Cost-effective omalizumab dosage for chronic urticaria: a systematic review and network meta-analysis

Chronic urticaria is a persistent skin condition characterized by recurrent wheals (hives) and/or angioedema lasting more than six weeks, significantly impacting quality of life and often requiring long-term management. Limited access to costly treatments like omalizumab poses challenges in low-income countries with high healthcare expenses and limited insurance coverage, prompting research into cost-effective dosages for effective management. This study aims to find the most cost-effective dosage for treating chronic urticaria in countries with healthcare affordability challenges. PubMed, MEDLINE, and Web of Science databases were searched for randomized controlled trials (RCTs) from January 1, 2010, to October 29, 2023. Studies assessing Omalizumab's efficacy in chronic spontaneous urticaria (CSU) patients unresponsive to antihistamines were included. Network meta-analyses (NMAs) were conducted using the "multinma" package in R, employing Bayesian random-effects models to synthesize data from multiple studies. Each outcome underwent separate analysis, with effect sizes illustrated via forest plots generated using Plotly in R. Individual studies' risk of bias was assessed using the Cochrane Risk of Bias Tool 2, and effect estimate certainty was rated via the GRADE approach. Consistency assumption was evaluated using the unrelated mean effects (UME) model, focusing on each data point's contribution to model fit. Present study showed that the 300 mg dose outperformed others and placebo in reducing urticaria activity score over 7 days (UAS7), weekly itch severity score (WWS), and weekly number of hives score (WIS). Response rates were notably higher with 300 mg, indicating its superiority in achieving treatment response. Given the significantly greater effect sizes of 150 mg and 300 mg over 75 mg and placebo, low doses aren't recommended for antihistamine-resistant cases. Initiating treatment with either a 300 mg dose for six months or starting with 150 mg and adjusting upwards as necessary is recommended, aligning with economic considerations until optimal dosages are established.