Predicting Chronic Spontaneous Urticaria Symptom Return After Omalizumab Treatment Discontinuation: Exploratory Analysis Marta Ferrer, MD, PhD, Ana Giménez-Arnau,

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Predicting Chronic Spontaneous Urticaria Symptom Return After Omalizumab Treatment Discontinuation: Exploratory Analysis Marta Ferrer, MD, PhD, Ana Giménez-Arnau, MD, PhD, Diego Saldana, PhD, Nico Janssens, PhD, Maria-Magdalena Balp, PhD, Sam Khalil, PhD, Valéry Risson, PhD The Journal of Allergy and Clinical Immunology: In Practice Volume 6, Issue 4, Pages 1191-1197.e5 (July 2018) DOI: 10.1016/j.jaip.2018.04.003 Copyright © 2018 The Authors Terms and Conditions

Figure 1 Example UAS7 curve during the omalizumab treatment phase (12 weeks) and follow-up phase (16 weeks) in ASTERIA II. UAS7 area above the curve (AAC) and area under the curve (AUC) were used as quantitative measures of the speed of response to treatment (yellow area) and speed and severity of symptom return (outcome variable; red area), respectively. UAS7, urticaria activity score over 7 days. The Journal of Allergy and Clinical Immunology: In Practice 2018 6, 1191-1197.e5DOI: (10.1016/j.jaip.2018.04.003) Copyright © 2018 The Authors Terms and Conditions

Figure 2 Median UAS7 AAC and AUC in each treatment group (ASTERIA I, ASTERIA II, and GLACIAL). (A) Median UAS7 AAC (weeks 0-4) and (B) median UAS7 AUC (16-week follow-up phase) for each treatment group. Error bars indicate 95% confidence intervals. Missing data are imputed using LOCF. AAC, Area above the curve; AUC, area under the curve; LOCF, last observation carried forward; UAS7, urticaria activity score over 7 days. The Journal of Allergy and Clinical Immunology: In Practice 2018 6, 1191-1197.e5DOI: (10.1016/j.jaip.2018.04.003) Copyright © 2018 The Authors Terms and Conditions

Figure 3 Distribution of UAS7 AUC during the follow-up phase (outcome variable; ASTERIA I and ASTERIA II). The dotted line represents the threshold selected using k-means to stratify patients; patients on the left are stratified as having “slow symptom return” and patients on the right of the line have “rapid symptom return.” Missing data are imputed using LOCF. AUC, Area under the curve; LOCF, last observation carried forward; UAS7, urticaria activity score over 7 days. The Journal of Allergy and Clinical Immunology: In Practice 2018 6, 1191-1197.e5DOI: (10.1016/j.jaip.2018.04.003) Copyright © 2018 The Authors Terms and Conditions

Figure 4 Heatmap representing the probability of symptom return with the predictive variables, early UAS7 AAC and baseline UAS7 (pooled data from ASTERIA I and II). Lower UAS7 AAC and higher baseline UAS7 (red/pink) indicates a higher probability of fast symptom return; higher UAS7 AAC and lower baseline UAS7 (green) indicate lower probability. For example, Patient A (UAS7 AAC = 138.5; UAS7 = 34.0) has 35.0% probability of fast symptom return. Missing data were imputed using LOCF. AAC, Area above the curve; LOCF, last observation carried forward; UAS7, urticaria activity score over 7 days. The Journal of Allergy and Clinical Immunology: In Practice 2018 6, 1191-1197.e5DOI: (10.1016/j.jaip.2018.04.003) Copyright © 2018 The Authors Terms and Conditions

Figure 5 Examples of individual UAS7 profiles of 3 patients from the GLACIAL study. Patients were treated with omalizumab 300 mg for 24 weeks. Patients A and C responded quickly and remained in remission after treatment discontinuation (Patient A: AAC = 138.5, AUC = 27.5; Patient C: AAC = 154.25, AUC = 0); Patient B responded slower and symptoms returned soon after treatment discontinuation (AAC = 75.0, AUC = 514.0). AAC, Area above the curve; AUC, area under the curve; UAS7, urticaria activity score over 7 days. The Journal of Allergy and Clinical Immunology: In Practice 2018 6, 1191-1197.e5DOI: (10.1016/j.jaip.2018.04.003) Copyright © 2018 The Authors Terms and Conditions

Figure E1 (A) Placebo and (B) omalizumab 300 mg patient heatmap images from the GLACIAL study. The Journal of Allergy and Clinical Immunology: In Practice 2018 6, 1191-1197.e5DOI: (10.1016/j.jaip.2018.04.003) Copyright © 2018 The Authors Terms and Conditions

Figure E2 Median UAS7 AAC and AUC in each treatment group. (A) Median UAS7 AAC (weeks 0-4) and (B) median UAS7 AUC (16-week follow-up phase) for each treatment group. Patients in the omalizumab 300 mg group had the fastest response to treatment (highest early AAC score) and slowest symptom return (smallest AUC during the follow-up phase). Error bars indicate 95% confidence intervals. Missing data are imputed using BOCF. AAC, Area above the curve; AUC, area under the curve; BOCF, baseline observation carried forward; UAS7, urticaria activity score over 7 days. The Journal of Allergy and Clinical Immunology: In Practice 2018 6, 1191-1197.e5DOI: (10.1016/j.jaip.2018.04.003) Copyright © 2018 The Authors Terms and Conditions

Figure E3 Baseline UAS7 scores and early response to omalizumab treatment (early AAC) were selected as predictive variables using the LASSO method with (A) minimum error rule (“aggressive” method) or (B) one standard error rule (“conservative” method). Missing data are imputed using BOCF. AAC, Area above the curve; bl, baseline; CSU, chronic spontaneous urticaria; CU, chronic urticaria; BOCF, baseline observation carried forward; LASSO, least absolute shrinkage and selection operator; UAS7, urticaria activity score over 7 days. The Journal of Allergy and Clinical Immunology: In Practice 2018 6, 1191-1197.e5DOI: (10.1016/j.jaip.2018.04.003) Copyright © 2018 The Authors Terms and Conditions

Figure E4 Heatmap representing the probability of fast symptom return with the predictive variables, early UAS7 AAC and baseline UAS7. Lower UAS7 AAC and higher baseline UAS7 (red/pink) indicates a higher probability of fast symptom return; higher UAS7 AAC and lower baseline UAS7 (green) indicate lower probability. Missing data were imputed using BOCF. AAC, Area above the curve; BOCF, baseline observation carried forward; UAS7, urticaria activity score over 7 days. The Journal of Allergy and Clinical Immunology: In Practice 2018 6, 1191-1197.e5DOI: (10.1016/j.jaip.2018.04.003) Copyright © 2018 The Authors Terms and Conditions

Figure E5 Adaptive prediction (BOCF imputation). (A) Improvement in the accuracy, (B) reduction in error, and (C) increase in the percentage population having 80% confidence is evident as increasing weeks of UAS7 data are used to fit the model. BOCF, Baseline observation carried forward; rms, root mean square; UAS7, urticaria activity score over 7 days. The Journal of Allergy and Clinical Immunology: In Practice 2018 6, 1191-1197.e5DOI: (10.1016/j.jaip.2018.04.003) Copyright © 2018 The Authors Terms and Conditions

Figure E6 Omalizumab (A) 75 mg, (B) 150 mg, (C) 300 mg, and (D) placebo heatmaps representing the probability of symptom return with the predictive variables, early UAS7 AAC and baseline UAS7 (pooled data from ASTERIA I and II). AAC, Area above the curve; UAS7, urticaria activity score over 7 days. The Journal of Allergy and Clinical Immunology: In Practice 2018 6, 1191-1197.e5DOI: (10.1016/j.jaip.2018.04.003) Copyright © 2018 The Authors Terms and Conditions