From the Guidelines
Rituximab is not indicated for the treatment of urticaria as a first-line or standard therapy, but it may be considered as an off-label option in severe, refractory chronic spontaneous urticaria cases that have failed standard therapies, including antihistamines, omalizumab, and other immunosuppressants. The use of rituximab in urticaria is based on its mechanism of depleting B cells that may produce autoantibodies against IgE receptors or IgE itself, which are implicated in some cases of chronic urticaria 1. However, evidence supporting its use comes primarily from small studies and case reports rather than large randomized controlled trials, and treatment decisions should be made by specialists experienced in managing severe urticaria after careful consideration of risks and benefits.
Key Considerations
- The international urticaria guideline recommends a step-wise approach to pharmacologic treatment, starting with antihistamines, followed by omalizumab, and then cyclosporine if necessary 1.
- Rituximab may be considered as an alternative option for patients who have not responded to standard therapies, but its use is not well established and requires careful monitoring for infusion reactions and infections.
- The latest update of the international urticaria guideline emphasizes the importance of using an "as much as needed and as little as possible" approach, stepping up and stepping down treatment based on levels of disease control assessed with the UCT 1.
Treatment Approach
- First-line treatment: antihistamines
- Second-line treatment: omalizumab
- Third-line treatment: cyclosporine
- Off-label option: rituximab for severe, refractory cases that have failed standard therapies
Monitoring and Safety
- Patients should be monitored for infusion reactions and infections when using rituximab
- Blood pressure and renal function should be monitored every 6 weeks when using cyclosporine 1
From the Research
Urticaria Treatment Overview
- Urticaria, also known as hives, is a common skin condition characterized by itchy, raised welts 2.
- The treatment of urticaria typically involves antihistamines, with second-generation antihistamines being the preferred choice due to their reduced sedative and anticholinergic effects 2.
Rituximab in Urticaria Treatment
- Rituximab, a chimeric murine/human monoclonal antibody directed against CD20, has been used to treat refractory chronic spontaneous urticaria (CSU) 3.
- A case study reported an 8-month remission of refractory CSU following the use of rituximab, suggesting its potential as a therapeutic approach 3.
- However, rituximab is not a commonly recommended treatment for urticaria, and its use is typically reserved for severe, refractory cases 4, 5, 6.
Alternative Treatments for Urticaria
- Omalizumab, an anti-IgE antibody, has been shown to be effective in treating CSU and is often used as a second-line treatment 4, 5, 6.
- Cyclosporine, an immunosuppressant, is also used to treat CSU, particularly in cases that are resistant to antihistamines and omalizumab 6.
- Newer treatments, such as Bruton tyrosine kinase inhibitors and anti-KIT monoclonal antibodies, are being developed and have shown promise in clinical trials 5.