CSU Management: From Antihistamine Escalation to Targeted Biologic Therapy

In an interview with Pharmacy Times, Aderonke Adeboye, PharmD, dermatology clinical pharmacy specialist at the Emory University Hospital Midtown, discussed key clinical and therapeutic considerations in managing chronic spontaneous urticaria (CSU) covered at the Immunology Day of Education 2026, held June 10. She outlined red flags—such as increasing hive frequency and severity, new discoloration, and angioedema—that signal a patient has outgrown standard second-generation antihistamine therapy and needs escalation. Adeboye explained that with newer options like dupilumab (Dupixent; Sanofi, Regeneron Pharmaceuticals) and remibrutinib (Rhapsido; Novartis) now available alongside omalizumab and cyclosporine, treatment selection should be guided by a patient's individual phenotype, including whether their disease is more IgE-driven or mediated through other pathways such as IL-4 and IL-13. She emphasized that specialty pharmacists play a critical role in supporting patients between office visits by reinforcing adherence, addressing barriers to injectable or oral therapies, and keeping patients engaged and accountable in their treatment journey.

Pharmacy Times: Can you please introduce yourself?

Aderonke Adeboye, PharmD: Aderonke Adeboye, I'm a dermatology clinical pharmacy specialist coming from Emory University out in Atlanta, Georgia.

Pharmacy Times: Many pharmacists may not immediately recognize CSU as a condition requiring specialty-level intervention. What are the key clinical signals that tell you a patient has moved beyond what standard antihistamine therapy can manage?

Adeboye: I think the biggest thing that kind of serves as a red flag for me is if a patient is not doing well on their standard second-generation antihistamine—if they're definitely having more flares, and flares can be all-encompassing. That may include increased hives, where the hives are increasing in frequency and also severity. Maybe there's certain discoloration that's coming along with that, as far as redness. Also, if they're experiencing any angioedema, that's a big sign and definitely warrants us to escalate therapy. But if a patient is just on their standard antihistamine and they're having those recurrent flares, where it's now, you know, impacting their quality of life—that definitely serves as a signal for us to make an intervention. And so, that intervention may only just be increasing their antihistamine dose fourfold, or really going into more advanced therapy.

Pharmacy Times: With biologics and emerging oral targeted agents now available for CSUs, how do you approach comparing these options for a patient—and what role does the specialty pharmacist play in that decision-making process?

Adeboye: I think the good thing about CSU now is that we have additional options. Thinking back to, like, some of our previous guidelines, it really was just, you know, our antihistamines, omalizumab, and then adding on cyclosporine. But now that we have additional options—you know, like you phrased it well—we do need to look at our patient and their individual characteristics. So, with CSU, our patients may have particular phenotypes, and with those phenotypes, some may have more of an auto-allergic-type presentation, or more of an autoimmune-type presentation. So, with the additional therapy options, such as dipilumab and remibutinib.

Pharmacy Times: Adherence and access are often the biggest barriers to advanced therapies. What specialty pharmacy strategies have you found most effective for keeping CSU patients engaged and supported long-term?

Adeboye: We can start to kind of predict if our patient is more of an IGE-driven response or if it's through maybe other mechanisms, such as IL-4 or IL-13. And then, if our patients really aren't presenting in either fashion, that also serves as a signal that they may respond better to some of the emerging treatments. You said engage, and that's really the biggest thing, and how we can keep our patients engaged is really to follow up with them. So, I feel like, being a specialty pharmacist, we really have that opportunity in between the patient's office visits to really follow up with them. And so, that may be including things as far as supporting their adherence, seeing if there are any barriers to their care: if a patient is on an injectable, do they feel comfortable with their injectable therapies? If they're on an oral agent, are they able to take their medicines twice daily? So, really supporting them through their journey is huge, and I feel like, with that support—just with all of us in general—if we have that support, really, you're keeping accountable and really being able to meet your goals.