Chronic spontaneous urticaria remains uncontrolled with antihistamine treatment
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Key takeaways:
- 84% of patients using H1 antihistamines had inadequate control.
- Patients switched antihistamines an average of 2.3 times.
- Patients up-dosed their antihistamines an average of 2.9 times.
ANAHEIM, Calif. — A high proportion of chronic spontaneous urticaria cases remained uncontrolled despite antihistamine changes, according to a presentation at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting.
These changes also may delay timely escalation to effective treatments, Tonya A. Winders, MBA, president of Global Allergy and Airways Patient Platform, said during her presentation.
“We’ve heard a bit about the burden of [chronic spontaneous urticaria (CSU)],” she said. “It can be very debilitating, very difficult to manage, and it is extremely frustrating for the patients who are living with CSU as well as for the physicians who are treating these patients.”
Second-generation antihistamines are the first-line treatment for CSU, Winders continued, but up-dosing of up to four times the standard dose can be used as needed.
“Yet even with this use of antihistamines, we know that greater than 60% of patients still have uncontrolled disease,” she said. “The Urticaria Voices study really aimed to assess the perceptions of patients living with CSU globally but also physician treatment patterns.”
Additionally, the researchers aimed to evaluate the control of different antihistamine regimens including up-dosing and switching, as well as identify unmet needs to improve care and patient experience.
Urticaria Voices involved 582 adults (62% women; mean age, 42.2 years) with CSU and 862 physicians from seven countries.
The patients completed a 40-minute online survey about their sociodemographics, Urticaria Control Test (UCT) scores and treatment.
The physicians, which included dermatologists (60%) and allergists (40%), completed a 30-minute online survey about treatment and disease management.
The patients with CSU included 460 (79%) who were using H1 antihistamines, which the researchers called first-line treatment for CSU, yet 84% of them had inadequately controlled disease based on UCT scores of less than 12.
Since initiating treatment for CSU (mean, 6.3 years), 80% reported switching their H1 antihistamine, with an average of 2.3 (standard deviation [SD], 2.4) times, and 62% reported up-dosing, with an average of 2.9 (SD, 1.7) times.
Also, 7% of these patients said that they did not experience any relief with up-dosing, whereas 68% reported partial improvement and 25% reported complete improvement. Further, 46% reported more drowsiness, and 11% reported additional side effects.
Among the physicians, 80% reported H1 antihistamines as their first-line treatment for CSU, with 56.7% specifically reporting second-generation H1 antihistamines. Also, 29.4% reported steroid use, most commonly hydrocortisone cream (14%) and oral steroids (11.4%).
“Even at four bursts of oral steroids a year, over the course of a lifetime, we know that there are adrenal suppression issues,” Winders said. “That’s something that’s of great concern to the patient community.”
Second lines of treatments, as reported by the physicians, included quadrupling the H1 antihistamine dose (32%), double dosing (21%), and switching to omalizumab (Xolair; Genentech, Novartis; 11%), dupilumab (Dupixent; Regeneron, Sanofi; less than 2%) or another second-generation H1 antihistamine (10%).
“Less than 13% overall had bio-initiation in that second-line treatment,” Winders said. “We definitely see a lot of that quadrupling.”
On average, physicians switched second-generation antihistamines four times before prescribing biologics.
These patterns were similar across different countries, the researchers found. For example, percentages of inadequately controlled CSU ranged from 69% in Canada to 91% in Italy. Also, treatment times ranged from 5.1 years in Canada to 9.8 years in Japan. Antihistamine switches ranged from 1.5 in Italy to 2.5 in Germany as well.
Specifically, 85% of patients in the United States had inadequately controlled CSU, with a mean of 2.4 (SD, 2) antihistamine switches and a mean of 2.2 (SD, 1.8) antihistamine up-dosings.
Also in the United States, 12% reported no improvement and 72% reported partial improvement with these changes, with 40% reporting drowsiness and 9% reporting other new side effects with up-dosing.
“The key takeaways from this portion of the Urticaria Voices study certainly reinforces and demonstrates a high proportion of patients that are living with CSU still remain inadequately controlled, even despite up-dosing and switching of antihistamines,” Winders said.
Up-dosing and switching of antihistamines also can delay timely escalation to more effective treatments such as biologics for patients with uncontrolled disease, Winders continued.
“There is certainly this unmet need and desire for new treatment options that offer rapid and sustainable relief for those patients living with chronic spontaneous urticaria,” she said.