1. The effective use of Omalizumab for the treatment of cold-induced urticaria
SHARON CHAN1, SARAH DENMAN1 & SINISA SAVIC1*
Department of Clinical Immunology and Allergy, St James’ University Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
* Correspondence to
Background
Cold induced urticaria (CiU) is a form of chronic inducible (physical) urticaria.
It is characterised by pruritic wheals with or without angioedema due to cutaneous mast cell activation that occurs on exposure to the cold.
1/3rd of patients get cold induced anaphylaxis REFERENCE.
With an appropriate clinical history, the diagnosis of CiU is confirmed by the presence of a positive cold stimulation test.
Conventional management of CiU includes:
Practical advice about avoiding cold exposure
Education about the risk of systemic reactions such as anaphylaxis, and their acute management
High dose antihistamines as prophylaxis
However, not all patients respond to the conventional therapy.
Here we present 3 CiU patients who had a positive response to Omalizumab.
Cases
Patient 1
38 year old female
Diagnosed age 18 years with CiU
Symptoms: Generalised urticaria, angioedema, light-headedness and loss of consciousness on exposure to cold.
PMH: No personal history of atopy
Previous Medication:
Chlorpheniramine 4mg TDS
Fexofenadine 180mg BD
Ranitidine 150mg BD
Sodium Cromoglycate 200mg TDS
Montelukast 10mg OD
Patient 2
42 year old female
Diagnosed at 32 years with CiU but symptoms since early 20s
Symptoms: Generalised urticaria on exposure to cold
PMH: allergic rhinosinusitis
Previous Medications:
Montelukast 10mg OD
Ranitidine 150mg BD
Fexofenadine 180mg BD
Patient 3
44 year old male
Diagnosed with CiU in early 20s
Symptoms: Generalised urticaria on exposure to cold, angioedema particularly to hands/fingers, loss of consciousness on exposure to extreme cold
PMH: No personal history of atopy, 7 year old daughter with CiU
Previous Medications:
Ranitidine 150mg BD
Chlorpheniramine 4mg QDS
Fexofenadine 180mg BD
Hydroxyzine 50mg ON
Starting dose: 300mg 4-weekly
Response: Response seen within first 3 months of treatment. No symptoms of CiU over winter period. Able to stop all other medications.
Duration of treatment: 13 months
Location of treatment: Home (9 months)
Current dose: 300mg 8-weekly (may need dose increase over winter months)
Starting dose: 300mg 4-weekly
Response: Response seen within first 2 doses. No significant episodes of urticaria since starting. Able to stop all other medications.
Duration of treatment: 18 months
Location of treatment: Home (12 months)
Current dose: 300mg 4-8 weekly depending on symptoms
Starting dose: 300mg 4-weekly
Response: Within first 2 doses saw improvement in symptoms. He still experiences flares but these are milder and shorter in duration. He is on no other medications.
Duration of treatment: 15 months
Location of treatment: Home (11 months)
Current dose: 300mg 4-weekly
Conclusion
Omalizumab is currently licensed for the treatment of chronic spontaneous urticaria but not CiU. However, many patients are not effectively controlled on standard treatments. In all our cases the patients symptoms were refractory to conventional therapy of high dose H1 and H2 antihistamines.
Although randomised control trials are lacking to support the use of Omalizumab in CiU there are growing number of case reports which describe an excellent response to Omalizumab in this condition REFERENCES. This case series adds to this body of literature.