifetime were included. (3) Results: Significantly elevated serum IL-31 levels were observed in CSU patients compared to the controls (p < 0.0001). Although no direct correlations were found between IL-31 and inflammatory markers (erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)), eosinophils, or total immunoglobulins E (IgE), significant differences in IL-31 levels were identified based on CSU severity, quality of life impact, itch intensity, and response to histamine H1 receptor antagonists (H1 antihistamines) (p < 0.05 for all). (4) Conclusions: Our findings underscore that IL-31 is not directly associated with general inflammation, eosinophilic response, or atopy in CSU. Nevertheless, its expression is influenced by key disease characteristics: severity, pruritus, and H1 antihistamine response. This investigation provides essential insights into CSU pathogenesis, potentially leading to novel therapeutic interventions. An enhanced understanding of these mechanisms is crucial due to the limitations of current treatment modalities in terms of fully managing CSU symptoms.

Biomarkers for Monitoring Treatment Response of Omalizumab in Patients with Chronic Urticaria

Chronic urticaria (CU) is a debilitating skin disease affecting around 1% of the population. CU can be subdivided into chronic spontaneous urticaria (CSU) and chronic inducible urticaria (CIndU). Different pathophysiological mechanisms have been proposed to play a role in the development of CU, and these are also being investigated as potential biomarkers in the diagnosis and management of the disease. As of now the only assessment tools available for treatment response are patient reported outcomes (PROs). Although these tools are both validated and widely used, they leave a desire for more objective measurements. A biomarker is a broad subcategory of observations that can be used as an accurate, reproducible, and objective indicator of clinically relevant outcomes. This could be normal biological or pathogenic processes, or a response to an intervention or exposure, e.g., treatment response. Herein we provide an overview of biomarkers for CU, with a focus on prognostic biomarkers for treatment response to omalizumab, thereby potentially aiding physicians in personalizing treatments.

Chronic Urticaria Treatment with Omalizumab—Verification of NLR, PLR, SIRI and SII as Biomarkers and Predictors of Treatment Efficacy

Biomarkers that are able to predict the response to omalizumab (OMA) in chronic spontaneous urticaria (CSU) are highly valued. The aim of our study was to evaluate the UAS7 (urticaria activity score assessed for 7 days), DLQI (dermatology life quality index), SII (systemic immune-inflammation index), SIRI (systemic inflammation response index), PLR (platelet/lymphocyte ratio) and NLR (neutrophil/lymphocyte ratio) in a group of 46 CSU a patients treated for 24 weeks with OMA (300 mg every 4 weeks). There were no statistically significant differences observed at the start nor at the end of the treatment between the two groups (responders vs. non-responders) and SII, SIRI, PLR and NLR. However, a statistically significant correlation was observed between severity of urticaria expressed in UAS7 scores and the quality of life (evaluated by DLQI). Furthermore, at week 24, both groups demonstrated significant improvement in quality of life. Our single center study did not confirm the usefulness of SII, SIRI, NLR or PLR as predictors of the response to OMA in CSU. However, it is of importance that even patients who did not respond to the treatment presented a significant improvement in quality of life. Additionally, we also observed that the efficacy of treatment was unchanged amongst patients who underwent a second series of treatment in cases of relapse.

Efficacy of Fangfeng Tongsheng Granule Combined with Levocetirizine in the Treatment of Chronic Urticaria and Its Effect on Serum Complement, IL-4, IgE, and IFN-γ Levels in Patients

Objectives

To investigate the efficacy of Fangfeng Tongsheng granule combined with levocetirizine in the treatment of chronic urticaria and its effect on serum complement, interleukin (IL)-4, immunoglobulin E (IgE), and interferon-γ (IFN-γ) levels in patients.

Methods

A total of 98 patients with chronic urticaria who were admitted to our hospital from July 2021 to March 2022 were selected and divided into random odd-even numbers. The odd numbers were included in the observation group, with a total of 49 cases, and they were treated with Fangfeng Tongsheng granule combined with levocetirizine; the even numbers were included in the control group, with a total of 49 cases and were treated with levocetirizine alone. The two groups of patients were treated continuously for 4 weeks, and the clinical efficacy of the two groups was observed. Before treatment, 2 weeks and 4 weeks after treatment, evaluate the clinical symptom scores of patients such as itching, flushing, wheal, edema, observe the improvement of clinical symptoms of patients, and the changes in Dermatology Life Quality Index (DLQI). Serum complement C3, C4, T lymphocyte subsets CD₃⁺, CD₄⁺, CD₈⁺ levels and CD₄⁺/CD₈⁺ ratio, IL-4, IgE, and IFN-γ levels and the occurrence of adverse reactions in the two groups were calculated and observed. All patients were followed up for 2 months after treatment to observe the recurrence of patients.

Results

The scores of clinical symptoms such as wheal, itching, flushing, edema, and attack frequency in the observation group at each time point after treatment were lower than those in the control group (F times were 725.365, 851.521, 936.411, 3943.136, and 2226.147, all P < 0.05 (F between-group were 40.642, 102.124, 188.523, 259.291, and 23.92, P < 0.05); the total effective rate of the observation group was 93.88% (46/49), which was significantly higher than that of the control group, 73.47% (36/49) (χ² = 7.470, P=0.006). The DLQI scores of the observation group at each time point after treatment were lower than those of the control group (F time was 282.214, P < 0.05; F between-group was 6.546, P < 0.05). There was no significant difference in serum C4 levels between the two groups at each time point (F time was 1.225, P > 0.05; F between-group was 0.408, P > 0.05); serum complement C3, CD₃⁺, and CD₄⁺/the ratio of CD₈⁺ and IFN-γ were higher than those in the control group (F time was 407.352, 107.823, 32.941, and 2354.147, P < 0.05; F between-group was 40.941, 24.710, 54.982, and 264.921, P < 0.05); the observation group at each time after treatment the levels of IgE and IL-4 were lower than those of the control group (F time were 373.124 and 395.612, P < 0.05; F between-group were 21.802 and 62.591, P < 0.05). The incidence of adverse reactions in the observation group was 12.24% (6/49) compared with 10.20% (5/49) in the control group, which had no significant difference (χ² = 0.102, P=0.749). Both groups were followed up for 2 months after treatment. The recurrence rate in the observation group was 12.24% (6/49), which was lower than that in the control group, which was 32.65% (16/49) (χ² = 5.861, P=0.015).

Conclusion

The application of Fangfeng Tongsheng granules combined with levocetirizine in patients with chronic urticaria can effectively improve the clinical symptoms of patients, improve clinical efficacy, reduce the impact of the disease on life, improve the immune status of patients, and reduce the risk of recurrence.

IL-31: State of the Art for an Inflammation-Oriented Interleukin

Interleukin 31 belongs to the IL-6 superfamily, and it is an itch mediator already studied in several diseases, comprising atopic dermatitis, allergic pathologies, and onco-hematological conditions. This research aims to assess the role of this cytokine in the pathogenesis of these conditions and its potential therapeutic role. The research has been conducted on articles, excluding reviews and meta-analysis, both on animals and humans. The results showed that IL-31 plays a crucial role in the pathogenesis of systemic skin manifestations, prognosis, and itch severity. Traditional therapies target this interleukin indirectly, but monoclonal antibodies (Mab) directed against it have shown efficacy and safety profiles comparable with biological drugs that are already available. Future perspectives could include the development of new antibodies against IL-31 both for humans and animals, thus adding a new approach to the therapy, which often has proven to be prolonged and specific for each patient.

The Role of Crosstalk of Immune Cells in Pathogenesis of Chronic Spontaneous Urticaria

Chronic spontaneous urticaria (CSU) is defined as recurrent episodes of spontaneous wheal development and/or angioedema for more than six weeks and at least twice a week. The core link in the pathogenesis of CSU is the activation of mast cells, T cells, eosinophils, and other immune cells infiltrating around the small venules of the lesion. Increased vascular permeability, vasodilatation, and recruitment of inflammatory cells directly depend on mast cell mediators’ release. Complex regulatory systems tightly influence the critical roles of mast cells in the local microenvironment. The bias toward Th2 inflammation and autoantibodies derived from B cells, histamine expressed by basophils, and initiation of the extrinsic coagulation pathway by eosinophils or monocytes exerts powerful modulatory influences on mast cells. Cell-to-cell interactions between mast cells and eosinophils/T cells also are regulators of their function and may involve CSU’s pathomechanism. This review summarizes up-to-date knowledge regarding the crosstalk between mast cells and other immune cells, providing the impetus to develop new research concepts and treatment strategies for CSU.

Follicular T Helper and Breg Cell Balance in Severe Allergic Asthma Before and After Omalizumab Therapy

Background

Severe allergic asthma (SAA) is based on type 2 (T2-high) immune responses to allergens promoting type 2 T helper (Th2) cell cytokine responses and production of IgE antibodies. Omalizumab was the first biological drug licensed for clinical use in the management of IgE-mediated SAA. Despite emerging evidence supporting the prominent role of follicular T cells (Tfh), Breg and Treg subsets, in the development and progression of SAA, no data are available on the impact of omalizumab therapy.

Methods

Ten SAA patients monitored at the Respiratory Diseases Unit of Siena University Hospital and ten healthy sex- and age-matched controls were enrolled in the study. Clinical and functional parameters were collected at baseline (T0) and after 6 months of therapy (T6). Cellular population analysis was determined through multicolour flow cytometry.

Results

SAA patients showed higher percentages of Th17.1, Tfh and Tfh2 while CD24^hiCD27^hi Breg cell, Treg and Tfr percentages were significantly lower than in controls. Higher percentages of Tfh2 in patients with nasal polyps than in those without and in controls were observed. At T6, significant decreases in Tfh and Tfh2 compared with T0 were observed. A slightly significant increase in Teffs was reported at T6 compared to T0. ΔIgE levels in serum were correlated with ΔCD19⁺CD24⁺CD27⁺ Breg cell percentages (r = − 0.86, p = 0.0022).

Conclusions

Our data explored the changes in Tfh cells, Tregs and Bregs in severe asthma. The restoration of immunological imbalance in SAA patients after omalizumab is certainly intriguing and represents a glimpse into the comprehension of immunological effects of treatment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40291-021-00545-3.

The efficacy of omalizumab treatment in chronic spontaneous urticaria is associated with basophil phenotypes

BACKGROUND

The mechanisms underlying disease pathogenesis in chronic spontaneous urticaria (CSU) and improvement with omalizumab are incompletely understood.

OBJECTIVES

This study sought to examine whether the rate of clinical remission is concordant with baseline basophil features or the rate of change of IgE-dependent functions of basophils and/or plasmacytoid dendritic cells during omalizumab therapy.

METHODS

Adults (n = 18) with refractory CSU were treated with omalizumab 300 mg monthly for 90 days. Subjects recorded daily urticaria activity scores, and clinical assessments with blood sampling occurred at baseline and on days 1, 3, 6, 10, 20, 30, 60, and 90 following omalizumab. At baseline, subjects were categorized by basophil functional phenotypes, determined by in vitro histamine release (HR) responses to anti-IgE antibody, as CSU-responder (CSU-R) or CSU-non-responder (CSU-NR), as well as basopenic (B) or nonbasopenic (NB).

RESULTS

CSU-R/NB subjects demonstrated the most rapid and complete symptom improvement. By day 6, CSU-R/NB and CSU-NR/NB had increased anti-IgE-mediated basophil HR relative to baseline, and these shifts did not correlate with symptom improvement. In contrast, CSU-NR/B basophil HR did not change during therapy. The kinetics of the decrease in surface IgE/FcεRI was similar in all 3 phenotypic groups and independent of the timing of the clinical response. Likewise, plasmacytoid dendritic cells' surface IgE/FcεRI decline and TLR9-induced IFN-α responses did not reflect clinical change.

CONCLUSIONS

Changes in basophil IgE-based HR, surface IgE, or FcεRI bear no relationship to the kinetics in the change in clinical symptoms. Baseline basophil count and basophil functional phenotype, as determined by HR, may be predictive of responsiveness to omalizumab.

Use of biologics in allergen immunotherapy

Biologics are drugs that are derived or synthesized from biological sources. A particular class are recombinant monoclonal antibodies. Their targeted application against distinct molecules of intercellular communication is of significant relevance in the treatment of tumor, inflammatory, or allergic diseases. But also in the context of allergen immunotherapy (AIT) they can be of special value. This is exemplified by the anti-IgE antibody omalizumab, which allows to achieve allergen tolerance in patients suffering from severe allergic reactions and increased risk of AIT-induced anaphylaxis. Furthermore, omalizumab administration during AIT effectively lowers the rsik of allergic side effects. This is demonstrated by a variety of studies and case reports of patients suffering either form respiratory, food, or insect venom allergy. Besides a direct blocking of IgE-mediated effects, T-cellular immune mechanisms might also be involved. Another interesting option is the applcation of recombinant IgG antibodes directed against specific epitopes of an allergen. Similar to AIT-induced IgG antibodies they can prevent the binding of allergens to IgE-antibodes as well as the hereby elicited allergic reactions.

Increased serum IL-31 levels in chronic spontaneous urticaria and psoriasis with pruritic symptoms

Background

Chronic spontaneous urticaria (CSU) is a common pruritic skin condition, the pathogenesis of which remains unclear. Interleukin-31 (IL-31) is a major pruritogenic cytokine that plays a role in inducing pruritus in various skin diseases.

Aim.

To 1) compare serum IL-31 levels among CSU patients, psoriasis patients with pruritic symptoms, and healthy subjects, 2) examine the correlations between serum IL-31 levels and disease severity, and 3) compare IL-31 levels in patients with and without CSU-associated auto-antibodies.

Methods

Patients with CSU, psoriasis with pruritic symptoms, and healthy volunteers were recruited in the study. Serum IL-31 levels were measured with commercial kits. Baseline characteristics, urticaria activity score, psoriasis area severity index, pruritic intensity score, and related laboratory results were collected.

Results

Sixty-five CSU patients, 30 psoriasis patients who had pruritus, and 31 healthy subjects participated in our study. The CSU patients had significantly higher mean serum IL-31 levels than the psoriasis patients (252.4 ± 115.5 vs 121.4 ± 16.6 pg/mL, P < 0.001). Both CSU and psoriasis patients also had significantly higher mean serum IL-31 when compared with the healthy subjects. Serum IL-31 levels of CSU and psoriasis patients did not differ significantly according to disease or itching severity. Thyroid antibodies and antinuclear antibodies were positive in 22 (33.8%) and 28 (43.1%) CSU patients, respectively. The CSU patients with ANA titers ≥1:160 had significantly higher mean serum IL-31 levels than in those who were negative for ANA and those with titers of 1:80 (P < 0.003 and P < 0.008, respectively).

Conclusion

Higher serum IL-31 levels were found in patients with CSU and psoriasis with pruritic symptoms. This suggests that IL-31 has a possible role in the pathogenesis of CSU and psoriasis with pruritic symptoms.

Effects of omalizumab on basophils: Potential biomarkers in asthma and chronic spontaneous urticaria

Omalizumab is an anti-IgE humanized monoclonal antibody approved for the treatment of severe asthma and chronic spontaneous urticaria. Omalizumab binds free serum IgE and antagonizes its interaction with FcεRI, which is considered the main pharmacodynamic mechanism responsible for the clinical response to the treatment. The reduction of IgE serum concentration down-regulates the cellular expression of FcεRI on basophils. However, the biological events occurring on basophils during the therapy with omalizumab are multiple and complex. Here we review the current evidence regarding the specific biological effects of omalizumab on basophils in patients with asthma and chronic spontaneous urticaria. In addition to the modulation of IgE receptors, omalizumab may affect basophils homeostasis, intra-cellular signaling, cellular responsiveness/activation and cytokine release. These effects may be partially responsible for the clinical success of omalizumab and potentially provide useful biological markers for future assessment of the clinical response to the treatment. However, further investigation is required to better elucidate the role of basophils during the treatment with omalizumab.