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Dai A, Kim SJ. Systemic calcineurin inhibitors tacrolimus and voclosporin: A review of off-label dermatologic uses. J Am Acad Dermatol 2024; 90:358-367. [PMID: 37307993 DOI: 10.1016/j.jaad.2023.05.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 05/08/2023] [Accepted: 05/18/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Systemic calcineurin inhibitors, cyclosporine, tacrolimus, and voclosporin, have been utilized in various dermatologic conditions. Although there have been numerous off-label dermatologic indications with published guidelines for cyclosporine, there is no established strong consensus for tacrolimus and voclosporin. OBJECTIVE To conduct a review of off-label use of systemic tacrolimus and voclosporin in various dermatoses to better inform treatment methods. METHODS A literature search was conducted using PubMed and Google Scholar. Relevant clinical trials, observational studies, case series, and reports regarding off-label dermatologic uses of systemic tacrolimus and voclosporin were included. RESULTS Tacrolimus shows promise for numerous dermatologic conditions, including psoriasis, atopic dermatitis/eczema, pyoderma gangrenosum, chronic urticaria, and Behcet's disease. Randomized controlled trial data are only available for voclosporin in psoriasis, which showed efficacy but did not meet noninferiority to cyclosporine. LIMITATIONS Data were limited and extracted from published papers. Studies differed in methodology, and nonstandardized outcomes limited the conclusions drawn. CONCLUSIONS In comparison to cyclosporine, tacrolimus can be considered for treatment-refractory disease or in patients with cardiovascular risk factors or inflammatory bowel disease. Voclosporin has only been utilized in psoriasis currently, and clinical trials in psoriasis show voclosporin's efficacy. Voclosporin can be considered for patients with lupus nephritis.
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Affiliation(s)
- Annie Dai
- Department of Dermatology, Baylor College of Medicine, Houston, Texas
| | - Soo Jung Kim
- Department of Dermatology, Baylor College of Medicine, Houston, Texas.
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LaCava AF, Fadugba OO. Cyclosporine for omalizumab-refractory chronic urticaria: a report of five cases. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2023; 19:78. [PMID: 37644553 PMCID: PMC10466821 DOI: 10.1186/s13223-023-00820-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 07/10/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND While both the AAAAI/ACAAI and the EAACI/GA2LEN/EuroGuiDerm/APAAACI guidelines recommend starting cyclosporine for patients with chronic urticaria who have had an inadequate response to omalizumab, many clinicians are hesitant to initiate cyclosporine due to paucity of clinical data. The objective of this study was to report real-life clinical outcomes in adult patients with chronic urticaria who had an inadequate response to omalizumab and were switched from omalizumab to cyclosporine. Medical records of adult patients with chronic urticaria who had an inadequate response with omalizumab and were later treated with cyclosporine were reviewed retrospectively. Data pertaining to treatment method, clinical response, and adverse effects were recorded. RESULTS/PRESENTATION OF CASES Five patients with omalizumab-refractory chronic urticaria, three of whom also had angioedema and one with an inducible urticaria, were treated with low doses of oral cyclosporine (1-3 mg/kg/d). Four of five patients in this case series had complete resolution of symptoms with oral cyclosporine, while continuing other standard therapies. Systemic side effects occurred in three patients which prompted drug discontinuation in two patients. DISCUSSION Cyclosporine alone was effective in inducing urticaria control in adult patients with chronic urticaria who had an inadequate response to omalizumab, though the impact of cyclosporine was limited by reversible adverse effects. Adverse effects were associated with pre-existing medical conditions. As novel chronic urticaria therapies are being investigated, this experience highlights the importance of uncovering chronic urticaria subtypes which tend to respond to cyclosporine, while providing alternative treatments with better tolerability.
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Affiliation(s)
- Anthony F. LaCava
- Department of Allergy and Clinical Immunology, Cleveland Clinic, 224 W. Exchange Street, Suite 380, Akron, OH 44302 USA
| | - Olajumoke O. Fadugba
- Division of Pulmonary, Allergy, & Critical Care Medicine, Section of Allergy & Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
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Poowuttikul P, Pansare M, Kamat D, Seth D. Approach to Children with Hives. Pediatr Ann 2021; 50:e191-e197. [PMID: 34044707 DOI: 10.3928/19382359-20210422-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Urticaria (or hives) is a pruritic and erythematous skin rash. Angioedema commonly occurs with urticaria. The term "chronic urticaria" is used when hives are present for more than 6 weeks. Acute urticaria is common in children, whereas chronic urticaria is rare. Causes of urticaria can be identified in many cases of acute urticaria with a thorough medical history. Laboratory evaluation may be needed to confirm the etiology of acute urticaria. Chronic urticaria is often idiopathic. Clinicians should avoid universal allergy testing for food allergens or aeroallergens in chronic urticaria as it usually does not help in identifying the cause, can lead to false-positive results, and unnecessary avoidance of allergens or foods. Urticarial vasculitis should be considered for lesions that are painful, present for more than 48 hours, leave scars/hyperpigmentation, or present with systemic symptoms such as fever, weight loss, and arthritis. Skin biopsy should be considered for suspected urticarial vasculitis. [Pediatr Ann. 2021(5):e191-e197.].
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Holm JG, Ivyanskiy I, Thomsen SF. Use of nonbiologic treatments in antihistamine-refractory chronic urticaria: a review of published evidence. J DERMATOL TREAT 2017; 29:80-97. [DOI: 10.1080/09546634.2017.1329505] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | - Ilya Ivyanskiy
- Department of Dermatology, Bispebjerg Hospital, Copenhagen, Denmark
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Simon Francis Thomsen
- Department of Dermatology, Bispebjerg Hospital, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
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Molderings GJ, Haenisch B, Brettner S, Homann J, Menzen M, Dumoulin FL, Panse J, Butterfield J, Afrin LB. Pharmacological treatment options for mast cell activation disease. Naunyn Schmiedebergs Arch Pharmacol 2016; 389:671-94. [PMID: 27132234 PMCID: PMC4903110 DOI: 10.1007/s00210-016-1247-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 04/11/2016] [Indexed: 12/20/2022]
Abstract
Mast cell activation disease (MCAD) is a term referring to a heterogeneous group of disorders characterized by aberrant release of variable subsets of mast cell (MC) mediators together with accumulation of either morphologically altered and immunohistochemically identifiable mutated MCs due to MC proliferation (systemic mastocytosis [SM] and MC leukemia [MCL]) or morphologically ordinary MCs due to decreased apoptosis (MC activation syndrome [MCAS] and well-differentiated SM). Clinical signs and symptoms in MCAD vary depending on disease subtype and result from excessive mediator release by MCs and, in aggressive forms, from organ failure related to MC infiltration. In most cases, treatment of MCAD is directed primarily at controlling the symptoms associated with MC mediator release. In advanced forms, such as aggressive SM and MCL, agents targeting MC proliferation such as kinase inhibitors may be provided. Targeted therapies aimed at blocking mutant protein variants and/or downstream signaling pathways are currently being developed. Other targets, such as specific surface antigens expressed on neoplastic MCs, might be considered for the development of future therapies. Since clinicians are often underprepared to evaluate, diagnose, and effectively treat this clinically heterogeneous disease, we seek to familiarize clinicians with MCAD and review current and future treatment approaches.
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Affiliation(s)
- Gerhard J Molderings
- Institute of Human Genetics, University Hospital of Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany.
| | - Britta Haenisch
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Stefan Brettner
- Department of Oncology, Hematology and Palliative Care, Kreiskrankenhaus Waldbröl, Waldbröl, Germany
| | - Jürgen Homann
- Allgemeine Innere Medizin, Gastroenterologie und Diabetologie, Gemeinschaftskrankenhaus, Bonn, Germany
| | - Markus Menzen
- Allgemeine Innere Medizin, Gastroenterologie und Diabetologie, Gemeinschaftskrankenhaus, Bonn, Germany
| | - Franz Ludwig Dumoulin
- Allgemeine Innere Medizin, Gastroenterologie und Diabetologie, Gemeinschaftskrankenhaus, Bonn, Germany
| | - Jens Panse
- Department of Hematology, Oncology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Joseph Butterfield
- Program for the Study of Mast Cell and Eosinophil Disorders, Mayo Clinic, Rochester, MN, 55905, USA
| | - Lawrence B Afrin
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, 55455, USA
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Savic S, Marsland A, McKay D, Ardern-Jones MR, Leslie T, Somenzi O, Baldock L, Grattan C. Retrospective case note review of chronic spontaneous urticaria outcomes and adverse effects in patients treated with omalizumab or ciclosporin in UK secondary care. Allergy Asthma Clin Immunol 2015. [PMID: 26195984 PMCID: PMC4507325 DOI: 10.1186/s13223-015-0088-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Omalizumab is approved in the UK as add-on treatment for chronic spontaneous urticaria (CSU) in patients with inadequate response to H1-antihistamines. Ciclosporin is an established but unlicensed 3rd line option for CSU. Two parallel retrospective observational studies were conducted to describe outcomes of treatment and adverse events with omalizumab or ciclosporin for CSU treatment. METHODS Data from UK specialist centres prescribing omalizumab (five centres) or ciclosporin (three centres) in CSU patients were collected from hospital records by clinical staff and pooled for analysis. RESULTS Forty-six patients prescribed omalizumab and 72 patients prescribed ciclosporin were included. Twenty-two (48%) omalizumab-treated patients had paired Urticaria Activity Scores (UAS7), showing a 25.4 point improvement during treatment (P < 0.0001). Paired Dermatology Life Quality Index (DLQI) was available in 28 (61%) omalizumab-treated and 17 (24%) ciclosporin-treated patients. At least a 75% improvement in DLQI score was observed in 79% of omalizumab-treated and 41% of ciclosporin-treated patients, and 65% of omalizumab-treated patients had complete resolution of their quality-of-life impairment (DLQI 0-1) versus 21% of ciclosporin-treated patients. Clinician comments reported symptom clearance in 15/36 (42%) omalizumab-treated and 10/60 (17%) ciclosporin-treated patients. Proportions of patients with adverse events were similar but those for omalizumab resembled CSU symptoms, making causality assignment difficult, whereas those for ciclosporin were consistent with its known adverse effect profile. CONCLUSIONS Validated patient-reported measures of disease severity and quality of life should be used routinely in CSU management. Based on clinician comments and DLQI scores, symptoms and quality of life showed a greater improvement in the omalizumab-treated cohort than in the ciclosporin-treated cohort.
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Affiliation(s)
- Sinisa Savic
- St James's University Hospital, Leeds, LS9 7TF UK
| | - Alexander Marsland
- Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, University of Manchester, Manchester, M6 8HD UK
| | - David McKay
- Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA UK
| | | | - Tabi Leslie
- Royal Free London NHS Foundation Trust, London, NW3 2QG UK ; St John's Institute of Dermatology, London, SE1 7EH UK
| | - Olivier Somenzi
- Novartis Pharmaceuticals UK Ltd, Camberley, Surrey, GU16 7SR UK
| | | | - Clive Grattan
- St John's Institute of Dermatology, London, SE1 7EH UK ; Dermatology Centre, Norfolk and Norwich University Hospital, Norwich, NR4 7UY UK
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Stitt JM, Dreskin SC. The potential role of omalizumab in the treatment of chronic urticaria. Immunotherapy 2015; 6:691-7. [PMID: 25186602 DOI: 10.2217/imt.14.31] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Treatment of chronic urticaria refractory to antihistamines presents a challenge to both people affected with the disease as well as the physicians who treat them. Omalizumab, a monoclonal antibody against IgE, has emerged as one potential solution to this challenge. In several clinical trials published between 2011 and 2013, omalizumab significantly reduced or eliminated symptoms of chronic urticaria. The optimal dose for chronic urticaria is 300 mg administered every 4 weeks, a dose that differs from those used in asthma, which are based on the patient's weight and IgE level. Omalizumab does not appear to cause lasting symptom remission, and the ideal duration of treatment for chronic urticaria has not been defined.
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Affiliation(s)
- Jenny M Stitt
- University of Colorado Denver, Division of Allergy & Clinical Immunology, Campus Box B164, Research Complex 2, Room 10002, 2700 E 19th Ave, Aurora, CO 80045, USA
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Morgan M, Cooke A, Rogers L, Adams-Huet B, Khan DA. Double-blind placebo-controlled trial of dapsone in antihistamine refractory chronic idiopathic urticaria. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2014; 2:601-6. [PMID: 25213055 PMCID: PMC4165520 DOI: 10.1016/j.jaip.2014.06.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 05/18/2014] [Accepted: 06/11/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Management of antihistamine refractory chronic idiopathic urticaria (CIU) has poorly defined therapeutic options. OBJECTIVE To evaluate the efficacy of dapsone (4,4'-diaminodiphenylsulfone) in antihistamine refractory CIU compared with placebo. METHODS Twenty-two patients with antihistamine refractory CIU were randomly assigned to 100 mg of dapsone daily or placebo for 6 weeks in a 14-week double-blind, placebo-controlled crossover trial. End points were measured from a daily diary that reflected the weekly hive score, the weekly itch score, and a visual analog scale (VAS) score. Secondary to a carryover effect, the first period results were analyzed as a parallel design that compared placebo with dapsone directly by using repeated-measures analysis. RESULTS After 6 weeks, the patients in the dapsone arm showed mean improvement over baseline in VAS (2.3 [95% CI, 0.6-4.1], P = .01), urticaria score (-3.5 [95% CI, -6.2 to -0.9], P = .01), and itch score (-4.8 [95% CI, -7.6 to -2.1], P = .001), whereas the placebo arm showed no improvement over baseline for VAS, urticaria, or itch scores. Dapsone showed greater improvement compared with placebo for itch (P = .047) and VAS (P = .04). Of the 22 patients, 3 showed complete resolution of hives and itch with dapsone, whereas 31% and 41% had ≥ 50% resolution of hives and itch, respectively. No serious adverse effects were observed with dapsone. CONCLUSION To our knowledge, this is the first double-blind, placebo controlled study of dapsone in CIU and indicates that dapsone has efficacy in patients with antihistamine refractory CIU.
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Affiliation(s)
- Matt Morgan
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Allergy, Asthma, and Immunology of North Texas, McKinney, Texas
| | - Andrew Cooke
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Laura Rogers
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Chicago Lake Shore Allergy and Asthma, Chicago, Ill
| | - Beverley Adams-Huet
- Division of Biostatistics, Department of Clinical Sciences, University of Texas, Southwestern Medical Center, Dallas, Texas
| | - David A Khan
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
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Bernstein JA, Lang DM, Khan DA, Craig T, Dreyfus D, Hsieh F, Sheikh J, Weldon D, Zuraw B, Bernstein DI, Blessing-Moore J, Cox L, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CR, Schuller DE, Spector SL, Tilles SA, Wallace D. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol 2014; 133:1270-7. [DOI: 10.1016/j.jaci.2014.02.036] [Citation(s) in RCA: 320] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 02/10/2014] [Accepted: 02/12/2014] [Indexed: 12/13/2022]
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Stitt JM, Dreskin SC. Urticaria and autoimmunity: where are we now? Curr Allergy Asthma Rep 2014; 13:555-62. [PMID: 23821106 DOI: 10.1007/s11882-013-0366-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
There is considerable debate whether chronic urticaria is an autoimmune disease or whether its features suggestive of autoimmunity are epiphenomena. A plethora of circumstantial evidence suggests that chronic urticaria is an autoimmune disease, but criteria to establish autoimmunity require direct proof and indirect evidence, and these are lacking in chronic urticaria. Current approaches to assessing for autoimmunity in vivo via the autologous serum skin test, and in vitro via either basophil histamine release or the basophil activation test are widely utilized, but the results of these tests have limited impact on prediction of the clinical course and efficacy of treatments. Recent guidelines for diagnosing autoimmune urticaria have been proposed, but further investigation is needed.
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Affiliation(s)
- Jenny M Stitt
- Division of Allergy and Clinical Immunology, University of Colorado Denver, Campus Box B164, Research Complex 2, Room 10002, 2700 E. 19th Ave., Aurora, CO, 80045, USA,
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Jung HC, Lee DH, Park HS, Lee HJ, Kwon JW. Chronic urticaria treated with tacrolimus. ALLERGY ASTHMA & RESPIRATORY DISEASE 2014. [DOI: 10.4168/aard.2014.2.5.391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Ho-Chul Jung
- Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Dong-Hyun Lee
- Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Hyun-Sun Park
- Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Ho-Jin Lee
- Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Jae-Woo Kwon
- Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea
- Department of Allergy and Clinical Immunology, Kangwon National University College of Medicine, Chuncheon, Korea
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[Chronic spontaneous urticaria]. Med Clin (Barc) 2013; 142:275-8. [PMID: 24120109 DOI: 10.1016/j.medcli.2013.07.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 07/17/2013] [Accepted: 07/25/2013] [Indexed: 11/21/2022]
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Khan DA. Alternative agents in refractory chronic urticaria: evidence and considerations on their selection and use. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2013; 1:433-440.e1. [PMID: 24565613 DOI: 10.1016/j.jaip.2013.06.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 06/02/2013] [Accepted: 06/19/2013] [Indexed: 10/26/2022]
Abstract
Patients with chronic urticaria (CU) who are refractory to antihistamines are frequently encountered by allergy specialists. Several alternative agents have been used to treat these patients; however, the evidence to support these agents is generally limited. This review focuses on some of the more commonly used alternative agents in refractory CU, including anti-inflammatory agents (montelukast, hydroxychloroquine, dapsone, sulfasalazine, methotrexate, colchicine), immunosuppressants (cyclosporine, tacrolimus, mycophenolate), and immunomodulatory agents (omalizumab, immune globulin). The evidence to support their use, dosing, potential toxicity, monitoring, and selection of these alternative agents is reviewed. Although numerous knowledge gaps exist for alternative agents in refractory CU, a rational, patient-based approach can be used with a goal of improving control and quality of life and minimizing adverse medication effects.
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Affiliation(s)
- David A Khan
- Division of Allergy & Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Tex.
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