Individualized Therapy Selection: Shared Decision-Making Among Omalizumab, Dupilumab, and Remibrutinib

The selection of a step-up agent in CSU should be driven by a shared decision-making framework that accounts for disease severity, patient preferences regarding route of administration, comorbid conditions, age (remibrutinib is indicated for adults only; dupilumab is approved for patients aged 12 and older), and access. No evidence-based algorithm currently dictates that 1 of the 3 agents, namely omalizumab, dupilumab, or remibrutinib, should be universally preferred in the absence of specific patient characteristics, and no agent is universally superior. Comorbid type 2 inflammatory conditions represent 1 of the clearer clinical signals for preferring dupilumab; patients with concurrent atopic dermatitis, asthma, eosinophilic esophagitis, or chronic rhinosinusitis with nasal polyps may obtain disease-modifying benefit across conditions from a single biologic. Conversely, patients who prioritize the established long-term safety profile and longest real-world track record may opt for omalizumab, while those who require speed of onset or prefer an oral formulation have a compelling case for remibrutinib.

Practical access and initiation logistics represent underappreciated determinants of real-world treatment outcomes. The cost of all 3 agents is substantial, and the agent a patient can realistically obtain, through insurance approval, patient assistance programs, or sample availability, may be the most important factor in the initial prescribing decision. Sample availability for remibrutinib has proven particularly useful for initiating therapy quickly, bypassing the authorization delays that can accompany biologic prescriptions and reducing the "activation energy" barrier that prevents some patients from starting a new therapy. Clinicians should also recognize that patients who fail or have suboptimal responses to 1 agent can be transitioned to another with a different mechanism of action — and communicating this explicitly to patients at the time of initial prescribing supports adherence by framing the treatment pathway as iterative rather than all-or-nothing.

In this video segment, Jason Hawkes, MD, describes his approach as laying out the clinical landscape and letting the patient choose, identifying several patient archetypes that may favor specific agents: those already managing multiple oral medications may prefer remibrutinib for ease of integration; needle-averse patients may similarly gravitate toward the oral formulation; and patients or family members already familiar with dupilumab from its use in other approved indications may approach it with reduced hesitancy. Nicole Chase, MD, characterizes this moment in CSU management as the arrival of "choose-your-own-adventure" pathways, emphasizing that the economics of patient preference, whether defined by time, convenience, cost, or comfort, should be central to every step-up therapy conversation. Both experts agree that getting patients onto any 1 of the 3 agents is clinically preferable to prolonged deliberation, and that the availability of alternatives reduces the stakes of any single initial choice.