Treatment Patterns, Healthcare Resource Utilization, and Spending Among Medicaid-Enrolled Children with Chronic Idiopathic/Spontaneous Urticaria in the United States

Cost and Cost-Effectiveness of the Management Strategies of Chronic Urticaria: A Systematic Review

Importance

Although treatment for chronic urticaria (CU) has improved over the past decades, evidence regarding costs and net benefits associated with these treatment strategies have yet to be comprehensively characterized and synthesized.

Objective

To summarize the cost and cost-effectiveness of CU management strategies.

Evidence Review

An extensive systematic literature search of 6 databases (MEDLINE, Embase, PubMed Cochrane, Scopus, and CINAHL) and gray literature sources, without language restriction, was conducted and updated to March 23, 2024. Articles that performed cost analysis or full economic evaluation among patients with CU were included. Two reviewers independently extracted data, such as annual costs of health care services or incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year (QALY). All monetary values were converted and inflated to 2023 US dollars. Evidence-based synthesis for health benefit was judged using the Evidence Rating Matrix by the Institute for Clinical and Economic Review.

Findings

Seventeen unique studies (11 cost analysis studies and 6 full economic evaluations) were included. With the wide variation in health care resources, services that included biologic omalizumab utilization had higher annual health care cost estimations for CU management than services that did not include omalizumab prescription (median [IQR] cost, $6933 [$5988-$8717] vs $5621 [$2488-$8754]). The biologic omalizumab, 300 mg, for H1 antihistamine-refractory chronic spontaneous urticaria (CSU) (3 studies) was found to have a median (IQR) ICER of $89 005 ($36 058-$145 694) per QALY (evidence rating as incremental or better; moderate certainty with substantial net health benefit). Routine laboratory testing among patients with CSU with otherwise normal histories and physical examination findings (1 study) had ICERs ranging from $1 427 928 to $1 950 524 per QALY (evidence rating as comparable or inferior; moderate certainty that the net health benefit is inferior).

Conclusions and Relevance

With limited evidence of cost-effectiveness, biologic omalizumab, 300 mg, for H1 antihistamine-refractory CSU was found to be cost-effective in US health care services at the willingness to pay threshold of $150 000 per QALY. Meanwhile, routine laboratory testing among patients with CSU without compelling indication was not cost-effective. Future studies in more diverse CU populations and resource settings are needed to fill evidence gaps.

Psychiatric comorbidities in children and adolescents with chronic urticaria

BACKGROUND

Chronic urticaria (CU) has been shown to impact patients' quality of life negatively and may coexist with psychiatric disorders. We systematically reviewed the published evidence of comorbid psychiatric disorders in children and adolescents with CU.

METHODS

A systematic review of studies published until February 2022 in PubMed, Google Scholar, and Scopus was performed. An a priori set of inclusion criteria was predefined for the studies to be included: (1) clear distinction between urticaria and other allergies; (2) precise distinction between acute and CU; (3) participants younger than 18 years old, exclusively; (4) use of appropriate standardized questionnaires, psychometric tools, and standard diagnostic nomenclature for the mental health and behavioral disorders diagnosis; and (5) manuscripts written or published in the English language.

RESULTS

Our search identified 582 potentially relevant papers. Only eight of them satisfied the inclusion criteria. Quantitative meta-analysis was not deemed appropriate, given the lack of relevant randomized control trials, the small number of relevant shortlisted, the small sample size of the patients included in each study, and the remarkable heterogeneity of the studies' protocols.

CONCLUSIONS

The included studies suggest an increased incidence of psychopathology among children and adolescents with CU as opposed to healthy age-matched individuals, but the data are scarce. Further research is required to clarify whether psychopathology is just a comorbid entity, the cause, or the consequence of CU. Meanwhile an interdisciplinary collaboration between allergists/dermatologists and psychiatrists is expected to substantially minimize CU burden and improve patients' quality of life.

Pharmacologic Management of Chronic Urticaria in Pediatric Patients: The Gap Between Guidelines and Practice

Chronic urticaria is an uncommon disorder in children but can present considerable morbidity, as well as frustration for the healthcare provider and parent. The prevalence is 0.1-0.3% but can vary considerably by country. Chronic spontaneous urticaria (no identifiable cause) is responsible for 70-80% of chronic urticaria, about half of this due to a subtype called chronic autoimmune urticaria identified by the presence of autoantibodies to IgE or the IgE receptor. Chronic urticaria that is triggered by external physical stimuli is called chronic inducible urticaria and is present in another 15-20%. Allergies, infection, and other underlying diseases such as thyroid disease, celiac disease, or Helicobacter pylori infection cause a minor proportion of cases. Chronic urticaria has considerable impact on quality of life and healthcare costs. An adverse impact on quality of life is more prevalent in older children and adolescents and can be comparable to other diseases of childhood such as diabetes and epilepsy. Healthcare costs can be 50% higher than the national estimates for healthy patients and include more hospitalizations, longer duration of hospitalizations, and more emergency department (ED) and outpatient visits. Allergic and autoimmune diseases can be comorbidities that add to healthcare utilization. Resolution can take years. Guidelines are available for diagnosis and treatment. A good history is the key to identifying the cause. Minimal laboratory tests are required and should be guided by the history. Patients with easily controlled urticaria may not need any laboratory tests. Suggested treatment emphasizes the use of non-sedating antihistamines, utilized in a step-wise fashion beginning with normal doses and advancing the dose based on the response up to four times the recommended dose for age. Other treatments are left to the urticaria specialist and are not discussed in this paper. These guidelines are not well utilized based on real-world studies; sedating antihistamines and oral steroids are overutilized. Medications should be taken daily, not as needed. Additional medications, if required, should be added to prior medications in a step-wise fashion. The gap between the guidelines for diagnosis and treatment and what is happening in the real world needs to be closed to reduce the cost and morbidity associated with this disorder.

Consensus on the diagnostic and therapeutic management of chronic spontaneous urticaria in adults - Brazilian Society of Dermatology

Background

Urticarias are frequent diseases, with 15% to 20% of the population presenting at least one acute episode in their lifetime. Urticaria are classified in acute ( ≤ 6 weeks) or chronic (> 6 weeks). They may be induced or spontaneous.

Objectives

To verify the diagnostic and therapeutic recommendations in chronic spontaneous urticaria (CSU), according to the experience of Brazilian experts, regarding the available guidelines (international and US).

Methods

A questionnaire was sent to Brazilian experts, with questions concerning diagnostic and therapeutic recommendations for CSU in adults.

Results

Sixteen Brazilian experts answered the questionnaire related to diagnosis and therapy of CSU in adults and data were analyzed. Final text was written, considering the available guidelines (International and US), adapted to the medical practices in Brazil. Diagnostic work up in CSU is rarely necessary. Biopsy of skin lesion and histopathology may be indicated to rule out other diseases, such as, urticarial vasculitis. Other laboratory tests, such as complete blood count, CRP, ESR and thyroid screening. Treatment of CSU includes second-generation anti-histamines (sgAH) at licensed doses, sgAH two, three to fourfold doses (non-licensed) and omalizumab. Other drugs, such as, cyclosporine, immunomodulatory drugs and immunosuppressants may be indicated (non-licensed and with limited scientific evidence).

Conclusions

Most of the Brazilian experts in this study partially agreed with the diagnostic and therapeutic recommendations of the International and US guidelines. They agreed with the use of sgAH at licensed doses. Increase in the dose to fourfold of sgAH may be suggested with restrictions, due to its non-licensed dose. Sedating anti-histamines, as suggested by the US guideline, are indicated by some of the Brazilian experts, due to its availability. Adaptations are mandatory in the treatment of CSU, due to scarce or lack of other therapeutic resources in the public health system in Brazil, such as omalizumab or cyclosporine.