Dear Editor
Chronic Urticaria (CU) is a skin disorder characterized by wheal and flare with a duration of more than 6 weeks affecting 1%-2% of the population (more common in women). Thirty to 35% of cases of CU have angioedema [1]. The etiology of chronic spontaneous urticarial is not usually clear, 40%-50% are idiopathic and 30%-40% are autoimmune [2, 3]. Quality of life in CU is usually disturbed which has a direct relation with severity [4]. The first line treatment choice of urticarial is second Antihistamines (AHs) such as cetirizine, loratadine, neotadine, and fexofenadine. Often CU patients are resolved by AHs [1]. 
Biologic medications are a new and expanding field of therapy for various disorders such as CU. Omalizumab as a recombinant, humanized, and monoclonal IgG1 anti-IgE antibody is the therapy choice as the third step approved by Food and Drug Administration (FDA) indication age >6 years (150 or 300 mg per 4 weeks subcutaneous) [5, 6]. Up to 80% of patients are well-controlled with Omalizumab [7]. In mild‐to‐moderate Coronavirus disease 2019 (COVID‐19), the infection could use Omalizumab but not in severe cases [8]. 
Ligelizumab is an anti-IgE (doses: 24 mg, 72 mg, and 240 mg) that was more effective than omalizumab in phase 2 of a clinical trial study in CU [7]. Mepolizumab is an anti-IL5 100 mg every four weeks. Dupilumab is a monoclonal agent blocking the IL-4/IL-13 axis. Benralizumab is an IL-5Ra blocker monoclonal antibody, 30mg every 4 weeks for 3 times, then every 8 weeks. Tezepelumab is a Thymic Stromal Lymphopoi-Etin (TSLP) blocker. Anti-TNF-a (Etanercept, Infliximab, Adalimumab) have been tested in patients over age18 with success. Abatacept is a monoclonal antibody that links cluster differentiation (CD) 80 and CD86. Rituximab is a chimeric monoclonal antibody that targets the CD20 [9] (Table 1). 


A study showed that Remibrutinib, Rilzabrutinib, and Fenebrutinib (BTK inhibitors) have been investigated in CSU (phases 2 and 3) [7]. A study showed that Remibrutinib (oral treatment option) is effective for patients with moderate to severe CSU [11].
Gil-Sierra et al. showed that Omalizumab had long-term effectiveness in CIU patients. Adverse drug reactions are rare due to biological agents. They are less toxic than traditional drugs [12]. 

Ethical Considerations
Compliance with ethical guidelines
There were no ethical considerations to be considered in this research.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Conflicts of interest
The author declare no conflict of interest

Acknowledgments
The author would like to thank the Clinical Research Development Unit of Bu-Ali Sina Hospital, Mazandaran University of Medical Sciences, Sari, for their support, cooperation, and assistance.


References

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