Transcript
Carsten Hamann:
I'm Carsten Hamann. I'm a practicing dermatologist in the Phoenix metro area. It's exciting that we have new guidelines for chronic spontaneous urticaria. I really appreciate that the community has gotten together to try to come up with some new takeaways, practical things to treat our patients.
I think some of the most key takeaways are that the workup for CSU does not have to be this extended lab workup. Prick testing, patch testing, IgE-specific labs are really not recommended anymore. And I think that clarity is really something that people should take away from these guidelines.
So the diagnosis of CSU is a clinical diagnosis. I think a lot of people have this misconception that you have to do this extended workup or that it's really difficult to diagnose CSU, but especially with these updated guidelines, it's really clear that all you need to do is a history and physical.
So does the patient have hives? Have they had them more days than not for more than six weeks? And that's how you diagnose CSU. You don't have to do a complicated score. You don't have to have them do a UAS7 or some sort of diary at home with regards to their symptoms. All you have to do is assess for the presence of weals for more than six weeks.
So once you've diagnosed CSU, it's exciting that we have more options to treat CSU. Most recently, remibrutinib and dupilumab were approved for CSU. And then we have omalizumab, which has been around for a long time, and it's great to have a wide range of options for treatment.
To start, all these patients should be put on antihistamines. The newer generation antihistamines, up to four times standard dose is what I recommend and what the guidelines recommend. If those patients do not get clear on that, they can be put on these more advanced therapies.
It's always great to have a lot of options for treating skin disease in chronic spontaneous urticaria. Again, we have these three advanced therapies, omalizumab, remibrutinib, and dupilumab. And I think choosing an initial treatment really depends a lot on the patient.
If the patient has other type 2 comorbidities, for example, eczema or COPD or asthma, I think the obvious choice is to start with dupilumab. The advantage of a medication like remibrutinib is it is probably the fastest. And so if you have a patient who's really in that most severe case, that's typically the first option that I reach for.
And then omalizumab is a little bit of an older medication, but we know from these meta-analyses and from just the clinical trials in general, it does work well. And so it can be a little bit more difficult to do in your clinic, but there's plenty of infusion suites and allergy offices that are very able to get these patients on drug quickly. So again, very great to have lots of options.
It's also really important to remember that anytime you start one of these advanced therapies, the patient should stay on their maintenance dose of antihistamines.
The guidelines do recommend routine lab monitoring with CRP, ESR and CBC. This is not something that I do very frequently in my office. That's kind of my hot take.
Obviously, any decision to do labs should be as a clinical assessment, but I think the big takeaway is doing these extended lab workups like TSH, TPO, other autoimmune labs. Certainly that's something you can do in your clinic, but that shouldn't impact your decision to start therapy for a patient.
So if you want to assess for thyroid disease in your CSU patients, that's very valid and reasonable, but that doesn't really dictate the treatment for your patient.
So never would you order a TPO antibody and then when it comes back, then you say, "Oh, this is CSU." That is an adjunctive comorbidity lab workup, not part of the diagnosis of CSU. CSU is purely a clinical diagnosis, and if you want to do a workup for other autoimmune comorbidity, that's certainly very reasonable, but that should be done in parallel with starting therapy.
