[Treatment of mast cell-mediated angioedema]

Mast cell-mediated angioedema represents the most common form of angioedema and may occur either in isolation or in association with urticaria. Clinically, the spectrum ranges from anaphylactic or anaphylactoid reactions, such as those occurring in allergic conditions, to chronic recurrent disease courses, for example, in the context of chronic spontaneous urticaria (CSU). Beyond classical IgE-mediated reactions observed in allergic diseases, it is now recognized that these conditions, as well as pseudoallergic reactions and chronic disorders such as CSU, are driven by more complex immunological mechanisms. In the treatment of acute mast cell-mediated angioedema, modern non-sedating second-generation H1 antihistamines remain the cornerstone of therapy. In patients at risk of anaphylaxis (e.g., in the setting of an allergic reaction), current guideline recommendations additionally include the use of glucocorticoids and epinephrine. The management of chronic spontaneous urticaria continues to follow a stepwise treatment algorithm; however, this approach has recently been expanded. In patients who fail to respond to second-generation H1 antihistamines (even at doses up to four times the standard dose), omalizumab, dupilumab, and remibrutinib may now be prescribed as add-on therapies (with dupilumab being indicated only in patients who have not previously received anti-IgE therapy). Additional therapeutic strategies, including anti-KIT monoclonal antibodies, are currently under clinical investigation. In contrast, no new therapeutic options have yet received regulatory approval for mast cell-mediated angioedema associated with chronic inducible urticaria.