‘Trifecta’ of Treatment Options for Chronic Spontaneous Urticaria

As new therapies emerge and guidance evolves, treatment strategies for chronic spontaneous urticaria (CSU) are shifting beyond traditional stepwise approaches.

In this exclusive MedPage Today video, Nicole Chase, MD, of St. Paul Allergy & Asthma in Minnesota, discusses how new international guidelines presented around the American Academy of Allergy, Asthma & Immunology annual meeting position newer therapies alongside established options, and what that may mean for clinical decision-making moving forward.

Following is a transcript of her remarks:

In Philadelphia for the academy meeting this year, there was tons on CSU. So the meeting happened and right at the same time, probably a couple weeks before, we had gotten the new international guidelines for CSU, these were released and published by the GA2LEN [Global Asthma and Allergy Excellence Network] group and everyone that had published the prior international guidelines. And what we’re seeing now is this trifecta of omalizumab [Xolair], dupilumab [Dupixent], remibrutinib [Rhapsido].

Omalizumab has been around since 2003. So we’ve seen lots and lots of safety data. We’ve seen lots of meta-analyses on everything you can think of. And really it seems to be very, very well tolerated, very safe, long term. I do think that the omalizumab group didn’t have tons of new… they’re not presenting tons of new data. At this point, we’ve seen some data historically about what if your IgE [immunoglobulin E] is this or that or whatever, doesn’t seem to matter.

The dupilumab folks are still talking about CUPID A and CUPID C looking at, OK, how else could we slice this apple? And I think that realistically they’re still going after that omalizumab-naive phenotype primarily, but I think that they want to show that it does work against the omalizumab failure group, but the CUPID B data is still just kind of hindering things.

I think personally that dupilumab, it’s a really nice drug. I think the biggest thing that they have going for them is they have nine indications now. And so this drug is going to be on formularies and is going to be very, very much a heavy hitter for other disease states, and that might just give it a nice positioning. I think that whether or not it should be equal to omalizumab is a good question. It does take longer. The clinical trials really do suggest that it takes longer for dupilumab to kick in, but I think that it actually works really well once it kicks in, at least close to omalizumab, if not as good.

So we saw some data from them, but nothing super, super exciting. I think the guidelines coming out right before the meeting was probably the most exciting thing for dupilumab showing it literally right on the same line as oma [omalizumab] and as remi [remibrutinib].

Remibrutinib has been a fan favorite for a while now. So this is Novartis’s BTK [Bruton’s tyrosine kinase] inhibitor. They have REMIX-1 and -2. They showed some additional data. I think the hottest thing for remi at the meeting was that they had talked about their onset-of-action story. And I think that this is where they’re trying to win the game by saying, look, all of the biologics, these large molecules like oma and dupilumab, they take longer to work. And our small molecule, BTK inhibitor, which is A) oral, but also is really, really fast acting. Their endpoints were at 12 weeks, but they’re hearing from clinicians that sometimes people feel better within a week or 2. And so they had some of this data at the meeting.

I love to under-promise and over-deliver. So a week or 2, I feel a little bit reluctant to tell patients that because if it doesn’t work that fast, if it takes a month, which is still amazingly fast, I think that whether that’s an appropriate strategy for them, I don’t know, but I think that that’s what we saw.

The other thing that was cool that they released was that they’re going to do a head-to-head. So head-to-head remi versus dupilumab in basically step-up CSU, so failing high-dose antihistamines, and they’re doing it at 4 weeks. So they’re basically setting the stage to say, look, if you’re going to pick a drug for CSU that you want to act quickly, we’re going to show you just really the actual mechanistic data that remi as a small molecule is faster than dupilumab, which of course it is. We know that. So I’m not super excited about this study, but I think it’s cool that they’re doing it. I love head-to-head in general.

The other really hot thing actually, just as an aside, is that remi was actually also shown to be effective in IgE-mediated peanut allergy. So that’s, I think, what many people are talking about. Remi works great for CSU and also will it work for other things? I think absolutely so is the answer. And so we got to see a little bit of a hint of that. That was fun.

Please enable JavaScript to view the comments powered by Disqus.