In this video, Jonathan A. Bernstein, MD, speaks about a challenging case presentation of a patient with chronic spontaneous urticaria and the diagnostic workup and treatment recommendations based on recent treatment guidelines. Dr Bernstein also spoke about these topics during his session titled “The Role of Biomarkers in Urticaria” at ACAAI Annual Scientific Meeting 2022.

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Jonathan A. Bernstein, MD, is a professor of clinical medicine at the University of Cincinnati College of Medicine in the Division of Rheumatology, Allergy and Immunology and Partner of Bernstein Allergy Group and Bernstein Clinical Research Center (Cincinnati, OH).

TRANSCRIPTION:

Dr Jonathan A. Bernstein: I'm Dr Jonathan Bernstein, Professor of Medicine at the University of Cincinnati and Partner of Bernstein Allergy Group and Clinical Research Center. So, this was a talk to discuss biomarkers as prognosticators for decision for treatment for chronic urticaria. And we started off with a case of a difficult-to-treat patient with chronic urticaria and quickly discuss the diagnostic workup and treatment recommendations based on our guidelines, which recommend an algorithmic approach beginning with monotherapy, using second generation antihistamines up to four times the recommended dose. But then this patient obviously was not responsive and we asked should certain testing be done? We talked about the pitfalls and limitations of doing testing randomly as oftentimes as an effect management. But in this case, there are some tests that have been looked at in the literature that seem to predict a good response or poor response to omalizumab versus cyclosporine as the next-step treatment for these patients.

And this was reviewed to try to direct the clinician, should they be ordering these tests to help make decisions. We did briefly talk about other subtypes of urticaria, such as progesterone and hypersensitivity, which typically occurs right before the menstrual cycle and can stop midway through the cycle or towards the end of the cycle. And this is something that people should consider when they're taking histories. We then also elaborated on chronic spontaneous urticaria phenotypes and how we now have several associated endotypes, such as antihistamine responsive hives, inducible hives, hives that have type one A autoimmunity where people make antibodies against self-antigens and type IIB autoimmunity where people have antibodies directed against the IG receptor on mass cells and basophils. And for instance, another phenotype could be neutrophilic urticaria where there's predominance of neutrophils in the histology.

So, we talked about the value of doing these tests and what has been shown in the literature, we reviewed that. We looked at the value of biopsies and discussed what other options there were for helping this patient in terms of next steps. And there's several treatment options, but there's no clear direction on which way a clinician should go. And current guidelines don't really advocate using biomarkers to help make these decisions for patients. So this is kind of a confusing area for a lot of clinicians on where do I go after omalizumab doesn't work and cyclosporine doesn't work, and so forth.

So, we did review these therapies. We talked about a need for alternative novel therapies, as not all patients are responsive to omalizumab and we didn't review that in great detail as my colleague Dr Saini did discuss these therapies in talk. So, the take-home messages from this talk was that chronic spontaneous urticaria (CSU) patients refractory to high dose second generation H1-antihistamines have heterogeneous phenotypes that respond differently to medications. Biomarkers may be useful prognosticators for treatment response to omalizumab and cyclosporine. Evidence-based analysis of literature determining the utility of biomarkers and treatment decisions for patients unresponsive to H1-antihistamines is required. And that was the gist of that discussion.