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Omalizumab for chronic urticaria: a case series and overview of the literature.
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PMID:  22493579     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
Omalizumab is a recombinant humanized monoclonal antibody that blocks the high-affinity Fc receptor of IgE. Omalizumab has been approved for the treatment of moderate to severe asthma; however, there is currently more and more data showing promising results in the management also of chronic urticaria. We present a case series of 19 patients with chronic urticaria treated in a university department with omalizumab and give an overview of the existing literature comprising an additional 59 cases as well as a total of 139 patients enrolled in two randomized controlled trials comparing omalizumab with placebo. The collective evidence points to omalizumab as a safe and effective treatment option for patients with chronic urticaria who do not sufficiently respond to standard therapy as recommended by existing guidelines.
Authors:
Ilya Ivyanskiy; Carsten Sand; Simon Francis Thomsen
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Publication Detail:
Type:  Journal Article     Date:  2012-01-30
Journal Detail:
Title:  Case reports in dermatology     Volume:  4     ISSN:  1662-6567     ISO Abbreviation:  Case Rep Dermatol     Publication Date:  2012 Jan 
Date Detail:
Created Date:  2012-04-11     Completed Date:  2012-10-02     Revised Date:  2013-05-29    
Medline Journal Info:
Nlm Unique ID:  101517685     Medline TA:  Case Rep Dermatol     Country:  Switzerland    
Other Details:
Languages:  eng     Pagination:  19-26     Citation Subset:  -    
Affiliation:
Department of Dermatology, Bispebjerg Hospital, Copenhagen, Denmark.
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Journal ID (nlm-ta): Case Rep Dermatol
Journal ID (iso-abbrev): Case Rep Dermatol
Journal ID (publisher-id): CDE
ISSN: 1662-6567
Publisher: S. Karger AG, Allschwilerstrasse 10, P.O. Box · Postfach · Case postale, CH–4009, Basel, Switzerland · Schweiz · Suisse, Phone: +41 61 306 11 11, Fax: +41 61 306 12 34, karger@karger.ch
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Copyright © 2012 by S. Karger AG, Basel
open-access:
collection publication date: Season: Jan-Apr Year: 2012
Electronic publication date: Day: 30 Month: 1 Year: 2012
pmc-release publication date: Day: 30 Month: 1 Year: 2012
Volume: 4 Issue: 1
First Page: 19 Last Page: 26
ID: 3322628
PubMed Id: 22493579
DOI: 10.1159/000336205
Publisher Id: cde-0004-0019

Omalizumab for Chronic Urticaria: A Case Series and Overview of the Literature
Ilya Ivyanskiy
Carsten Sand
Simon Thomsen Francis*
Department of Dermatology, Bispebjerg Hospital, Copenhagen, Denmark
Correspondence: *Simon Francis Thomsen, Department of Dermatology, Bispebjerg Hospital, DK-2400 Copenhagen NV (Denmark), Tel. +45 2613 9838, E-Mail sft@city.dk

Introduction

Urticaria is a condition characterized by localized or widespread pruritic wheals that typically exist for no more than 24 h. By definition acute urticaria lasts no longer than six weeks, whereas chronic urticaria lasts longer, often several years. Chronic urticaria can be classified into several subtypes but these may have overlapping features [1]. Chronic urticaria that has no detectable cause is termed chronic idiopathic urticaria. Autoimmune urticaria is not a well-defined term but it is generally recognized that those with autoimmune urticaria have anti-IgG antibodies against the high-affinity IgE receptor (FceRI) on mast cells and basophils or directly to IgE antibodies. These can be documented with the urticaria histamine release (HR) test. Autoimmune urticaria affects about one third of all patients with chronic urticaria [2].

H1 antihistamines are recommended as first-line therapy for chronic urticaria; leukotriene receptor antagonists are indicated as second-line therapy, whereas immunosuppressive drugs such as corticosteroids, azathioprine or cyclosporine A should be reserved for severe recalcitrant disease [3].

Omalizumab is a recombinant humanized monoclonal antibody that blocks the high-affinity Fc receptor of IgE. Omalizumab has been approved for the treatment of moderate to severe asthma. However, there is currently more and more data showing promising results in the management of patients suffering from other allergic conditions such as chronic urticaria [4]. Omalizumab is usually recommended when other systemic therapies have failed [3].

Here we present a case series of chronic urticaria patients in a university department treated with omalizumab and give an overview of the existing literature concerning omalizumab treatment of therapy-resistant chronic urticaria.


Methods

The cases reported herein were selected consecutively from the Department of Dermatology at Bispebjerg Hospital in Copenhagen. All patients were initially referred to the department with a diagnosis of urticaria and were considered eligible for this report if they began treatment with omalizumab for urticaria during the one-year period from November 2010 to October 2011. For each case, the type and duration of urticaria was recorded as well as any previous medical treatment. If available, the results of relevant serological markers including serum total IgE and the urticaria HR test were noted. A histamine release >16.5% was regarded as positive (Reflab, Copenhagen, Denmark). All patients were treated with omalizumab at an initial dose of 150 mg once every two weeks, which was the department's standard dosing regimen. The clinical response to treatment with omalizumab was recorded and for each patient it was possible to score the individual response to treatment as: no response, partial response, or almost complete/complete resolution of symptoms during treatment. Furthermore, the duration and any side effects of omalizumab were recorded.

The response to treatment in our case series was compared with reports from the existing English language literature retrieved from PubMed using the search terms: ‘urticaria’, ‘omalizumab’ and ‘anti-IgE’. Cross-references were retrieved but this did not identify additional studies. Studies published by December 2011 were included. Three non-English case reports were identified but these were not further considered.


Results

A total of 19 patients (14 females) began treatment with omalizumab during the observation period (table 1). The mean age at the time of omalizumab initiation was 36 years for females and 49 for males. The mean duration of disease at initiation of omalizumab in the sample was 21 months for females and 24 months for males (one male patient had a duration of nine years). A total of 12 patients (63%) were classified as having chronic idiopathic urticaria, six patients (32%) had chronic autoimmune urticaria demonstrated by a positive urticaria HR test, whereas one patient had delayed pressure urticaria.

All patients had antihistamine-resistant disease and all but two had been treated with other systemic drugs; 14 (74%) with prednisolone, 7 (37%) with azathioprine, cyclosporine A and/or mycophenolate mofetil, and 6 (32%) with TNF-a inhibitors.

In total, 11 patients (58%) experienced almost complete or complete resolution of symptoms during treatment with omalizumab, whereas five (26%) experienced partial resolution; three patients (16%) had no benefit of the treatment and of these, one had to discontinue treatment due to side effects (nausea, headache and flu-like symptoms). However, in general, treatment was tolerated very well and only three patients (16%) reported side effects. These three patients were all females and among the youngest in the sample (15, 19 and 29 years of age).


Discussion

The present case series included 19 patients with therapy-resistant chronic urticaria. On an initial dose of omalizumab of 150 mg once every two weeks, a total of 84% of the patients experienced resolution of symptoms to a degree that exceeded the effect of previous treatments. The symptomatic effect of the treatment occurred in many of the patients after one or just a few days and no serious side effects were reported.

These data add to the growing body of evidence supporting the use of omalizumab as a safe and effective treatment option for chronic urticaria. Particularly, by December 2011, to our knowledge, a total of 59 cases of chronic urticaria treated with omalizumab have been reported in the literature comprising five cases of solar urticaria, two cases of heat urticaria, two cases of cold urticaria, three cases of delayed pressure urticaria, three cases of urticaria factitia, three cases of cholinergic urticaria, 40 cases of chronic idiopathic urticaria, and 16 cases of chronic autoimmune urticaria. Furthermore, a total of 139 patients have been enrolled in two randomized controlled trials comparing omalizumab with placebo (table 2) [5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30]. The first randomized trial was restricted to patients with IgE against thyroperoxidase; 27 patients were randomized to omalizumab and 22 to placebo [29]. The absolute mean decrease in the urticaria activity score (UAS) during the 24 weeks of treatment was 17.8 points in the experimental group and 7.9 points in the placebo group. According to the investigator's global assessment, as many as 67% of the patients in the experimental group were assessed as having achieved complete resolution of symptoms during the study compared with only 4% in the placebo group. The second trial included 90 patients with chronic idiopathic urticaria randomized to one of three different doses of omalizumab (75, 300 or 600 mg) or to placebo [30]. The absolute mean decrease in the UAS four weeks after a single dose of omalizumab was 14.6 points in the group receiving 600 mg omalizumab, 19.9 points in the group receiving 300 mg omalizumab, 9.8 points in the group receiving 75 mg omalizumab, and 6.9 points in the group receiving placebo. The mean decrease in the groups receiving 300 and 600 mg omalizumab was statistically significantly greater than in the placebo group. A total of 28.6, 36.0, and 4.4% of the patients had complete resolution of urticaria symptoms after receiving a single dose of 600, 300 and 75 mg omalizumab, respectively. No patients in the placebo group had complete resolution of symptoms. Both randomized trials reported mild but rather frequent side effects such as diarrhoea, headache, dysmenorrhoea and upper respiratory tract infections that, however, did not differ in prevalence between the groups receiving active treatment and placebo.

The rapid improvement of urticaria symptoms reported in almost all previous cases treated with omalizumab indicates that IgE plays an important role in chronic urticaria. However, although anti-IgE mechanisms are thought to be the principal mode of action for omalizumab, several of the published cases support a role of other mechanisms such as induction of eosinophil apoptosis, downregulation of the inflammatory cytokines IL-2, IL-4, IL-13 and TNF-a, increase in the activity of CD4+ cells by ATP release, decrease in basophil releasability as well as a marked decrease in the expression of FceRI [18, 20, 21, 25]. These observations offer an explanation for the successful results also among patients with low levels of IgE.

The dosing of omalizumab for chronic urticaria is in many cases based on the recommendations for asthma, i.e. based on serum total IgE levels and the weight of the patient [4]. We saw a marked effect in most of our patients of treatment with 150 mg once every two weeks. In comparison, most of the previous cases were treated with a higher dose, predominantly with an initial dose of 300 mg, which was also the dose that produced the most marked clinical response in the experimental trials [30]. On the contrary, earlier published case reports, in general, overestimated the effect of omalizumab compared with the controlled trials, and also did not report side effects or scored them as negligible or absent.

Despite an undeniable value of omalizumab for chronic urticaria, it is still not clear why the drug is effective in some patients and less so in others. Nevertheless, the collective evidence points to omalizumab as a safe and effective treatment option for patients with chronic urticaria who do not sufficiently respond to standard therapy as recommended by existing guidelines [3].


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Article Categories:
  • Published: January, 2012

Keywords: Key Words Omalizumab, Anti-IgE, Chronic urticaria, Biologics.

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