Management of Chronic Spontaneous Urticaria with Cyclosporine in the Era of Omalizumab
Abstract
Introduction: In chronic spontaneous urticaria (CSU) unresponsive to anti H1-histamines, national recommendations propose omalizumab, which is not always promptly available. Thus, other treatments should be discussed. In this context, we have analysed efficacy and safety of cyclosporine and possible relations between characteristics of urticaria and response to cyclosporine.
Material and Methods: Retrospective study of CSU patients from a department of dermatology treated with cyclosporine (2010-2016). We evaluated the demographic and clinic-laboratorial parameters, doses, treatment duration, follow-up, side effects and efficacy, using the weekly urticarial activity score 7 (UAS7). Statistical significance was considered for p < 0.05.
Results: We evaluated 23 patients (19 female/4 male; mean age 46.0y ± 14.0) with CSU which evolved for 129.7 ± 128.1 months and who were treated with cyclosporine (mean dose 3.2 ± 0.3 mg/kg). There was a good response in 10 patients (44%) at the first month, with a significant mean UAS7 reduction. Side effects from cyclosporine occurred in eight patients, leading to treatment suspension in six patients (26%), mostly due to arterial hypertension and infections. None of the parameters evaluated was associated with response to cyclosporine.
Conclusion: Cyclosporine was effective in 44% of patients with moderate to severe CSU. When omalizumab is not immediately available, it may be worth trying cyclosporine, with a narrow monitoring for adverse effects.
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References
Costa C, Gonçalo M. Abordagem diagnóstica e terapêutica da urticária crónica espontânea: recomendações em Portugal. Acta Med Port. 2016;29:763-81.
Gaig P, Olona M, Muñoz Lejarazu D, Caballero MT, Domínguez FJ, Echechipia S, et al. Epidemiology of urticaria in Spain. J Investig Allergol Clin Immunol. 2004;14:214-20.
Asero R, Pinter E, Marra AM, Tedeschi A, Cugno M, Marzano AV. Current challenges and controversies in the management of chronic spontaneous urticaria. Expert Rev Clin Immunol. 2015;11:1073-82.
Kolkhir P, André F, Church MK, Maurer M, Metz M. Potential blood biomarkers in chronic spontaneous urticaria. Clin Exp Allergy. 2017; 47:19-36.
Ferrer M. Immunological events in chronic spontaneous urticaria. Clin Transl Allergy. 2015;5:30.
Viegas LP, Ferreira MB, Kaplan AP. The maddening itch: an approach to chronic urticaria. J Investig Allergol Clin Immunol. 2014;24:1-5.
Costa AC, Campina S, Andrade P, Filipe P, Guilherme A, Gonçalo M. Urticária crónica – do diagnóstico ao tratamento. Rev Soc Port Dermatol Venereol. 2016;74: 315-25.
Kaplan AP. Clinical practice. Chronic urticaria and angioedema. N Engl J Med. 2002; 346:175-9.
Zuberbier T, Aberer W, Asero R, Abdul Latiff AH, Baker D, Ballmer-Weber B, et al. The EAACI/GA2LEN/EDF/WAO Guideline for the Definition, Classification, Diagnosis and Management of Urticaria. The 2017 Revision and Update. Allergy. 2018 (in press).
Marzano A V, Pigatto P, Cristaudo A, Ayala F, Rossi O, Senna G, et al. Management of chronic spontaneous urticaria: practical parameters. G Ital Dermatol Venereol. 2015; 150:237-46.
Chang TW, Chen C, Lin CJ, Metz M, Church MK, Maurer M. The potential pharmacologic mechanisms of omalizumab in patients with chronic spontaneous urticarial. J Allergy Clin Immunol. 2015;135:337-42.
Khalaf A, Li W, Jinquan T. Current advances in the management of urticaria. Arch Immunol Ther Exp. 2008; 56:103-14.
Ferrer M, Bartra J, Giménez-Arnau A, Jauregui I, Labrador-Horrillo M, Ortiz de Frutos J, et al. Management of urticaria: not too complicated, not too simple. Clin Exp Allergy. 2015; 45:731-43.
Weller K, Zuberbier T, Maurer M. Chronic urticaria: tools to aid the diagnosis and assessment of disease status in daily practice. J Eur Acad Dermatol Venereol. 2015; 29 (Suppl 3):38-44.
Kessel A, Toubi E. Low-dose cyclosporine A is a good option for severe chronic urticaria. J Allergy Clin Immunol. 2009;123:970.
Savic S, Marsland A, McKay D, Ardern-Jones MR, Leslie T, Somenzi O, et al. Retrospective case note review of chronic spontaneous urticarial outcomes and adverse effects in patients treated with omalizumab or ciclosporin in UK secondary care. Allergy Asthma Clin Immunol. 2015;11:21.
Godse KV. Cyclosporine in chronic idiopathic urticarial with positive autologous serum skin test. Indian J Dermatol. 2008;53:101-2.
Mehta A Godse K, Patil S, Nadkarni N, Gautam M. Treatment of refractory chronic urticaria. Indian J Dermatol. 2015;60:230-7.
Boubouka CD, Charissi C, Kouimintzis D, Kalogeromitros D, Stavropoulos PG, Katsarou A. Treatment of autoimmune urticaria with low-dose cyclosporin A: A one-year follow-up. Acta Derm Venereol. 2011;91:50-4.
Baskan EB, Tunali S, Turker T, Saricaoglu H. Comparison of short- and long-term cyclosporine A therapy in chronic idiopathic urticaria. J Dermatolog Treat. 2004;15:164-8.
Hollander SM, Joo SS, Wedner HJ. Factors that predict the success of cyclosporine treatment for chronic urticaria. Ann Allergy Asthma Immunol. 2011;107:523-8.
Seth S, Khan DA. The comparative safety of multiple alternative agents in refractory chronic urticarial patients. J Allergy Clin Immunol Pract. 2017;5:165-70.
Kessel A, Toubi E. Cyclosporine-A in severe chronic urticaria: the option for long-term therapy. Allergy. 2010;65:1478-82.
Chang HW, Cheng HM, Yen HR, Hsu CY, Lee YC, Chiang JH, et al. Association between chronic idiopathic urticaria and hypertension: A population-based retrospective cohort study. Ann Allergy Asthma Immunol. 2016;116:554-8.
Giménez-Arnau AM. Omalizumab for treating chronic spontaneous urticaria: an expert review on efficacy and safety. Expert Opin Biol Ther. 2017;17:375-85.
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