Treatment with biological products for chronic urticaria

Background: Chronic urticaria is characterized by repeatedly occurring itchy wheals and/or angioedema for at least six weeks. The prevalence of chronic urticaria is increasing globally, with variations observed among different regions. Chronic urticaria has a long duration and may recur over time. Effective and tolerable treatment for such patients is crucial due to unpredictable, recurrent, and disabling symptoms, as well as the significant impact on quality of life. Current Concepts: Recent guidelines recommend the regular use of non-sedative second generation antihistamines as the first line of treatment for chronic urticaria. For patients whose urticarial symptoms persist or worsen with the approved dose of antihistamines, the guideline recommends the second line of treatment, which involves either increasing the dosage of the initial antihistamine or combining it with three other kinds of antihistamines. However, almost half of patients with chronic urticaria are refractory to antihistamines. Recently, treatment modulating immunoglobulin E (IgE) levels and activities was found to provide an efficient therapeutic approach. Omalizumab, the only approved anti-IgE treatment to date for patients with chronic urticaria, has demonstrated strong evidence of both efficacy and safety. Recent international guidelines recommend omalizumab as the first choice of treatment for antihistamine-refractory chronic spontaneous urticaria. Discussion and Conclusion: As omalizumab is not a curative and disease-modifying agent, there is a subpopulation of patients with chronic spontaneous urticaria who partly or have never responded to omalizumab. To address this, ongoing research is exploring the therapeutic potential of other biological products that target various aspects, such as type 2 inflammation, complement system, and the c-kit pathway.