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Cakmak ME, Bostan OC, Kaya SB, Karakaya G, Kalyoncu AF, Damadoglu E. Assessment of clinical phenotypic characteristics of patients with angioedema without wheals in a turkish population. Allergy Asthma Proc 2024; 45:240-246. [PMID: 38982609 DOI: 10.2500/aap.2024.45.240034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2024]
Abstract
Background: Angioedema (AE) is defined as localized, self-limited swelling of subcutaneous tissues and mucosa. Objective: The aim of this study was to compare the phenotypic characteristics of patients with AE without wheals. Methods: This prospective study included adult patients with recurrent AE without wheals. Demographic and laboratory data of the patients were recorded in the patient file when they presented to the outpatient clinic between August 2018 and August 2020. The patients were contacted by phone to evaluate whether their AE had gone into remission between October 2023 and January 2024. The phenotypic characteristics of AE subtypes were compared. Results: The study included a total of 143 patients. The average age, age of onset of AE, rates of diabetes mellitus, hypertension and coronary artery disease were higher in the patients with angiotensin-converting enzyme inhibitor (ACEI) use related acquired AE (AAE) (AAE-ACEI). The rates of allergic rhinitis, drug allergy, atopy, and aeroallergen sensitivity, and the median total immunoglobulin E level were higher in patients with idiopathic histaminergic AAE (AAE-IH). The rate of face and/or perioral AE attacks was higher in the patients with AAE-ACEI, AAE-IH, and idiopathic non-histaminergic AAE. The rate of AE attacks in limbs, abdominal, genital and other parts of the body was higher in patients with hereditary AE (HAE). The baseline AE activity score was lower in the patients with AAE-IH and higher in the patients with HAE. In long-term follow-up, the remission rate of AE attacks was significant higher in patients with AAE-ACEI and AAE-IH. Conclusion: The phenotypic characteristic features of Turkish patients with AE without wheals may vary, depending on the underlying AE pathogenesis. C1 inhibitor level and function, complement C4 and C1q, and genetic tests contributed to the diagnosis; other laboratory tests did not contribute to the diagnosis.
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Affiliation(s)
- Mehmet Erdem Cakmak
- From the Department of Allergy and Clinical Immunology, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey
| | - Ozge Can Bostan
- Department of Allergy and Clinical Immunology, Adıyaman Training and Research Hospital, Adıyaman, Turkey
| | - Saltuk Bugra Kaya
- Division of Allergy and Clinical Immunology, Department of Chest Diseases, Inonu University School of Medicine, Malatya, Turkey, and
| | - Gul Karakaya
- Division of Allergy and Clinical Immunology, Department of Chest Diseases, Hacettepe University School of Medicine, Ankara, Turkey
| | - Ali Fuat Kalyoncu
- Division of Allergy and Clinical Immunology, Department of Chest Diseases, Hacettepe University School of Medicine, Ankara, Turkey
| | - Ebru Damadoglu
- Division of Allergy and Clinical Immunology, Department of Chest Diseases, Hacettepe University School of Medicine, Ankara, Turkey
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Shaker M, Mauger D, Fuhlbrigge AL. Value-Based, Cost-Effective Care: The Role of the Allergist-Immunologist. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:132-139. [PMID: 35944893 DOI: 10.1016/j.jaip.2022.07.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/19/2022] [Accepted: 07/21/2022] [Indexed: 01/11/2023]
Abstract
Asthma and allergic disease impact millions of patients and are associated with high costs. Up to 30% of all medical care involves wasted spending. Across the spectrum of care provided by the allergist-immunologist, there are opportunities to improve value and reduce medical waste. Several examples highlight this reality. Evidence suggests that most patients may receive cost-effective care in the management of chronic spontaneous urticaria without the need for laboratory testing. For patients with asthma, although a single maintenance and reliever therapy approach may be cost-effective, insurance-mandated therapy changes are not, and may harm patients. Biologics may be very effective in improving asthma control but are too expensive for this indication-as demonstrated by cost-effectiveness analyses and highlighted by the Institute of Clinical and Economic Review, which concluded that the value-based price for asthma biologics ranges between $6500 and 14,3000 per year. Early introduction may prevent food allergy, but screening before first introduction is neither necessary nor cost-effective, although early salvage food oral immunotherapy may result in improved quality of life and cost savings. Evidence does not support the presence of allergic disease as a risk factor for anaphylaxis to coronavirus disease 2019 vaccination, and risk-stratified vaccination approaches do not appear cost-effective. Allergen immunotherapy is a very cost-effective treatment option. The practice of allergy-immunology has continued to evolve in recent years and can provide a leading example of high-value practice.
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Affiliation(s)
- Marcus Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH; Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH.
| | - David Mauger
- Department of Public Health Sciences, Division of Biostatistics and Bioinformatics, The Pennsylvania State University, State College, Pa
| | - Anne L Fuhlbrigge
- Pulmonary Science and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo
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3
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Kulthanan K, Rujitharanawong C, Munprom K, Trakanwittayarak S, Phumariyapong P, Prasertsook S, Ungprasert P. Prevalence, Clinical Manifestations, Treatment, and Clinical Course of Chronic Urticaria in Elderly: A Systematic Review. J Asthma Allergy 2022; 15:1455-1490. [PMID: 36299736 PMCID: PMC9590340 DOI: 10.2147/jaa.s379912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/23/2022] [Indexed: 11/05/2022] Open
Abstract
Purpose Data specific to the epidemiology, clinical features, and management of chronic urticaria (CU) in the geriatric population remain limited and not well understood. We aim to systematically review the prevalence, clinical manifestations, treatment, and clinical course of elderly patients with CU. Patients and methods Original articles that included data of elderly (aged >60 years) with CU that were published until February 2021 were searched in PubMed, Scopus, and Embase using predfefined search terms. Related articles were evaluated according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. Results Among the included 85 studies and 1,112,066 elderly CU patients, most (57.4%) were women. The prevalence of elderly CU in the general population ranged from 0.2–2.8%, and from 0.7–33.3% among all CU patients. Compared to adult CU, elderly CU patients had a higher percentage of wheal alone (73.9%), and lower rate of positive autologous serum skin test and atopy. Gastrointestinal diseases were the most common comorbidity (71.9%), and there was a high rate of malignancies and autoimmune diseases. Second generation H1-antihistamines were commonly used, and achievement of complete control was most often reported. Omalizumab was prescribed in 59 refractory patients, and a significant response to treatment was reported in most patients. The treatment of comorbidities also yielded significant improvement in CU. Conclusion Elderly CU was found to be different from adult CU in both clinical and laboratory aspects. H1- antihistamines are effective as first-line therapy with minimal side-effects at licensed doses. Treatment of secondary causes is important since the elderly usually have age-related comorbidities.
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Affiliation(s)
- Kanokvalai Kulthanan
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chuda Rujitharanawong
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kanyalak Munprom
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Phumithep Phumariyapong
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Suthasanee Prasertsook
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Patompong Ungprasert
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA,Correspondence: Patompong Ungprasert, Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA, Tel +1 216 986 4000, Fax +1 216 986 4953, Email
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4
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Affiliation(s)
- David M Lang
- From the Cleveland Clinic, Respiratory Institute, Department of Allergy and Clinical Immunology, Cleveland
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5
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Poowuttikul P, Pansare M, Kamat D, Seth D. Approach to Children with Hives. Pediatr Ann 2021; 50:e191-e197. [PMID: 34044707 DOI: 10.3928/19382359-20210422-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Urticaria (or hives) is a pruritic and erythematous skin rash. Angioedema commonly occurs with urticaria. The term "chronic urticaria" is used when hives are present for more than 6 weeks. Acute urticaria is common in children, whereas chronic urticaria is rare. Causes of urticaria can be identified in many cases of acute urticaria with a thorough medical history. Laboratory evaluation may be needed to confirm the etiology of acute urticaria. Chronic urticaria is often idiopathic. Clinicians should avoid universal allergy testing for food allergens or aeroallergens in chronic urticaria as it usually does not help in identifying the cause, can lead to false-positive results, and unnecessary avoidance of allergens or foods. Urticarial vasculitis should be considered for lesions that are painful, present for more than 48 hours, leave scars/hyperpigmentation, or present with systemic symptoms such as fever, weight loss, and arthritis. Skin biopsy should be considered for suspected urticarial vasculitis. [Pediatr Ann. 2021(5):e191-e197.].
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Dunn CL, Dunn CP, Ayars AG. When long-standing hives are not chronic spontaneous urticaria. Ann Allergy Asthma Immunol 2021; 126:733-734. [PMID: 33677054 DOI: 10.1016/j.anai.2021.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/19/2021] [Accepted: 02/28/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Charles L Dunn
- United States Air Force Medical Service Corps, Joint Base Elmendorf-Richardson, Anchorage, Alaska
| | - Clinton P Dunn
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington.
| | - Andrew G Ayars
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington
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Bai L, Gao S, Burstein F, Kerr D, Buntine P, Law N. A systematic literature review on unnecessary diagnostic testing: The role of ICT use. Int J Med Inform 2020; 143:104269. [PMID: 32927268 DOI: 10.1016/j.ijmedinf.2020.104269] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/10/2020] [Accepted: 09/02/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND The negative impact of unnecessary diagnostic tests on healthcare systems and patients has been widely recognized. Medical researchers in various countries have been devoting effort to reduce unnecessary diagnostic tests by using different types of interventions, including information and communications technology-based (ICT-based) intervention, educational intervention, audit and feedback, the introduction of guidelines or protocols, and the reward and punishment of staff. We conducted a review of ICT based interventions and a comparative analysis of their relative effectiveness in reducing unnecessary tests. METHOD A systematic Boolean search in PubMed, EMBase and EBSCOhost research databases was performed. Keyword search and citation analysis were also conducted. Empirical studies reporting ICT based interventions, and their implications on relative effectiveness in reducing unnecessary diagnostic tests (pathology tests or medical imaging) were evaluated independently by two reviewers based on a rigorously developed coding protocol. RESULTS 92 research articles from peer-reviewed journals were identified as eligible. 47 studies involved a single-method intervention and 45 involved multi-method interventions. Regardless of the number of interventions involved in the studies, ICT-based interventions were utilized by 71 studies and 59 of them were shown to be effective in reducing unnecessary testing. A clinical decision support (CDS) tool appeared to be the most adopted ICT approach, with 46 out of 71 studies using CDS tools. The CDS tool showed effectiveness in reducing test volume in 38 studies and reducing cost in 24 studies. CONCLUSIONS This review investigated five frequently utilized intervention methods, ICT-based, education, introduction of guidelines or protocols, audit and feedback, and reward and punishment. It provides in-depth analysis of the efficacy of different types of interventions and sheds insights about the benefits of ICT based interventions, especially those utilising CDS tools, to reduce unnecessary diagnostic testing. The replicability of the studies is limited due to the heterogeneity of the studies in terms of context, study design, and targeted types of tests.
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Affiliation(s)
- Lu Bai
- Faculty of Information Technology, Monash University, Melbourne, VIC, Australia
| | - Shijia Gao
- Faculty of Information Technology, Monash University, Melbourne, VIC, Australia
| | - Frada Burstein
- Faculty of Information Technology, Monash University, Melbourne, VIC, Australia.
| | - Donald Kerr
- USC Business School, University of the Sunshine Coast, Sippy Downs, QLD, Australia
| | - Paul Buntine
- Emergency Department, Box Hill Hospital, Melbourne, VIC, Australia; Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
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Oliver ET, Hogan MB. Eliminating Low-Value Medical Care in Chronic Spontaneous Urticaria. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2370-2371. [PMID: 32620436 DOI: 10.1016/j.jaip.2020.04.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/28/2020] [Accepted: 04/28/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Eric T Oliver
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Md.
| | - Mary Beth Hogan
- Section of Allergy/Immunology, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV
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Shaker MS, Oppenheimer J, Grayson M, Stukus D, Hartog N, Hsieh EWY, Rider N, Dutmer CM, Vander Leek TK, Kim H, Chan ES, Mack D, Ellis AK, Lang D, Lieberman J, Fleischer D, Golden DBK, Wallace D, Portnoy J, Mosnaim G, Greenhawt M. COVID-19: Pandemic Contingency Planning for the Allergy and Immunology Clinic. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1477-1488.e5. [PMID: 32224232 PMCID: PMC7195089 DOI: 10.1016/j.jaip.2020.03.012] [Citation(s) in RCA: 210] [Impact Index Per Article: 52.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 03/18/2020] [Indexed: 01/15/2023]
Abstract
In the event of a global infectious pandemic, drastic measures may be needed that limit or require adjustment of ambulatory allergy services. However, no rationale for how to prioritize service shut down and patient care exists. A consensus-based ad-hoc expert panel of allergy/immunology specialists from the United States and Canada developed a service and patient prioritization schematic to temporarily triage allergy/immunology services. Recommendations and feedback were developed iteratively, using an adapted modified Delphi methodology to achieve consensus. During the ongoing pandemic while social distancing is being encouraged, most allergy/immunology care could be postponed/delayed or handled through virtual care. With the exception of many patients with primary immunodeficiency, patients on venom immunotherapy, and patients with asthma of a certain severity, there is limited need for face-to-face visits under such conditions. These suggestions are intended to help provide a logical approach to quickly adjust service to mitigate risk to both medical staff and patients. Importantly, individual community circumstances may be unique and require contextual consideration. The decision to enact any of these measures rests with the judgment of each clinician and individual health care system. Pandemics are unanticipated, and enforced social distancing/quarantining is highly unusual. This expert panel consensus document offers a prioritization rational to help guide decision making when such situations arise and an allergist/immunologist is forced to reduce services or makes the decision on his or her own to do so.
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Affiliation(s)
- Marcus S Shaker
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, NH; Dartmouth Geisel School of Medicine, Hanover, NH
| | | | - Mitchell Grayson
- Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio
| | - David Stukus
- Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio
| | - Nicholas Hartog
- Spectrum Health Helen DeVos Children's Hospital, Grand Rapids, Mich
| | - Elena W Y Hsieh
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Nicholas Rider
- The Texas Children's Hospital, Section of Immunology, Allergy, and Retrovirology and the Baylor College of Medicine, Houston, Texas
| | - Cullen M Dutmer
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Timothy K Vander Leek
- Pediatric Allergy and Asthma, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Harold Kim
- Western University and McMaster University, London, ON, Canada
| | - Edmond S Chan
- BC Children's Hospital, The University of British Columbia, Vancouver, BC, Canada
| | - Doug Mack
- McMaster University, Hamilton, ON, Canada; Halton Pediatric Allergy, Burlington, ON, Canada
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - David Lang
- Department of Medicine, Section of Allergy and Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Jay Lieberman
- Division of Allergy and Immunology, The University of Tennessee, Memphis, Tenn
| | - David Fleischer
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - David B K Golden
- Division of Allergy and Clinical Immunology, John Hopkins University School of Medicine, Baltimore, Md
| | - Dana Wallace
- Nova Southeastern University College of Allopathic Medicine, Fort Lauderdale, Fla
| | - Jay Portnoy
- Children's Mercy, University of Missouri-Kansas City School of Medicine, Kansas City, Mo
| | - Giselle Mosnaim
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, NorthShore University Health System, Evanston, Ill
| | - Matthew Greenhawt
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.
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Shaker M, Oppenheimer J, Wallace D, Lang DM, Rambasek T, Dykewicz M, Greenhawt M. Optimizing Value in the Evaluation of Chronic Spontaneous Urticaria: A Cost-Effectiveness Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:2360-2369.e1. [PMID: 31751758 DOI: 10.1016/j.jaip.2019.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 10/31/2019] [Accepted: 11/03/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Chronic spontaneous urticaria (CSU) affects approximately 1% of the general population. The cost-effectiveness of routine laboratory testing for secondary causes of CSU has not been formally evaluated. OBJECTIVE To characterize the cost-effectiveness of routine laboratory screening in adults with CSU. METHODS A Markov model using cohort analysis and microsimulations was created for adult patients aged 20 years, over a 10-year time horizon, randomized to receive screening laboratory testing or a no-testing approach. Laboratory results were derived from a previously published retrospective analysis of adult patients with CSU. Cost-effectiveness was evaluated at a willingness to pay threshold of $100,000/quality-adjusted life-year using the incremental cost-effectiveness ratio (ICER) in patients with untreated CSU, and patients treated with antihistamines, cyclosporine, or omalizumab. RESULTS Average laboratory costs per simulated patient with CSU were $573 (standard deviation [SD], $41), with only 0.16% (SD, 3.99%) of tests resulting in improved clinical outcomes. Testing costs per laboratory-associated positive outcome were $358,052 (no therapy), $357,576 (antihistamine therapy), $354,115 (cyclosporine), and $262,121 (omalizumab). Screening tests were not cost-effective, with ICERs of $856,905 (no therapy), $855,764 (antihistamine therapy), $847,483 (cyclosporine), and $627,318 (omalizumab). In the omalizumab-treated subgroup, testing could be cost-effective below $220 or if it resulted in a 0.73% rate of CSU resolution. From a simulated US population perspective, nation-wide screening costs could reach $941,750,741 to $1,833,501,483. CONCLUSIONS In CSU, the likelihood of clinical improvement from laboratory testing is very low, and testing is not cost-effective. These data support recommendations to not routinely perform laboratory testing in patients with CSU with otherwise normal histories and physical evaluations.
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Affiliation(s)
- Marcus Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH; Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH.
| | - John Oppenheimer
- Department of Internal Medicine, Rutgers New Jersey Medical School, Newark, NJ
| | - Dana Wallace
- Department of Medicine, Nova Southeastern Allopathic Medical School, Fort Lauderdale, Fla
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Todd Rambasek
- Division of Allergy and Immunology, Ohio University Heritage College of Osteopathic Medicine, Sandusky, Ohio
| | - Mark Dykewicz
- Department of Internal Medicine, Section of Allergy and Immunology, Saint Louis University School of Medicine, St. Louis, Mo
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Food Challenge and Research Unit, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
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Carrillo-Martin I, Dudgeon MG, Chamorro-Pareja N, Haehn DA, Rivera-Valenzuela MG, Spaulding AC, Heckman MG, Diehl NN, Irizarry-Alvarado JM, Helmi H, Gonzalez-Estrada A. Cost-Utility of Routine Testing in Chronic Urticaria/Angioedema: A Cohort Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2823-2832. [DOI: 10.1016/j.jaip.2019.04.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 04/17/2019] [Accepted: 04/21/2019] [Indexed: 12/14/2022]
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Ahmed F, Fried AJ, Spielman S, Secor W, MacGinnitie AJ. Utility of measuring tryptase levels in children and young adults. Ann Allergy Asthma Immunol 2019; 123:398-399. [PMID: 31400462 DOI: 10.1016/j.anai.2019.07.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/30/2019] [Accepted: 07/31/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Fatimah Ahmed
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Ari J Fried
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Sara Spielman
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - William Secor
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Andrew J MacGinnitie
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
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13
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Yuan I, Katari P, Shaker M. Vitamin D treatment for chronic urticaria: a case report. J Med Case Rep 2019; 13:193. [PMID: 31234909 PMCID: PMC6591990 DOI: 10.1186/s13256-019-2121-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 05/14/2019] [Indexed: 01/01/2023] Open
Abstract
Introduction Chronic urticaria is characterized by recurrent hives, with or without angioedema, persisting for 6 weeks or longer. Although often suspected by patients, in fact specific allergen triggers are infrequent. In contrast, the condition may be associated with autoimmune and thyroid disorders. While some evidence suggests an association of chronic urticaria with vitamin D levels, measurement of vitamin D or supplementation is not a part of diagnostic or treatment recommendations. Case presentation We present a case of a 14-year-old white boy with refractory chronic urticaria who experienced prompt remission with high-dose vitamin D repletion when vitamin D deficiency was identified as an incidental finding. Conclusions In some patients, vitamin D may have a role in the pathophysiology and treatment of chronic urticaria; however, the cost-effectiveness of routine laboratory screening in chronic urticaria is unknown.
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Affiliation(s)
- Irene Yuan
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Priya Katari
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Marcus Shaker
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA. .,Dartmouth-Hitchcock Medical Center, Section of Allergy and Clinical Immunology, Lebanon, NH, 03756, USA.
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Shahzad Mustafa S, Sánchez-Borges M. Chronic Urticaria: Comparisons of US, European, and Asian Guidelines. Curr Allergy Asthma Rep 2018; 18:36. [PMID: 29796863 DOI: 10.1007/s11882-018-0789-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW Chronic urticaria is a common dermatological condition that has significant impact on quality of life. Multiple international societies have published guidelines, and although these guidelines generally agree on the definition of urticaria, as well as approach to diagnosis and management, there have been notable differences to date. These differences have been reconciled by the recent publication of the 2017 revision and update published by the EAACI/GA2LEN/EDF/WAO. RECENT FINDINGS The 2017 revision and update to the guidelines for chronic urticaria are the most comprehensive consensus document to date, and reconcile previously existing differences between the US, European, and Asian guidelines. The purpose of our review is to present basic background on urticaria and discuss classification, diagnosis, and most importantly, management. We present differences from previous US, European, and Asian guidelines and reconcile the previous differences by summarizing the 2017 revision and update published by the EAACI/GA2LEN/EDF/WAO.
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Affiliation(s)
- S Shahzad Mustafa
- Allergy and Clinical Immunology, Rochester Regional Health, Rochester, NY, USA. .,University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Mario Sánchez-Borges
- Allergy and Clinical Immunology Department, Centro Médico Docente La Trinidad, Caracas, Venezuela
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15
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Zuberbier T, Bernstein JA. A Comparison of the United States and International Perspective on Chronic Urticaria Guidelines. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1144-1151. [PMID: 29779967 DOI: 10.1016/j.jaip.2018.04.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 04/19/2018] [Accepted: 04/20/2018] [Indexed: 11/30/2022]
Abstract
Urticaria is a heterogeneous skin disorder that may be acute or chronic and is defined by the appearance of wheals, angioedema, or both. The European perspective is expressed in a recent international guideline and the American perspective has been based on the US Joint Task Force chronic urticaria practice parameter published in 2014. Both the international guideline (initiated by the European societies European Academy of Allergology and Clinical Immunology [EAACI]/Global Allergy and Asthma European Network [GA2LEN]/European Dermatology Forum [EDF] in collaboration with the World Allergy Organization [WAO]) and the US (American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma and Immunology) guideline have been developed to help direct primary care physicians and specialists in the management of their patients with urticaria. The EAACI/GA2LEN/EDF/WAO guideline applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to developing consensus recommendations and these were then discussed in a Delphi conference including more than 250 specialists in the field and have been endorsed by more than 40 international societies. In contrast, the US Joint Task Force CU practice parameter made recommendations based on scientific evidence whenever possible; however, when there was insufficient evidence, recommendations were based on expert consensus opinion. Although both agree on most points regarding the definition, general evaluation, and treatment, there are some differences that exist between the 2 guidelines. Most of these differences pertain to recommendations based on expert opinion because of weak scientific evidence. Within this document, we compare the recommendations of these 2 groups, highlighting the key similarities and differences.
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Affiliation(s)
- Torsten Zuberbier
- Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Kolkhir P, Metz M, Altrichter S, Maurer M. Comorbidity of chronic spontaneous urticaria and autoimmune thyroid diseases: A systematic review. Allergy 2017; 72:1440-1460. [PMID: 28407273 DOI: 10.1111/all.13182] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2017] [Indexed: 02/01/2023]
Abstract
Patients with chronic spontaneous urticaria (CSU) are widely held to often have other autoimmune disorders, including autoimmune thyroid disease. Here, we systematically evaluated the literature on the prevalence of thyroid autoimmunity in CSU and vice versa. There is a strong link between CSU and elevated levels of IgG antithyroid autoantibodies (AAbs), with most of a large number of studies reporting rates of ≥10%. Levels of IgG against thyroid peroxidase (TPO) are more often elevated in CSU than those of other IgG antithyroid AAbs (strong evidence). Levels of IgG antithyroid AAbs are more often elevated in adult patients with CSU than in children (strong evidence). Patients with CSU exhibit significantly higher levels of IgG antithyroid AAbs (strong evidence) and IgE-anti-TPO (weak evidence) than controls. Elevated IgG antithyroid AAbs in CSU are linked to the use of glucocorticoids (weak evidence) but not to disease duration or severity/activity, gender, age, or ASST response (inconsistent evidence). Thyroid dysfunction rates are increased in patients with CSU (strong evidence). Hypothyroidism and Hashimoto's thyroiditis are more common than hyperthyroidism and Graves' disease (strong evidence). Thyroid dysfunction is more common in adult patients with CSU than in children (strong evidence) and in female than in male patients with CSU (weak evidence). Urticaria including CSU is more prevalent in patients with thyroid autoimmunity than in controls (weak evidence). CSU can improve in response to treatment with levothyroxine or other thyroid drugs (strong evidence). Pathogenic mechanisms in CSU patients with thyroid autoimmunity may include IgE against autoantigens, immune complexes, and complement.
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Affiliation(s)
- P. Kolkhir
- Department of Dermatology and Venereology; I.M. Sechenov First Moscow State Medical University; Moscow Russia
| | - M. Metz
- Department of Dermatology and Allergy; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - S. Altrichter
- Department of Dermatology and Allergy; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - M. Maurer
- Department of Dermatology and Allergy; Charité - Universitätsmedizin Berlin; Berlin Germany
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Abstract
Conditions such as chronic rhinitis, urticaria, angioedema, and asthma are frequently seen in clinics and hospitals, and there are a core group of medications that are often used to treat these conditions. Knowing the indications, optimal dosing, and side-effect profile of these medications can improve outcomes. Chronic rhinitis due to various causes is one of the most common reasons for primary care physician visits. Knowing the indications for use, forms of administration, and side-effect profiles of these medications can help improve patient outcomes in these common conditions. This review focuses on the medications used to treat these conditions.
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Affiliation(s)
- Andrew G Ayars
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, WA 98195, USA; Center for Allergy and Inflammation, UW Medicine at South Lake Union, 750 Republican Street, Box 358061, Seattle, WA 98109-4725, USA.
| | - Matthew C Altman
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, WA 98195, USA; Center for Allergy and Inflammation, UW Medicine at South Lake Union, 750 Republican Street, Box 358061, Seattle, WA 98109-4725, USA
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Marrouche N, Grattan C. Update and insights into treatment options for chronic spontaneous urticaria. Expert Rev Clin Immunol 2014; 10:397-403. [PMID: 24527948 DOI: 10.1586/1744666x.2014.892416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic spontaneous urticaria (CSU) is defined as itchy weals, angio-oedema, or both, arising spontaneously without external physical stimuli. Symptoms of the disease continue to develop for more than 6 weeks. It carries a high socioeconomic burden with considerable health care costs. Second generation H1-antihistamines are the mainstay of urticaria treatment and are the only licensed option. However, many patients are resistant to H1-antihistamine therapy. Omalizumab has proven to be an effective therapeutic option in patients with recalcitrant chronic urticaria. Ciclosporin appears to be more beneficial in patients with functional histamine releasing autoantibodies as a cause of their disease. This review article will highlight the major therapeutic options available today for the management of CSU knowing that good quality evidence for efficacy of many agents is scarce except for H1-antihistamines and omalizumab.
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Affiliation(s)
- Nadine Marrouche
- Department of Dermatology, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, UK
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Zuberbier T, Aberer W, Asero R, Bindslev-Jensen C, Brzoza Z, Canonica GW, Church MK, Ensina LF, Giménez-Arnau A, Godse K, Gonçalo M, Grattan C, Hebert J, Hide M, Kaplan A, Kapp A, Abdul Latiff AH, Mathelier-Fusade P, Metz M, Saini SS, Sánchez-Borges M, Schmid-Grendelmeier P, Simons FER, Staubach P, Sussman G, Toubi E, Vena GA, Wedi B, Zhu XJ, Nast A, Maurer M. Methods report on the development of the 2013 revision and update of the EAACI/GA2 LEN/EDF/WAO guideline for the definition, classification, diagnosis, and management of urticaria. Allergy 2014; 69:e1-29. [PMID: 24898678 DOI: 10.1111/all.12370] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2014] [Indexed: 10/25/2022]
Abstract
This methods report describes the process of guideline development in detail. It is the result of a systematic literature review using the 'Grading of Recommendations Assessment, Development and Evaluation' (GRADE) methodology and a structured consensus conference held on 28 and 29 November 2012, in Berlin. It is a joint initiative of the Dermatology Section of the European Academy of Allergy and Clinical Immunology (EAACI), the EU-funded network of excellence, the Global Allergy and Asthma European Network (GA(2) LEN), the European Dermatology Forum (EDF), and the World Allergy Organization (WAO) with the participation of delegates of 21 national and international societies. This guideline covers the definition and classification of urticaria, taking into account the recent progress in identifying its causes, eliciting factors and pathomechanisms. In addition, it outlines evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS) and is published in Allergy 2014; 69:868-887.
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Affiliation(s)
- T. Zuberbier
- Department of Dermatology and Allergy; Allergy-Centre-Charité; Charité - University Hospital Berlin; Berlin Germany
| | - W. Aberer
- Department of Dermatology; Medical University of Graz; Graz Austria
| | - R. Asero
- Allergy Clinic; Clinica San Carlo; Paderno Dugnano Italy
| | - C. Bindslev-Jensen
- Department of Dermatology and ; Allergy Centre; Odense University Hospital and University of Southern Denmark; Odense Denmark
| | - Z. Brzoza
- Department of Internal Diseases, Allergology and Clinical Immunology in Katowice; Medical University of Silesia; Katowice Poland
| | - G. W. Canonica
- Respiratory Diseases & Allergy; University of Genoa; IRCCS AOU SanMartino; Genoa Italy
| | - M. K. Church
- Department of Dermatology and Allergy; Allergy-Centre-Charité; Charité - University Hospital Berlin; Berlin Germany
| | - L. F. Ensina
- Federal University of Sao Paulo; Sao Paulo Brazil
| | - A. Giménez-Arnau
- Hospital del Mar. Parc de Salut Mar; Universitat Autònoma; Barcelona Spain
| | - K. Godse
- Department of Dermatology; Dr. D. Y. Patil Medical College & Hospital; Nerul Navi Mumbai India
| | - M. Gonçalo
- Clinic of Dermatology; Faculty of Medicine and University Hospital; Coimbra Portugal
| | - C. Grattan
- St John's' Institute of Dermatology; Guy's' and St Thomas' Hospitals NHS Foundation Trust; London UK
| | - J. Hebert
- Center for Applied Research on Allergy Québec; Québec QC Canada
| | - M. Hide
- Department of Dermatology; Institute of Biomedical and Health Sciences; Hiroshima University; Hiroshima Japan
| | - A. Kaplan
- Division of Pulmonary and Critical Care Medicine, Allergy and Clinical Immunology; Department of Medicine; Medical University of South Carolina; Charleston SC USA
| | - A. Kapp
- Department of Dermatology and Allergy; Hannover Medical School; Hannover Germany
| | - A. H. Abdul Latiff
- Department of Paediatrics; Pantai Hospital Kuala Lumpur; Bangsar Malaysia
| | - P. Mathelier-Fusade
- Department of Dermatology and Allergy; University Hospital of Tenon; Paris France
| | - M. Metz
- Department of Dermatology and Allergy; Allergy-Centre-Charité; Charité - University Hospital Berlin; Berlin Germany
| | - S. S. Saini
- Johns Hopkins Asthma and Allergy Center; Baltimore MD USA
| | - M. Sánchez-Borges
- Allergy and Clinical Immunology Department; Centro Médico-Docente La Trinidad; Caracas Venezuela
| | | | - F. E. R. Simons
- Department of Pediatrics & Child Health; University of Manitoba; Winnipeg MB Canada
- Department of Immunology; University of Manitoba; Winnipeg MB Canada
| | - P. Staubach
- Department of Dermatology; University Medical Center Mainz; Mainz Germany
| | - G. Sussman
- Division of Allergy and Clinical Immunology; University of Toronto; Toronto ON Canada
| | - E. Toubi
- Bnai-Zion Medical Center; Faculty of Medicine; Technion; Haifa Israel
| | - G. A. Vena
- Unit of Dermatology and Venereology; Department of Biomedical Sciences and Human Oncology; University of Bari; Bari Italy
| | - B. Wedi
- Department of Dermatology and Allergy; Hannover Medical School; Hannover Germany
| | - X. J. Zhu
- Department of Dermatology; Peking University First Hospital; Beijing China
| | - A. Nast
- Department of Dermatology and Allergy; Allergy-Centre-Charité; Charité - University Hospital Berlin; Berlin Germany
| | - M. Maurer
- Department of Dermatology and Allergy; Allergy-Centre-Charité; Charité - University Hospital Berlin; Berlin Germany
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Bernstein JA, Lang DM, Khan DA, Craig T, Dreyfus D, Hsieh F, Sheikh J, Weldon D, Zuraw B, Bernstein DI, Blessing-Moore J, Cox L, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CR, Schuller DE, Spector SL, Tilles SA, Wallace D. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol 2014; 133:1270-7. [DOI: 10.1016/j.jaci.2014.02.036] [Citation(s) in RCA: 320] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 02/10/2014] [Accepted: 02/12/2014] [Indexed: 12/13/2022]
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Stitt JM, Dreskin SC. Urticaria and autoimmunity: where are we now? Curr Allergy Asthma Rep 2014; 13:555-62. [PMID: 23821106 DOI: 10.1007/s11882-013-0366-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
There is considerable debate whether chronic urticaria is an autoimmune disease or whether its features suggestive of autoimmunity are epiphenomena. A plethora of circumstantial evidence suggests that chronic urticaria is an autoimmune disease, but criteria to establish autoimmunity require direct proof and indirect evidence, and these are lacking in chronic urticaria. Current approaches to assessing for autoimmunity in vivo via the autologous serum skin test, and in vitro via either basophil histamine release or the basophil activation test are widely utilized, but the results of these tests have limited impact on prediction of the clinical course and efficacy of treatments. Recent guidelines for diagnosing autoimmune urticaria have been proposed, but further investigation is needed.
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Affiliation(s)
- Jenny M Stitt
- Division of Allergy and Clinical Immunology, University of Colorado Denver, Campus Box B164, Research Complex 2, Room 10002, 2700 E. 19th Ave., Aurora, CO, 80045, USA,
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Sánchez-Borges M, Asero R, Ansotegui IJ, Baiardini I, Bernstein JA, Canonica GW, Gower R, Kahn DA, Kaplan AP, Katelaris C, Maurer M, Park HS, Potter P, Saini S, Tassinari P, Tedeschi A, Ye YM, Zuberbier T. Diagnosis and treatment of urticaria and angioedema: a worldwide perspective. World Allergy Organ J 2012; 5:125-47. [PMID: 23282382 PMCID: PMC3651155 DOI: 10.1097/wox.0b013e3182758d6c] [Citation(s) in RCA: 126] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
: Urticaria and angioedema are common clinical conditions representing a major concern for physicians and patients alike. The World Allergy Organization (WAO), recognizing the importance of these diseases, has contributed to previous guidelines for the diagnosis and management of urticaria. The Scientific and Clinical Issues Council of WAO proposed the development of this global Position Paper to further enhance the clinical management of these disorders through the participation of renowned experts from all WAO regions of the world. Sections on definition and classification, prevalence, etiology and pathogenesis, diagnosis, treatment, and prognosis are based on the best scientific evidence presently available. Additional sections devoted to urticaria and angioedema in children and pregnant women, quality of life and patient-reported outcomes, and physical urticarias have been incorporated into this document. It is expected that this article will supplement recent international guidelines with the contribution of an expert panel designated by the WAO, increasing awareness of the importance of urticaria and angioedema in medical practice and will become a useful source of information for optimum patient management worldwide.
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Affiliation(s)
- Mario Sánchez-Borges
- Department of Allergy and Clinical Immunology, Centro Médico-Docente La Trinidad, Caracas, Venezuela
| | - Riccardo Asero
- Ambulatorio di Allergologia, Clinica San Carlo, Paderno-Dugnano, Milan, Italy
| | - Ignacio J Ansotegui
- Department of Allergy and Immunology, Hospital Quirón Bizkaia, Bilbao, Spain
| | - Ilaria Baiardini
- Allergy and Respiratory Disease Clinic, University of Genova, Ospedale S.Martino di Genova, Genoa, Italy
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology/Allergy Section University of Cincinnati, Cincinnati, OH
| | - G Walter Canonica
- Allergy and Respiratory Disease Clinic, University of Genova, Ospedale S.Martino di Genova, Genoa, Italy
| | - Richard Gower
- Department of Medicine, University of Washington, Spokane, WA
| | - David A Kahn
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Allen P Kaplan
- Division of Pulmonary and Critical Care Medicine and Allergy and Immunology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Connie Katelaris
- Department of Allergy and Immunology, University of Western Sydney and Campbelltown Hospital, Sydney, Australia
| | - Marcus Maurer
- Universitätsmedizin Berlin. Allergie-Centrum-Charité, Berlin, Germany
| | - Hae Sim Park
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, South Korea
| | - Paul Potter
- Allergy Diagnostic & Clinical Research Unit, University of Cape Town Lung Institute, Groote Schuur, South Africa
| | - Sarbjit Saini
- Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Paolo Tassinari
- Immunology Institute, Faculty of Medicine, Universidad Central de Venezuela, Caracas, Venezuela
| | - Alberto Tedeschi
- U.O. Allergologia e Immunologia Clinica, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Young Min Ye
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, South Korea
| | - Torsten Zuberbier
- Universitätsmedizin Berlin. Allergie-Centrum-Charité, Berlin, Germany
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Abstract
PURPOSE OF REVIEW The purpose of the review is to review the pathophysiology, available data, and our current recommendations for calcineurin inhibitor (cyclosporine and tacrolimus) treatment in antihistamine refractory chronic idiopathic urticaria (CIU) patients. RECENT FINDINGS Low-dose cyclosporine (<5 mg/kg per day) may have unique immunological modulating properties beyond mast cell and basophil stabilization in CIU. Starting CIU treatment with very low cyclosporine dosages (1 mg/kg per day) and titrating based on response and side-effects may decrease adverse events while preserving efficacy. In cyclosporine responsive patients failing cyclosporine taper, case series data support the safety and efficacy of long-term (5-10 years), very low dose (1-2 mg/kg per day) cyclosporine treatment with appropriate clinical monitoring. SUMMARY For CIU patients refractory to antihistamines, low-dose cyclosporine therapy (<3 mg/kg per day) with appropriate laboratory monitoring provides an alternative with an acceptable side-effect profile. Long-term (>12 months) moderate-dose (2.5-5 mg/kg per day) cyclosporine treatment may cause longitudinal increases in serum creatinine. However, decreasing or stopping cyclosporine dosing reverses measured nephrotoxicity in the vast majority of patients, and some patients with careful monitoring can tolerate very low-dose cyclosporine (<2 mg/kg per day) for longer periods. Tacrolimus is an alternative to cyclosporine with a slightly different adverse effect profile. Minimal data are available on its use in chronic urticaria.
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Current World Literature. Curr Opin Allergy Clin Immunol 2012; 12:570-3. [DOI: 10.1097/aci.0b013e328358c69e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Not all that itches is urticaria. Ann Allergy Asthma Immunol 2012; 109:10-3. [PMID: 22727151 DOI: 10.1016/j.anai.2012.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 05/10/2012] [Accepted: 05/11/2012] [Indexed: 11/23/2022]
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Viswanathan RK, Biagtan MJ, Mathur SK. The role of autoimmune testing in chronic idiopathic urticaria. Ann Allergy Asthma Immunol 2012; 108:337-341.e1. [PMID: 22541405 DOI: 10.1016/j.anai.2012.02.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 02/02/2012] [Accepted: 02/22/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND The clinical implications of autoimmune testing in chronic idiopathic urticaria (CIU) are not well established. OBJECTIVE To identify the association of autoimmune biomarkers in CIU with disease severity. METHODS We retrospectively evaluated 195 patients with a diagnosis of CIU for the presence of antinuclear antibody (ANA), anti-thyroglobulin antibody (ATG), anti-thyroperoxidase antibody (ATPO), and Chronic Urticaria (CU) Index. The patients were categorized into controlled and refractory subgroups based on their response to antihistamines with or without a leukotriene receptor antagonist. RESULTS The percentage of patients with a positive test for ANA (titer>1:160), ATG, ATPO, and CU Index were 29%, 6%, 26%, and 38%, respectively. Among those tested, the percentage of patients categorized as refractory was significantly higher in those with a positive CU index (80% vs 46%; P = .01) or a positive ANA titer (50% vs 30%; P = .04) than those with negative test results; however, a similar relationship was not observed for ATPO or ATG antibodies. Odds ratios of individual or combinations of autoimmune biomarkers in CIU were examined for associations with refractoriness to antihistamines with or without a leukotriene receptor antagonist. The CU Index alone has an odds ratio of 4.5 (P = .005), whereas the combination of ANA, ATG, and ATPO has an odds ratio of 3.1 (P = .01) and ANA alone has an odds ratio of 2.3 (P = .04) for correlating with a refractory outcome. CONCLUSION Our data indicate the CU Index independently has the strongest correlation with disease severity followed by the combination of ANA, ATG, and ATPO and the ANA alone.
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Affiliation(s)
- Ravi K Viswanathan
- Division of Allergy, Pulmonary and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Department of Medicine, William S. Middleton Veterans Hospital, Madison, Wisconsin
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