title: Treatment of chronic spontaneous urticaria with an inadequate response to H1-antihistamines: an expert opinion.
abstract: Chronic spontaneous urticaria (CSU) is characterized by the sudden, continuous or intermittent appearance of pruritic wheals (hives), angioedema, or both for six weeks or more, with no known specific trigger. The international EAACI/GA2LEN/EDF/WAO urticaria guideline advises standard-dose, second-generation H1-antihistamines as first-line therapy. However, H1-antihistamine treatment leads to absence of symptoms in fewer than 50% of patients. Updosing of second-generation H1-antihistamines (up to fourfold) as recommended by the EAACI/GA2LEN/EDF/WAO urticaria guideline as second-line therapy, can improve response, but many patients remain symptomatic. Definitions of response are often subjective and a consensus is needed regarding appropriate treatment targets. There is also an unmet need for biomarkers to assess CSU severity and activity and to predict treatment response. The EAACI/GA2LEN/EDF/WAO urticaria guideline recommends add-on omalizumab, ciclosporin A (CsA), or montelukast third-line treatment in patients with an inadequate response to high-dose H1-antihistamines. Omalizumab is currently the only licensed systemic biologic for use in CSU. Both omalizumab and CsA are effective third-line CSU treatments; montelukast appears to have lower efficacy in this setting. Omalizumab carries a label warning for anaphylaxis, although no cases of anaphylaxis were reported in the phase III trials of omalizumab in CSU and it is generally well tolerated in patients with CSU. Omalizumab arguably has a better safety profile than CsA.
authors.affiliation: Aarhus University Hospital, Aarhus, Denmark.
authors.forename: Christian
authors.initials: C
authors.lastname: Vestergaard
authors.affiliation: Bnai-Zion Medical Centre, Haifa, Israel.
authors.forename: Elias
authors.initials: E
authors.lastname: Toubi
authors.affiliation: Charité-Universitätsmedizin, Berlin, Germany.
authors.forename: Marcus
authors.initials: M
authors.lastname: Maurer
authors.affiliation: University of Salerno, Salerno, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Triggiani
authors.affiliation: University Hospital Zurich, Zurich, Switzerland.
authors.forename: Barbara
authors.initials: B
authors.lastname: Ballmer-Weber
authors.affiliation: Salford Royal Hospital and University of Manchester, Manchester, UK.
authors.forename: Alexander
authors.initials: A
authors.lastname: Marsland
authors.affiliation: Clinica Universidad de Navarra, Pamplona, Spain.
authors.forename: Marta
authors.initials: M
authors.lastname: Ferrer
authors.affiliation: University Medical Centre, Utrecht, The Netherlands.
authors.forename: André
authors.initials: A
authors.lastname: Knulst
authors.affiliation: Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: Ana
authors.initials: A
authors.lastname: Giménez-Arnau
mesh_terms: D000085:Acetates / Q000627:therapeutic use*; D018926:Anti-Allergic Agents / Q000627:therapeutic use*; D002908:Chronic Disease; D003521:Cyclopropanes; D016572:Cyclosporine / Q000627:therapeutic use*; D004359:Drug Therapy, Combination; D019983:Guideline Adherence; D006634:Histamine H1 Antagonists / Q000008:administration & dosage / Q000627:therapeutic use*; D006801:Humans; D055118:Medication Adherence; D000069444:Omalizumab / Q000627:therapeutic use*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D011804:Quinolines / Q000627:therapeutic use*; D019233:Retreatment; D013440:Sulfides; D017211:Treatment Failure; D014581:Urticaria / Q000188:drug therapy*
chemical_list: D000085:Acetates; D018926:Anti-Allergic Agents; D003521:Cyclopropanes; D006634:Histamine H1 Antagonists; D011804:Quinolines; D013440:Sulfides; D000069444:Omalizumab; D016572:Cyclosporine; C093875:montelukast
keywords: H1-antihistamines; chronic spontaneous urticarial; omalizumab; response; treatment