Latest / The Science of Skin / Chronic Spontaneous Urticaria (CSU) Explained: New Oral BTK Inhibitor Rhapsido for Chronic Hives

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Chronic Spontaneous Urticaria (CSU) Explained: New Oral BTK Inhibitor Rhapsido for Chronic Hives · The Science of Skin

• 0:00
  SPEAKER_02: This episode is sponsored by Navartists, with content independently created by the Science of Skin Podcast.
• 0:14
  SPEAKER_01: Hello and welcome to the Science of Skin Podcast.
• 0:17
  SPEAKER_01: My name is Dr.
• 0:17
  SPEAKER_01: Ted Lane.
• 0:18
  SPEAKER_01: I'm a board-certified dermatologist practicing in Austin, Texas.
• 0:21
  SPEAKER_01: And with me today is a very special gift, also a board-certified dermatologist, also practicing in Texas, although a little bit north of me.
• 0:31
  SPEAKER_01: This is Dr.
• 0:32
  SPEAKER_01: Michelle Tarbox.
• 0:33
  SPEAKER_01: Michelle is the chair and program director of the Department of Dermatology at Texas Tech College of Medicine.
• 0:40
  SPEAKER_01: She is a dear friend, a colleague, and just an amazing, an amazing person.
• 0:45
  SPEAKER_01: Michelle, you also run a podcast called Dermosphere, where you use clinically actionable, recently published literature to provide all sorts of great knowledge to your listeners.
• 0:57
  SPEAKER_01: And uh I I have been remiss that I have not caught it yet, but I am going to.
• 1:02
  SPEAKER_01: And so thank you so much for coming on, Michelle.
• 1:05
  SPEAKER_00: Well, thank you so much for having me.
• 1:07
  SPEAKER_00: I think it is so much fun to share knowledge with colleagues, especially in an engaging way, that lets us also have a nice discussion with friends.
• 1:14
  SPEAKER_01: Yeah.
• 1:15
  SPEAKER_01: So as a reminder, everybody, if you have any questions, comments, or ideas for future podcast episodes, shoot us an email at inquiry at scienceofskinsummit.com.
• 1:25
  SPEAKER_01: That's inquiry at scienceofskinsummit.com.
• 1:29
  SPEAKER_01: All right, today we are talking about the evolving treatment landscape for chronic spontaneous urticaria.
• 1:36
  SPEAKER_01: And we will be focusing on Rhapsodo, which is the brand name for Remy Brutinib.
• 1:42
  SPEAKER_01: And Remy Brutinib Dr.
• 1:43
  SPEAKER_01: Tarbox is a very interesting, especially in dermatology, is a very interesting molecule because it's the first BTK inhibitor we have in our field.
• 1:51
  SPEAKER_00: Yeah, it's very fascinating how it works and the different cell types that it also functions in, which makes me kind of excited for the potential for this to develop into other areas with neglected disease states.
• 2:02
  SPEAKER_00: So this has been a really exciting time to be a dermatologist that treats chronic spontaneous articaria.
• 2:08
  SPEAKER_01: Okay.
• 2:08
  SPEAKER_01: So I think what we should do, Michelle, because this is the first in a series of episodes about chronic spontaneous articaria.
• 2:15
  SPEAKER_01: And so if you don't mind, if I pick your brain a little bit about the definition of this disease, like what type of articaria qualifies as chronic spontaneous article?
• 2:25
  SPEAKER_00: The nice thing about defining this disease state is it's really pretty straightforward.
• 2:29
  SPEAKER_00: So if a patient has either angioedema or hives or both of those things that have lasted longer than six weeks, that we don't have an identifiable trigger for, like they don't happen every time they eat shrimp, or they don't happen every time they have cold, like water or something touch their skin.
• 2:46
  SPEAKER_00: We can't figure out why it's happening.
• 2:48
  SPEAKER_00: Then that is a diagnosis of chronic spontaneous urticaria.
• 2:52
  SPEAKER_00: So the name fortunately kind of says it's all of the diagnosis.
• 2:55
  SPEAKER_00: Chronic longer than six weeks, spontaneous, not connected predictably to any specific trigger, and then urticaria, which encompasses the angioedema and the hives patients can experience.
• 3:06
  SPEAKER_01: I have to say that I had CSU when I was in third grade.
• 3:10
  SPEAKER_01: And I will never forget it because I it would affect my feet, so I couldn't walk uh in the morning.
• 3:17
  SPEAKER_01: I'd skipped so much school because of chronic spontaneous urticaria.
• 3:21
  SPEAKER_01: I was on steroids so much because of it as well, which of course are the wrong thing to be on.
• 3:27
  SPEAKER_01: Um but I I definitely can identify with patients that have CSU because I it was miserable and I was lucky that it I kind of grew out of it, which is pretty, pretty common actually, Michelle, right?
• 3:39
  SPEAKER_00: Especially when it has its onset in childhood.
• 3:41
  SPEAKER_00: Children can grow out of it.
• 3:42
  SPEAKER_00: Adults can have a period of activity with chronic spontaneous certicaria that asks that acts up for several years, and then it can also spontaneously remit.
• 3:50
  SPEAKER_00: So kind of everything about it can be sort of spontaneous.
• 3:53
  SPEAKER_00: Spontaneity is often fun, but not when it corresponds to the onset of itchy plaques that you can't do anything about.
• 4:01
  SPEAKER_01: Yeah, and they can be on your face, they can be anywhere, and they can occur anytime.
• 4:05
  SPEAKER_01: I would remember waking up at night scratching my poor parents.
• 4:08
  SPEAKER_01: I don't know how they dealt with me, because I would run in their room.
• 4:10
  SPEAKER_01: Um so it can affect the entire family, right?
• 4:13
  SPEAKER_01: Much like many other inflammatory skin diseases or autoimmune diseases can.
• 4:17
  SPEAKER_01: So it's really important for us to have new medications to treat this.
• 4:22
  SPEAKER_01: And, you know, while we have had omoligiumab, Dr.
• 4:25
  SPEAKER_01: Tarbox, right, which anti-IgE, it's it's it's something that's usually given in the office, although after a few times in the office, it can be given as an injection at home.
• 4:34
  SPEAKER_01: And that works well.
• 4:36
  SPEAKER_01: But even before we get to omolygiumab, we should talk about what kind of the guidelines tell us to use for CSU, which is which is really, you know, or oral antihistamines.
• 4:49
  SPEAKER_00: You know, there are some steps that you follow when you're treating patients who have CSU.
• 4:53
  SPEAKER_00: And one of the reasons I think for that is that sometimes the condition does spontaneously remit, and sometimes it responds to what I would consider the first rung on the therapeutic ladder, which is antihistamines.
• 5:05
  SPEAKER_00: So you often start out with oral antihistamines trying to get the urticaria under control.
• 5:10
  SPEAKER_00: And in some patients, that is sufficient.
• 5:12
  SPEAKER_00: Some patients will continue to have the onset of the hives unpredictably, which tends to be one of the things that contributes to the impact on quality of life.
• 5:20
  SPEAKER_00: And then you start to accelerate up the treatment ladder.
• 5:22
  SPEAKER_00: So you start with like regular doses of antihistamines.
• 5:26
  SPEAKER_00: And if that's not working, you increase the dosing frequency up to four times the normal dose, which some patients can will look at you kind of like you have three heads when you say that, because they're like, it says once a day.
• 5:38
  SPEAKER_00: And I'm like, I know it does say that, but it is safe to take it.
• 5:41
  SPEAKER_00: Actually, and Novartis, to their credit, published a paper that discussed the use of up to eight times daily dosing.
• 5:48
  SPEAKER_00: And we discussed that on the dermistor podcast of oral antihistamines, with still a very good safety signal.
• 5:54
  SPEAKER_00: And some patients did improve at that accelerated dosing.
• 5:57
  SPEAKER_00: But you know, you do have to worry about the side effects of antihistamines like dry mouth or fatigue, which can be treatment limiting in some patients.
• 6:05
  SPEAKER_01: I found that patients, even though they may be controlled on three to four pills per day, get so tired of taking that many pills.
• 6:13
  SPEAKER_01: And so when you talk about other options, whether injectable or oral medications that are much fewer number of tablets, they get pretty excited about it.
• 6:23
  SPEAKER_01: Um because it just gets onerous on them to remember to take it.
• 6:28
  SPEAKER_01: And I think by taking that many, they also it reminds them of their disease all the time.
• 6:32
  SPEAKER_01: Even when they don't have the hives, it reminds them of a being in a bad place.
• 6:37
  SPEAKER_00: You know, that's something one of my patients taught me about, actually.
• 6:40
  SPEAKER_00: We talk a lot about the burden of the disease, but we don't always think about the burden of the treatment.
• 6:45
  SPEAKER_00: And one of my patients told me, you know, taking this many pills every single day makes me feel like I'm really, really sick.
• 6:52
  SPEAKER_00: And it's made me change my behavior.
• 6:54
  SPEAKER_00: I don't act the same way I used to act.
• 6:56
  SPEAKER_00: I don't work out as much as I used to.
• 6:58
  SPEAKER_00: I don't go out as much as I did before because subconsciously I feel like I shouldn't be doing that because I'm so sick, I'm taking this medicine four times a day.
• 7:05
  SPEAKER_00: I'm really thinking about my condition all the time.
• 7:08
  SPEAKER_00: And it does have a significant impact on quality of life.
• 7:11
  SPEAKER_01: Yeah.
• 7:12
  SPEAKER_01: When we're talking about antihistamines, of course, we're talking about the second generation antihistamines considered non-sedating antihistamines.
• 7:18
  SPEAKER_01: We're not talking about Benadryl, for example, or hydroxizine.
• 7:22
  SPEAKER_01: We're really talking about, you know, the brand names Claritin, Allegros, or Texizol.
• 7:27
  SPEAKER_01: Those are the those are the second generation quote unquote non-sedating antihistamines, although, gosh, I certainly have had patients as we updose to three or four times start feeling some sedation.
• 7:38
  SPEAKER_00: Yeah, me too, as well.
• 7:39
  SPEAKER_00: And, you know, some of the antihistamines I feel work better for chronic spontaneous urticaria than others.
• 7:45
  SPEAKER_00: What's your favorite go-to, Ted?
• 7:46
  SPEAKER_01: You know, I okay, so I have always used loratidine or claritin, uh, but I was talking to an allergist, not your husband, but a different allergist, and and they were saying, you know, phexophenidine may be a little bit more effective.
• 8:01
  SPEAKER_01: Um, what do you think?
• 8:04
  SPEAKER_00: You know, I actually do like to use phexophenidine, possibly because I have been biased by my husband, who is an allergist.
• 8:09
  SPEAKER_00: This may be something that circulates more in the allergy world, but I usually use the phexophenidine 180 milligram dose.
• 8:16
  SPEAKER_00: Of course, you have to tell the patient you don't need the decongestant, so don't get the allegrady, just the plain one, and you're gonna take that on the schedule we discuss.
• 8:24
  SPEAKER_00: Sometimes we'll also use cetirazine, especially potentially at nighttime.
• 8:28
  SPEAKER_00: About 25% of patients do get some sedation from cetirazine, but some patients also find it's a little bit more therapeutically efficacious.
• 8:35
  SPEAKER_00: The important thing I think to drive home is that there's not a magic combination of antihistamines that's gonna work for each unique patient.
• 8:41
  SPEAKER_00: So many people come to me after being on what I would say is a veritable carousel of different antihistamines that didn't work properly to control their disease fully, and they're just frustrated and tired and want something that works.
• 8:53
  SPEAKER_01: Totally agree.
• 8:55
  SPEAKER_01: And if you look at the national guidelines, the 2026 updated guidelines published by the Quad AI, which is the American Allergy.
• 9:02
  SPEAKER_01: I can't, it's an acronym I can never remember all the A's for, but essentially the allergy people.
• 9:09
  SPEAKER_01: They essentially essentially say stick to the same uh uh brand, right?
• 9:16
  SPEAKER_01: You don't want to do two of one and two of the other.
• 9:19
  SPEAKER_01: They essentially the the guidelines tell you to stick to the same one and updose the same one.
• 9:25
  SPEAKER_01: So uh, but I just like you, I have found that sometimes adding satirazine, especially at night, can be helpful.
• 9:31
  SPEAKER_01: So I hear the guidelines, but I'm gonna raise them a satirazine.
• 9:35
  SPEAKER_00: I think that um individualization can always be helpful, but you're absolutely right that you know it's not like a potion where you're like, oh, a little sprinkle of you know, allegra and a little whiff of Leratidine, and perhaps a little like sprinkle of like clear claritine is gonna help.
• 9:52
  SPEAKER_01: It's funny that the allergy people are the ones that publish the guidelines because we don't really think about this as being an allergic disease.
• 9:58
  SPEAKER_01: Uh and so, and then that's why it kind of lands squarely in the dermatology space and why we are treating it so much now, not only because we have these great new medications like Rhapsoda, which we'll go into a little bit more, but also because it's not truly allergy.
• 10:12
  SPEAKER_01: And so there's really two types of uh reasons for chronic spontaneous certicary.
• 10:18
  SPEAKER_01: There's a type one kind of autoimmune response or auto allergic response, I should say, and the type two B autoimmune response.
• 10:26
  SPEAKER_01: And do you want to take one of those and I'll take the other, Michelle?
• 10:30
  SPEAKER_00: Sure.
• 10:30
  SPEAKER_00: I think that sounds like a lot of fun.
• 10:32
  SPEAKER_00: So when we're talking about the auto allergic one, um, we're talking about a person who's reacting to self-allergen, the way that I react to ragweed pollen.
• 10:41
  SPEAKER_00: So I hate ragweed.
• 10:43
  SPEAKER_00: I wish God hadn't created it.
• 10:44
  SPEAKER_00: It's horrible, it's the bane of my existence, and it has two peaks during the year, because of course it does.
• 10:49
  SPEAKER_00: Whenever my mast cells, which are very primed to react to ragweed pollen, encounter an IgE molecule that's attached itself to one of those dad gum pollen molecules, and then they fit into the IgE receptor, the high affinity IgE receptor on the mast cell, my mast cells dutifully degranulate and they release a slew of antihist of histamine and different kinds of prostaglandins and things that cause all the fun symptoms of being allergic to ragweed with the sneezing and the wheezing and the snot.
• 11:17
  SPEAKER_00: So not fun, not a cool thing to have to deal with.
• 11:20
  SPEAKER_00: That is a normal allergy with an auto allergy.
• 11:24
  SPEAKER_00: Your body becomes primed to react to endogenous or self-allergens.
• 11:28
  SPEAKER_00: So sometimes these are enzymes, sometimes these are interleukins, sometimes these are proteins that are normal inside of our body that our body's immune system should completely ignore, that unfortunately they have become primed to react to in an allergic way.
• 11:43
  SPEAKER_00: And that auto allergic process can create this chronic spontaneous urticaria that may correspond to periods of transient tissue damage or other kinds of circumstances that would cause the antigen to be released more significantly in the body and create the unpredictable article eruption of chronic spontaneous articaria.
• 12:02
  SPEAKER_00: And it's kind of frustrating for patients because we teach people in like sort of inadvertently through the media about their medical conditions.
• 12:10
  SPEAKER_00: When you see a person who has hives or angioedema in the media, it's always a reaction to something.
• 12:16
  SPEAKER_00: And it's always either played for horror or for humor.
• 12:19
  SPEAKER_00: So it's either like in My Girl, where the little girl passes away, unfortunately, because she gets stung by a whole lot of bees and has a very overwhelming allergic type reaction to the bee venom, or it's played for humor, like in the Nutty Professor, when there's that patient who just won't stop eating shrimp and she comes in and she's all swollen in her face and her fingers are swollen.
• 12:37
  SPEAKER_00: She says, I can't help myself.
• 12:38
  SPEAKER_00: And she's like having a little hard time talking because she's got angioedema.
• 12:42
  SPEAKER_00: Whenever patients have seen these things portrayed, there's always an identifiable trigger.
• 12:46
  SPEAKER_00: And so when they come to see us, they really, really want to know what is the thing I can avoid so that this stops happening to me.
• 12:53
  SPEAKER_00: Because they really would like for this thing to stop happening to them because it's overwhelming and obnoxious and anxiety-provoking.
• 13:00
  SPEAKER_00: And the difficult thing to get across sometimes is that the trigger for patients to have chronic spontaneous urticaria is a self-allergen or a self-antigen.
• 13:09
  SPEAKER_00: So I always tell my patients, you know, I like the fact that we call this chronic spontaneous urticaria or CSU because the allergen or the antigen is actually you.
• 13:18
  SPEAKER_00: And we don't want to get rid of you.
• 13:19
  SPEAKER_00: So let's treat the urticaria.
• 13:21
  SPEAKER_01: That's right.
• 13:22
  SPEAKER_01: So they're kind of allergic to themselves, right?
• 13:24
  SPEAKER_01: And there's they can't avoid themselves.
• 13:26
  SPEAKER_01: That would be amazing sometimes.
• 13:28
  SPEAKER_01: But uh otherwise, unfortunately, you just have to treat it and hopefully it runs its course and spontaneously resolves as well.
• 13:36
  SPEAKER_01: So in addition to the type one kind of auto-allergic response, which Dr.
• 13:40
  SPEAKER_01: Tarbox just went through so elegantly, we have the type 2B autoimmune response.
• 13:46
  SPEAKER_01: And instead of a protein acting as an as an antigen, which would cross-link it itself, could cross-link the high affinity IgE receptors.
• 13:55
  SPEAKER_01: Uh, there are unfortunately antibodies made to yourself.
• 13:59
  SPEAKER_01: So you could have IgG antibodies that are considered autoantibodies, which may cross-link IgE antibodies already bound to their high affinity receptors.
• 14:11
  SPEAKER_01: And by cross-linking to IgE, it can again cause the receptors to come together, and that leads to intracellular activation of BTK, which would again lead to histamine response.
• 14:24
  SPEAKER_01: So you could have IgG antibodies against IgE, you could have IgG antibodies against the receptor, the high affinity FC epsilon R1 receptor, and both of those can lead to degranulation of the mast cell.
• 14:38
  SPEAKER_01: So uh unfortunately, there's two totally different ways this can happen, and it's really difficult to determine which way, you know, which type each patient a patient may have.
• 14:47
  SPEAKER_01: I I certainly can't think of a way, Dr.
• 14:49
  SPEAKER_01: Tarbox, I don't know if you have a way of, you know, by clinical appearance or any other lab abnormality, we could figure that out.
• 14:57
  SPEAKER_01: I don't know.
• 14:58
  SPEAKER_00: You know, the only very kind of nebulous way you could help to sort through that is to check IgE levels because the autoimmune type of chronic spontaneous certicaria does tend to have lower IgE levels, but that is just a generalization, it's not an absolute rule.
• 15:14
  SPEAKER_00: And so you can't necessarily predict what type of chronic spontaneous certicaria a patient is experiencing.
• 15:20
  SPEAKER_01: Yeah, by the IgE level.
• 15:21
  SPEAKER_01: I agree.
• 15:22
  SPEAKER_01: Okay.
• 15:23
  SPEAKER_01: So we hinted, so so thank you for that.
• 15:25
  SPEAKER_01: I think we've kind of gone through the pathogenesis of disease, but you know, we hinted at BTK.
• 15:30
  SPEAKER_01: Can we focus on that a little bit?
• 15:31
  SPEAKER_01: This brutans tyrosine kinase, that is intracellular to mass cells.
• 15:36
  SPEAKER_01: But as you alluded to earlier, it is in many other cells as well.
• 15:41
  SPEAKER_01: Remi brutinib is interesting because of its specificity for this particular BTK, though, isn't it?
• 15:50
  SPEAKER_00: Yeah, that's I think one of the strengths of the medication is that it's able to be more specific than previous generations of medications that inhibit brutons tyrosinase or other tyrosine kinases.
• 16:02
  SPEAKER_00: Tyrosyn kinases are all over the place.
• 16:04
  SPEAKER_00: We run into them constantly in dermatology.
• 16:07
  SPEAKER_00: There are syndromes caused by mutations in them, there are neoplasms caused by mutations in them, and they're expressed in a lot of cells.
• 16:13
  SPEAKER_00: So we know that they're in mast cells.
• 16:15
  SPEAKER_00: There are brutons tyrosin kinase, if we just even focus on that one, is expressed also in B cells, basophils, our monocytes and macrophages, some of our dendritic cells, including the plasmacytoid type, which the derm path nerdomy loves to talk about, um, platelets and osteoclasts and neutrophils, other granulocytes like eosinophils can sometimes even express BTK.
• 16:35
  SPEAKER_00: So it is in a lot of different cells, and it is in almost every single, actually, it's basically in every single cell type that participates in chronic spontaneous certicaria as well, and is something that I think is able to interfere with the faulty signaling pathway that gets activated when patients suffer from chronic spontaneous certicaria.
• 16:55
  SPEAKER_01: We're just going to take a few seconds to hear from our sponsor, Dr.
• 16:58
  SPEAKER_01: Tarbox, but when we come back, let's let's focus a little bit more on BTK its efficacy and safety, okay?
• 17:04
  SPEAKER_02: That sounds great.
• 17:06
  SPEAKER_02: This episode is sponsored by Navartis with content independently created by the Science of Skin Podcast.
• 17:12
  SPEAKER_01: Well, Dr.
• 17:13
  SPEAKER_01: Tarbox, thank you so much for reviewing BTK across the different cell types.
• 17:17
  SPEAKER_01: And and now let's focus on Remy Brutinib, which is the BTK, kind of mast cell BTK that I call it for CSU.
• 17:26
  SPEAKER_01: And as you alluded to earlier, again, it can be possibly used for other disease states as well.
• 17:32
  SPEAKER_01: We just don't have data on that.
• 17:34
  SPEAKER_01: But focusing on Remy Brutinib for CSU, it just makes a lot of sense, doesn't it, to kind of target CSU as the first indication for this new drug.
• 17:44
  SPEAKER_00: I think so.
• 17:45
  SPEAKER_00: And I think it's a great entry point to look at the potential utility of this family of medications in many of the disease states that we treat.
• 17:53
  SPEAKER_00: And I'm very excited to have options for our patients that have CSU.
• 17:57
  SPEAKER_00: You know, like many dermatologists trained around the time that I was trained, we sort of de-emphasized education around chronic spontaneous certificaria because the only medication we had available to us had some significant black box warning that made it a little bit less typical to be administered in a dermatologist's office and more likely to be used in an allergist's office.
• 18:17
  SPEAKER_00: And there were also a lot of very strange, almost Goldilocks-like rules about using omolyziumab when it first came out.
• 18:24
  SPEAKER_00: You had to have IgE levels that weren't too high, but also not too low.
• 18:28
  SPEAKER_00: You had to have, you know, checking on some inflammatory markers, you had to watch the patient in your office for the potential of anaphylaxis.
• 18:34
  SPEAKER_00: And I think for all of these reasons, it fell out of the house of dermatology and kind of landed in the house of allergy.
• 18:41
  SPEAKER_00: And the allergists faced the same frustration and difficulties we do as patients wanting to know what the trigger is, what is the source, how can I, you know, avoid something and stop this from happening.
• 18:51
  SPEAKER_00: And in my particular experience, what would happen is patients would get referred to our hospital to Mr.
• 18:56
  SPEAKER_00: Dr.
• 18:56
  SPEAKER_00: Tarbox, who is an allergist, and our referral team would look at the referral and say, well, that's urticaria, that's a skin disease.
• 19:03
  SPEAKER_00: And they would send it to Mrs.
• 19:04
  SPEAKER_00: Dr.
• 19:04
  SPEAKER_00: Tarbox, and then I would have to call my husband surreptitiously and be like, I got another one of your patients.
• 19:09
  SPEAKER_00: It's urticaria, and I have to start omellizumab.
• 19:11
  SPEAKER_00: What do I do?
• 19:12
  SPEAKER_00: And he would be like, All right, I'll walk you through it.
• 19:14
  SPEAKER_00: And he was very kind and helpful.
• 19:16
  SPEAKER_00: And at one point he just kind of made me put my big girl pants on and he said, Michelle, isn't urticaria a skin disease?
• 19:22
  SPEAKER_00: And I was like, yes.
• 19:23
  SPEAKER_00: And he was like, you can do this.
• 19:25
  SPEAKER_00: And so he gave me the encouragements to be comfortable managing patients on omolysumab or cyclosporin, which were our only options for a while.
• 19:32
  SPEAKER_00: Did you use much cyclosporin for urticaria before other options became available like dipiliumab or rhapsido?
• 19:39
  SPEAKER_01: Oh my gosh, Michelle, very rarely uh I would turn more to omolisiumab than I would to cyclosporin, honestly.
• 19:46
  SPEAKER_00: Yeah, not easy drugs.
• 19:47
  SPEAKER_00: I would use the cyclosporin if patients had a significant reason why we wouldn't want to choose omolisiumab.
• 19:53
  SPEAKER_00: Often it would be needle phobia.
• 19:55
  SPEAKER_00: I feel like needle phobia has changed a lot over time.
• 19:58
  SPEAKER_00: I actually think it's the GLP ones.
• 20:00
  SPEAKER_00: I think that people are getting comfortable with injecting themselves with things.
• 20:04
  SPEAKER_00: But the um kind of outcome of that was I had to become comfortable and confident in treating my patients who had CSU because often they'd waited a very long time to get to somebody that could help them.
• 20:16
  SPEAKER_00: And the patient that really made me decide that this was going to be something I learned a lot about and got good at was a very sweet patient named Rose, who was a physical therapist in our hospital who had both delayed pressure urticaria, where she would get these awful, you know, deep, painful urticaria lesions on her feet after standing all day in the hospital in her work, but also chronic spontaneous urticaria that would come up all over her body.
• 20:38
  SPEAKER_00: And she's working directly with patients.
• 20:40
  SPEAKER_00: Some of her patients that she was working with might feel like they had to not try to touch her because they were worried that what she had was contagious, which is something a lot of our patients with CSU encounter.
• 20:50
  SPEAKER_00: And this poor woman had gained like 50 or 60 pounds because she just kept getting prednisone to try to control her urticaria.
• 20:59
  SPEAKER_00: And she was just desperate by the time she got to my office to have something that would help her.
• 21:04
  SPEAKER_00: And it was that day I decided, you know what, I've got to get good at this.
• 21:07
  SPEAKER_00: These patients need me, and they deserve to have somebody who understands how to take care of this that is in the world and in the house of dermatology because that is a likely place for them to end up.
• 21:17
  SPEAKER_00: And so I'm so grateful we now have three viable options that are good choices to help treat our patients with chronic spontaneous certicaria.
• 21:24
  SPEAKER_01: Yeah, I totally agree.
• 21:26
  SPEAKER_01: I love this story.
• 21:27
  SPEAKER_01: I mean, I don't, not for Rose, but I I love this story because it speaks to the to the kind of average epidemiology of CSU.
• 21:35
  SPEAKER_01: I mean, we know that women are twice as likely as as men to be burdened by this disease.
• 21:40
  SPEAKER_01: Okay.
• 21:41
  SPEAKER_01: The global estimate, the global prevalence we know is increasing as well.
• 21:45
  SPEAKER_01: So I think we're just gonna see more and more of it.
• 21:48
  SPEAKER_01: Unfortunately, the onset of symptoms is usually in the young adults, so 20 to 40 years of age, when you're the busiest, when especially young women have maybe have kids or starting out on their career.
• 21:58
  SPEAKER_01: And unfortunately, women are aren't poorly.
• 22:00
  SPEAKER_01: Heard by the medical establishment anyway.
• 22:02
  SPEAKER_01: So, so there's so many reasons why this resonates with me regarding kind of prednisone courses as she has rotated through, you know, urgent care centers and ERs and her primary care doctor and maybe an allergist.
• 22:15
  SPEAKER_01: I just, I totally understand how this happened to her.
• 22:18
  SPEAKER_01: And it's a complete failure by the medical establishment until she hit your office, of course.
• 22:24
  SPEAKER_01: And then just Michelle, you know, the median duration of disease is two to five years.
• 22:28
  SPEAKER_01: So we need something.
• 22:29
  SPEAKER_01: It's not like this will go away in a couple of months in the majority of patients.
• 22:32
  SPEAKER_01: We need something that for the long term these patients can be on.
• 22:36
  SPEAKER_01: They feel comfortable being on with a beneficial safety profile that's also highly efficacious.
• 22:42
  SPEAKER_01: And unfortunately, H1, the second generation H1 antihistamines are really only effective, even with updosing about 50% of the time.
• 22:52
  SPEAKER_01: So there's just millions of people, millions of people out there who need something else.
• 22:59
  SPEAKER_01: And while omoligiumab is an incredible medication, I certainly am not denigrating that medication at all.
• 23:05
  SPEAKER_01: It's difficult for many patients.
• 23:07
  SPEAKER_01: And so to have a pill like Rambibruten and Rhapsodo that you take twice daily, boy, it really meets the desires and kind of expectations of our patients at this point in time.
• 23:19
  SPEAKER_01: And I just think we're so lucky to have it now.
• 23:23
  SPEAKER_00: You know, we are in such an exciting time to be dermatologists taking care of patients that need us.
• 23:28
  SPEAKER_00: We have so many more tools than we used to have before.
• 23:31
  SPEAKER_00: And we have a lot more knowledge and understanding of why some of these disease states occur.
• 23:36
  SPEAKER_00: So I'm so excited to be practicing in this era where we're starting to really be able to offer meaningful solutions to people.
• 23:43
  SPEAKER_01: In future episodes, we'll cover the exact kind of efficacy outcomes from the phase two and three trials.
• 23:50
  SPEAKER_01: We will go into the safety data uh in in fine detail.
• 23:55
  SPEAKER_01: But I think for this, our first episode, just kind of talking, like we have, but speaking about in general terms, what is CSU?
• 24:02
  SPEAKER_01: How does it, how does it occur, why does it occur, who does it affect, uh, uh what how this drug works and what pathway, as and as again, you've gone through so so beautifully.
• 24:12
  SPEAKER_01: Uh I think this is a great introductory episode to what will be five episodes for uh our CSU patients.
• 24:20
  SPEAKER_01: So uh Michelle, thank you so much.
• 24:23
  SPEAKER_01: I I really appreciate your time.
• 24:25
  SPEAKER_01: Your expertise is just amazing, specifically in CSU and many other diseases, which I know you'll be lecturing on at our conference of science, the skin summit, very soon.
• 24:35
  SPEAKER_01: So thank you for coming to Austin as well.
• 24:37
  SPEAKER_01: Correct.
• 24:38
  SPEAKER_01: Um and and again, I just want to highlight, guys, for those dermatologists and NPs and PAs listening, this is squarely in our wheelhouse.
• 24:47
  SPEAKER_01: CSU is squarely a dermatologic disease.
• 24:50
  SPEAKER_01: We we realize it's it's not necessarily an allergic disease.
• 24:53
  SPEAKER_01: It is a skin disease that we can treat.
• 24:56
  SPEAKER_01: And as we use some of our kind of new medications, such as Rhapsodo and some of the other medications that have been crossed over from other disease states into CSU, I think we should feel more comfortable treating these patients.
• 25:10
  SPEAKER_01: And goodness, they certainly deserve to be treated.
• 25:12
  SPEAKER_01: Uh, and and so let us be the first line now.
• 25:16
  SPEAKER_01: Uh, Michelle, any final words on CSU that you'd like to leave us with?
• 25:21
  SPEAKER_00: I love what you just said.
• 25:22
  SPEAKER_00: You know, let's be there for our patients.
• 25:24
  SPEAKER_00: When they come to us, often they've seen two to six or seven other doctors trying to get help for this condition that is running and ruining their lives, that is jumping onto their, you know, body in any moment that it wants to.
• 25:38
  SPEAKER_00: If you want a giggle, there is a very silly uh sort of independent movie that's available on YouTube called The Horribly Slow Murder with the Extremely Inefficient Weapon.
• 25:48
  SPEAKER_00: And this is a very silly movie about a person who's basically chased around by this sort of ghoulish creature that has a spoon, and he just keeps whacking him with this spoon.
• 25:59
  SPEAKER_00: And this patient goes to the doctor and tries to explain what's happening to him, and that this all these bruises on his body that are spoon-shaped and things, and the doctor is like, that sounds ridiculous, because the person's not getting whacked with the spoon when he's in the doctor's office, and then he leaves and immediately gets whacked again with the spoon.
• 26:15
  SPEAKER_00: And I think that this is almost like a visual metaphor for what happens to our CSU patients, because some people will be very dismissive of the symptomatology.
• 26:23
  SPEAKER_00: They'll be like, oh, it's just hives, it's not that big of a deal.
• 26:26
  SPEAKER_00: But really, part of the problem is people don't know when it's gonna happen.
• 26:29
  SPEAKER_00: They don't know when it's gonna show up, they don't know where it's gonna show up, they don't know how it's gonna show up.
• 26:34
  SPEAKER_00: And the patients kind of live in this sort of suspended state where they can't really engage fully in their lives because they don't know what their skin is gonna do.
• 26:43
  SPEAKER_00: And sometimes when they go to get help, I have this happen all the time.
• 26:47
  SPEAKER_00: They don't have any hives when they come to see me.
• 26:49
  SPEAKER_00: I have a theory that it's because they're hopeful that they're finally gonna get some help.
• 26:53
  SPEAKER_00: And I feel like the hope actually elevates them out of the stress-induced state that might predispose them to the urticaria.
• 26:59
  SPEAKER_00: And I've had so many patients just so grateful that we believed them, you know, that we believed that they're suffering from their urticaria.
• 27:07
  SPEAKER_00: I train all my patients who have CSU to take pictures when they flare and to keep it in a folder so we can look at their chronicity.
• 27:13
  SPEAKER_00: And there's also a really good app called the Cruise app at C-R-U-S E.
• 27:18
  SPEAKER_00: And that's actually a digital tracker for urticaria symptoms that you can use and take to your doctor when you have your appointment so you can make sure that they can see the severity of your condition and also look into disease state control.
• 27:29
  SPEAKER_00: Make sure that the treatments they're using are giving you the control that you need.
• 27:32
  SPEAKER_00: But I really empathize with the fact that, you know, sometimes patients are dismissed.
• 27:37
  SPEAKER_00: And so when they come to us, when they finally reach a board-certified dermatologist, we should be able to give them a solution that they can enact that gives them relief.
• 27:47
  SPEAKER_01: Couldn't agree more.
• 27:48
  SPEAKER_01: Um, so eloquent.
• 27:50
  SPEAKER_01: Thank you so much, Dr.
• 27:51
  SPEAKER_01: Tarbox.
• 27:52
  SPEAKER_01: Um, everyone, thank you so much for listening to this, our first episode in a series on CSU.
• 27:58
  SPEAKER_01: Uh, my name is Dr.
• 27:59
  SPEAKER_01: Ted Lane.
• 27:59
  SPEAKER_01: We had the amazing Dr.
• 28:00
  SPEAKER_01: Michelle Tarbox from Texas Tech University as our guest today.
• 28:04
  SPEAKER_01: Please, if you've enjoyed the episode, give us a five-star rating.
• 28:08
  SPEAKER_01: Subscribe to our podcast.
• 28:09
  SPEAKER_01: We found that the growth of the podcast has really occurred by word of mouth.
• 28:13
  SPEAKER_01: So uh please tell all your colleagues and friends about the Science of Skin podcast.
• 28:18
  SPEAKER_01: Don't forget about Dermosphere, which is Dr.
• 28:20
  SPEAKER_01: Tarbox's uh podcast as well.
• 28:23
  SPEAKER_01: Uh, can't wait to get started on that one, Michelle.
• 28:25
  SPEAKER_01: Um, and and thank you so much for listening, everybody.
• 28:29
  SPEAKER_01: Uh, I hope you enjoyed the episode.
• 28:40
  SPEAKER_02: This episode is sponsored by Navartis, with content independently created by the Science of Skin podcast.