Chronic urticaria: Which systemic therapies yield the best outcomes?

Study details. As part of the AAAAI/ACAAI guideline update, this systematic review and Bayesian network meta-analysis synthesized data from 93 studies (83 randomized controlled trials, 10 nonrandomized studies; N = 11,398) evaluating 42 systemic treatments for chronic urticaria unresponsive to antihistamines. Outcomes included urticaria and angioedema activity, quality of life, and adverse events. The GRADE approach was used to assess certainty of evidence.

Results. Standard-dose omalizumab (300 mg q4wks) and remibrutinib (an investigational oral BTK inhibitor developed by Novartis) were among the most effective treatments for improving urticaria symptoms and quality of life, with high-certainty evidence. Remibrutinib’s safety profile, however, remains less certain. Dupilumab improved itch and wheals but lacked data on angioedema and quality of life. Cyclosporine may be effective but was associated with higher adverse event rates. Other agents (azathioprine, dapsone, hydroxychloroquine, mycophenolate, sulfasalazine, vitamin D) showed modest benefit, while benralizumab, quilizumab, and tezepelumab didn’t differ from placebo.

Clinical impact. For patients with chronic urticaria refractory to antihistamines, omalizumab and remibrutinib offer the most reliable efficacy with acceptable safety. These findings support prioritizing biologics in treatment algorithms and highlight the need for individualized risk-benefit assessments, especially when considering immunosuppressants.

Source:

Chu AWL, et al. (2025, July 11). J Allergy Clin Immunol. Comparative efficacy and safety of biologics and systemic immunomodulatory treatments for chronic urticaria: Systematic review and network meta-analysis. https://pubmed.ncbi.nlm.nih.gov/40663028/