Chronic urticaria

Efficacy of oral tofacitinib in refractory chronic spontaneous urticaria and urticarial vasculitis

The treatment of chronic urticaria (CU) is difficult, currently, antihistamines (AH) are the mainstay of treatment, however, up to 40% of patients do not respond to even high (four-fold) daily doses of AH. Tofacitinib is, a small-molecule that blocks JAK1/3 and inhibits intracellular signaling of multiple key cytokines involved in the inflammatory cascade and its beneficial effects were reported in patients with mast cell activation disease but there is no report in patients with urticaria. Here, we present four cases of refractory CU and one case of urticarial vasculitis (UV) that were managed with tofacitinib. Despite the long-term unresponsiveness of various treatments in our patients, the addition of tofacitinib significantly improved the urticarial activity and ultimately led to tapering and discontinuation of cyclosporine or AH. In conclusion, tofacitinib appears to downregulate inflammatory phenomena associated with mast cells and might be a new therapeutic option for patients with refractory CU or UV.

[Omalizumab for the treatment of chronic urticaria: Real-life findings]

OBJECTIVE

Assessment of the efficacy and safety of omalizumab in chronic urticaria refractory to conventional treatment (H1-antihistamines at high dosage and montelukast) in real-life practice.

PATIENTS AND METHODS

A retrospective, descriptive, single-centre study was performed of the data for all patients presenting refractory chronic spontaneous urticaria or inducible urticaria and receiving omalizumab (300mg every four weeks) from November 2012 to June 2016.

RESULTS

In all, 23 patients were included. Omalizumab led to complete or significant remission in 19 patients (83%) with chronic urticaria, with remission in 9 patients (47%) occurring within 72hours of the first injection. One patient had a partial response and 3 (13%) showed no response. Only 2 patients (9%) in complete remission stopped their treatment at 1 and 3 years. 52% of patients presented non-serious adverse events, which in one case resulted in treatment withdrawal.

CONCLUSION

Omalizumab exhibited good real-life efficacy in a small series of chronic urticaria patients in France.

The Application of Auriculotherapy to the Treatment of Chronic Spontaneous Urticaria: A Systematic Review and Meta-analysis

Auriculotherapy has been extensively used for chronic spontaneous urticaria in China. However, the evidence of its effectiveness and safety for the treatment of chronic spontaneous urticaria is insufficient. Hence, we conducted this study to compare auriculotherapy or auriculotherapy joint treatment with Western medicine for the cure of chronic spontaneous urticaria. This meta-analysis of seven randomized controlled trials showed that auriculotherapy or auriculotherapy joint treatment was significantly superior to Western medicine in curing clinical signs and symptoms of chronic spontaneous urticaria [odds ration (OR), 2.61; 95% confidence interval (CI), 1.54-4.43; p = 0.0004) and also better in total effect rate (OR, 3.81; 95% CI, 2.07-7.01; p＜0.0001). But, auriculotherapy or auriculotherapy joint treatment was similar to Western medicine in improving clinical signs and symptoms of chronic spontaneous urticaria (OR, 0.74; 95% CI, 0.35-1.56; p = 0.42). Auriculotherapy or auriculotherapy joint treatment was safer than Western medicine for curing chronic spontaneous urticaria (OR, 0.26; 95% CI, 0.09-0.80; p = 0.02). Auriculotherapy alone or auriculotherapy joint treatment appears to be more effective and safer than Western medicine that contains antihistamines in the treatment of chronic spontaneous urticaria. However, these findings should be interpreted with caution due to the unclear risk bias of methodological quality, and further studies with large-scale, better, and more rigorously designed protocol are necessary to prove these findings.

Cost Utility of Omalizumab Compared with Standard of Care for the Treatment of Chronic Spontaneous Urticaria

BACKGROUND

Chronic spontaneous urticaria (CSU) negatively impacts patient quality of life and productivity and is associated with considerable indirect costs to society.

OBJECTIVE

The aim of this study was to assess the cost utility of add-on omalizumab treatment compared with standard of care (SOC) in moderate or severe CSU patients with inadequate response to SOC, from the UK societal perspective.

METHODS

A Markov model was developed, consisting of health states based on Urticaria Activity Score over 7 days (UAS7) and additional states for relapse, spontaneous remission and death. Model cycle length was 4 weeks, and total model time horizon was 20 years in the base case. The model considered early discontinuation of non-responders (response: UAS7 ≤6) and retreatment upon relapse (relapse: UAS7 ≥16) for responders. Clinical and cost inputs were derived from omalizumab trials and published sources, and cost utility was expressed as incremental cost-effectiveness ratios (ICERs). Scenario analyses included no early discontinuation of non-responders and an altered definition of response (UAS7 <16).

RESULTS

With a deterministic ICER of £3183 in the base case, omalizumab was associated with increased costs and benefits relative to SOC. Probabilistic sensitivity analysis supported this result. Productivity inputs were key model drivers, and individual scenarios without early discontinuation of non-responders and adjusted response definitions had little impact on results. ICERs were generally robust to changes in key model parameters and inputs.

CONCLUSIONS

In this, the first economic evaluation of omalizumab in CSU from a UK societal perspective, omalizumab consistently represented a treatment option with societal benefit for CSU in the UK across a range of scenarios.

A prospective ten-year follow-up of patients with chronic urticaria

BACKGROUND

Chronic urticaria can be the initial clinical presentation of a number of different diseases. The objective of the present study was to report the associated diseases during a ten-year clinical-laboratory follow-up in patients with an initial diagnosis of chronic spontaneous urticaria (CSU) of unknown cause.

METHODS

A prospective, longitudinal cohort study with a ten-year clinical-laboratory follow-up was conducted. Patients with a history of urticarial plaques of over six weeks presenting as the only clinical symptom were selected. Individuals with other clinical conditions, urticaria of known causes or chronic physical urticaria were excluded. The following tests were initially performed: haemogram, urine type I, stool parasite exam and sedimentation rate. The following exams were ordered during follow-up: PPD; urine culture; serology tests; antithyroid and antinuclear antibodies, rheumatoid factor, lupus anticoagulant; thyroid hormones; serum immunoglobulin; paranasal sinus and thorax radiographs; testing for BK and Helicobacter pylori; and prick tests.

RESULTS

Infections were diagnosed in 29% of patients (syphilis, parasitosis, H. pylori, urinary infection, tuberculosis, hepatitis B and C); autoimmune diseases in 21% (thyroiditis, rheumatoid arthritis and antiphospholipid antibody syndrome); primary immunodeficiencies in 4% (IgA and IgG2 deficiencies); and chronic myeloid leukaemia in 1%. At ten-years of follow-up, the urticaria diagnosis was CSU of unknown cause in 45% of the cases.

CONCLUSION

This ten-year clinical-laboratory follow-up of 100 individuals with chronic urticaria as the initial diagnosis revealed the presence of associated diseases in over half of the cases. The most prevalent diseases were infections and autoimmune diseases besides primary immunodeficiencies and blood diseases.

The care pathway for children with urticaria, angioedema, mastocytosis

Cutaneous involvement characterized by urticarial lesions with or without angioedema and itch is commonly observed in routine medical practice. The clinical approach may still remain complex in real life, because several diseases may display similar cutaneous manifestations. Urticaria is a common disease, characterized by the sudden appearance of wheals, with/without angioedema. The term Chronic Urticaria (CU) encompasses a group of conditions with different underlying causes and different mechanisms, but sharing the clinical picture of recurring wheals and/or angioedema for at least 6 weeks. Hereditary Angioedema (HAE) is a rare disorder characterized by recurrent episodes of non-pruritic, non-pitting, subcutaneous or submucosal edema affecting the extremities, face, throat, trunk, genitalia, or bowel, that are referred as “attacks”. HAE is an autosomal dominant disease caused by a deficiency of functional C1 inhibitor, due to a mutation in C1-INH gene (serping 1 gene) characterized by the clonal proliferation of mast cells, leading to their accumulation, and possibly mediator release, in one or more organs. In childhood there are two main forms of mastocytosis, the Systemic and the Cutaneous. The clinical features of skin lesions in urticaria, angioedema and mastocytosis may differ depending on the aetiologic factors, and the underlying pathophysiological mechanisms. The diagnostic process, as stepwise approach in routine clinical practice, is here reviewed for CU, HAE and mastocytosis, resulting in an integrated method for improved management of these cutaneous diseases. Taking into account that usually these conditions have also a relevant impact on the quality of life of children, affecting social activities and behavior, the availability of care pathways could be helpful in disentangle the diagnostic issue achieving the most cost-effective ratio.

Recurrence of chronic urticaria caused by reinfection by Helicobacter pylori

OBJECTIVE

To describe a case of chronic urticaria in a female adolescent associated with Helicobacter pylori infection, confirmed in two different occasions, with improvement of urticaria after the antibacterial treatment.

CASE DESCRIPTION

A 13-year-old female patient sought medical care with chronic urticaria and epigastric pain unresponsive to medical treatment. Laboratorial tests for further investigation were normal except for the upper gastrointestinal endoscopy with biopsy showing moderate chronic active gastritis associated with Helicobacter pylori. After specific and appropriate treatment, the patient had remission of the symptoms. A new upper gastrointestinal endoscopy to control the treatment after nine months was normal. After five years, the patient returned with recurrence of urticaria and epigastric pain. She was taking antihistamines, without any improvement. It was again submitted to screening protocol for chronic urticaria with normal results. She was submitted to upper gastrointestinal endoscopy, which showed positive urease test. The patient started a new treatment for Helicobacter pylori with disappearance of chronic urticaria and epigastric pain within seven days.

COMMENTS

The reported case suggests a causal relationship between the positive diagnosis of Helicobacter pylori and the occurrence of chronic urticaria, showing the remission of symptoms after the institution of effective therapy for this agent. Chronic urticaria is a disease of complex etiology, and although controversial, there is growing evidence of Helicobacter pylori involvement with extraintestinal diseases, including chronic urticaria.

Oral H1 antihistamines as monotherapy for eczema

BACKGROUND

Eczema is a common skin disease in many countries, and although the majority of cases of eczema occur before the age of five years and often resolve during childhood or adolescence, it can also persist into adulthood. Itch is the most important aspect of eczema, often impacting significantly on the quality of life of an affected individual.

OBJECTIVES

To assess the effects of oral antihistamines (H1 antagonists) as monotherapy in children and adults with eczema.

SEARCH METHODS

We searched the following databases up to March 2012: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2012, Issue 3), MEDLINE (from 1946), EMBASE (from 1974), and LILACS (from 1982). We examined the reference lists of excluded studies in order to identify further references to relevant trials. We searched trials registers for ongoing and unpublished trials. We also handsearched the abstracts of the International Research Workshops on eczema, as well as the conference proceedings of the European Academy of Dermatology and Venereology (EADV) and the European Academy of Allergology and Clinical Immunology (EAACI), from 2000 to 2011.

SELECTION CRITERIA

We sought to include randomised controlled trials that assessed the effects and safety of oral H1 antihistamines as monotherapy in children and adults with eczema. We excluded studies that compared an antihistamine versus another antihistamine and had no placebo control arm. We also excluded topical antihistamines and oral H1 antihistamines as 'add-on' therapy and studies using any concomitant therapy other than emollients or moisturisers, principally because some of these forms of concomitant therapy may be considered treatment modifiers in assessments of the effects of antihistamines on eczema.

DATA COLLECTION AND ANALYSIS

Our search retrieved 409 references to studies. Based on assessments of their titles, abstracts, or both, we excluded all except 36 of these studies. After evaluation of the full text of each report, we excluded a further 35 studies, and 1 study is awaiting classification pending a response from the trial investigators.

MAIN RESULTS

No randomised controlled trials met our inclusion criteria.

AUTHORS' CONCLUSIONS

There is currently no high-level evidence to support or refute the efficacy or safety of oral H1 antihistamines used as monotherapy for eczema. Because most of the studies allowed the use of concomitant medications and involved multi-therapeutic approaches, meaningful assessments of the individual effects of oral H1 antihistamines on eczema were not feasible. Although well-designed randomised controlled trials excluding concomitant medications appear to be needed, consideration should be given to the potential ethical issues raised with the use of antihistamines as monotherapy for the management of eczema by withholding the use of rescue or additional therapies. A further systematic review of studies in which concomitant therapies were permitted might be of value in determining the potential benefits of oral H1 antihistamines as add-on therapy.

Oral H1 antihistamines as monotherapy for eczema

BACKGROUND

Eczema is a common skin disease in many countries, and although the majority of cases of eczema occur before the age of five years and often resolve during childhood or adolescence, it can also persist into adulthood. Itch is the most important aspect of eczema, often impacting significantly on the quality of life of an affected individual.

OBJECTIVES

To assess the effects of oral antihistamines (H1 antagonists) as monotherapy in children and adults with eczema.

SEARCH METHODS

We searched the following databases up to March 2012: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2012, Issue 3), MEDLINE (from 1946), EMBASE (from 1974), and LILACS (from 1982). We examined the reference lists of excluded studies in order to identify further references to relevant trials. We searched trials registers for ongoing and unpublished trials. We also handsearched the abstracts of the International Research Workshops on eczema, as well as the conference proceedings of the European Academy of Dermatology and Venereology (EADV) and the European Academy of Allergology and Clinical Immunology (EAACI), from 2000 to 2011.

SELECTION CRITERIA

We sought to include randomised controlled trials that assessed the effects and safety of oral H1 antihistamines as monotherapy in children and adults with eczema. We excluded studies that compared an antihistamine versus another antihistamine and had no placebo control arm. We also excluded topical antihistamines and oral H1 antihistamines as 'add-on' therapy and studies using any concomitant therapy other than emollients or moisturisers, principally because some of these forms of concomitant therapy may be considered treatment modifiers in assessments of the effects of antihistamines on eczema.

DATA COLLECTION AND ANALYSIS

Our search retrieved 409 references to studies. Based on assessments of their titles, abstracts, or both, we excluded all except 36 of these studies. After evaluation of the full text of each report, we excluded a further 35 studies, and 1 study is awaiting classification pending a response from the trial investigators.

MAIN RESULTS

No randomised controlled trials met our inclusion criteria.

AUTHORS' CONCLUSIONS

There is currently no high-level evidence to support or refute the efficacy or safety of oral H1 antihistamines used as monotherapy for eczema. Because most of the studies allowed the use of concomitant medications and involved multi-therapeutic approaches, meaningful assessments of the individual effects of oral H1 antihistamines on eczema were not feasible. Although well-designed randomised controlled trials excluding concomitant medications appear to be needed, consideration should be given to the potential ethical issues raised with the use of antihistamines as monotherapy for the management of eczema by withholding the use of rescue or additional therapies. A further systematic review of studies in which concomitant therapies were permitted might be of value in determining the potential benefits of oral H1 antihistamines as add-on therapy.