Abstract
Chronic urticaria affects a significant percent of the global population and carries a higher burden of unmet medical need. Current standard-of-care includes antihistamines and omalizumab, but omalizumab is not effective in all patients and has not been found to induce long-term disease remission. This review evaluates the diverse therapeutic pipeline spanning IgE-based and non-IgE-based mast cell targeting strategies, including recent clinical data. The therapeutic landscape has expanded rapidly with multiple mechanisms under investigation. IgE-targeted approaches include omalizumab biosimilars, with CT-P39 having received Food and Drug Administration (FDA) approval. Dupilumab received FDA approval for antihistamine-refractory chronic spontaneous urticaria supporting the targeting of type 2 cytokines, interleukin-4, and interleukin-13, in this disease. Bruton's tyrosine kinase inhibitors have promise, with remibrutinib receiving FDA approval and demonstrating significant reductions in UAS7 in phase 3 trials. c-Kit (c-Kit or KIT) inhibition with barzolvolimab demonstrates robust efficacy with sustained effects post-treatment. Finally, Janus kinase inhibitors, Mas-related G protein-coupled receptor X2 antagonists, and other novel mechanisms are advancing through clinical trials. Although some programs have been discontinued due to safety concerns or lack of efficacy such as fenebrutinib (Bruton's tyrosine kinase inhibitor), THB001 (c-Kit inhibitor), EP262 (Mas-related G protein-coupled receptor X2 antagonist), tezepelumab (anti-TSLP), and lirentelimab and AK006 (sialic acid binding immunoglobulin-like lectin-targeting agents), these studies have informed many of the other positive studies. In summary, in the last year, we have seen the chronic urticaria pipeline mature with multiple phase 3 programs and new approvals representing diverse mechanisms of action. Nevertheless, significant therapeutic gaps persist for omalizumab-refractory disease and chronic-inducible urticaria.