Safety of omalizumab treatment in patients with chronic spontaneous urticaria and COVID-19

COVID-19 infection in chronic spontaneous urticaria treated with omalizumab: two case reports

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COVID-19 and Its Impact on Common Diseases in the Allergy Clinics

Coronavirus disease 2019 (COVID-19) is a highly contagious viral disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It has various effects on asthma, allergic rhinitis, atopic dermatitis, and urticaria and may change the course of the disease depending on the severity of the infection and control status of the disease. Conversely, these diseases may also impact the course of COVID-19. Patients with chronic urticaria and atopic dermatitis may have COVID-19-induced disease exacerbations and biological treatments reduce the risk of exacerbations. Poor asthma control is linked to severe COVID-19 while allergic asthma is associated with lower risk of death and a lower rate of hospitalization due to COVID-19 compared with nonallergic asthma. The use of intranasal corticosteroids is associated with lower rates of hospitalization due to COVID-19 in patients with allergic rhinitis, whereas the effect of inhaled corticosteroids is confounded by asthma severity. These observations reinforce the importance of keeping allergic diseases under control during pandemics. The use of biologicals during COVID-19 is generally regarded as safe, but more evidence is needed. The pandemic substantially changed the management of allergic disorders such as home implementation of various biologicals, allergen immunotherapy, food introduction, and increased use of telemedicine and even home management of anaphylaxis to reduce emergency department burden and reduce risk of infection. Physicians need to be aware of the potential impact of COVID-19 on allergic diseases and educate their patients on the importance of continuing prescribed medications and adhering to their treatment plans to maintain optimal control of their disease.

Long-Term Omalizumab Therapy in Patients with Chronic Spontaneous Urticaria: Does it Increase the Risk of COVID-19?

INTRODUCTION

Based on the existing literature, omalizumab (OMZ) is considered a safe treatment modality in chronic spontaneous urticaria (CSU) during the coronavirus disease 19 (COVID-19) era.

OBJECTIVES

The aim of this study is to evaluate the effects of OMZ on CSU patients regarding COVID-19 infection.

METHODS

In this retrospective study, files of CSU patients using OMZ during the COVID-19 pandemic were reviewed in terms of demographic features, medical history including COVID-19 vaccination status, clinical characteristics, pretreatment laboratory parameters, duration, and dosing regimen of OMZ treatment. Patients with a history of COVID-19 infection while on OMZ therapy and patients without COVID-19 history were compared with respect to these parameters. The urticaria activations following COVID-19 infection or vaccination were also recorded.

RESULTS

Sixty-eight patients with CSU (female:male ratio = 1.8:1; mean age = 47.2 ± 15.1 years) continued to receive OMZ treatment. The median duration of OMZ treatment was 12 months (range: 6-60). Twelve patients (17.6%) were diagnosed with COVID-19 showing no exacerbation in urticaria. The duration of OMZ treatment was significantly higher in the group with COVID-19 infection history compared to patients with no history of COVID-19 (P = 0.01). Among 51 patients (75%) vaccinated against COVID-19, urticaria activation occurred in 4 patients without any recurrence following booster vaccinations.

CONCLUSIONS

Considering the likelihood of increased COVID-19 infection risk in the setting of long-term OMZ in CSU patients, the duration of OMZ therapy might be kept at a minimum, or a temporary interruption of the treatment period might be preferred, particularly in high-risk patients regarding COVID-19.

Treating asthma in the time of COVID

The Precision Interventions for Severe and/or Exacerbation-Prone Asthma clinical trials network is actively assessing novel treatments for severe asthma during the coronavirus disease (COVID-19) pandemic and has needed to adapt to various clinical dilemmas posed by the COVID-19 pandemic. Pharmacologic interactions between established asthma therapies and novel drug interventions for COVID-19 infection, including antivirals, biologics, and vaccines, have emerged as a critical and unanticipated issue in the clinical care of asthma. In particular, impaired metabolism of some long-acting beta-2 agonists by the cytochrome P4503A4 enzyme in the setting of antiviral treatment using ritonavir-boosted nirmatrelvir (NVM/r, brand name Paxlovid) may increase risk for adverse cardiovascular events. Although available data have documented the potential for such interactions, these issues are largely unappreciated by clinicians who treat asthma, or those dispensing COVID-19 interventions in patients who happen to have asthma. Because these drug-drug interactions have not previously been relevant to patient care, clinicians have had no guidance on management strategies to reduce potentially serious interactions between treatments for asthma and COVID-19. The Precision Interventions for Severe and/or Exacerbation-Prone Asthma network considered the available literature and product information, and herein share our considerations and plans for treating asthma within the context of these novel COVID-19-related therapies.

The effect of COVID-19 on patients recieving omalizumab treatment

Background and aim

Although exposure during drug administration and susceptibility to coronavirus disease-19 (COVID-19) infection secondary to immunomodulatory effects constitute potential risks for patients with chronic spontaneous urticaria (CSU) or asthma on omalizumab (OMZ), there is a risk of loss of response following discontinuation of OMZ. There are few studies describing the clinical course of COVID-19 in patients receiving OMZ.

Materials and methods

A total of 103 patients on OMZ were included in the study between February 2021 and January 2022.

Results

Fourteen (13.6%) of the patients participating in the study had SARS-CoV-2 infection, of whom 3 (21.4%) required hospitalization and 11 (78.6%) were treated in an outpatient clinic. During the pandemic, 17 (16.5%) of the patients interrupted their OMZ treatment. Patients on OMZ for six months or less had a lower rate of interruption (2.5%) than those on OMZ for more than 6 months (25.4%). Patients interrupted treatment for the following reasons: 3 (17.6%) had COVID-19, 10 (58.9%) did not attend the hospital visit due to concern about contamination with SARS-CoV-2, and 4 (23.5%) thought that OMZ treatment would facilitate contamination with SARS-CoV-2. After interrupting OMZ, 3 (25%) female patients and 5 (100%) male patients presented no worsening of their symptoms. Three (13%) of the patients on OMZ for asthma and 11 (13.8%) of those on the drug for urticaria had COVID-19 infection. Patients presenting CSU and severe asthma are completely different, with different potential consequences of OMZ interruption. Nine (52.9%) patients had aggravated symptoms following interruption of OMZ treatment. Three of them described worsening of asthma symptoms and a need to increment their maintenance therapy due to asthma exacerbation after nearly three weeks of interruption, and 6 of them had hives and pruritus as urticaria exacerbation nearly four weeks after interruption of OMZ. The asthma patients did not stop their other treatments, including inhaled corticosteroids.

Conclusion

Use of OMZ does not increase the risk of SARS-CoV-2 infection, COVID-19-related pneumonia, or COVID-19-related hospitalization. We advise patients not to interrupt OMZ treatment during the COVID-19 pandemic unless advised to do so by their doctors, and we recommend that they receive instruction concerning self-administration of OMZ to avoid visiting hospitals in the event of a pandemic.

Sleep Quality as a Predictor of Quality-of-Life and Emotional Status Impairment in Patients with Chronic Spontaneous Urticaria: A Cross-Sectional Study

Chronic Spontaneous Urticaria (CSU) leads to a decreased quality of life in patients because of pruritus and skin lesions. However, there is still little evidence on the impact that a worse sleep quality could have on the quality of life and emotional disorders in these patients. The aims of the present study are to analyze the potential impact of sleep quality on the quality-of-life and emotional status of patients with CSU. A cross-sectional study of 75 CSU patients was performed. Socio-demographic variables and disease activity, quality of life, sleep, sexual disfunction, anxiety, depression and personality traits were collected. A majority of 59 of the patients suffered from poor sleep quality. Sleep quality impairment was associated with worse disease control, greater pruritus and swelling and poorer general and urticaria-related quality-of-life (p < 0.05). Patients with poor sleep quality showed an increased prevalence of anxiety (1.62-fold) and depression risk (3.93-fold). Female sexual dysfunction, but not male, was found to be linked to poorer sleep quality (p = 0.04). To conclude, sleep quality impairment in patients with CSU is related to poor quality-of-life, worse disease control and higher rates of anxiety and depression. Global management of the disease should take sleep quality into account to improve the care of CSU patients.

The course of COVID-19 in patients with chronic spontaneous urticaria receiving omalizumab treatment

Background and aim

Although there are case reports and guideline recommendations that states omalizumab can be used in chronic spontaneous urticaria (CSU) patients during SARS-CoV-2 pandemic, there are scarce studies showing the course of Coronavirus disease 2019 (COVID-19) in CSU patients receiving omalizumab.

Materials and methods

A total of 370 patients with chronic urticaria were included in the study between June 2020 and December 31, 2020.

Results

Sixty patients (16.2%) became infected with the SARS-CoV-2. The rate of pneumonia and hospitalization were 4.1% and 1.9%. There was no significant difference was determined between the CSU patients with omalizumab treatment and the non-receivers in regard to the rate of SARS-CoV-2 (+) (P: 0.567) and in regard to the rate of SARS-CoV-2 related pneumonia and hospitalization (P: 0.331 and P: 0.690). Gender, duration of CSU, serum IgE levels, omalizumab treatment, and atopy were not found to be associated with an increased risk for SARS-CoV-2 positivity in patients with CSU.

Conclusion

Our study shows that the use of omalizumab does not increase the risk of COVID-19 infection, COVID-19-related pneumonia and COVID-19-related hospitalizations in CSU patients.

Pediatric chronic spontaneous urticaria: a brief clinician's guide

INTRODUCTION

Chronic urticaria (CU) appears with daily or intermittent/recurrent wheals with/without angioedema for more than six weeks. When no specific eliciting factors are found, chronic urticaria is defined as spontaneous (CSU). Up to 50% of patients with CSU do not respond to therapy, leading to a prolonged disease course and the need for expensive therapies, impacting the quality of life (QoL) and healthcare resources.

AREAS COVERED

: Diagnosis of CSU is made when other potential causes of chronic urticaria are excluded. CSU therapy aims to achieve complete control of symptoms and normalization of QoL. Current treatment options for urticaria aim to target mast cell mediators such as histamine, or activators, such as autoantibodies. Guidelines recommend starting with second generation antihistamines (sgAHs) and adding omalizumab therapy if symptoms are not controlled. This review aims to provide a practical guide for CSU in the pediatric population.

EXPERT OPINION

: Treatment options for pediatric CSU are primarily based on adult data that have been extrapolated for children. Current guidelines should be re-evaluated based on pediatric data, new biological treatments, and the COVID-19 pandemic. Future research is needed to investigate strategies to personalize current treatments and identify potential predictive biomarkers.

Retrospective evaluation of patients with chronic spontaneous urticaria using omalizumab during the COVID-19 pandemic

INTRODUCTION

Omalizumab (OMZ) is a monoclonal anti-immunoglobulin E antibody used in patients with chronic spontaneous urticaria (CSU). The data about using OMZ during the coronavirus disease 19 (COVID-19) pandemic are limited. The aim of this study was to evaluate the status of having COVID-19 and relationships between COVID-19, vaccination, and urticaria symptoms of CSU patients on OMZ.

METHOD

We conducted a retrospective cohort study of 36 adult CSU patients treated with OMZ. Demographic data, the results of COVID-19 real-time polymerase chain reaction (RT-PCR), and vaccination status were recorded from the electronic medical records.

RESULTS

Thirty-six patients, 23 women, and 13 men were evaluated. The mean age was 45.81 years. Two patients were diagnosed with COVID-19 while using OMZ. Four patients interrupted their OMZ treatment during the pandemic, and OMZ treatments were restarted in all patients. There were 28 patients who had at least one dose of vaccine (inactive and/or mRNA vaccine). Only one patient had an urticaria exacerbation after the first dose of mRNA vaccine.

CONCLUSION

As a result, our findings have shown that omalizumab treatment in CSU patients during the COVID-19 pandemic does not increase the risk of COVID-19 infection and omalizumab can be used safely.

Colchicine in Managing Skin Conditions: A Systematic Review

(1) Background: Colchicine is a natural alkaloid with anti-inflammatory properties used to treat various disorders, including some skin diseases. This paper aims to incorporate all the available studies proposing colchicine as a treatment alternative in the management of cutaneous conditions. (2) Methods: In this systematic review, the available articles present in various databases (PubMed, Scopus-Embase, and Web of Science), proposing colchicine as a treatment for cutaneous pathological conditions, have been selected. Exclusion criteria included a non-English language and non-human studies. (3) Results: Ninety-six studies were included. Most of them were case reports and case series studies describing colchicine as single therapy, or in combination with other drugs. Hidradenitis suppurativa, pyoderma gangrenosum, erythema nodosum, erythema induratum, storage diseases, perforating dermatosis, bullous diseases, psoriasis, vasculitis, acne, urticaria, stomatitis, actinic keratosis, and pustular dermatosis were the main diseases discussed in literature. Although the therapeutic outcomes were variable, most of the studies reported, on average, good clinical results (4) Conclusions: Colchicine could be, as a single therapy or in combination with other drugs, a possible treatment to manage several skin diseases.

Impact of Anti-Type 2 Inflammation Biologic Therapy on COVID-19 Clinical Course and Outcome

SARS-CoV-2 pandemic had a general and deep impact on the clinical management of chronic diseases, including respiratory and allergic disorders. At the beginning of the pandemic, one of the main concerns was the potential impact of immunosuppressive/immunomodulatory drugs on COVID-19 clinical course. In this review, we aim to summarize and analyze the available clinical evidence from patients treated with anti-type 2 inflammation biologics (including anti-IgE, anti-IL-5 and anti-IL-4 agents), who developed COVID-19. Overall, the treatment with anti-Th2 biologics can be considered safe during COVID-19. It does not worsen the clinical course and outcome of COVID-19, and it may be actually protective somehow from developing severe forms. Moreover, patients treated with these biological agents do not seem to be more prone to get infected by SARS-CoV-2.

The effect of allergy and asthma as a comorbidity on the susceptibility and outcomes of COVID-19

The coronavirus disease 2019 (COVID-19) pandemic causes an overwhelming number of hospitalization and deaths with a significant socioeconomic impact. The vast majority of studies indicate that asthma and allergic diseases do not represent a risk factor for COVID-19 susceptibility nor cause a more severe course of disease. This raises the opportunity to investigate the underlying mechanisms of the interaction between an allergic background and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The majority of patients with asthma, atopic dermatitis, allergic rhinitis, chronic rhinosinusitis, food allergies and drug allergies exhibit an over-expression of type 2 immune and inflammatory pathways with the contribution of epithelial cells, innate lymphoid cells, dendritic cells, T cells, eosinophils, mast cells, basophils, and the type 2 cytokines interleukin (IL)-4, IL-5, IL-9, IL-13, and IL-31. The potential impact of type 2 inflammation-related allergic diseases on susceptibility to COVID-19 and severity of its course have been reported. In this review, the prevalence of asthma and other common allergic diseases in COVID-19 patients is addressed. Moreover, the impact of allergic and non-allergic asthma with different severity and control status, currently available asthma treatments such as inhaled and oral corticosteroids, short- and long-acting β2 agonists, leukotriene receptor antagonists and biologicals on the outcome of COVID-19 patients is reviewed. In addition, possible protective mechanisms of asthma and type 2 inflammation on COVID-19 infection, such as the expression of SARS-CoV-2 entry receptors, antiviral activity of eosinophils and cross-reactive T-cell epitopes, are discussed. Potential interactions of other allergic diseases with COVID-19 are postulated, including recommendations for their management.

COVID-19 Disease Leading to Chronic Spontaneous Urticaria Exacerbation: A Romanian Retrospective Study

(1) Background: The COVID-19 pandemic has resulted in the exacerbation of various chronic diseases. Due to the potential impact of SARS-CoV-2 on mast cells, we aimed to analyze the relevance of COVID-19 disease on chronic spontaneous urticaria (CSU) clinical presentation and biological profile. (2) Methods: This study is a retrospective case series of patients with CSU diagnosed and treated in the Allergy Department of the Professor Doctor Octavian Fodor RIGH, (Cluj-Napoca, Romania). Patients were assessed for disease activity and level of control with the weekly urticaria activity score and the visual analogue scale. Results were correlated with COVID-19 severity and with nonspecific markers of inflammation during and after the SARS-CoV-2 infection. (3) Results: SARS-CoV-2 impacted a significant proportion (33%) of the CSU patients, of which 71% developed a moderate-severe form of COVID-19. Most of the patients (68%) had moderate-severe forms of CSU and 65% took AH1 treatment (one dose, two-fold dose or four-fold dose). The rest of them (35%) received the second-line treatment (40.3% Omalizumab, 53% Prednisolone and 4.8% Cyclosporine). In Omalizumab treated group of UCS patients we observed that COVID-19 disease was not severe. We established a positive correlation between the severity of the infection and that of the CSU clinical presentation, with most bothersome symptoms of urticaria being experienced by moderate to severe COVID-19 CSU patients (47%). Inflammatory markers were positively correlated (p = 0.01) with a more severe clinical profile of CSU, in accordance with our hypothesis that the level of inflammation triggered by COVID-19 disease has a role in CSU exacerbation. The non-specific inflammatory markers, such as CRP, were positively associated with the UAS7 score (R2 = 0.363; p = 0.001). An increased rate of exacerbation of CSU was observed in moderate-severe COVID-19 infection. (4) Conclusions: COVID-19 disease can result in the exacerbation of chronic spontaneous urticaria, more likely in moderate to severe forms of infection.