Comparative efficacy of omalizumab, dupilumab, and remibrutinib in chronic spontaneous urticaria: a network meta-analysis of randomized control trials

Chronic spontaneous urticaria (CSU) is a skin condition that significantly impairs quality of life. While omalizumab remains the standard treatment for patients who have failed antihistamines, emerging therapies show promise in randomized control trials (RCTs). This study aims to compare the relative efficacy of omalizumab, dupilumab, and remibrutinib in CSU. Four databases were searched for RCTs evaluating omalizumab (75/150/300 mg Q4W), dupilumab (300 mg Q2W), or remibrutinib (25 mg BID) in CSU. Urticaria Activity Score (UAS7), Itch Severity Score (ISS7), Dermatology Life Quality Index (DLQI; DLQI 0/1), disease control (UAS7 ≤ 6), and symptom remission (UAS7 = 0) were assessed at weeks 12/24. Frequentist random-effects network meta-analysis were conducted in R. Fifteen studies (4,913 patients) were included. Omalizumab 300 mg demonstrated the greatest efficacy in UAS7, ISS7, symptom remission, and disease control at both timepoints. Remibrutinib showed the greatest DLQI improvement and second-highest UAS7 reduction and odds of symptom remission. Dupilumab provided sustained itch relief but delayed efficacy. Lower omalizumab doses lacked durability at 24 weeks. Omalizumab 300 mg, followed by remibrutinib, exhibited the highest effect sizes across major outcomes for CSU. Newer therapies such as remibrutinib and dupilumab appear generally effective, offering promising tools for CSU patients who may not respond to standard treatments. <b>CAPSULE SUMMARY</b>This network meta-analysis compares omalizumab, dupilumab, and remibrutinib in CSU. Omalizumab 300 mg every four weeks consistently showed the greatest efficacy across outcomes. Remibrutinib improved quality of life, while dupilumab primarily reduced itch.Findings support omalizumab as first-line biologic, with remibrutinib and dupilumab as promising alternatives in possibly distinct populations. This network meta-analysis compares omalizumab, dupilumab, and remibrutinib in CSU. Omalizumab 300 mg every four weeks consistently showed the greatest efficacy across outcomes. Remibrutinib improved quality of life, while dupilumab primarily reduced itch. Findings support omalizumab as first-line biologic, with remibrutinib and dupilumab as promising alternatives in possibly distinct populations.