POLL: When Do You Typically Initiate Biologic Therapy in Patients with CSU?

A recent retrospective descriptive study evaluated real-world treatment patterns and health care resource utilization among veterans with chronic spontaneous urticaria (CSU), with a particular focus on the timing of biologic therapy initiation.¹ Using data from the Veterans Health Administration (VHA) Corporate Data Warehouse between 2011 and 2021, investigators identified 26,387 adult patients meeting diagnostic criteria for CSU, defined by recurrent urticaria and/or angioedema without an identifiable cause.

The study population had a mean age of 54.9 years and was predominantly male (76.4%), reflecting the Veteran demographic, although CSU prevalence was higher among women overall. A substantial proportion of patients had comorbid conditions, including hypertension (35.9%), sleep disorders (32.5%), depression (26.3%), and anxiety (24.7%). Additionally, many patients were overweight or obese, and over one-fifth were current smokers.

Treatment patterns revealed that most patients (89.8%) initiated some form of therapy within 12 months of diagnosis. Commonly used treatments included antihistamines, corticosteroids, leukotriene receptor antagonists, and immunosuppressants such as cyclosporine. However, use of biologic therapies remained notably low: only 2.6% of patients initiated a biologic within the first year. Among those who did, the median time from diagnosis to biologic initiation was 337 days, indicating a substantial delay in escalation to advanced therapy.

Health care resource utilization increased across all measured categories following CSU diagnosis. Pharmacy claims rose from 66.8% in the pre-index period to 89.8% post-index, reflecting greater medication use. Outpatient visits were already high prior to diagnosis (92.4%) and increased further to 96.7% afterward, highlighting the need for ongoing clinical management. Inpatient admissions and emergency room visits also increased, with the median hospital stay lengthening from 4 to 5 days. Notably, emergency room utilization was highest among patients aged 50 to 69 years, and significant differences were observed across sex and racial groups.

These findings point to two key issues in CSU management: underutilization and delayed initiation of biologic therapies, and a substantial, increasing burden on health care resources. Despite guideline recommendations supporting biologics for moderate to severe CSU, many patients remain on conventional therapies that may not provide adequate long-term disease control. Potential barriers to biologic use may include patient hesitancy, provider prescribing patterns, and limited awareness or access.

The observed increase in health care resource utilization after diagnosis suggests that many patients continue to experience uncontrolled symptoms, driving repeated health care encounters. Earlier initiation of targeted biologic therapies in appropriate patients could improve disease control and potentially reduce health care utilization.

Some study limitations include the retrospective design, potential gaps in data capture outside the VHA system, and limited generalizability due to the predominantly male Veteran population. Nonetheless, this large real-world analysis highlights important gaps in CSU care and suggests that optimizing treatment strategies—particularly through earlier biologic use—may improve outcomes and reduce the overall burden of disease.

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Reference

1. Sun LD, Behl A, Danilov PN, et al. Healthcare Resource Utilization and Use of Biologics in Chronic Spontaneous Urticaria. J Dermatol. Published online April 4, 2026. doi:10.1111/1346-8138.70234