Benefits of Complete Response to Treatment in Patients With Chronic Spontaneous Urticaria

TAKE-HOME MESSAGE

• The authors of this Chronic Urticaria Registry–based study found that patients with a complete clinical response to treatment of their chronic spontaneous urticaria (CSU) had significantly improved sleep and quality of life, although only a small percentage of patients achieved a complete response. The patients' self-assessments were often discordant with physician assessments of clinical response to CSU treatment. Episodic disease, male sex, and omalizumab treatment were predictive of complete control of CSU.
• Complete control of CSU significantly improves sleep and quality of life compared with partial or no control of the disease.

–  Kelly B. Scarberry, MD

Written by

 

 

Adam Friedman MD, FAAD

Chronic spontaneous urticaria (CSU) is a disabling, distressing, and underappreciated SKIN condition (yes, all caps to remind everyone that this is a dermatologic disease over which we should have purview), with an estimated point prevalence of up to 2.6% globally. The etiology of CSU is elusive and its course unpredictably relentless, creating a perfect health-related quality of life (HRQoL) storm. Furthermore, concerning data highlight that the majority of CSU patients do not achieve complete response (CR; defined as a weekly Urticaria Activity Score [UAS7] of 0 — ever hear of that tool before?) with standard doses of second-generation non-sedating (eh, not always*) antihistamines (sgAH), and, even with employing dose escalation (up to fourfold the recommended dose), over a third of patients remain symptomatic. If this isn't a call to action, I don't know what is.

Enter the following study to better put a finger of the erratic pulse of CSU. Using real-world data from the global CU registry (CURE), investigators sought to better clarify the burden of uncontrolled disease, trackable disease metrics, and markers for success. First and foremost, from their analysis, approximately 1 in 10 patients achieved complete clearance of their disease, which is distressing. Limitation alert: patients in the CURE registry are likely so because they sought out a CSU expert due to poor control…but still!

Several key bullet points emerged from a hoard of authors/investigators that jumped of the CSU grenade:

• Level of urticaria control is best assessed with patient-reported outcome measures.
  • These should be used wherever possible, and for us should be relatively easy! We are quite skilled at soliciting the patient experience. And what pray tell is a good target for said inquiry? Sleep! Sleep disturbance were noted to be drastically underappreciated by physicians in patients with CSU as a burdensome and clinically relevant consequence of the disease.
• Presence of angioedema without wheals, episodic disease, male sex, and treatment with omalizumab are associated with complete control of CSU.
  • Certainly using a targeted systematic FDA-approved therapy makes sense, but the other features are certainly helpful when approaching the flop sweat–inducing questions "Well, how likely will I get better on treatment?"
• Proportion of complete disease control increases over time but may not be sustained.
  • This is useful, just as open-label extension data can help determine whether some patients meet primary outcome level success at a later time point. This point suggests that some patients may be late CR bloomers; so, all hope is not lost.
• Complete control of CSU at baseline entry is associated with better quality of life and sleep.
  • Self explanatory

Only by achieving complete clearance of their CSU can patients fully eliminate negative impacts on their sleep and HRQoL. Dermatology should own this proudly, as our passion to go therapeutically aggressive and off-label is our badge of honor. Lets do this!

*Fexofenadine is the least sedating of the sgAH in this author's opinion.

Abstract

BACKGROUND AND OBJECTIVE

Chronic spontaneous urticaria (CSU) is a distressing disease. We report real-world data from the global Chronic Urticaria Registry (CURE) about associations between various CSU states and sleep impairment, plus important health-related quality-of-life (HRQoL) outcomes and compared different methods to assess CSU states.

METHODS

CURE data were collected at baseline and 6-monthly follow-ups (FU). Assessments included CSU states using the Urticaria Control Test (UCT), weekly Urticaria Activity Score (UAS7), and Physician Global Assessment (PhyGA) of treatment response. Complete response to treatment (CR, UAS7 = 0), complete control of disease (CC, UCT = 16), and PhyGA = CR were assessed, plus the Dermatology Life Quality Index and the Chronic Urticaria Quality-of-Life Questionnaire (CU-Q2oL) sleep domain.

RESULTS

Overall, 2078 patients were included. At baseline, 9.8%, 17.9%, and 42.3% of patients had UCT = 16, UAS7 = 0, or PhyGA = CR, respectively, which increased at FU1 and FU2. Patients with higher UCT scores had better sleep and HRQoL. The presence of angioedema without wheals, episodic disease, omalizumab treatment, and male sex were associated with CC (P < .05). Among 469 patients who achieved CC or CR, 16.4% (n = 77) showed CC or CR with all 3 instruments. Agreement between UCT = 16 and UAS7 = 0 measurements was moderate (κ = 0.581), but poor between UCT = 16 and PhyGA = CR (κ = 0.208).

CONCLUSIONS

Few patients had CR/CC of their CSU at baseline entry. Disease control strongly related to good sleep and better HRQoL; therefore, it is important to aim for CR in CSU treatment. Patient-reported UCT and UAS7 assessments demonstrated a more accurate measurement of CSU state versus physician assessments.

The Journal of Allergy and Clinical Immunology: In Practice

The Benefit of Complete Response to Treatment in Patients With Chronic Spontaneous Urticaria-CURE Results

J Allergy Clin Immunol Pract 2023 Feb 01;11(2)610-620.e5, P Kolkhir, PA Laires, P Salameh, R Asero, M Bizjak, M Košnik, J Dissemond, M van Doorn, T Hawro, A Kasperska-Zajac, M Zajac, E Kocatürk, J Peter, CAS Parisi, CA Ritchie, K Kulthanan, P Tuchinda, D Fomina, E Kovalkova, M Khoshkhui, S Kouzegaran, N Papapostolou, A Du-Thanh, A Kamegashira, R Meshkova, A Vitchuk, A Bauer, C Grattan, P Staubach, L Bouillet, AM Giménez-Arnau, M Maurer, K Weller 

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

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