Use of anti-TNFs for difficult-to-treat urticaria: response to Cooke et al.

Dear editor

We read with interest the recent paper by Cooke et al about the use of biologic agents for intractable urticaria.1 Particularly, the authors reckon that the evidence supporting the use of anti-TNFs is limited by the small numbers of patients in non-controlled studies, often with urticarial disorders not typical of chronic urticaria such as vasculitis and delayed pressure urticaria. However, we want to draw the authors’ and readers’ attention to our report from 2013 about the use of adalimumab and etanercept in 20 patients with chronic urticaria with or without angioedema2 (updated in 2015 with an additional five patients).3 This report is to date the largest series of patients published and adds substantially to the small body of evidence supporting the use of anti-TNFs in subgroups of patients with chronic urticaria unresponsive to conventional therapy or omalizumab. Notably, 60% of our patients obtained complete or almost complete resolution of urticaria and angioedema after onset of therapy with either adalimumab or etanercept, whereas another 15% of our patients experienced partial response to therapy. Some of our patients were previously unresponsive to or experienced side effects from omalizumab. Duration of treatment ranged between 2 and 39 months. We observed side effects in 30% of our patients, particularly mild recurrent upper respiratory infections, whereas one patient experienced severe central nervous system toxicity. We propose that adalimumab and etanercept may be effective in some patients with chronic urticaria who do not respond sufficiently to high-dose antihistamines or in whom other immunosuppressive drugs or omalizumab are ineffective or associated with unacceptable side effects. However, patients should be monitored closely due to the possibility of severe side effects of anti-TNF treatment. We agree that larger ran-domized controlled trials are needed before a definite recommendation can be made in regards to the use of anti-TNFs for chronic urticaria.