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Medscape
4 days ago
- Health
- Medscape
Top 3 Chronic Urticaria Treatments Highlighted in Meta-Analysis
In managing antihistamine-refractory chronic urticaria, omalizumab and remibrutinib stand out among the most effective treatments across multiple patient-important outcomes, followed by dupilumab, which shows improvement in urticaria activity, according to a meta-analysis of 42 systemic treatments in 93 studies. All three treatments for chronic urticaria, a condition defined by wheal and itch symptoms persisting 6 weeks or more, have favorable safety profiles, according to the researchers, led by Alexandro W. L. Chu, MD, with the Department of Medicine and the Evidence in Allergy Group at McMaster University in Hamilton, Ontario, Canada. Findings were published in The Journal of Allergy and Clinical Immunology as part of an update of chronic urticaria guidelines for the American Academy of Allergy, Asthma & Immunology (AAAAI), American College of Allergy, Asthma & Immunology (ACAAI), and Joint Task Force on Practice Parameters (JTFPP). The meta-analysis examined patient-important outcomes beyond itch and wheal assessment such as angioedema, sleep quality, urticaria- and angioedema-related quality of life, and adverse events at the longest available time point. The researchers used measures including the 7-day Urticaria Activity Score, Chronic Urticaria Quality of Life Questionnaire and Angioedema Quality of Life Questionnaire. Dupilumab improves itch and wheals, 'but it is uncertain whether it improves angioedema or quality of life,' the researchers wrote. Cyclosporine, while it may be among the most effective, the analysis noted, may also be among the most harmful treatments with a high frequency of adverse events. In the intermediate range of effectiveness is low-dose omalizumab (doses below the standard 300 mg or administration less frequent than every 4 weeks) and that low dose also has a favorable safety profile, the data showed. 'Azathioprine, dapsone, hydroxychloroquine, mycophenolate, sulfasalazine, and vitamin D may improve outcomes, while benralizumab, quilizumab, and tezepelumab may not differ from placebo, though the evidence is uncertain,' the report stated. 'Findings were consistent across age groups and baseline severity and were robust to subgroup analyses.' Patients' comorbidities may also steer treatment selection, the authors wrote. 'For instance, patients with concomitant food allergies may favor omalizumab, while those with chronic rhinosinusitis with nasal polyposis or atopic dermatitis may favor dupilumab.' Remibrutinib Rachel Meltzer, MD, MPH, director of the Pruritus Clinic at Brigham and Women's Hospital and instructor in dermatology at Harvard Medical School, both in Boston, told Medscape Medical News the most important aspect of the meta-analysis is the side-by-side comparison of the treatments, particularly the comparison with the bruton tyrosine kinase inhibitor remibrutinib, which, she noted, is not yet approved by the FDA for any indication in dermatology. 'The only people who have any clinical experience with it are the people running the trials at the moment,' she said, and information from them indicates that 'remibrutinib does sound promising. The exciting thing is that it's an oral medicine and it seems to have a good safety and efficacy profile, whereas now, if someone fails our standard oral regimen, the move frequently has been to go to Zolair/omalizumab or less frequently in dermatology, cyclosporine.' 'Omalizumab has been approved for quite some time and that's been kind of the go-to if you need to escalate therapy if people fail the first-line high-dose antihistamines,' she said. Dupilumab, she said, 'wouldn't be the first thing I'd try unless someone had a comorbidity of atopic dermatitis or asthma or allergic rhinitis with nasal polyps,' she said. It was approved in April for chronic spontaneous urticaria. This is the first review of chronic urticaria treatments that has 'systematically analyzed the overall relative benefits and harms of all available options or appraised the evidence using robust and standardized approaches,' the authors wrote. This study was commissioned by the AAAAI and the ACAAI through the JTFPP. Several authors reported multiple ties to pharmaceutical companies, which are available with the full text. Meltzer reported no relevant financial relationships.
Time Magazine
30-04-2025
- Health
- Time Magazine
Are Allergy Shots Worth It?
Nearly a third of American adults have some kind of allergy. If you're one of them, you're probably eager to find a solution. Allergy shots can provide long-lasting relief for certain non-food allergies, but there are some downsides. Is the time commitment, discomfort, and cost worth it? To help make that decision, here's the latest science behind allergy immunotherapy, how long the effects of the shots last, and what the future of allergy shots may hold. How do allergy shots work? Allergy shots have been around in one form or another since the 1910s. The idea is to desensitize an allergic person to a specific allergen, like pollen or cat dander. Your allergist will determine exactly what you're allergic to and then 'they make a specialized cocktail of allergens for that person,' says Dr. David Morris, chief of allergy and immunology at Dayton Children's Hospital. This cocktail contains very small, diluted amounts of those allergens and is then injected under your skin. 'This stimulates the immune system to feel like these things are normal and not foreign,' says allergist Dr. J. Allen Meadows, executive director of advocacy and governmental affairs at the American College of Allergy, Asthma & Immunology (ACAAI) and a pediatric allergist at the University of Alabama at Birmingham. After your shot, you'll be observed for about 30 minutes. 'This is because you do have the potential to have a reaction; we're giving you something injectable that you're allergic to,' Morris says. Serious reactions are rare but can be life-threatening, according to the American Academy of Allergy, Asthma, and Immunology (AAAAI). For the next several months, you'll get one or two shots a week containing increasing amounts of your allergens. This process helps you slowly build a tolerance to those allergens, Meadows says. After about seven months, your doctor will be able to space out your doses to every two weeks. Eventually, you get to what's considered a maintenance dose, which is when you can move to 'a shot a month at a high dose of what you're allergic to,' says otolaryngologist Dr. Marc Dubin, chief medical officer at ENT Speciality Partners. You'll likely stick to that once-a-month shot for three to five years. It can take as long as 12 months on your maintenance dose before you notice your symptoms are improving. In other words, allergy shots are definitely a time commitment. If you can make the time, however, then comes the payoff: 'It changes your immune system on a long-term basis,' Meadows says. You don't have to take any more shots, and you're free of your allergy symptoms—often for decades, he says. 'Some allergists will say the results last 'forever,' but forever is a long time, so I'm not as comfortable with that.' Who gets the best results? Anyone older than 5 can benefit from allergy shots, according to the AAAAI. People with pollen allergies tend to really appreciate the treatment effects, Morris says. 'For a patient's quality of life, pollen is the [most] noticeable one, because people are miserable during pollen season, and they notice they're no longer miserable,' he says. But if your symptoms are severe to start with, you might not see as much relief, Dubin says. You shouldn't get allergy shots if you currently have severe asthma symptoms, or if you're taking certain medications, including beta-blockers for high blood pressure and certain antidepressants, he adds. Allergy shots can also be used for people who are allergic to insect stings, but the process often takes longer and comes with more risks, Dubin says. If your symptoms start to come back after a course of allergy shots, you can go for another round. In fact, that's quite common in Morris' practice, considering he treats children: They might complete allergy shots in childhood and repeat the process in their 30s, he says. How much do allergy shots cost? Insurance coverage varies from person to person, but most people can expect to have some out-of-pocket costs for allergy shots—anywhere from $1,000 to $4,000 for office-visit copays and the treatment itself, Morris says. 'I have seen some of the insurers charge a copay for every shot,' Morris says. 'So if you're getting 28 shots—one a week for six months—and you've got a $25 copay, you start to do the math.' The cost alone can make allergy shots unrealistic for some people. What advancements are in the pipeline? Some health care providers are using shorter timelines for administering allergy shots, sometimes referred to as rapid desensitization or cluster or rush immunotherapy. Instead of getting one shot a week during your build-up phase, you might get several shots a week—even more than one shot in a day, Morris says. This expedites the time it takes to reach the maintenance phase to a few weeks or months. However, people generally have a higher risk of having a reaction on a faster allergy shot schedule, he adds. There is also a tablet form of allergen immunotherapy that works for people who are allergic to ragweed, some grasses, and dust. You let the tablet dissolve under your tongue at least three days a week. While under-the-tongue tablets and drops have been popular in Europe for some time, this method hasn't really caught on in the U.S., where most insurance providers don't cover it without prior authorization, Meadows says. While the tablets can make your mouth itchy, the risk of serious side effects is low. So another plus of this technique is you can do it yourself at home without needing to be monitored by your doctor, Dubin says. Although it's still in early research phases, Morris is intrigued by a new technique involving injecting allergens into a lymph node, where immune cells live, rather than under the skin, called intralymphatic immunotherapy. This approach kicks in quickly: It takes just three injections over two months. However, it requires an ultrasound to deliver the shot, so it takes some technical skill and the right equipment, he says. It's currently available at a limited number of health care facilities, but it's not yet approved by the U.S. Food and Drug Administration. 'Not all these are going to be right for every patient, [but] I'm excited for patients to get some quality-of-life improvements,' Morris says. 'I recommend people see a board-certified allergist and discuss these treatments and the risks and benefits and decide what's right for them.'
