1
|
Keller L, Perera EK, Bindon B, Khatiwada A, Stitt JM, Dreskin SC. Total IgE as a biomarker of omalizumab response in chronic spontaneous urticaria: A meta-analysis. Allergy Asthma Proc 2024; 45:97-99. [PMID: 38449010 DOI: 10.2500/aap.2024.45.230092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
Background: Omalizumab is approved for the treatment of chronic spontaneous urticaria (CSU) that is refractory to antihistamines. Total immunoglobulin E (IgE) levels have emerged as a possible biomarker to predict response to omalizumab. However, the existing literature is heterogenous, with conflicting conclusions with regard to the role of total IgE levels. Objective: We sought to clarify the role of evaluating total IgE levels in patients with CSU by performing a meta-analysis on the existing literature to determine if meaningful changes exist between responders and nonresponders to omalizumab. Methods: A total of 68 unique citations were returned and screened by two independent reviewers. Editorials, reviews, and case reports were excluded, and a total of 33 original articles were identified and underwent secondary evaluation. Studies that present mean ± standard deviation total IgE levels and/or 95% confidence intervals (CI) were included, whereas studies with < 25 subjects were excluded. Three studies ultimately met these criteria. Results: We found a mean difference in total IgE levels between those who responded to omalizumab versus those without a response of 49.76 (95% CI, 7.13-92.38; p = 0.02), which demonstrated higher mean IgE values in responders compared with nonresponders. Conclusion: This study presents additional evidence that supports evaluation of total IgE levels as it pertains to response to omalizumab therapy in CSU. When considering the current evidence, it seems reasonable to consider the baseline total IgE level as a biomarker to predict the treatment response to omalizumab. Based on the existing literature, we cannot conclude at what threshold nonresponse is more likely to occur.
Collapse
Affiliation(s)
- Levi Keller
- From the Division of Allergy and Clinical Immunology, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Ekta K Perera
- Division of Pulmonary and Sleep Medicine, Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas
| | - Brittany Bindon
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, University of Chicago Medicine, Chicago, Illinois, and
| | - Aastha Khatiwada
- Division of Biostatistics and Bioinformatics, National Jewish Health, Denver, Colorado
| | - Jenny M Stitt
- From the Division of Allergy and Clinical Immunology, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Stephen C Dreskin
- From the Division of Allergy and Clinical Immunology, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| |
Collapse
|
2
|
Kulumbegov B, Chikovani T, Gotua M, Kikodze N, Magen E. Interleukin-33, endothelin-1, and inflammatory parameters in chronic spontaneous urticaria. Allergy Asthma Proc 2023; 44:429-435. [PMID: 37919851 DOI: 10.2500/aap.2023.44.230051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Background: Endothelin-1 (ET-1) and interleukin-33 (IL-33) can modulate the activation of mast cells and basophils in the pathophysiology of allergic diseases, interplaying with other mediators of "low-grade inflammation." Objective: To compare ET-1, IL-33, the neutrophil-lymphocyte ratio (NLR), eosinophil-lymphocyte ratio (ELR), platelet-lymphocyte ratio (PLR), eosinophil-basophil ratio (EBR), systemic immune inflammation index (SII), and system inflammation response index (SIRI) in patients with chronic spontaneous urticaria (CSU) and are antihistamine sensitive (AHS), antihistamine resistant (AHR), omalizumab sensitive (OmS), and omalizumab resistant (OmR). Methods: A prospective observational study enrolled 68 consecutive patients with CSU diagnosed and managed according to the dermatology section of the European Academy of Allergology and Clinical Immunology (EAACI), the European Union funded network of excellence, the Global Allergy and Asthma European Network (GA2LEN), the European Dermatology Forum (EDF), and the World Allergy Organization guidelines. Patients with a urticaria control test score of >12 are considered treatment sensitive, and ≤ 12 are considered resistant. The control group consisted of 20 sex-matched subjects without urticarial diseases. Total immunoglobulin E (IgE), antinuclear antibodies (ANA), thyroid stimulating hormone, antithyroid peroxidase, mean platelet volume (MPV), NLR, ELR, PLR, EBR, SII, SIRI, ET-1, and IL-33 were measured at the study entry and compared between the study groups. Results: Thirty AHS group, 38 AHR group, and 20 control group patients were included. The AHS, AHR, and control groups did not differ in demographic parameters, but the CSU groups were characterized by higher indicators of inflammation. In comparison with the AHS group, the AHR group was characterized by higher levels of IL-33 (p = 0.007), ET-1 (p = 0.032), C-reactive protein (p = 0.016), MPV (p = 0.002), and higher rates of positive ANA (p = 0.019). Of the 38 patients from the AHR group, 30 (79%) were included in the OmS group and 8 (21%) were included in the OmR group. The OmR group was characterized by higher levels of C-reactive protein (p = 0.022), EBR (p < 0.001), higher rates of ANA (p = 0.004), and lower levels of ET-1 (p = 0.025) than the OmS group. Conclusion: Our study did not confirm NRL, PRL, SII, and SIRI, PLR as the biomarkers of treatment response to antihistamines and/or omalizumab in CSU. Higher blood levels of IL-33 and ET-1 characterize AHR CSU.
Collapse
Affiliation(s)
| | - Tinatin Chikovani
- Immunology Department, Tbilisi State Medical University, Tbilisi, Georgia, and
| | - Maia Gotua
- From the Center of Allergy and Immunology, Tbilisi, Georgia
| | - Nino Kikodze
- Immunology Department, Tbilisi State Medical University, Tbilisi, Georgia, and
| | - Eli Magen
- Assuta Ashdod University Medical Center, Ben Gurion University of the Negev, Ashdod, Israel
| |
Collapse
|
3
|
Magen E, Merzon E, Green I, Magen I, Geishin A, Golan-Cohen A, Vinker S, Israel A. Chronic idiopathic eosinopenia and chronic spontaneous urticaria. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2583-2586. [PMID: 37088375 DOI: 10.1016/j.jaip.2023.03.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 02/10/2023] [Accepted: 03/31/2023] [Indexed: 04/25/2023]
Affiliation(s)
- Eli Magen
- Leumit Health Services, Tel Aviv-Yafo, Israel; Medicine A Department, Assuta Ashdod University Medical Center, Ben Gurion University of the Negev, Beer Sheva, Israel.
| | - Eugene Merzon
- Leumit Health Services, Tel Aviv-Yafo, Israel; Adelson School of Medicine, Ariel University, Ariel, Israel
| | - Ilan Green
- Leumit Health Services, Tel Aviv-Yafo, Israel; Department of Family Medicine, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Israel Magen
- Medicine A Department, Assuta Ashdod University Medical Center, Ben Gurion University of the Negev, Beer Sheva, Israel; Tbilisi State Medical University, Tbilisi, Georgia
| | - Akim Geishin
- Leumit Health Services, Tel Aviv-Yafo, Israel; Department of Family Medicine, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Avivit Golan-Cohen
- Leumit Health Services, Tel Aviv-Yafo, Israel; Department of Family Medicine, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Shlomo Vinker
- Leumit Health Services, Tel Aviv-Yafo, Israel; Department of Family Medicine, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Ariel Israel
- Leumit Health Services, Tel Aviv-Yafo, Israel; Department of Family Medicine, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| |
Collapse
|
4
|
Magen E, Merzon E, Green I, Magen I, Waitman DA, Kahan NR. A comparative study of chronic spontaneous urticaria and chronic mast cell mediated angioedema. Allergy Asthma Proc 2023; 44:122-129. [PMID: 36872441 DOI: 10.2500/aap.2023.44.220101] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Background: Mast cell-mediated angioedema (MC-AE) is considered a form of chronic spontaneous urticaria (CSU). Objective: To investigate the clinical and laboratory features that distinguish MC-AE from antihistamine-responsive CSU (CSU), and antihistamine-resistant CSU (R-CSU) with and without concomitant AE. Methods: A retrospective observational study using the electronic patient record data base of patients with MC-AE, CSU, R-CSU, and sex- and age-matched control group (control), with a case-control ratio of 1:2. Results: A total of 986 subjects in the CSU group, 148 in the R-CSU group, 64 in the MC-AE group, and 1198 in the control group were compared. The R-CSU group without AE was characterized by lower total IgE levels (118.5 ± 84.7 IU/mL) and higher High sensitivity-C reactive protein (hs-CRP) levels (138.9 ± 94.2 IU/mL, p = 0.027; and 7.4 ± 6.9 mg/L versus 5.1 ± 6.8 mg/L, p = 0.001) than the CSU without AE group. The R-CSU group with AE was characterized by lower total IgE levels (112.1 ± 81.3 IU/mL) than the CSU group with AE (141.7 ± 89.5 IU/mL; p < 0.001), higher hs-CRP levels (7.1 ± 6.1 mg/L versus 4.7 ± 5.9 mg/L; p < 0.001). There were fewer female subjects in the MC-AE group (31 [48.4%]) than in the CSU with AE and in the R-CSU with AE 223 (67.8%) and 18 (66.7%), respectively; p = 0.012). MC-AE group was characterized by less eyelid/perioral/facial involvement and more limb involvement than in the CSU with AE and R-CSU with AE groups (p < 0.001). Conclusion: Low IgE in MC-AE and higher IgE in CSU may signify two distinct types of immune dysregulation. Due to clinical and laboratory differences between MC-AE and CSU, we suggest questioning the assumption that MC-AE is a form of CSU.
Collapse
Affiliation(s)
- Eli Magen
- From the Leumit Research Institute & Department of Family Medicine, Leumit Health Services, Tel Aviv-Yafo, Israel
| | - Eugene Merzon
- From the Leumit Research Institute & Department of Family Medicine, Leumit Health Services, Tel Aviv-Yafo, Israel
| | - Ilan Green
- From the Leumit Research Institute & Department of Family Medicine, Leumit Health Services, Tel Aviv-Yafo, Israel
| | - Israel Magen
- Medicine A Department, Assuta Ashdod University Hospital, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheba, Israel
| | - Dan-Andrei Waitman
- From the Leumit Research Institute & Department of Family Medicine, Leumit Health Services, Tel Aviv-Yafo, Israel
| | - Natan R Kahan
- From the Leumit Research Institute & Department of Family Medicine, Leumit Health Services, Tel Aviv-Yafo, Israel
| |
Collapse
|
5
|
Khan S, Chopra C, Mitchell A, Nakonechna A, Yong P, Karim MY. Resistant Chronic Spontaneous Urticaria - A Case Series Narrative Review of Treatment Options. ALLERGY & RHINOLOGY (PROVIDENCE, R.I.) 2022; 13:21526575221144951. [PMID: 36578314 PMCID: PMC9791268 DOI: 10.1177/21526575221144951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Chronic spontaneous urticaria (CSU) can be extremely debilitating to the patient and challenging for the treating clinician. The National Institute of Health and Clinical Excellence (NICE) in the United Kingdom (UK) recommendation of omalizumab for patients who fail to respond to high-dose anti-histamines has improved treatment options and quality of life. However, there is still lack of clear guidelines for treatment of patients resistant to standard and anti-IgE therapies. Methods We discuss the therapeutic strategies employed among nine extremely resistant CSU cases and the heterogeneity between guidelines from different societies. Results Patients with anti-histamine-resistant urticaria either remained on omalizumab or started on immunosuppressive drugs (dapsone or ciclosporin) when they stopped responding to omalizumab. We used clinical assessment, skin biopsies (when available) and previous published reports to consider dapsone (for predominantly neutrophilic infiltration), or ciclosporin at doses between 2 and 4 mg/kg/day. One patient with ciclosporin-resistant urticaria responded to mycophenolate mofetil. Two patients remain on long-term omalizumab due to its relative safety and efficacy including 1 patient with underlying antibody deficiency where omalizumab was preferred over risks of using immunosuppressive medications. Conclusions These case studies bring to light the real-world difficulties in managing patients with resistant CSU and the need for generating the evidence base on alternative therapeutic options such as synergistic use of biologics and immunosuppressive drugs.
Collapse
Affiliation(s)
- Sujoy Khan
- Department of Immunology & Allergy, Queen's Centre, Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, Cottingham, UK,Sujoy Khan, Department of Immunology & Allergy, Queen's Centre, Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, Cottingham HU16 5JQ, UK.
| | - Charu Chopra
- Department of Clinical Immunology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Alla Nakonechna
- Department of Immunology & Allergy, Queen's Centre, Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, Cottingham, UK,University of Liverpool, Liverpool, UK
| | - Patrick Yong
- Department of Immunology & Allergy, Frimley Health NHS Foundation Trust, Frimley, Camberley, UK
| | | |
Collapse
|
6
|
Predictors of Response to Oral Medications and Low-Histamine Diet in Patients with Chronic Urticaria. J Immunol Res 2022; 2022:5243825. [PMID: 35242884 PMCID: PMC8888069 DOI: 10.1155/2022/5243825] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/24/2022] [Accepted: 02/08/2022] [Indexed: 11/30/2022] Open
Abstract
Background Chronic urticaria (CU) is comprised of diverse phenotypes, and thus, a shift towards a precision medical approach is warranted in its management. Methods This study enrolled 78 patients with CU. Serum erythrocyte sedimentation rate, hemoglobin, hematocrit, eosinophil count, IgE, antinuclear antibody (ANA), and serum diamine oxidase (DAO) levels of the patients were measured and were compared according to the patient's response to second-generation antihistamines (sgAH), corticosteroids, leukotriene receptor antagonist (LTRA), H2 blockers, and low-histamine diet. Results Age- and sex-adjusted logistic regression analysis showed that patients with duration of CU > 3 years (adjusted odd ratio [aOR] = 4.39) and a DAO level < 10 U/mL (aOR = 3.90) were significantly associated with a good sgAH response. Age > 50 years (aOR = 0.02), duration of chronic urticaria > 3 years (aOR =0.06), and an ANA titer ≥ 1 : 80 (aOR = 0.03) were significantly and inversely associated with corticosteroid response. A low-histamine diet response was significantly associated with LTRA response (aOR = 67.29). In addition, a DAO level < 5.4 U/mL (aOR = 71.95) was significantly associated with H2 blocker response. Furthermore, concomitant angioedema (aOR = 10.56), multiple food triggers (aOR = 11.69), and a DAO level < 5.4 U/mL (aOR = 3.78) were significantly associated with a low-histamine diet response. Conversely, dermatographic urticaria and a hematocrit level < 36% were significantly and inversely associated with low-histamine diet response. Conclusions Several promising biomarkers were identified in this study to predict the efficacy of chronic urticaria treatment. DAO could be a novel biomarker for predicting the efficacy not only of dietary intervention but also for antagonists of H1 and H2 receptors.
Collapse
|
7
|
Magen E, Yakov A, Green I, Israel A, Vinker S, Merzon E. Chronic spontaneous urticaria after BNT162b2 mRNA (Pfizer-BioNTech) vaccination against SARS-CoV-2. Allergy Asthma Proc 2022; 43:30-36. [PMID: 34983707 DOI: 10.2500/aap.2022.43.210111] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background: The factors that trigger and exacerbate chronic spontaneous urticaria (CSU) are well known, but it is not unclear whether messenger RNA (mRNA) vaccination against severe acute respiratory syndrome coronavirus 2 can trigger new cases of CSU or a relapse of CSU after long-term remission. Objective: To study the clinical cases of patients with new-onset CSU and CSU in remission who relapsed within 3 months after BNT162b2 mRNA vaccination. Methods: All patients with a CSU diagnosis within 12 weeks of BNT162b2 mRNA vaccination were retrospectively identified and included in the new-onset CSU and the relapsed CSU groups. The first control group (CSU control group) retrospectively consisted of patients diagnosed with CSU in complete clinical remission for ≥ 6 months, with no CSU relapse after vaccination. The second control group (healthy control group) consisted of subjects who were fully vaccinated and without CSU, matched 1:2 for age and sex with patients with CSU. Results: Twenty-seven patients were included in the relapsed CSU group, 32 patients in the new-onset CSU group, 179 patients in the CSU control group, and 476 subjects in the healthy control group. The relapsed CSU and new-onset CSU groups had more allergic comorbidities overall (19 [70.4%] and 13 [40.6%], respectively) than the CSU control group and the healthy control group (50 [27.9%] and 110 [23.1%], respectively; p < 0.001). Multiple logistic regression analysis showed that a positive autologous serum skin test result, overall allergic comorbidities, and basopenia were positively associated with the probability of CSU relapse within 3 months after BNT162b2 mRNA vaccination (odds ratio [OR] 5.54 [95% confidence interval {CI}, 2.36-13.02], p < 0.001); OR 6.13 [95% CI, 2.52-14.89], p = 0.001; and OR 2.81 [95% CI, 1.17-6.72, p = 0.020, respectively). Conclusion: It is possible that BNT162b2 mRNA vaccination serves as a provoking and/or relapsing factor of CSU in individuals with allergic diseases and/or predisposed autoimmunity.
Collapse
Affiliation(s)
- Eli Magen
- From the Leumit Research Institute and Department of Family Medicine, Leumit Health Services, Ashkelon, Israel
| | - Avi Yakov
- From the Leumit Research Institute and Department of Family Medicine, Leumit Health Services, Ashkelon, Israel
| | - Ilan Green
- From the Leumit Research Institute and Department of Family Medicine, Leumit Health Services, Ashkelon, Israel
| | - Ariel Israel
- From the Leumit Research Institute and Department of Family Medicine, Leumit Health Services, Ashkelon, Israel
| | - Shlomo Vinker
- From the Leumit Research Institute and Department of Family Medicine, Leumit Health Services, Ashkelon, Israel
| | - Eugene Merzon
- From the Leumit Research Institute and Department of Family Medicine, Leumit Health Services, Ashkelon, Israel
| |
Collapse
|
8
|
Bellanti JA, Settipane RA. The challenge of COVID-19 that permeates the practice of allergy/immunology. Allergy Asthma Proc 2021; 42:1-4. [PMID: 33404384 PMCID: PMC7768063 DOI: 10.2500/aap.2021.42.200116] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|