D3.299 - Cholinergic urticaria treated with dupilumab

A 19-year-old male with no known pathological history of interest has been followed up in consultation since June 2023 for mild cholinergic urticaria of years of evolution. In November 2023 begins disabling clinical deterioration in the context of treatment with testosterone due to his transgender treatment process despite maximum doses of antihistamines. Treatment with omalizumab was started at a urticaria dose (300 mg sc every 4 weeks), without response, so the dose was escalated to the maximum dose (600 mg sc every 15 days), without clinical improvement. The next therapeutic step was attempted with cyclosporine at a dose of 3 mg/kg body weight/day, reaching therapeutic levels but with no response. Cyclosporine combined with omalizumab was subsequently prescribed but no response was obtained. Testosterone treatment is changed to a weekly subcutaneous regimen, trying to avoid quarterly testosterone peaks, but no improvement is achieved either. The clinic is disabling to carry out the basic activities of daily living. Since the next therapeutic step does not have sufficient scientific evidence (case series with various immunosuppressants), it is proposed to use dupilumab as compassionate use in this case. Discussion Dupilumab is approved as a treatment for chronic spontaneous urticaria in Japan, it is pending review for the same indication in the EMA and there are various studies in chronic urticaria and case series that include inducible urticaria (due to pressure, cold and cholinergic), with good results. Conclusions - On June 18, 2024, Dupilumab 600 mg sc was started in a single dose and subsequently 300 mg every 14 days, presenting an excellent response and being able to reduce the dose of antihistamines. - However, in October 2024 there was a symptomatic recurrence. He reports that he only remains asymptomatic for 48 hours after the administration of Dupilumab.