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Moñino-Romero S, Hackler Y, Okas TL, Grekowitz EM, Fluhr JW, Hultsch V, Kiefer LA, Pyatilova P, Terhorst-Molawi D, Xiang YK, Siebenhaar F, Maurer M, Kolkhir P. Positive Basophil Tests Are Linked to High Disease Activity and Other Features of Autoimmune Chronic Spontaneous Urticaria: A Systematic Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2411-2416. [PMID: 37286132 DOI: 10.1016/j.jaip.2023.05.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/21/2023] [Accepted: 05/19/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Chronic spontaneous urticaria (CSU) is believed to be Autoimmune (aiCSU) (type IIb CSU) in at least 8% of patients, associated with mast cell-activating IgG autoantibodies. Basophil tests such as the basophil activation test (BAT) and basophil histamine release assay (BHRA) are considered the best single tests for an aiCSU diagnosis. To date, the strength of associations among a positive BAT and/or BHRA (BAT/BHRA+) and CSU features, patient demographics, and response to treatment remains poorly characterized. OBJECTIVE To evaluate the strength of current evidence on basophil tests as parameters for CSU characteristics. METHODS We performed a systematic literature search and review to assess the relationship between BAT/BHRA+ and clinical and laboratory parameters of CSU. Of 1,058 records found in the search, 94 studies were reviewed by experts in urticaria and 42 were included in the analysis. RESULTS In CSU patients, BAT/BHRA+ showed a strong level of evidence for an association with high disease activity and low levels of total IgE. A weak level of evidence was shown for the association of BAT/BHRA+ and the presence of angioedema, and basopenia. CONCLUSIONS Our results suggest that aiCSU defined by BAT/BHRA+ is more active or severe and is linked to other aiCSU markers such as low total IgE/basopenia. Basophil tests should be standardized and implemented in routine clinical care to improve the diagnosis and treatment of patients with aiCSU.
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Affiliation(s)
- Sherezade Moñino-Romero
- Allergology and Immunology Department, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Berlin, Germany; Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Yana Hackler
- Allergology and Immunology Department, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Berlin, Germany; Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Tiia-Linda Okas
- Department of Immunology, Institute of Biomedicine and Translational Medicine, University of Tartu, Tartu, Estonia
| | - Eva Maria Grekowitz
- Allergology and Immunology Department, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Berlin, Germany; Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Joachim W Fluhr
- Allergology and Immunology Department, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Berlin, Germany; Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Vincent Hultsch
- Allergology and Immunology Department, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Berlin, Germany; Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lea Alice Kiefer
- Allergology and Immunology Department, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Berlin, Germany; Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Polina Pyatilova
- Allergology and Immunology Department, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Berlin, Germany; Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Dorothea Terhorst-Molawi
- Allergology and Immunology Department, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Berlin, Germany; Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Yi-Kui Xiang
- Allergology and Immunology Department, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Berlin, Germany; Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Frank Siebenhaar
- Allergology and Immunology Department, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Berlin, Germany; Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Marcus Maurer
- Allergology and Immunology Department, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Berlin, Germany; Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Pavel Kolkhir
- Allergology and Immunology Department, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Berlin, Germany; Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
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Kolkhir P, Muñoz M, Asero R, Ferrer M, Kocatürk E, Metz M, Xiang YK, Maurer M. Autoimmune chronic spontaneous urticaria. J Allergy Clin Immunol 2022; 149:1819-1831. [PMID: 35667749 DOI: 10.1016/j.jaci.2022.04.010] [Citation(s) in RCA: 86] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 03/17/2022] [Accepted: 04/14/2022] [Indexed: 12/23/2022]
Abstract
Chronic spontaneous urticaria (CSU) is a debilitating mast cell-driven disease characterized by recurrent wheals and/or angioedema. Substantial progress has been made in dissecting the 2 main autoimmune mechanisms that drive the pathogenesis of CSU. Type I autoimmune (autoallergic) CSU is associated with IgE antibodies against autoantigens, for example, thyroid peroxidase and IL-24. Type IIb autoimmune CSU is mediated by autoantibodies that activate mast cells, for example, via IgE and FcεRI, and is present in less than 10% of patients with CSU when strict criteria are used, that is, triple positivity of autologous serum skin test, immunoassays for IgG autoantibodies, and basophil activation tests. A subpopulation of patients with CSU has both types. Type IIb autoimmune CSU is characterized by higher disease severity, concomitant autoimmune diseases, low levels of total IgE, elevated levels of IgG-anti-thyroid peroxidase, basopenia, eosinopenia, poor response to antihistamines and to omalizumab, and a good response to cyclosporine. Novel targeted therapies for CSU are under development such as ligelizumab, an anti-IgE, fenebrutinib and remibrutinib, Bruton's tyrosine kinase inhibitors, and dupilumab, an anti-IL-4Rα. Further studies should investigate the overlap between autoallergic and type IIb autoimmune CSU, optimize the diagnosis of both autoimmune endotypes using easy-to-perform, noninvasive, and inexpensive markers, and assess differences in response to therapy.
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Affiliation(s)
- Pavel Kolkhir
- Institute of Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany; I.M. Sechenov First Moscow State Medical University (Sechenov University), Division of Immune-Mediated Skin Diseases, Moscow, Russia
| | - Melba Muñoz
- Institute of Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany; Clinician Scientist Program, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Riccardo Asero
- Ambulatorio di Allergologia, Clinica san Carlo, Paderno Dugnano, Italy
| | - Marta Ferrer
- Department of Allergy and Clinical Immunology, Clínica Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra Pamplona (IDISNA), Spain, RETIC de Asma, Reacciones Adversas y Alérgicas, Madrid (ARADyAL), Spain, Madrid, Spain
| | - Emek Kocatürk
- Koç University School of Medicine, Department of Dermatology, Istanbul, Turkey
| | - Martin Metz
- Institute of Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Yi-Kui Xiang
- Institute of Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Marcus Maurer
- Institute of Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany.
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Marcelino J, Baumann K, Skov PS, Pereira Santos MC, Wyroslak I, Scheffel J, Altrichter S, Woetmann A, Pereira-Barbosa M, Costa C, Maurer M. What Basophil Testing Tells Us About CSU Patients - Results of the CORSA Study. Front Immunol 2021; 12:742470. [PMID: 34650565 PMCID: PMC8507496 DOI: 10.3389/fimmu.2021.742470] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/13/2021] [Indexed: 11/13/2022] Open
Abstract
Basophil testing is the most effective single approach for diagnosing type-IIb autoimmune chronic spontaneous urticaria (TIIbaiCSU). A positive basophil test has been linked to long disease duration, higher disease activity, a poor response to antihistamines and omalizumab, and a better response to cyclosporine and fenebrutinib. As of now it is unclear what other features are connected to a positive basophil test in chronic spontaneous urticaria (CSU). We aimed to identify features of basophil test-positive CSU patients. We performed a cross-sectional study of 85 CSU patients. Basophil testing was done with the basophil activation test (BAT) and the basophil histamine release assay (BHRA). Data were analysed using SPSS: Student's t-test, Chi-square test, Odds Ratio, Spearman's correlation test. Of 85 CSU patients, 44% and 28% tested positive with the BAT and BHRA, respectively. These patients showed higher disease activity and impact, lower levels of disease control and total serum IgE, as well as higher rates of having a positive autologous serum skin test (ASST), angioedema, nocturnal symptoms, symptoms for >5 days/week, and thyroid autoantibodies. The ASST, by itself, was not a good predictor of basophil test results, but it predicted a positive basophil test in up to 100% of cases when combined with angioedema, thyroid autoantibodies or low IgE. In conclusion, a positive basophil test is linked to known features of TIIbaiCSU and novel characteristics including nocturnal symptoms. Further studies on basophil test-positive and -negative CSU patients can help to better understand CSU endotypes and to develop better management approaches.
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Affiliation(s)
- João Marcelino
- Immunoallergology Department, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte E.P.E., Lisbon, Portugal
| | - Katrine Baumann
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany.,Contract Research Dprt., RefLab ApS, Copenhagen, Denmark
| | - Per Stahl Skov
- Contract Research Dprt., RefLab ApS, Copenhagen, Denmark.,Odense Research Center for Anaphylaxis (ORCA), Urticaria Center of Reference and Excellence (UCARE), Odense University Hospital, Odense, Denmark
| | - Maria Conceição Pereira Santos
- Laboratory of Clinical Immunology, Faculdade de Medicina, Instituto de Medicina Molecular, Universidade de Lisboa, Lisbon, Portugal
| | - Inga Wyroslak
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jörg Scheffel
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Sabine Altrichter
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Anders Woetmann
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Manuel Pereira-Barbosa
- Immunoallergology Department, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte E.P.E., Lisbon, Portugal
| | - Célia Costa
- Immunoallergology Department, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte E.P.E., Lisbon, Portugal
| | - Marcus Maurer
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
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Fenebrutinib in H 1 antihistamine-refractory chronic spontaneous urticaria: a randomized phase 2 trial. Nat Med 2021; 27:1961-1969. [PMID: 34750553 PMCID: PMC8604722 DOI: 10.1038/s41591-021-01537-w] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 09/10/2021] [Indexed: 12/28/2022]
Abstract
Bruton's tyrosine kinase (BTK) is crucial for FcεRI-mediated mast cell activation and essential for autoantibody production by B cells in chronic spontaneous urticaria (CSU). Fenebrutinib, an orally administered, potent, highly selective, reversible BTK inhibitor, may be effective in CSU. This double-blind, placebo-controlled, phase 2 trial (EudraCT ID 2016-004624-35 ) randomized 93 adults with antihistamine-refractory CSU to 50 mg daily, 150 mg daily and 200 mg twice daily of fenebrutinib or placebo for 8 weeks. The primary end point was change from baseline in urticaria activity score over 7 d (UAS7) at week 8. Secondary end points were the change from baseline in UAS7 at week 4 and the proportion of patients well-controlled (UAS7 ≤ 6) at week 8. Fenebrutinib efficacy in patients with type IIb autoimmunity and effects on IgG-anti-FcεRI were exploratory end points. Safety was also evaluated. The primary end point was met, with dose-dependent improvements in UAS7 at week 8 occurring at 200 mg twice daily and 150 mg daily, but not at 50 mg daily of fenebrutinib versus placebo. Asymptomatic, reversible grade 2 and 3 liver transaminase elevations occurred in the fenebrutinib 150 mg daily and 200 mg twice daily groups (2 patients each). Fenebrutinib diminished disease activity in patients with antihistamine-refractory CSU, including more patients with refractory type IIb autoimmunity. These results support the potential use of BTK inhibition in antihistamine-refractory CSU.
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Maurer M, Zuberbier T, Siebenhaar F, Krause K. Chronic urticaria - What does the new guideline tell us? J Dtsch Dermatol Ges 2019; 16:584-593. [PMID: 29750467 DOI: 10.1111/ddg.13531] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 04/06/2018] [Indexed: 01/13/2023]
Abstract
Patients with chronic urticaria experience significant impairment, and require an effective treatment. Such treatment is preceded by a thorough diagnostic workup and measurement of disease activity, disease burden and disease control using well--established tools. Treatment is subsequently adjusted according to patient needs and therapeutic response, based on the tenet "as much as necessary, as little as possible" (in that order). Once disease control has been achieved, it is recommended that intermittent attempts at medication withdrawal be made in order to identify spontaneous disease remission. Chronic urticaria should be treated until spontaneous remission occurs.
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Affiliation(s)
- Marcus Maurer
- Department of Dermatology, Venereology, and Allergology, Charité - University Medical Center, Berlin, Germany
| | - Torsten Zuberbier
- Department of Dermatology, Venereology, and Allergology, Charité - University Medical Center, Berlin, Germany
| | - Frank Siebenhaar
- Department of Dermatology, Venereology, and Allergology, Charité - University Medical Center, Berlin, Germany
| | - Karoline Krause
- Department of Dermatology, Venereology, and Allergology, Charité - University Medical Center, Berlin, Germany
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Maurer M, Zuberbier T, Siebenhaar F, Krause K. Chronische Urtikaria – Was bringt die neue Leitlinie? J Dtsch Dermatol Ges 2018; 16:585-595. [DOI: 10.1111/ddg.13531_g] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 04/06/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Marcus Maurer
- Klinik für DermatologieVenerologie und AllergologieCharité – Universitätsmedizin Berlin Redaktion Prof. Dr. D. Nashan, Dortmund
| | - Torsten Zuberbier
- Klinik für DermatologieVenerologie und AllergologieCharité – Universitätsmedizin Berlin Redaktion Prof. Dr. D. Nashan, Dortmund
| | - Frank Siebenhaar
- Klinik für DermatologieVenerologie und AllergologieCharité – Universitätsmedizin Berlin Redaktion Prof. Dr. D. Nashan, Dortmund
| | - Karoline Krause
- Klinik für DermatologieVenerologie und AllergologieCharité – Universitätsmedizin Berlin Redaktion Prof. Dr. D. Nashan, Dortmund
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