Safety of omalizumab administration in chronic spontaneous
urticaria during COVID-19 infection: a case report.
Marisa Paulino1, Célia Costa1, Elisa
Pedro1
1Immunoallergology department, Hospital de Santa Maria
– Centro Hospitalar Universitário Lisboa Norte, Portugal
Dr. Marisa Paulino has nothing to disclose.
Dr. Célia Costa has nothing to disclose.
Dr. Elisa Pedro has nothing to disclose.
Keywords : Omalizumab, COVID-19, urticaria
To the Editor:
COVID-19 pandemic affected
millions of people worldwide since was first reported in December
20191. As the pandemic expanded around the world
medical practice suffered substantial changes. Healthcare systems
worldwide had to adapt to provide the best and safest care for patients
as well as ensure the safety of medical personnel. Patients with severe
allergic disease provide the major challenge for
allergists2. Biologicals are widely used in the
management of severe allergic diseases and have long become part of our
daily practice, however, SARS-CoV-2 infection risks in these patients
lacks evidence2. Recent reports regarding Dupilumab
(anti-IL3 and IL-4) administration in infected patients with chronic
rhinosinusitis with nasal polyps3 and severe atopic
dermatitis4,5 showed no increase in risk of severe
COVID-19.
Omalizumab is a monoclonal antibody targeting IgE approved for the
treatment of severe asthma, chronic spontaneous urticaria
(CSU)6. We report a case of a 45-year-old female with
CSU treated with omalizumab that contracted COVID-19.
Urticaria symptoms began at 42 years-old, 1 year prior to the first
appointment, initially with only symptomatic dermographism: wheeling and
itching 5-10 minutes after scratching the skin or in areas of friction
from clothes. After six months she had an episode of generalized
maculopapular, itching lesions with individual duration of less than
24hours that worsened after sun exposure developing areas of angioedema.
She recurred to her general practitioner that prescribed bilastine
20mg/day, topical corticosteroid and referred her to our urticaria Unit.
At first appointment she was medicated with bilastine 20mg/day
maintaining daily wheals with a weekly urticaria activity score (UAS7)
between 24-25 for the following 12 weeks.
H1-Antihistamine dosage was increased until a maximum
dosage of 4/day was achieved. Skin prick tests for aeroallergens and
food allergens were negative. Autologous serum skin test (ASST) was
negative. Blood workup was clear. She had a positive respiratory test
for Helicobacter pylori that required two eradication treatments to
achieve a negative result but without influence on the urticaria
activity.
The patient quality of life deteriorated further as the disease
progressed with an increased absenteeism from work (health care
assistant), strained personal and social relationships and reduced
self-esteem.
After failure of the second line of treatment
(H1-Antihistamine 4/day), omalizumab was proposed. She
started treatment in November 2019 with 300mg subcutaneously every 4
weeks at our day care unit. At first administration she was medicated
with bilastine 20mg 4/day. The UAS7 was 21, urticaria control test (UCT)
was 7 and Dermatology Life Quality Index (DLQI) was 7. At the fourth
administration she had her CSU controlled: UAS7 0, UCT 16 and DLQI 0,
and reduced the dose of bilastine 20mg to 2/day.
Due to the COVID-19 pandemic, the patient chose not to take omalizumab
in March 2020, imposing an 8-week interval between administrations. At
that time she reported only a slight increase in pruritus (UAS7 7).
Omalizumab was resumed on April 28th. Triage was
performed before administration excluding COVID-19 symptoms, fever or
contact with infected individuals.
Her husband started exhibiting COVID-19 symptoms on May
3rd (fever, cough, dyspnea, diarrhea) and 1 day later
she noticed anosmia and arthralgia, both were positive to SARS-CoV-2
(RT-PCR of nasopharyngeal exudate) on May 5th. CSU was
controlled and she reported only a slight increase in pruritus with the
need for increasing H1-Antihistamine dosage from 2 to
4/day. She maintained mild symptoms and tested negative after 3.5 weeks.
Only anosmia persisted but with a slight improvement. As she was
quarantined at the time, she was unable to attend treatment in May but
maintained the scheduled treatments in June 23rd as
CSU was controlled.
No worsening of CSU symptoms or increase in COVID-19 severity was
observed in this case despite the administration of omalizumab in the
week prior to SARS-CoV-2 infection.
Viral infections are known as triggers or eliciting factors for chronic
urticaria6, SARS-CoV-2 infection as also been reported
to manifest with acute urticaria7. The effects of
COVID-19 in CSU control are unknown, in the reported case, no worsening
of symptoms was observed.
According to the EAACI consensus on biologicals, patients with severe
allergic disease should maintain treatment with biologicals if there is
a safe environment, and at-home administration should be encouraged.
Regardless of disease severity, patients with COVID-19 should interrupt
treatment until recovery is established2.
More evidence is needed to assert the safety of biologicals during COVID
infection and effect of the disease in severe allergic patients.
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140 patients infected with SARS-CoV-2 in Wuhan, China. Allergy Eur
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for Patients with allergic disease in times of the COVID‐19 pandemic: an
EAACI Statement. Allergy Eur J Allergy Clin Immunol . Published
online 2020. doi:10.1111/all.14407
3. Förster-Ruhrmann U, Szczepek AJ, Claus Bachert habil, Heidi Olze
habil. COVID-19 infection in a patient with severe chronic
rhinosinusitis with nasal polyps during therapy with dupilumab. J
Allergy Clin Immunol . Published online 2020.
doi:10.1016/j.jaci.2020.05.005
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risk for COVID-19 infection in patients treated with Dupilumab for
atopic dermatitis in a high-epidemic area - Bergamo, Lombardy, Italy.J Eur Acad Dermatol Venereol . Published online 2020.
doi:10.1111/jdv.16552
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EAACI/GA2LEN/EDF/WAO guideline for the
definition,classification, diagnosis and management of urticaria.Allergy Eur J Allergy Clin Immunol . 2018;73(7):1393-1414.
7. Galván Casas C, Català A, Carretero Hernández G, et al.
Classification of the cutaneous manifestations of COVID-19: a rapid
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