Use Of Omalizumab In Cold Urticaria Refractory To Therapy

Abstract

Cold urticaria is a type of chronic inducible urticaria that can present with anaphylaxis, angioedema, and diffuse urticaria following a cold exposure. We hypothesize that the patients who failed first line therapy will improve with omalizumab. Three patients – 6 y.o. male, 10 y.o. female, and 22 y.o. male – were diagnosed with positive 5-minute ice cube test and history of urticaria/anaphylaxis after cold exposure. Two patients had repeated episodes of anaphylaxis secondary to cold water exposure. All failed maximal first line antihistamine therapy and were given omalizumab therapy. Omalizumab was approved by insurance in all three patients under the diagnosis code of chronic idiopathic urticaria (ICD-10 L50.1). After being started on omalizumab, all parameters monitored have improved – quality of life, decreased frequency of urticarial eruptions, increased tolerance to cold exposure, and no episodes of anaphylaxis. Patient 3 has shown significant reduction in response to the 5-minute ice cube test, which was limited to erythema after the first dose of omalizumab. Omalizumab may be a powerful adjunct for cold urticaria treatment in patients who fail maximal antihistamine therapy, though there is little evidence published to-date that omalizumab is effective to decrease hives and prevent anaphylaxis in this situation. Patients with cold urticaria who have failed multiple antihistamine therapies should be considered for omalizumab therapy, especially due to the risk for anaphylaxis. Initiation of omalizumab may result in improvement of symptoms, increasing quality of life, and prevention of anaphylaxis.