US, world guidelines differ on when to use omalizumab in treating urticaria

Key takeaways:

• Both guidelines begin with antihistamines.
• Guidelines in the US recommend further antihistamine use before trying omalizumab.
• Researchers recommend updating the US guidelines.

WASHINGTON — Urticaria treatment guidelines in the United States include more options than the World Allergy Organization’s guidelines, according to a poster presented at the American Academy of Allergy, Asthma & Immunology Annual Meeting.

These differences indicate a need to update the American guidelines, John J. Cherneskie Jr, MD, a specialist in internal medicine with the section of allergy, asthma and immunology, department of medicine, Penn State College of Medicine, told Healio.

“There might be some discrepancies, with all the new data that is out there,” Cherneskie said.

The World Allergy Organization (WAO) last updated its urticaria guidelines in 2022, and the American Academy of Allergy, Asthma & Immunology and the American College of Allergy, Asthma and Immunology last updated their joint guidelines in 2014.

“We noticed that we’re a little bit behind the Europeans,” Cherneskie said.

Both guidelines recommend beginning treatment with a standard dose of a second-generation antihistamine, but they diverge after that.

The WAO guidelines next recommend increasing antihistamine doses up to four times, followed by 300 mg of omalizumab (Xolair; Genentech, Novartis) every 4 weeks and then 600 mg every 2 weeks if control remains inadequate.

If the lack of control persists, under the WAO guidelines, physicians can treat the urticaria with up to 5 mg of cyclosporine per kilogram of body weight.

The American guidelines offer options with the second step, beginning with increasing the dose of the second-generation antihistamine. They also recommend adding another second-generation antihistamine, an H₂ antagonist, a leukotriene receptor antagonist or a first-generation antihistamine that should be taken before bed.

Step 3 in the American guidelines increases the dosage of potent antihistamines including hydroxyzine or doxepin. In step 4, physicians should add an alternative agent such as cyclosporine, though Cherneskie expressed concerns about cyclosporine’s side effects.

“I don’t know that that’s used quite as much anymore, given the safety profile of omalizumab,” Cherneskie said.

Or, step 4 advises physicians to use omalizumab, other anti-inflammatory agents, immunosuppressants or biologics.

“The rest of the world jumps to omalizumab much sooner,” Cherneskie said. “That’s most often what most clinicians do in practice in the U.S.”

Recent studies have indicated that omalizumab is safe and effective in treating urticaria along with other drugs in the pipeline such as dupilumab, Cherneskie said, but the guidelines in the United States remain unchanged.

“A lot of the research data is out there,” Cherneskie said. “It’s just a matter of getting everyone together and publishing new guidelines.”

For now, Cherneskie advised physicians to follow the WAO’s procedures.

“Until our guidelines are updated, it’s actually probably a pretty good idea to use the European guidelines,” he said.