A comprehensive international study has identified the most effective treatments for chronic hives, also known as urticaria, particularly when standard antihistamines fail to provide relief. This extensive research, conducted by a team at McMaster University in Canada, offers crucial guidance for both patients and healthcare providers, ensuring a more informed approach to treatment.
Chronic hives are characterized by persistent redness, swelling, and intense itching, with symptoms lasting for six weeks or more. When antihistamines, the conventional first-line treatment, do not alleviate symptoms, systemic therapies become necessary. The study analyzed data from 93 trials involving 11,398 participants, primarily adolescents and adults experiencing moderate to severe chronic urticaria.
Comprehensive Analysis of Treatment Options
The researchers employed a systematic review and Bayesian network meta-analysis (BNMA) to compare various treatments, focusing on patient-relevant outcomes such as the severity of itching and swelling, quality of life, and potential adverse effects. The study excluded trials involving antihistamines, steroids, and alternative medicines, ensuring a focused evaluation of systemic treatments.
According to Derek Chu, MD, PhD, the study’s corresponding author and assistant professor in the Department of Medicine at McMaster, “This first comprehensive analysis of all advanced treatment options for chronic urticaria provides a clear and evidence-based ‘menu of treatment options’ for patients and their clinicians to choose from.”
Among the treatments rated with high certainty of evidence, omalizumab (commonly known as Xolair) and remibrutinib emerged as the most effective options. Omalizumab, an injectable monoclonal antibody, works by blocking the action of immunoglobulin E (IgE), a key player in allergic reactions and inflammation. Remibrutinib, an oral medication, inhibits Bruton’s tyrosine kinase (BTK), a specific pathway involved in the release of histamine and other inflammatory mediators.
Potential and Challenges of New Treatments
While remibrutinib has shown promising results in Phase 3 clinical trials, it is not yet available commercially. Another treatment, dupilumab (Dupixent), is an injectable immunotherapy that targets interleukin-4 (IL-4) and interleukin-13 (IL-13) proteins, which are linked to inflammation. The study indicated that dupilumab likely reduces itching and wheal severity, but its effects on swelling and overall quality of life remain uncertain due to limited data.
The study also examined cyclosporine, an immunosuppressive medication that can effectively reduce itching and wheals. However, it carries a higher risk of side effects, including kidney toxicity and elevated blood pressure.
Despite the valuable insights gained, the study has its limitations. Most included trials were short-term, making it difficult to evaluate the long-term safety of the treatments assessed. Additionally, older medications like sulfasalazine, azathioprine, and methotrexate provided low or very low certainty of evidence due to their small sample sizes or non-randomized nature. Notably, children were underrepresented, with only one trial involving participants under 12, which limits guidance for pediatric cases.
Patients now have access to a clearer hierarchy of treatment options beyond antihistamines, allowing for more personalized care. Practical considerations, such as cost, the potential for needle phobia, and convenience, will also play a key role in treatment decisions.
The findings were published in The Journal of Allergy and Clinical Immunology and received funding from the American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI). This study marks a significant advancement in the evidence-based treatment of chronic urticaria, paving the way for improved patient outcomes.
