Reviews/Chronic Spontaneous Urticaria Treatment/Urticaria relapses after cyclosporine
Immunosuppression · CSU-CYC-02 · v1
Borderline: within 4 points of the Likely/Uncertain boundary, so a re-grade could land either side.
Across the urticaria studies that actually followed patients after they stopped cyclosporine, relapse is the common pattern. In the best-controlled series, six of eight patients who had responded relapsed within six weeks, and only a quarter stayed in remission [2]. A newer trial saw symptoms rebound promptly once the drug was stopped [4], and a small early series saw all three patients recur [9]. The clearest counter-signal is a group of children, where only about a third relapsed [8]. All of this evidence comes from patients with severe disease that had already failed antihistamines, not from the broad population of everyone with chronic spontaneous urticaria, and relapse was judged by symptom scores that were defined and timed differently from study to study.
In the only placebo-controlled series that reports a relapse proportion, six of eight randomized responders relapsed within six weeks and only five of nineteen responders (26%) had not relapsed by the study endpoint [2]. A noninferiority trial reports that disease relapsed promptly on stopping ciclosporine, with UAS7 rising from 0.28 back toward 4.13 by day 180 [4]. A three-patient series reports recurrence of urticaria and angioedema in every patient on stopping therapy [9]. A long-term cohort found a subset (20%) required continued therapy, some for 5–10 years, to maintain remission [12]. Indirect support comes from more therapeutic failures after shorter 8-week versus 16-week courses [3]. The contested point: The division is over whether 'most' holds: the controlled adult series points to a clear majority relapsing [2], while a pediatric cohort shows relapse in only 5 of 16 (~31%) [8]. It also turns on scope, since every included study enrolled only severe, antihistamine-refractory responders rather than the general CSU population.
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Population overreach: the claim says 'most CSU patients', but all included evidence is confined to severe, antihistamine-refractory responders to cyclosporine, not the general CSU population.
Direct contradiction of 'most': pediatric cohort [8] shows relapse in only 5 of 16 (~31%), below a majority, demonstrating real heterogeneity.
Where it remains uncertain. A pediatric cohort relapsed in only 5 of 16 (~31%) [8], and all evidence is confined to severe antihistamine-refractory responders judged by symptom scores [2][4].
Aleatory
Even among severe responders, outcomes range from prompt recurrence to sustained remission in a minority (26% not relapsed in [2]; 5 of 16 in [8]).
The load-bearing papers from a corpus of 16, each classified by what it does to the claim. Every DOI is taken from the corpus the claim was graded on.
Primary controlled evidence that a majority (~74%) of responders relapse after cyclosporine, most within 6 weeks.
Panel auditInternal validity: medium · scope of inference: Adults with severe antihistamine-refractory chronic 'idiopathic' urticaria who responded to a 4-week cyclosporin course.Key limitations: small sample · short 4-week course · relapse not statistically tested
Independent RCT corroborating prompt relapse on discontinuation.
Panel auditInternal validity: medium · scope of inference: Adults with antihistamine-refractory, steroid-dependent chronic spontaneous/refractory urticaria.Key limitations: small sample · authors note limited generalisability · relapse rate not expressed as a proportion
Case series: recurrence in all patients on stopping (small n).
“On stopping therapy, all side effects resolved and the urticaria and angioedema recurred.”
Panel auditInternal validity: low · scope of inference: Three adults with severe chronic urticaria (two with angioedema) treated with high-dose cyclosporine.Key limitations: n=3 · no control · discontinuation driven by side effects
Counter-signal: relapse in a minority (~31%) of antihistamine-resistant children.
“Relapses responsive to repeated cyclosporine occurred in 5 of the patients after 1 week to 15 months (median, 6 months).”
Panel auditInternal validity: low · scope of inference: Children aged 9-18 with antihistamine-resistant chronic idiopathic urticaria treated with cyclosporine.Key limitations: retrospective · children only · small subgroup
4 of 16 papers shown. The full review lists all of them, with the panel’s arbitration →
Claims are graded at each quarterly release, and re-graded between releases only when a pivotal trial lands. Every change is a new version of the claim.
Multiple independent primary studies support majority relapse after discontinuation, but modest samples, heterogeneous relapse definitions and one contradicting cohort keep this Likely rather than Established.
Release 2026-q4 re-graded every claim from its corpus under protocol v0.19. An earlier release's grade is shown for the record; it came from an earlier protocol and is not a movement.
Assumptions that carry weight but are not themselves established.
The panel records the gap that would most move the claim, and the study that would close it.
Relapse rate in unselected CSU. All evidence is confined to severe antihistamine-refractory responders [2][4][8], so the claim's 'most CSU patients' scope is untested. The panel rates this the highest-importance open gap for the claim, and names the study design that would close it: Prospective discontinuation cohort recruiting across CSU severity strata with a pre-specified relapse definition.
Open question: What share of unselected CSU patients relapse after stopping cyclosporine, beyond severe refractory responders? Why it is still open: Every included study enrolled only severe antihistamine-refractory responders [2][4][8].
Priors is a sceptical first reader, not peer review, and not medical advice.
Release 2026-q4 · graded 21 Oct 2026 · protocol v0.19