TNF-Alpha Inhibitors for Chronic Urticaria: Experience in 20 Patients

Patients with severe chronic urticaria may not respond to antihistamines, and other systemic treatment options may either be ineffective or associated with unacceptable side effects. We present data on efficacy and safety of adalimumab and etanercept in 20 adult patients with chronic urticaria. Twelve (60%) patients obtained complete or almost complete resolution of urticaria after onset of therapy with either adalimumab or etanercept. Further three patients (15%) experienced partial response. Duration of treatment ranged between 2 and 39 months. Those responding completely or almost completely had a durable response with a mean of 11 months. Six patients (30%) experienced side effects and five patients had mild recurrent upper respiratory infections, whereas one patient experienced severe CNS toxicity that could be related to treatment with TNF-alpha inhibitor. Adalimumab and etanercept may be effective and relatively safe treatment options in a significant proportion of patients with chronic urticaria who do not respond sufficiently to high-dose antihistamines or in whom standard immunosuppressive drugs are ineffective or associated with unacceptable side effects. 1. Introduction Chronic urticaria not responding to high-dose antihistamines is a therapeutic challenge, and in such cases other systemic treatment options should be considered. The literature is scarce in defining effective immunosuppressive drugs that may be used for long-term treatment. Systemic corticosteroids are usually effective but are not feasible as maintenance therapy, and other immunosuppressive drugs such as azathioprine, methotrexate [1], oral tacrolimus [2], and mycophenolate mofetil [3] have only been used in case reports or small patient series. In two randomised, double-blind, and placebo-controlled trials cyclosporine A was found to be effective in controlling recalcitrant chronic urticaria [4, 5]. Finally, recent reports also point to omalizumab, a recombinant monoclonal antibody that inhibits the high-affinity Fc receptor of IgE, as an effective agent in patients with refractory chronic urticaria [6–8]. Tumour necrosis factor alpha (TNF-alpha) inhibitors have so far only been used to treat a total of eight patients with chronic urticaria according to available publications [9–11]. Here we present our experience in 20 adult patients with severe refractory chronic urticaria who were received with either adalimumab or etanercept and thereby significantly expand our knowledge of the use of TNF-alpha inhibitors for this indication. 2. Report The patients described herein were