Jason Hawkes, MD: Urticaria Characteristics, Patient Concerns, and Therapies

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At the Maui Derm NP+PA Fall 2024 Conference in Nashville this week, Jason Hawkes, MD, gave a presentation titled, “Acute and Chronic Spontaneous Urticaria: Diagnostic and Therapeutic Strategies.” During the demonstration, Hawkes spoke about his approach to urticaria, its mechanisms, and the current state of the disease field.¹

“This disease is so visible, [patients] start to withdraw socially,” Hawkes said. “We start to see substance abuse disorders. We start to see quality of life impact that's as bad as having severe coronary artery disease. These are patients that really need intervention. They need a quick diagnosis. They need therapies that work. So don't underestimate the impact that urticaria has on your patient.”

Defining Urticaria and Its Characteristics

Hawkes started the conversation by discussing the epidemiology of the disease, its prevalence, and different types of urticaria:

Hawkes, a patient of urticaria himself, said this diseases parked his interest in dermatology. The presentation included interactive elements, encouraging attendees to give their diagnosis and treatment recommendations for several presented case studies and practical examples.

Addressing Black Box Warnings

Another topic Hawkes touched on was addressing black box warnings, specifically when it comes to omalizumab for urticaria. The major warning noted in packaging is that of anaphylaxis, which Hawkes stated was reported in asthma clinical trials but not in trials for urticaria. He said he tells patients that the medication generally has good safety, with common adverse effects being headache, nasal pharyngitis, and arthralgia. He assures them that studies found anaphylaxis is rare, occurring in 0.1% of cases, and typically within the first few doses. He found this is less frequent compared to the baseline rate of 2% for anaphylaxis without treatment. Patients are sometimes provided with an EpiPen as a precaution, though its use for this medication is uncommon.

“Have my patients used the EpiPen? Absolutely. Did they use it for their urticaria? No. They use it for peanut allergy or bee sting or something like that. I’m fine giving patients the EpiPen because we know they have this hypersensitivity,” Hawkes said.

Overall, Hawkes said the risk of anaphylaxis should not deter use of the medication, as it was not seen within urticaria clinical trials and the risk that does exist is significantly lower than the baseline risk.

New and Upcoming Therapies

To wrap up his urticaria session, Hawkes talked about available and upcoming therapies for the disease. “Some of the therapies we've used traditionally, like omalizumab, blocking IgE, really haven't had a high uptake by dermatology, but now we're shifting into a new area of therapies. We're seeing dupilumab, which is very well known to dermatologists. At late-stage approval, we just got the study C results in the phase 3 program, looking about a third of patients getting a complete response, total clearance of their urticaria,” Hawkes said in an interview with Dermatology Times on the discussion. “Very exciting for a drug that can be used for many similar atopic conditions and a great safety profile for our providers.”

What Hawkes finds the most interesting is the Bruton's tyrosine kinase (BTK) inhibitor remibrutinib. He stated that the mechanism is what makes it stand out, “It’s really central to mast cell. Blocking it has improved advantages over blocking just IgE, because there are other actions that can activate the high affinity IgE receptor, we can still block that downstream signaling. We expect it to work, not only in urticaria, but also a number of other mast cell disorders. There’s a lot in this pipeline, very busy over the next few years.”

References

1. Hawkes J. Acute and chronic spontaneous urticaria: Diagnostic and therapeutic strategies. Presented at Maui Derm NP+PA Fall 2024, September 15-18; Nashville, Tennessee.