The Expanding Field of Biologics in the Management of Chronic Urticaria

Gut Microbiome Composition in Patients with Chronic Urticaria: A Review of Current Evidence and Data

Recent studies have linked gut microorganism composition and chronic urticaria (CU); however, the underlying mechanisms responsible for this connection are unknown. Since the human immune system is in homeostasis with microbiota, and the composition of the microbiome regulates the development and function of the immune system, it is likely that an alteration of microbiota components (a dysbiosis) could influence the course of chronic spontaneous urticaria (CSU), including disease severity, patient quality of life and treatment outcome. To date, several studies have identified changes in the gut microbiota composition of patients with CSU, though only a few have exhibited metabolic abnormalities associated with gut dysbiosis. The studies on CSU patients predominantly showed that the relative abundance of beneficial bacteria was decreased (Firmicutes and Bacteroides), while that of opportunistic bacteria was increased (Enterobacteria and Proteobacteria). In addition, serum metabolome analysis revealed that gut microbiota-associated alterations in unsaturated fatty acids and the butanoate metabolism pathway may play a role in CSU. These findings are potentially associated with inflammation mediated by the imbalance of Th1/Th2/Th17 cytokines, which might contribute to CSU pathogenesis. Further research in this field could improve clinical, diagnostic, and therapeutic approaches to patients with CSU. By applying new knowledge on gut microbial communities and metabolomics, future CSU therapies could modify the microbiota composition using agents such as probiotics or other similar agents, which, in combination with current standard therapies, could hopefully lead to a reduction in symptoms and an improved quality of life for CSU patients.

Comparison between chronic spontaneous urticaria and chronic induced urticaria on the efficacy of omalizumab treatment: A systematic review and meta-analysis

This meta-analysis aimed to assess the efficacy of omalizumab in the treatment of refractory-to-antihistamines chronic induced urticaria (CIndU) in comparison with that of refractory-to-antihistamines chronic spontaneous urticaria (CSU). We retrieved interventional studies and observational studies on omalizumab efficacy to CIndU patients and efficacy comparison between CSU and CIndU both refractory to H1-antihistamines in electronic databases (accessed till May 2022). The odd ratio (OR) and 95% confidence interval (CI) was calculated with a random-effect model in this meta-analysis. The majority of patients with different CIndU subtypes gained complete or partial response and good safety after omalizumab treatment. A total of five studies with 355 CSU patients and 103 CIndU patients were included for the meta-analysis. There was no significant difference in the efficacy of omalizumab in the treatment of CSU and CIndU (OR -0.83, 95% CI [0.84, 2.21], P > 0.05). Based on the validity of omalizumab in the treatment of various CIndU subtypes and non-differential efficacy between CSU and CIndU, it is reasonable to list omalizumab as a third-line treatment of refractory CIndU.

Biomarkers of Gut Microbiota in Chronic Spontaneous Urticaria and Symptomatic Dermographism

Background

Chronic urticaria (CU) is a chronic inflammatory skin disease associated with Th2 immune response. The two most common subtypes of CU, i.e., chronic spontaneous urticaria and symptomatic dermographism (CSD), often coexist. However, the pathogenesis of CSD is still unclear. Gut microbiota plays an important role in immune-related inflammatory diseases. The purpose of this study was to explore the correlation between gut microbiota and CSD.

Methods

A case-control study was conducted on CSD patients as well as gender- and age-matched normal controls (NCs). The 16S ribosomal DNA sequencing of fecal samples was used to detect the gut microbiota of all subjects. QPCR was used to further verify the species with differences between the two groups.

Results

The alpha diversity of gut microbiota decreased in CSD patients, accompanied by significant changes of the structure of gut microbiota. Subdoligranulum and Ruminococcus bromii decreased significantly in CSD patients and had a potential diagnostic value for CSD according to receiver operating characteristic curve (ROC) analysis. Enterobacteriaceae and Klebsiella were found to be positively correlated with the duration of CSD, while Clostridium disporicum was positively correlated with the dermatology life quality index (DLQI).

Conclusions

The gut microbiota of CSD patients is imbalanced. Subdoligranulum and Ruminococcus bromii are the gut microbiota biomarkers in CSD.

What's New in the Treatment of Urticaria and Angioedema

Chronic urticaria and angioedema are diseases often managed by Allergy and Immunology specialists. Recent international guidelines have outlined a stepwise approach to management of patients using dose escalation of second-generation antihistamines followed by use of omalizumab and finally cyclosporine in more refractory cases. In select patients (those with refractory chronic urticaria), nonbiologic alternative medications with anti-inflammatory or immunosuppressant activity may be considered. Angioedema without wheals may have several different pathophysiologic mechanisms. Optimal management of mast cell-mediated angioedema is less clear but is often managed similar to chronic spontaneous urticaria. Drug-induced angioedema due to angiotensin-converting enzyme inhibitors is a common cause of angioedema in the emergency department. Although bradykinin is thought to be a primary mediator for this type of angioedema, studies of targeted therapies have been generally disappointing. In contrast, several targeted therapies have been proven successful using acute and preventive approaches for management of hereditary angioedema. Further developments, including novel biologics, novel oral therapies, and gene therapy approaches, may hopefully continue to broaden therapeutic options to ensure optimal individual management of patients with hereditary angioedema.

Cholinergic Urticaria: Clinical Presentation and Natural History in a Tropical Country

BACKGROUND

Cholinergic urticaria (CholU) is a subset of chronic inducible urticaria characterized by the recurrent pinpoint-sized wheals that are induced by exercising or increasing core body temperature. Currently, the data of CholU in tropical climate is still limited.

OBJECTIVE

To investigate the clinical features and natural course of CholU in a tropical country.

MATERIALS AND METHODS

This retrospective chart review study analyzed the data of CholU patients aged over 18 years who visited Siriraj Urticaria Clinic, Siriraj Hospital, Bangkok, Thailand, between January 2007 and September 2019. Demographic data, clinical presentations, and results of provocation tests and other laboratory investigations were evaluated and compared with other studies reported in temperate zones.

RESULTS

Sixteen out of 2,175 chronic urticaria patients (0.7%) were diagnosed with CholU. The median age of CholU patients was 28.0 ± 11.7 years with male predominance (56.3%). Three patients (18.8%) had a history of atopy. Fifteen patients (93.8%) were positive to the exercise provocation test. Nonsedating antihistamine drugs were a main treatment (73.8%). Six patients (37.5%) were in remission at the time of the study, with a mean duration 4.3 years. The Kaplan-Meier survival analysis demonstrated that 12.5%, 35.5%, and 67.9% of patients would have disease remission within 1 year, 5 years, and 13 years, respectively.

CONCLUSIONS

The prevalence of CholU differs in each geographic region and is found to be low in tropical countries with a median duration 4.3 years. The prevalence of atopy and anaphylaxis with CholU is also lower in tropical countries than in temperate.

Chronic Spontaneous Urticaria: A Review of Pathological Mechanisms, Diagnosis, Clinical Management, and Treatment

Urticaria is a poorly understood and underestimated clinical condition characterised by the sudden onset of itchy wheals and/or angioedema, which usually resolve within 24 and 72 hours, respectively. It is generally classified as being acute (lasting <6 weeks) or chronic (continuous or intermittent for ≥6 weeks). Chronic urticaria can be further classified as chronic spontaneous urticaria (CSU) and chronic inducible urticaria, appearing in response to specific eliciting factors, such as heat, cold, or sun exposure, or following the application of pressure. Scientific advances have been made in the understanding of pathological mechanisms and treatment, especially associated with CSU. The exact pathological mechanism of how urticaria develops is still not yet fully understood, but the clinical implications on the patients’ quality of life are severe and have been associated with mental disorders and metabolic diseases. The diagnosis of urticaria is based on medical history and clinical manifestations. The treatment pathway begins with the administration of second-generation, nonsedating, nonimpairing histamine 1 receptor antihistamines and, in case of nonresponse, with new-generation biological drugs. The current review presents an update of the pathological mechanisms, diagnosis, clinical management, and treatment of CSU. It also focusses on the future implications of new-generation drugs and their effects on the clinical practice.

Chronic urticaria and thyroid pathology

Urticaria is defined as the sudden appearance of erythematous, itchy wheals of variable size, with or without angioedema (AE) (swelling of the deeper layers of the skin). Its classification depends on time course of symptoms and the presence of eliciting factors. When it lasts less than 6 weeks it is classified as acute urticaria (AU), and if the symptoms persist for more than 6 weeks, it is classified as chronic urticaria (CU). Current International Guidelines also classify CU as chronic spontaneous urticaria (CSU) and inducible urticarial, according to the absence or presence of environmental triggering factors. CSU is defined as urticaria and/or angioedema in which there is no evidence of a specific eliciting factor. CSU is associated with autoimmunity in 30-45% of the cases, sharing some immunological mechanisms with other autoimmune diseases, and is associated with autoimmune thyroid disease (ATD) in about 4.3%-57.4% patients. Several studies suggest that adequate therapy with anti-thyroid drugs or levothyroxine in early stages of ATD and CSU, may help to remit the latter; but there is still a lack of double-blind, placebo-controlled studies that support this hypothesis in patients without abnormal thyroid hormone levels. The objective of this review is to describe the pathophysiology of chronic spontaneous urticaria and its association with autoimmune thyroid disease.

From regulatory limitations to new opportunities: Real-life experience on the effectiveness of short courses of omalizumab in the treatment of chronic idiopatic urticaria

Economic sustainability of long-term continuous treatment of antihistamine refractory chronic urticaria with omalizumab may be an issue. We assessed the efficacy of relatively short courses (5-6 months) of omalizumab in patients with chronic idiopathic urticaria (CIU). We retrospectively studied 40 patients (observed between June 2015 and January 2019) affected by moderate-to-severe CIU refractory to anti-H1 antihistamines (up to fourfold doses). Omalizumab was administered every 4 weeks for 24 weeks, then for 20 weeks in case of a relapse of moderate-to-severe degree, then again for 24 weeks in case of a second relapse. Monthly clinical evaluations were performed. Mean disease severity significantly dropped after 1 month and further decreased thereafter, with 30 complete remissions after the first course of treatment. In 2-4 months, 18 patients had a relapse of moderate-to-severe degree. The profile of response to the second course of omalizumab was similar to the first. A third course was necessary for seven patients. No adverse effects were recorded. Courses of 5-6 months of omalizumab may induce rapid significant improvement of urticaria and many prolonged complete remissions. In case of relapse, further courses show a similar profile of response and may induce additional long-term complete remissions.

Emerging Biomarkers and Therapeutic Pipelines for Chronic Spontaneous Urticaria

Chronic spontaneous urticaria (CSU) is defined as the appearance of evanescent wheals, angioedema, or both, for at least 6 weeks. CSU is associated with intense pruritus and poor quality of life, with higher odds of reporting depression, anxiety, and sleep difficulty. As of yet, the assessment of the activity and course of the disease along with the response to several treatments in CSU are based purely on the patient's medical history and the use of the patient-reported outcomes. Recently, several reports have suggested that certain parameters could be considered as potential disease-related biomarkers. Moreover, with the advent of such biomarkers, newer biologic agents are coming forth to revolutionize the management of potential refractory diseases such as CSU. The purpose of this article is to review the most promising biomarkers related to important aspects of CSU, such as the disease activity, the therapeutic response, and the natural history of the disease, and discuss the mechanisms of action and therapeutic effectiveness of the latest agents available or currently under investigation for the management of antihistamine-refractory CSU. The knowledge of these features could have an important impact on the management and follow-up of patients with CSU.