Omalizumab Withdrawal Protocol for Chronic Spontaneous Urticaria: Clinical Case

Abstract

Background: Chronic spontaneous urticaria is characterized by the daily appearance of hives and/or angioedema (Fig. 1) without a specific trigger, lasting more than 6 weeks. Treatment is based on second-generation H1 antihistamines, and in patients with an insufficient response, therapy with omalizumab has been effective; however, it is a costly and long-term treatment. The WAO (World Allergy Organization) has proposed a tapering regimen upon achieving complete remission.

Case report: A 66-year-old female was referred for evaluation due to generalized hives of 6 years' duration under treatment with fexofenadine 180 mg, with a partial response. Triple doses of H1 antihistamines were started, with no improvement, maintaining the UCT (Urticaria Control Test) at 5 points, and omalizumab 300 mg was added every 4 weeks, with an adequate clinical response. After complete remission, omalizumab tapering began in November 2023 according to the WAO protocol (Fig. 2). The final dose was administered in March 2025.

Conclusion: We present the case of a patient with chronic spontaneous urticaria. After achieving complete remission with omalizumab, the tapering protocol proposed by the WAO was implemented. During this period, our patient remained asymptomatic, with UCT scores greater than 13, allowing for progressive reduction of antihistamine use. The omalizumab tapering protocol for the treatment of chronic spontaneous urticaria is safe and effective, reduces the risk of disease reactivation, and prevents prolonged treatment.

Keywords: Antihistamine, tapering, omalizumab, UCT, Chronic urticaria.