Original article
Intervention
Factors that predict the success of cyclosporine treatment for chronic urticaria

https://doi.org/10.1016/j.anai.2011.08.013Get rights and content

Background

Chronic urticaria (CU) is a frequent, difficult clinical problem. When first-line therapy fails, patients are often treated with alternative therapies that either have a poor side effect profile or little evidence to support effectiveness.

Objective

To describe our low-dose cyclosporine-treated CU population and factors predicting a positive outcome.

Methods

A retrospective chart review was conducted of adult CU patients treated with cyclosporine. Elements of the history, physical examination, diagnostic testing, efficacy, and side effects were extracted for statistical analysis.

Results

Chronic urticaria was defined as having urticaria more than 3 days per week for 6 consecutive weeks. Sixty-eight adults with CU who fulfilled the intake criteria and completed a course of cyclosporine were identified. After taking cyclosporine at an average dose of 1.8 ± 1.1 mg/kg, 53 (78%) patients attained complete remission defined as ≤1 day of hives per month. Recurrence occurred in only 7 patients; all achieved remission with resumption of cyclosporine. A history of hives (P = .01), shorter duration of urticaria (mean: 55.2 weeks vs 259.63 weeks; P = .03), and positive CU Index (P = .05) predicted a favorable response to cyclosporine. Notably, autologous serum skin testing, prior response to steroids, atopic status, or presence of antithyroid antibodies was not predictive. Male sex and a positive ANA trended toward significance (P = .1). Side effects were generally mild and seen in 35% of patients; all were reversible by dose reduction.

Conclusion

Cyclosporine is an effective treatment for CU, and a history of hives, shorter duration of disease, and CU index ≥10 predict a successful response.

Introduction

Urticaria is a common disorder, with a lifetime prevalence estimated to be 12% to 22%.1 The prevalence in the general population is approximately 1%, but this rises to greater than 10% when allergy and dermatology clinics are surveyed.1 Chronic urticaria (CU), defined as hives persisting for 6 weeks or longer, accounts for one third of these cases. In contrast to acute urticaria, CU can be quite difficult to treat. Chronic urticaria is much more prevalent in adults than children and has a nearly 4:1 female-to-male ratio.2

In most case series of CU, 80% to 90% of cases will not have an identifiable cause, leading to the moniker chronic idiopathic urticaria (CIU).3 However, studies have demonstrated an association between autoantibodies to the α-chain of the high-affinity receptor for immunoglobulin E (IgE; FcϵRIα) in 30%-50% of patients with CIU.4 This along with the coexistence of CU and antithyroid antibodies 5 has led to the concept that a large proportion of CIU patients have an autoimmune basis for their hives. This group of patients with CU had been called autoantibody-associated chronic urticaria or autoimmune urticaria.

Given the presumed autoimmune nature of many CIU patients, that over 30% of these patients fail a conservative regimen of antihistamines alone2 is not unexpected. When they do, they often are placed on short bursts of oral steroids that have many unwanted side effects. In an effort to avoid steroids, other immunomodulatory medications have been tried. One of the more common second-line treatments used is cyclosporine, but few large-scale trials have been conducted to evaluate its efficacy and safety for the treatment of CIU. We present a retrospective analysis of our CU patients treated with cyclosporine designed to evaluate its safety and efficacy as well as factors predicting its success.

Section snippets

Study Design

This retrospective chart review included all patients seen in the Washington University School of Medicine Allergy and Immunology clinics between January 1, 2000 and April 1, 2010 who had their CU treated with cyclosporine.

Patient Selection

An initial query into the WUMED database included the terms ‘urticaria,' ‘hive,' and ‘cyclosporine.' The charts that returned were extensively evaluated to make sure that the patients had the following inclusion criteria: They had to have CU as defined as typical hives that

Baseline Characteristics

Of the 285 patients identified for this study, 106 met the inclusion criteria, and 68 had completed treatment with cyclosporine for CU as detailed in Figure 1. Of those that did not meet the inclusion criteria, most did not receive cyclosporine because either the urticaria resolved spontaneously or it was controlled with other medications such as antihistamines. For those that completed treatment, 53 (78%) were female and 55 (81%) were white. The average age at first visit was 40 years, and the

Discussion

This retrospective chart review showed that a history of urticaria, a shorter duration of hives, and a positive CU Index were each associated with an improved response to cyclosporine for the treatment of urticaria. Based on a thorough literature review, we are the first to find these predictive factors.

The finding that a positive CU Index correlates with the successful treatment of CU with an immune-modulating agent such as cyclosporine was not surprising. Although no gold standard has been

References (9)

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Disclosures: No funding was used for this study, nor do any authors have any financial relationships with an interest in this subject matter.

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