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Kaplan AP, Ferrer M. An algorithm for the diagnosis, pathogenesis and treatment of chronic spontaneous urticaria, 2024 update. Allergy 2024. [PMID: 38558416 DOI: 10.1111/all.16113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 03/12/2024] [Accepted: 03/22/2024] [Indexed: 04/04/2024]
Affiliation(s)
- Allen P Kaplan
- Department of Medicine, The Medical University of South Carolina, Charleston, South Carolina, USA
| | - Marta Ferrer
- Department of Allergy, Clinica Universidad de Navarra, Pamplona, Spain
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Efficacy of Different Dosing Regimens of IgE Targeted Biologic Omalizumab for Chronic Spontaneous Urticaria in Adult and Pediatric Populations: A Meta-Analysis. Healthcare (Basel) 2022; 10:healthcare10122579. [PMID: 36554102 PMCID: PMC9778713 DOI: 10.3390/healthcare10122579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Chronic urticaria is a debilitating skin condition that is defined as itchy hives at least twice a week and lasting for six or more weeks, with or without angioedema. Chronic spontaneous urticaria (CSU) is a form of disease that is witnessed in two-thirds of those with chronic urticaria. This meta-analysis explores the efficacy of differential dosages of omalizumab for outcomes of weekly itching scores, weekly wheal scores, urticarial assessment score 7 (UAS7), and responder rates. Adhering to PRISMA Statement 2020 guidelines, a systematic search of PubMed/MEDLINE, Scopus, Embase, and Web of Science was conducted until 15 September 2022. A combination of the following keywords was used: omalizumab and chronic urticaria. Data comprising clinical trial ID, name, author/year, country, dosage and time of intervention, inclusion criteria, mean age, female gender, and racial grouping information were obtained. The meta-analytical outcomes were analyzed in RevMan 5.4. The risk-of-bias assessment was conducted using version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2). A total of 10 trials comprising 1705 patients with CSU were included. Notably, 1162 belonged to the intervention group, while 543 were controls. A total of 70.4% of the participants were female in the intervention group, while 65.6% of them were female in the control group. The overall mean age was 38.64 ± 10.66 years. Weekly itch score outcomes were most notable with 150 mg dosage (Cohen’s d = −2.6, 95% CI = −4.75, −0.46, p = 0.02). The weekly wheal score outcomes had the largest effect size with 300 mg dosage (Cohen’s d = −1.45, 95% CI = −2.2, −0.69, p = 0.0002). For UAS7 outcomes, the largest effect size was yielded with 150 mg dosage (Cohen’s d = −6.92, 95% CI: −10.38, −3.47, p < 0.0001). The response rate to omalizumab had a likelihood of being higher with 300 mg of intervention compared to placebo (OR = 8.65, 95% CI = 4.42, 16.93, p < 0.0001). Well-rounded urticarial symptom resolution was observed with 150 mg and 300 mg dosages of omalizumab. Improvement of UAS7 was more comparable with 150 mg dosage, whereas the chance of response to treatment was higher with 300 mg dosage. Our findings support omalizumab as an effective intervention for adult and pediatric populations that are resistant to many therapies, including high-dose H1-antihistamines.
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Anti-IgE-gerichtete Therapie der Urtikaria in der dermatologischen Praxis. DIE DERMATOLOGIE 2022; 73:788-794. [PMID: 35925212 PMCID: PMC9215321 DOI: 10.1007/s00105-022-05023-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/31/2022] [Indexed: 11/28/2022]
Abstract
Es wurde eine retrospektive Datenanalyse von 26 Patienten mit chronisch spontaner Urtikaria (CSU), von denen 12 mit Anti-IgE-Therapie (Omalizumab) behandelt wurden, vorgenommen. Die Subkohorte der Omalizumab-therapierten Patienten hatte schwerere und länger andauernde klinische Verläufe, war mit verschiedenen Therapien und häufig stationär vorbehandelt und zeigte häufiger ein begleitendes Angioödem. Die Erhebung des Urticaria Activity Scores aus den 7‑Tages-Werten für Quaddeln und Juckreiz (UAS7) war ein wichtiges und geeignetes Instrument für die Indikationsstellung und Beurteilung des Therapieverlaufes unter Praxisbedingungen. Ein aufwendiges Laborscreening hingegen scheint wenig aussagestark für Schwere, Prognose und Therapieverlauf. Omalizumab erwies sich als gut verträgliche und sichere Therapieoption. Ein Drittel der Patienten erreichte Erscheinungsfreiheit, ein weiteres eine sehr gute Besserung. Bei einem Drittel blieb die Wirkung komplett aus, selbst wenn die Omalizumab- und/oder die Begleittherapien eskaliert wurden.
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Thiede RM, Fazel M, MacDonald KM, Abraham I. Does synthetic pharmacotherapy still have a place in treating chronic spontaneous urticaria? Expert Opin Pharmacother 2022; 23:1563-1567. [PMID: 36173375 DOI: 10.1080/14656566.2022.2128671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Rebecca M Thiede
- Division of Dermatology, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Mohammad Fazel
- Division of Dermatology, College of Medicine, University of Arizona, Tucson, AZ, USA
| | | | - Ivo Abraham
- Matrix45, Tucson, AZ, USA.,Center for Health Outcomes and PharmacoEconomic Research, University of Arizona, Tucson, AZ, USA.,Department of Pharmacy Practice and Science, R. Ken Coit College of Pharmacy, University of Arizona, Tucson, AZ, USA.,Department of Family and Community Medicine, R. Ken Coit College of Pharmacy, University of Arizona, Tucson, AZ, USA
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Toubi E, Vadasz Z. The Emerging Role of IL-17 in the Immune-Pathogenesis of Chronic Spontaneous Urticaria. Immunotargets Ther 2020; 9:217-223. [PMID: 33134229 PMCID: PMC7592154 DOI: 10.2147/itt.s266410] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 09/23/2020] [Indexed: 11/23/2022] Open
Abstract
Chronic spontaneous urticaria (CSU) is considered to be an autoimmune disorder (type I and type II) in 50% of all cases. However, autoreactive T cells and their proximity with activated mast cells in the skin of CSU patients are believed to be the primary event in mast cell degranulation. The finding of anti-FcɛRIα on mast cells or IgE autoantibodies against thyroid antigens should be considered to be a consequence of the auto-reactive T cells’ recognition of the above-mentioned antigens. Our recent finding of increased Th17 and IL-17 expression in both CD4+ T cells and mast cells in the skin of severe CSU patients is supportive for the major role that T cells perform in the pathogenesis of CSU. Supporting this are numerous previous reports in which increased serum IL-17 was found to be in association with CSU disease severity. The beneficial effect of anti-IL-17A (secukinumab) in CSU patients in whom high dose anti-histamines, recurrent course of steroids and omalizumab fail to achieve a reasonable response should be investigated as a new therapeutic strategy in future studies with a large cohort of patients.
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Affiliation(s)
- Elias Toubi
- The Outpatient Allergy Clinic, The Holy Family Hospital, Nazareth, Israel
| | - Zahava Vadasz
- The Proteomic Unit, The Division of Clinical Immunology, Bnai-Zion Medical Center, Faculty of Medicine, Technion, Haifa, Israel
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Combination therapy with omalizumab and an immune-suppressive agent for resistant chronic spontaneous rrticaria - A real-life experience. World Allergy Organ J 2020; 13:100448. [PMID: 32774663 PMCID: PMC7403771 DOI: 10.1016/j.waojou.2020.100448] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 11/20/2022] Open
Abstract
Background Chronic Spontaneous Urticaria (CSU) is a relatively common immune mediated disease that can be effectively treated nowadays. Nevertheless, for some patients remission cannot be achieved following current treatment recommendations, defined as resistant CSU (r-CSU). Treating r-CSU is challenging, and, currently, there are no recommended interventions. In this real-life study we describe successful therapy of 18 r-CSU patients using an "intensified protocol" of anti-IgE-antibody (omalizumab) concomitantly with an immunosuppressant. We defined the r-CSU phenotype and compared it to omalizumab-responsive CSU (Or-CSU) phenotype. Methods Clinical and serological data of 72 CSU patients (ie, 18 r-CSU and 54 age and sex matched Or-CSU) were retrospectively collected and analyzed. All patients were diagnosed with CSU for ≥6 months and treated at the Sheba Medical Center during 2013–2018. Results Of 289 CSU patients, 18 (6%) were diagnosed with r-CSU and treated with the "intensified protocol" including omalizumab and cyclosporine-A (16p), methotrexate (1p), and azathioprine (1p). Of which, 14/18 (78%) achieved complete remission, 2/18 (11%) partial remission, and 2/18 (11%) no remission. During follow-up no serious adverse events were documented. r-CSU patients received higher doses of antihistamine (p < 0.0001) and omalizumab (425 ± 58 mg/month vs. 283 ± 86 mg/month; p < 0.0001) compared to Or-CSU. The r-CSU phenotype was linked with concomitant autoimmunity (p = 0.0005) and a lower level of IgE prior to initiation of therapy (p = 0.027). Conclusion r-CSU may be a distinct CSU phenotype characterized by severe disease, concomitant autoimmunity, and lower baseline-IgE levels (low "autoallergy"). An "intensified protocol" with omalizumab and an immunosuppressive agent was found to be efficacious and safe for r-CSU. Further larger studies are required to verify these results.
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Treatment of urticaria: a clinical and mechanistic approach. Curr Opin Allergy Clin Immunol 2020; 19:387-392. [PMID: 31246664 DOI: 10.1097/aci.0000000000000538] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW This manuscript describes the recommended therapy of chronic spontaneous urticaria based on our understanding of the pathogenesis of hive formation. Thus, the mechanism of action of each medication is elaborated in addition to a discussion of clinical utility. RECENT FINDINGS The main drugs are antihistamines, omalizumab, and cyclosporine with a success rate of 40-55, 65-80, and 70-80%, respectively. Used in sequence, over 90% of patients can be successfully treated. The addition of omalizumab represents a major advance because of its efficacy, easy utility, and favorable side-effect profile. The interaction with IgE eliminates any reaction with antigens to which it might be directed, down regulates IgE receptors on mast cells and basophils, and leads to down-regulation of mast cell functions with amelioration of hives. SUMMARY The use of antihistamines in high dosage (at least four times a day) is effective in close to half the patients with CSU. For antihistamine resistance, the use of omalizumab has revolutionized therapy of antihistamine-resistant cases because of its efficacy and excellent side-effect profile. If the response is insufficient, cyclosporine is the next choice. Patients should be monitored regarding any adverse effects on blood pressure or renal function. All these are far safer than extended use of corticosteroid.
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Hon KL, Leung AKC, Ng WGG, Loo SK. Chronic Urticaria: An Overview of Treatment and Recent Patents. ACTA ACUST UNITED AC 2020; 13:27-37. [PMID: 30924425 PMCID: PMC6751347 DOI: 10.2174/1872213x13666190328164931] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 03/19/2019] [Accepted: 03/19/2019] [Indexed: 12/21/2022]
Abstract
Background: Up to 1% of the general population in the USA and Europe suffer from chronic urticaria (CU) at some point in their lifetime. CU has an adverse effect on the quality of life. Objective: This study aims to provide an update on the epidemiology, pathogenesis, clinical manifesta-tions, diagnosis, aggravating factors, complications, treatment and prognosis of CU. Methods: The search strategy included meta-analyses, randomized controlled trials, clinical trials, reviews and pertinent references. Patents were searched using the key term “chronic urticaria” at the following links: www.google.com/patents, www.uspto.gov, and www.freepatentsonline.com. Results: CU is a clinical diagnosis, based on the episodic appearance of characteristic urticarial lesions that wax and wane rapidly, with or without angioedema, on most days of the week, for a period of six weeks or longer. Triggers such as medications, physical stimuli, and stress can be identified in 10 to 20% of cases. C-reactive protein/erythrocyte sedimentation rate, and complete blood cell count with differential are the screening tests that may be used to rule out an underlying disorder. The mainstay of therapy is reassurance, patient education, avoidance of known triggers, and pharmacotherapy. Second-generation H1 antihistamines are the drugs of choice for initial therapy because of their safety and efficacy profile. If satisfactory improvement does not occur after 2 to 4 weeks or earlier if the symptoms are intolerable, the dose of second-generation H1 antihistamines can be increased up to fourfold the manufacturer’s recom-mended dose (all be it off license). If satisfactory improvement does not occur after 2 to 4 weeks or earlier if the symptoms are intolerable after the fourfold increase in the dosage of second-generation H1 antihis-tamines, omalizumab should be added. If satisfactory improvement does not occur after 6 months or earli-er if the symptoms are intolerable after omalizumab has been added, treatment with cyclosporine and sec-ond-generation H1 antihistamines is recommended. Short-term use of systemic corticosteroids may be considered for acute exacerbation of CU and in refractory cases. Recent patents for the management of chronic urticaria are also discussed. Complications of CU may include skin excoriations, adverse effect on quality of life, anxiety, depression, and considerable humanistic and economic impacts. On average, the duration of CU is around two to five years. Disease severity has an association with disease duration. Conclusion: CU is idiopathic in the majority of cases. On average, the duration of CU is around two to five years. Treatment is primarily symptomatic with second generation antihistamines being the first line. Omalizumab has been a remarkable advancement in the management of CU and improves the quality of life beyond symptom control.
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Affiliation(s)
- Kam L Hon
- Department of Paediatrics, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Alexander K C Leung
- Department of Pediatrics, The University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Wing G G Ng
- Department of Pediatrics, The University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Steven K Loo
- The Institute of Integrative Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
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Türk M, Carneiro-Leão L, Kolkhir P, Bonnekoh H, Buttgereit T, Maurer M. How to Treat Patients with Chronic Spontaneous Urticaria with Omalizumab: Questions and Answers. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:113-124. [DOI: 10.1016/j.jaip.2019.07.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 06/29/2019] [Accepted: 07/12/2019] [Indexed: 12/19/2022]
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Deza G, Ricketti PA, Giménez-Arnau AM, Casale TB. Emerging Biomarkers and Therapeutic Pipelines for Chronic Spontaneous Urticaria. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 6:1108-1117. [PMID: 30033912 DOI: 10.1016/j.jaip.2018.02.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 02/12/2018] [Accepted: 02/16/2018] [Indexed: 01/19/2023]
Abstract
Chronic spontaneous urticaria (CSU) is defined as the appearance of evanescent wheals, angioedema, or both, for at least 6 weeks. CSU is associated with intense pruritus and poor quality of life, with higher odds of reporting depression, anxiety, and sleep difficulty. As of yet, the assessment of the activity and course of the disease along with the response to several treatments in CSU are based purely on the patient's medical history and the use of the patient-reported outcomes. Recently, several reports have suggested that certain parameters could be considered as potential disease-related biomarkers. Moreover, with the advent of such biomarkers, newer biologic agents are coming forth to revolutionize the management of potential refractory diseases such as CSU. The purpose of this article is to review the most promising biomarkers related to important aspects of CSU, such as the disease activity, the therapeutic response, and the natural history of the disease, and discuss the mechanisms of action and therapeutic effectiveness of the latest agents available or currently under investigation for the management of antihistamine-refractory CSU. The knowledge of these features could have an important impact on the management and follow-up of patients with CSU.
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Affiliation(s)
- Gustavo Deza
- Department of Dermatology, Hospital del Mar- Institut Mar d'Investigacions Mèdiques, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Peter A Ricketti
- Division of Allergy and Immunology, University of South Florida College of Medicine, Tampa, Fla
| | - Ana M Giménez-Arnau
- Department of Dermatology, Hospital del Mar- Institut Mar d'Investigacions Mèdiques, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.
| | - Thomas B Casale
- Division of Allergy and Immunology, University of South Florida College of Medicine, Tampa, Fla
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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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Pathania YS, Bishnoi A, Parsad D, Kumar A, Kumaran MS. Comparing azathioprine with cyclosporine in the treatment of antihistamine refractory chronic spontaneous urticaria: A randomized prospective active-controlled non-inferiority study. World Allergy Organ J 2019; 12:100033. [PMID: 31193160 PMCID: PMC6518319 DOI: 10.1016/j.waojou.2019.100033] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 04/16/2019] [Accepted: 04/16/2019] [Indexed: 11/30/2022] Open
Abstract
Background Literature on the efficacy of azathioprine in antihistamine refractory chronic spontaneous urticaria (CSU) is limited. Objective To compare the efficacy and safety of azathioprine with respect to cyclosporine in the treatment of refractory CSU. Methods In this prospective, randomized, active-controlled, non-inferiority study, 80 patients of refractory CSU were administered either cyclosporine (group A, n = 40) or azathioprine (group B, n = 40) for 90 days and followed up for further 90 days. The treatment efficacy was assessed every 15th day using urticaria activity score (UAS7) and outcome scoring scale (OSS). Serum IgE levels, autologous serum skin test (ASST) and autologous plasma skin test (APST) were additionally measured at baseline and 90th day. Results Primary end point (≥75% reduction in UAS7 at 90th day) was achieved by 31/40 (79.5%) patients in group A and 32/40 (80%) patients in group B (proportion difference -0.5%, 95% confidence interval [CI] of difference -17.13 to 18.09; point estimates favoring B, CIs demonstrating non-inferiority). At 180th day, ≥75% reduction in UAS7 was maintained in 19/40 (47.95%) patients in group A and 24/40 (60%) patients in group B (proportion difference -12.5%, 95% CI of difference -9.00 to 32.46, point estimates favoring B, CIs demonstrating non-inferiority). Thus, the number of patients who could maintain ≥75% reduction in UAS7 at 180th day reduced significantly in group A (proportion difference 30%, 95% CI of difference 8.78 to 47.77), but not in group B (proportion difference 20%, 95% CI of difference -0.10 to 38.10). The values of mean UAS7 significantly decreased from 28.70 ± 4.42 and 28.88 ± 4.25 at baseline, to 5.56 ± 5.12 and 7.0 ± 4.48 at 90th day in group A and B respectively (group A, mean difference -23.27, 95% CI of difference -25.33 to -21.22; group B, mean difference -21.87, 95% CI of difference -23.78 to -19.96). It increased significantly to 9.98 ± 5.46 in group A at 180th day (mean difference 4.55, 95% CI of difference 2.98 to 6.12), but not in group B (mean UAS7 180th day 7.88 ± 5.53, mean difference 0.88, 95% CI of difference -0.82 to 2.57). The reduction in number of patients having positive ASST post-treatment was significant in group A, whereas reduction in IgE levels was more significant in group B. Conclusion The present study concludes that azathioprine is not inferior to cyclosporine in the treatment of refractory CSU, and it can be a valuable adjunct, especially in resource poor settings.
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Affiliation(s)
- Yashdeep Singh Pathania
- Department of Dermatology, Venereology and Leprology, PGIMER, Sector 12, Chandigarh, 160012, India
| | - Anuradha Bishnoi
- Department of Dermatology, Venereology and Leprology, PGIMER, Sector 12, Chandigarh, 160012, India
| | - Davinder Parsad
- Department of Dermatology, Venereology and Leprology, PGIMER, Sector 12, Chandigarh, 160012, India
| | - Ashok Kumar
- National Institute of Nursing Education, PGIMER, Sector 12, Chandigarh, 160012, India
| | - Muthu Sendhil Kumaran
- Department of Dermatology, Venereology and Leprology, PGIMER, Sector 12, Chandigarh, 160012, India
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Antia C, Baquerizo K, Korman A, Alikhan A, Bernstein JA. Urticaria: A comprehensive review: Treatment of chronic urticaria, special populations, and disease outcomes. J Am Acad Dermatol 2019; 79:617-633. [PMID: 30241624 DOI: 10.1016/j.jaad.2018.01.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Second-generation antihistamines are considered first-line agents in the treatment of chronic urticaria because of their safety and efficacy profile. Some patients require higher doses of H1 antihistamines alone or in combination with other classes of medications, including H2 antihistamines, leukotriene receptor antagonists, or first-generation H1 antihistamines. One major therapeutic advance has been omalizumab, a humanized monoclonal anti-immunoglobulin E that was recently approved by the US Food and Drug Administration for the treatment of chronic urticaria that is unresponsive to H1 antagonists. In addition, the second article in this continuing medical education series outlines several evidence-based alternative treatments for urticaria and the differences in recommendations between 2 major consensus groups (the European Academy of Allergy and Clinical Immunology/World Allergy Organization and the American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force).
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Affiliation(s)
- Camila Antia
- Department of Dermatology, University of Cincinnati, Cincinnati, Ohio.
| | | | - Abraham Korman
- College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Ali Alikhan
- Department of Dermatology, University of Cincinnati, Cincinnati, Ohio
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Saini SS, Kaplan AP. Chronic Spontaneous Urticaria: The Devil's Itch. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2018; 6:1097-1106. [PMID: 30033911 PMCID: PMC6061968 DOI: 10.1016/j.jaip.2018.04.013] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/15/2018] [Accepted: 04/23/2018] [Indexed: 11/20/2022]
Abstract
Chronic urticaria is defined as the presence of urticaria for a period exceeding 6 weeks, assuming symptoms for most days of the week. It is divided into chronic inducible urticarias and chronic spontaneous urticaria, previously termed chronic idiopathic urticaria. The latter designation emphasizes that patients can experience urticaria independent of any exogenous stimulus even if one can define circumstances that may worsen symptoms. A search for such an external "cause" is fruitless because the underlying abnormality is "intrinsic," whether it is autoimmune, or some unknown process. Approximately 40% of patients with chronic spontaneous urticaria report accompanying episodes of angioedema, whereas 10% have angioedema as their primary manifestation. In most cases, it is a self-limiting disorder, persisting for 2 to 5 years in most cases, although 20% of patients suffer for more than 5 years. The treatment that has evolved is largely empiric, based on double-blind, placebo-controlled studies whenever possible, but is not yet targeted to any particular pathogenic mechanism. In this article, we review the current status regarding pathogenesis, discuss the diagnostic workup, and update the approach to treatment including consideration of published guidelines, our own experience, and guideline updates that are being prepared.
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Affiliation(s)
- Sarbjit S Saini
- Department of Medicine, Division of Allergy and Clinical Immunology, Johns Hopkins Asthma and Allergy Center, Baltimore, Md.
| | - Allen P Kaplan
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Allergy and Clinical Immunology, Medical University of South Carolina, Charleston, SC
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Biomarkers to Diagnose, Assess and Treat Chronic Spontaneous Urticaria: Not There Yet. CURRENT TREATMENT OPTIONS IN ALLERGY 2017. [DOI: 10.1007/s40521-017-0147-z] [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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Stokes J. Anti-IgE Treatment for Disorders Other Than Asthma. Front Med (Lausanne) 2017; 4:152. [PMID: 28983485 PMCID: PMC5613080 DOI: 10.3389/fmed.2017.00152] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 09/05/2017] [Indexed: 12/21/2022] Open
Abstract
Immunoglobulin E (IgE) plays a key role in the pathogenesis of many allergic diseases. Thus, IgE-mediated immunologic pathways are an attractive target for intervention in allergic diseases. Omalizumab is a recombinant humanized monoclonal antibody that binds IgE and has been used treat allergic asthma for over a decade. Currently, omalizumab is approved for the treatment of both allergic asthma and chronic spontaneous urticaria. Since IgE plays a critical role in other allergic diseases, anti-IgE therapy has been evaluated in other allergic diseases in small clinical trials and case reports. Omalizumab has demonstrated efficacy in treating allergic rhinitis, atopic dermatitis, physical urticarias, mast cell disorders, food allergy, and other allergic diseases. In addition, the use of omalizumab with conventional allergen immunotherapy improves both safety and effectiveness.
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Affiliation(s)
- Jeffrey Stokes
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
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18
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Chang HW, Cheng HM, Yen HR, Hsu CY, Lee YC, Chiang JH, Sun MF. Association between chronic idiopathic urticaria and hypertension: A population-based retrospective cohort study. Ann Allergy Asthma Immunol 2017; 116:554-8. [PMID: 27264565 DOI: 10.1016/j.anai.2016.04.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Revised: 03/28/2016] [Accepted: 04/05/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Chronic idiopathic urticaria (CIU) is defined as urticaria that is not caused by external triggers. The pathogenesis of CIU remains unknown. A previous study investigated whether hypertension is associated with extended duration of CIU. OBJECTIVE To investigate the possible association between CIU and hypertension. METHODS We performed a population-based retrospective cohort study of 2,460 patients with CIU and 9,840 age-, sex-, and index year-matched comparison patients, using the National Health Insurance of Taiwan database. The median follow-up periods were 7.13 years for the CIU cohort and 7.20 years for the non-CIU cohort. The distributions by sex and age were similar for both cohorts. RESULTS The CIU cohort had a 1.37-fold (95% CI, 1.22-1.53) greater risk of developing subsequent hypertension than the non-CIU cohort after adjusting for sex, age, comorbidities, and nonsedating antihistamine use. CONCLUSION This nationwide retrospective cohort study found that CIU is associated with a higher future risk of hypertension after adjusting for sex, age, comorbidities, and nonsedating antihistamine use. The detailed pathophysiologic mechanisms require further clarification in prospective studies.
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Affiliation(s)
- Heng-Wei Chang
- Department of Chinese Medicine, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Hui-Man Cheng
- Department of Integration of Traditional Chinese and Western Medicine, China Medical University Hospital, Taichung, Taiwan; School of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Hung-Rong Yen
- Department of Chinese Medicine, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Chinese Medicine, China Medical University, Taichung, Taiwan; School of Chinese Medicine, China Medical University, Taichung, Taiwan; Research Center for Chinese Medicine and Acupuncture, China Medical University, Taichung, Taiwan
| | - Chung Y Hsu
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
| | - Yu-Chen Lee
- Department of Chinese Medicine, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Jen-Huai Chiang
- Research Center for Chinese Medicine and Acupuncture, China Medical University, Taichung, Taiwan; Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Mao-Feng Sun
- Department of Chinese Medicine, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Chinese Medicine, China Medical University, Taichung, Taiwan.
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19
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Joshi S, Khan DA. The Expanding Field of Biologics in the Management of Chronic Urticaria. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1489-1499. [PMID: 28734860 DOI: 10.1016/j.jaip.2017.05.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 05/03/2017] [Accepted: 05/17/2017] [Indexed: 10/19/2022]
Abstract
Chronic urticaria (CU) is the occurrence of urticaria with or without angioedema for at least 6 weeks. Management has traditionally involved antihistamines as first-line therapy with various alternative therapies for refractory cases. Largely based on the success of biologics for various diseases, this class of drugs has come to the forefront of medical research. The first and only Food and Drug Administration-approved biologic for the management of CU is omalizumab (humanized anti-IgE mAb). In the past decade, a substantial amount of research has been centered on the mechanism of action, efficacy, dosing, and safety of omalizumab. This review will focus on the data surrounding the management of CU with omalizumab, off-label use of other biologics for CU, and biologics currently under investigation for use in CU. We will also discuss management considerations and areas of interest for future research.
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Affiliation(s)
- Shyam Joshi
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - David A Khan
- University of Texas Southwestern Medical Center, Dallas, Texas.
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20
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Sánchez J, Zakzuk J, Cardona R. Evaluation of a Guidelines-Based Approach to the Treatment of Chronic Spontaneous Urticaria. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:177-182.e1. [PMID: 28709817 DOI: 10.1016/j.jaip.2017.06.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 05/29/2017] [Accepted: 06/02/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND International scientific associations have made recommendations for the management of chronic spontaneous urticaria (CSU) that have been summarized in clinical guidelines. OBJECTIVE To evaluate the clinical impact of guideline recommendations for CSU management. METHODS A multicenter, triple-blinded, prospective, randomized study (the Urticaria Research of Tropical Impact and Control Assessment project; ClinicalTrials.gov identifier: NCT01940393) was performed. Patients older than 12 years and diagnosed with CSU were recruited and treated according to the European Academy of Allergy and Clinical Immunology/Global Allergy and Asthma European Network/European Dermatology Forum/World Allergy Organization guideline recommendations. The Dermatology Quality of Life Index (DLQI) was assessed every 2 weeks. As a first line of treatment, patients received a daily oral dose of antihistamine. After 4 weeks, in those patients without clinical response (DLQI ≤ 5), a higher dose (up to 4 times) of antihistamine was administered as a second line of therapy. After 2 months of follow-up, unresponsive patients received omalizumab or cyclosporine (as add-on therapy) for 4 months as a third line of treatment. RESULTS One hundred fifty patients were enrolled. After the first line of treatment, 88 patients (58.7%) reached a DLQI of 5 or less. With the second line of treatment, disease control rate was 76.7%. With the third line, 12 patients from the omalizumab group (8%) and 11 patients from the cyclosporine group (7.3%) reached a good clinical control (additional 15.3%). Control rate with line 1 treatment was superior at 1 month than at 2 weeks (P < .0001). CONCLUSIONS The application of these guideline recommendations for CSU led to a high rate of disease control, assessed by scoring severity and patients' perception of quality of life. These results support the usefulness of guideline recommendations.
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Affiliation(s)
- Jorge Sánchez
- Group of Experimental and Clinical Allergy, IPS Universitaria, University of Antioquia, Medellín, Colombia; Institute for Immunological Research, University of Cartagena, Cartagena, Colombia; Foundation for the Development of Medical and Biological Sciences, Cartagena, Colombia.
| | - Josefina Zakzuk
- Institute for Immunological Research, University of Cartagena, Cartagena, Colombia; Foundation for the Development of Medical and Biological Sciences, Cartagena, Colombia
| | - Ricardo Cardona
- Group of Experimental and Clinical Allergy, IPS Universitaria, University of Antioquia, Medellín, Colombia
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21
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Gómez RM, Jares E, Canonica GW, Baiardini I, Passalacqua G, Sánchez Borges M, Kaplan AP, Baena-Cagnani CE. Why a registry of Chronic Urticaria (CUR) is needed. World Allergy Organ J 2017; 10:16. [PMID: 28546849 PMCID: PMC5433157 DOI: 10.1186/s40413-017-0147-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 03/23/2017] [Indexed: 11/10/2022] Open
Abstract
Chronic urticaria (CU) has a major effect on patients’ quality of life. While there have been progressive advances regarding its pathogenesis and treatment, much remains to be done. Registries of other chronic non-communicable diseases have shown many benefits, such as additional basic knowledge and management approaches to diabetes mellitus. Standards of care as well as diagnostic approaches can be elaborated and compared from different sites, using validated instruments. Registries in allergic diseases are also becoming well recognized, and the first registry on CU, accessible from SLaai’s webpage, includes parameters for identification, evaluation and management. In our vision, informatics strategies have the potential to improve care for chronic illnesses such as CU. The registry represents a valid instrument from which to obtain a sufficient sample size for epidemiological studies and/or clinical research planning, including feasibility and potential enrollment. It can also provide invaluable data for adapting guidelines to local populations, as well as diagnostic approaches and cost-effective interventions in the context of organizational efforts to improve patient care.
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Affiliation(s)
- R M Gómez
- Fundación Ayre at Instituto Médico Alas, Sarmiento 771, 330-31, 4400 Salta, Argentina.,Allergy & Asthma Unit, Hospital San Bernardo, Salta, Argentina
| | - E Jares
- Libra Foundation, Buenos Aires, Argentina
| | - G W Canonica
- Allergy & Respiratory Diseases Clinic, University of Genova, IRCCS AOU S.Martino, Genoa, Italy
| | - I Baiardini
- Allergy & Respiratory Diseases Clinic, University of Genova, IRCCS AOU S.Martino, Genoa, Italy
| | - G Passalacqua
- Allergy & Respiratory Diseases Clinic, University of Genova, IRCCS AOU S.Martino, Genoa, Italy
| | - M Sánchez Borges
- Allergy & Immunology Dpt, Centro Médico Docente La Trinidad, Caracas, Venezuela
| | - A P Kaplan
- The Medical University of South Carolina, Charleston, SC USA
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22
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Kaplan AP. Chronic Spontaneous Urticaria: Pathogenesis and Treatment Considerations. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2017; 9:477-482. [PMID: 28913986 PMCID: PMC5603475 DOI: 10.4168/aair.2017.9.6.477] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 04/06/2017] [Accepted: 04/08/2017] [Indexed: 12/02/2022]
Abstract
The treatment of chronic spontaneous urticaria begins with antihistamines; however, the dose required typically exceeds that recommended for allergic rhinitis. Second-generation, relatively non-sedating H1-receptor blockers are typically employed up to 4 times a day. First-generation antihistamines, such as hydroxyzine or diphenhydramine (Atarax or Benadryl), were employed similarly in the past. Should high-dose antihistamines fail to control symptoms (at least 50%), omalizumab at 300 mg/month is the next step. This is effective in 70% of antihistamine-refractory patients. H2-receptor blockers and leukotriene antagonists are no longer recommended; they add little and the literature does not support significant efficacy. For those patients who are unresponsive to both antihistamines and omalizumab, cyclosporine is recommended next. This is similarly effective in 65%–70% of patients; however, care is needed regarding possible side-effects on blood pressure and renal function. Corticosteroids should not be employed chronically due to cumulative toxicity that is dose and time dependent. Brief courses of steroid e.g., 3–10 days can be employed for severe exacerbations, but should be an infrequent occurrence. Finally, other agents, such as dapsone or sulfasalazine, can be tried for those patients unresponsive to antihistamines, omalizumab, and cyclosporine.
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Affiliation(s)
- Allen P Kaplan
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Allergy and Clinical Immunology, Medical University of South Carolina, Charleston, SC, USA.
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23
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IgE-Related Chronic Diseases and Anti-IgE-Based Treatments. J Immunol Res 2016; 2016:8163803. [PMID: 28097159 PMCID: PMC5209625 DOI: 10.1155/2016/8163803] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 11/02/2016] [Indexed: 12/23/2022] Open
Abstract
IgE is an immunoglobulin that plays a central role in acute allergic reactions and chronic inflammatory allergic diseases. The development of a drug able to neutralize this antibody represents a breakthrough in the treatment of inflammatory pathologies with a probable allergic basis. This review focuses on IgE-related chronic diseases, such as allergic asthma and chronic urticaria (CU), and on the role of the anti-IgE monoclonal antibody, omalizumab, in their treatment. We also assess the off-label use of omalizumab for other pathologies associated with IgE and report the latest findings concerning this drug and other new related drugs. To date, omalizumab has only been approved for severe allergic asthma and unresponsive chronic urticaria treatments. In allergic asthma, omalizumab has demonstrated its efficacy in reducing the dose of inhaled corticosteroids required by patients, decreasing the number of asthma exacerbations, and limiting the effect on airway remodeling. In CU, omalizumab treatment rapidly improves symptoms and in some cases achieves complete disease remission. In systemic mastocytosis, omalizumab also improves symptoms and its prophylactic use to prevent anaphylactic reactions has also been discussed. In other pathologies such as atopic dermatitis, food allergy, allergic rhinitis, nasal polyposis, and keratoconjunctivitis, omalizumab significantly improves clinical manifestations. Omalizumab acts in two ways: by sequestering free IgE and by accelerating the dissociation of the IgE-Fcε receptor I complex.
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24
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Bishnoi A, Parsad D, Vinay K, Kumaran MS. Phototherapy using narrowband ultraviolet B and psoralen plus ultraviolet A is beneficial in steroid-dependent antihistamine-refractory chronic urticaria: a randomized, prospective observer-blinded comparative study. Br J Dermatol 2016; 176:62-70. [PMID: 27258736 DOI: 10.1111/bjd.14778] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Literature on the efficacy of phototherapy in steroid-dependent antihistamine-refractory chronic urticaria (CRU) is limited. OBJECTIVES To assess and compare the efficacy of psoralen plus ultraviolet A (PUVA) and narrowband ultraviolet B (NB-UVB) in steroid-dependent CRU. METHODS In this randomized, prospective observer-blinded comparative study, 50 patients with steroid-dependent CRU (6 months of spontaneous urticaria with no response after 3 consecutive months of antihistamines and steroid dependence) were administered either PUVA (group A) or NB-UVB (group B) for 90 days, with a post-treatment follow-up of 90 days. The treatment efficacy was assessed using the average urticaria activity score 7 (aUAS7) and outcome scoring scale (OSS) every 2 weeks. RESULTS The mean values of aUAS7 progressively decreased from 4·9 ± 0·8 and 5·0 ± 0·7 at baseline to 1·9 ± 0·7 and 1·4 ± 0·7 in groups A and B, respectively, by day 90. This further decreased to 1·5 ± 0·8 and 1·4 ± 1·0 at day 180 in both groups. The values of OSS progressively increased from baseline (1·6 ± 0·5 in group A and 1·3 ± 0·5 in group B) to 3·9 ± 0·3 and 4·0 ± 0·3 in groups A and B, respectively, by day 90, and 3·9 ± 0·5 and 4·0 ± 0·6 by day 180. NB-UVB fared statistically better than PUVA at different time points. Adverse events encountered were minimal and did not warrant treatment discontinuation. CONCLUSIONS Phototherapy, especially NB-UVB, is an effective, safe and affordable therapeutic modality for steroid-dependent CRU and should be tried prior to third-line treatment options such as omalizumab, ciclosporin and other immunosuppressants.
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Affiliation(s)
- A Bishnoi
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - D Parsad
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - K Vinay
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - M S Kumaran
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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25
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Greiwe J, Bernstein JA. Therapy of antihistamine-resistant chronic spontaneous urticaria. Expert Rev Clin Immunol 2016; 13:311-318. [PMID: 27744711 DOI: 10.1080/1744666x.2017.1249467] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Chronic urticaria affects up to 1-3% of the general population and contributes to significant direct and indirect medical costs as well as decreased quality of life, which has a significant economic impact on our health care system. Areas covered: Given the prevalence of this condition on a large sector of the population, finding lasting relief for refractory cases is essential and is the focus of this review. Expert commentary: The choice of appropriate therapy in chronic refractory urticaria is not a 'one-size fits all' approach. Treatment should take multiple factors into consideration including the chronicity of hives, presence of physical urticaria, type of cellular infiltrate on skin histopathology, patient age, concomitant comorbid conditions, as well as patient preference and cost.
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Affiliation(s)
- Justin Greiwe
- a Bernstein Allergy Group , Cincinnati , OH , USA.,b Department of Internal Medicine, Division of Immunology Rheumatology and Allergy , University of Cincinnati College of Medicine , Cincinnati , OH , USA
| | - Jonathan A Bernstein
- a Bernstein Allergy Group , Cincinnati , OH , USA.,b Department of Internal Medicine, Division of Immunology Rheumatology and Allergy , University of Cincinnati College of Medicine , Cincinnati , OH , USA
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26
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Abstract
Urticaria is a common symptom seen in pediatric patients, and it has multiple allergic and nonallergic causes. Unfortunately, it is far too common that when children present acutely for urticaria, they are told that it is an "allergy." This statement often leads to increased anxiety while the patient waits to be evaluated by an allergist/immunologist. This article discusses the frequency that allergic reactions are involved in urticaria and provides examples of potential nonallergic causes. Additionally, the article discusses approaches to treatment that may be appropriate to initiate in the pediatrician's office or acute setting. This article is intended to provide a broader understanding of urticaria and its management in the outpatient or emergency setting so that we are able to tell our patients more than"you're probably just allergic to something." [Pediatr Ann. 2016;45(11):e399-e402.].
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27
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Dreyfus DH. Differential Diagnosis of Chronic Urticaria and Angioedema Based on Molecular Biology, Pharmacology, and Proteomics. Immunol Allergy Clin North Am 2016; 37:201-215. [PMID: 27886907 DOI: 10.1016/j.iac.2016.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Differential diagnosis of urticaria and angioedema has been based on the phenotype as either acute or chronic depending on the duration of more than 6 to 8 weeks, respectively. Additional subdivisions include poorly defined terms such as idiopathic, spontaneous, or autoimmune. In this article, the author suggests that an increased understanding of the acquired and innate immune system and data from novel proteomic technology have blurred the lines between these categories of diagnosis. Specific molecular pathways and response to specific medications should be incorporated in classification and diagnosis schemes.
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Affiliation(s)
- David H Dreyfus
- Yale School of Medicine, Gesher LLC, Allergy, Asthma and Clinical Immunology, 4 Clifton Avenue, Waterbury CT 06710, USA.
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28
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Abstract
Chronic urticaria (CU) is defined as wheals, angioedema, or both, that last more than 6 weeks. Second-generation antihistamines are considered the first-line therapy for CU. Unfortunately, many patients will fail antihistamines and require alternative therapy, including immune response modifiers or biologics. Multiple biological agents have been evaluated for use in antihistamine-refractory CU, including omalizumab, rituximab, and intravenous immunoglobulin; omalizumab is the most efficacious. Because of the success of omalizumab, multiple new biologics that are directed at the IgE pathway are under investigation. This review summarizes the relevant data regarding the efficacy of biologics in antihistamine-refractory CU.
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Affiliation(s)
- Adeeb Bulkhi
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida, Tampa, FL, USA; Department of Internal Medicine, College of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Andrew J Cooke
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida, Tampa, FL, USA
| | - Thomas B Casale
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida, Tampa, FL, USA.
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29
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Guillén-Aguinaga S, Jáuregui Presa I, Aguinaga-Ontoso E, Guillén-Grima F, Ferrer M. Updosing nonsedating antihistamines in patients with chronic spontaneous urticaria: a systematic review and meta-analysis. Br J Dermatol 2016; 175:1153-1165. [PMID: 27237730 DOI: 10.1111/bjd.14768] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2016] [Indexed: 12/12/2022]
Abstract
There is a lack of large, randomized, double-blind studies that address antihistamine updosing for chronic spontaneous urticaria (CSU). The objective of this systematic review is to explore and analyse available data to provide clinical evidence for the efficacy of antihistamine updosing. We searched the literature in Medline, Scopus, Google Scholar, Embase, Web of Science and Cochrane databases using the keywords 'chronic, urticaria, antihistamines' to identify studies published between January 1990 and November 2014. We assessed quality using the Jadad score that evaluates quality of randomization, double-blinding and losses to follow-up. We identified 1042 articles and 15 articles were included in the final evaluation. We performed two meta-analyses, one that included studies that analysed treatment response among groups receiving different antihistamine dosages vs. placebo, and another that analysed antihistamine updosing in those patients who did not respond to standard dosages. Only five articles obtained a high quality level score. We did not find significant differences in response rates or number of weals in those patients who received a standard dosage vs. a high dosage. We found a significant improvement only in the pruritus variable of the Urticaria Activity Score scale. The estimated relative risk for improvement by increasing the antihistamine dosage was 2·27 [95% confidence interval (CI) 1·68-3·06]; however, there was significant heterogeneity. The proportion of nonrespondent patients with CSU who responded to antihistamine updosing was 63·2% (95% CI 57-69·6). We found that updosing antihistamines significantly improved control of pruritus but not weal number. However, the relative weakness of the studies and the significant heterogeneity among them made it difficult to reach a final conclusion.
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Affiliation(s)
- S Guillén-Aguinaga
- Department of Allergy and Clinical Immunology, Clinica Universidad de Navarra, Pamplona, Spain
| | | | - E Aguinaga-Ontoso
- Murcia Department of Health, Center of Health Technology Innovation, Murcia, Spain.,Department of Socio-Sanitary Sciences, Medical School, University of Murcia, Murcia, Spain
| | - F Guillén-Grima
- Department of Preventive Medicine, Clinica Universidad de Navarra, Pamplona, Spain.,Navarra's Health Research Institute IDISNA, Pamplona, Spain
| | - M Ferrer
- Department of Allergy and Clinical Immunology, Clinica Universidad de Navarra, Pamplona, Spain.,Navarra's Health Research Institute IDISNA, Pamplona, Spain
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30
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Wu EY, Saini SS. Chronic Idiopathic Urticaria. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 3:1003-4; quiz 105. [PMID: 26553623 DOI: 10.1016/j.jaip.2015.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 07/20/2015] [Accepted: 07/24/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Eveline Y Wu
- North Carolina Children's Hospital, Division of Allergy, Immunology, and Rheumatology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Sarbjit S Saini
- Johns Hopkins Asthma & Allergy Center, Division of Allergy & Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
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31
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Moy AP, Murali M, Nazarian RM. Identification of a Th2- and Th17-skewed immune phenotype in chronic urticaria with Th22 reduction dependent on autoimmunity and thyroid disease markers. J Cutan Pathol 2016; 43:372-8. [PMID: 26785710 DOI: 10.1111/cup.12673] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Revised: 12/30/2015] [Accepted: 01/17/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Chronic urticaria is a condition with many inciting factors and often presents a therapeutic challenge to clinicians. In addition to a central role for mast cells, an immune dysregulated state related to cytokine/chemokine alterations is increasingly being recognized. METHODS Biopsies of chronic urticaria (n = 11) and normal skin (n = 5) were evaluated with immunostains for CD117, CD3 and dual stains for CD4/T-bet, GATA-3, STAT-3 or BNC-2 (transcription factors specific and mutually exclusive for Th1, Th2, Th17 and Th22 cells, respectively). Clinical data, including autoantibodies and thyroid function tests, and the number of CD117+ mast cells and percent of Th1, Th2, Th17 and Th22 of CD3+ T-cells were compared. RESULTS Th2 cells and Th17 cells were significantly more frequent in chronic urticaria than controls. In contrast, there was no significant difference in mast cells, Th1 cells or Th22 cells. Three of nine chronic urticaria patients had evidence of autoimmune disease; biopsies from these patients trended toward a greater number of mast cells and decreased percent of Th-cell subtypes as compared with those without autoimmunity markers, with significantly less Th22 cells. CONCLUSIONS These findings provide novel insight into the role of Th2 and Th17 in chronic urticaria pathophysiology and may impact therapy.
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Affiliation(s)
- Andrea P Moy
- Pathology Service, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Mandakolathur Murali
- Pathology Service, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Rosalynn M Nazarian
- Pathology Service, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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32
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Hsieh FH. Year in review: urticaria and angioedema. Ann Allergy Asthma Immunol 2015; 114:166-7. [PMID: 25744898 DOI: 10.1016/j.anai.2014.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 11/25/2014] [Accepted: 12/01/2014] [Indexed: 10/23/2022]
Affiliation(s)
- Fred H Hsieh
- Allergy and Immunology, Respiratory Institute, Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.
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33
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Abstract
Chronic urticaria (CU) is a common condition faced by many clinicians. CU has been estimated to affect approximately 0.5%-1% of the population, with nearly 20% of sufferers remaining symptomatic 20 years after onset. Antihistamines are the first-line therapy for CU. Unfortunately, nearly half of these patients will fail this first-line therapy and require other medication, including immune response modifiers or biologics. Recent advances in our understanding of urticarial disorders have led to more targeted therapeutic options for CU and other urticarial diseases. The specific biologic agents most investigated for antihistamine-refractory CU are omalizumab, rituximab, and intravenous immunoglobulin (IVIG). Of these, the anti-IgE monoclonal antibody omalizumab is the best studied, and has recently been approved for the management of CU. Other agents, such as interleukin-1 inhibitors, have proved beneficial for Schnitzler syndrome and cryopyrin-associated periodic syndromes (CAPS), diseases associated with urticaria. This review summarizes the relevant data regarding the efficacy of biologics in antihistamine-refractory CU.
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Affiliation(s)
- Andrew Cooke
- Department of Internal Medicine, Division of Allergy and Immunology, University of South Florida, Tampa, FL, USA
| | - Adeeb Bulkhi
- Department of Internal Medicine, Division of Allergy and Immunology, University of South Florida, Tampa, FL, USA ; Department of Internal Medicine, College of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Thomas B Casale
- Department of Internal Medicine, Division of Allergy and Immunology, University of South Florida, Tampa, FL, USA
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Ferrer M, Bartra J, Giménez-Arnau A, Jauregui I, Labrador-Horrillo M, Ortiz de Frutos J, Silvestre JF, Sastre J, Velasco M, Valero A. Management of urticaria: not too complicated, not too simple. Clin Exp Allergy 2015; 45:731-43. [PMID: 25429900 PMCID: PMC4403957 DOI: 10.1111/cea.12465] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2014] [Indexed: 11/27/2022]
Abstract
In spite of being an old disease and apparently easy to diagnose, chronic spontaneous urticaria (CSU) is still perceived as an uncontrollable and difficult to manage disease. The perception of the patient is that his/her condition is not well understood and that is suffering from a disorder with hidden causes that doctors are not able to tackle. Sometimes patients go through a number of clinicians until they found some CSU expert who is familiar with the disease. It is surprising that myths and believes with no scientific support still persist. Guidelines are not widely implemented, and recent tools to assess severity are infrequently used. European and American recent guidelines do not agree in several key points related to diagnosis and treatment, which further contributes to confusion. With the aim to clarify some aspects of the CSU picture, a group of allergists and dermatologists from the Spanish Dermatology and Allergy societies developed a Frequent Asked Questions leaflet that could facilitate physicians work in daily practice and contribute to a better knowledge of common clinical scenarios related to patients with CSU.
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Affiliation(s)
- M Ferrer
- Department of Allergy and Clinical Immunology, Clínica Universidad de NavarraPamplona, Spain
| | - J Bartra
- Allergy Unit, Pneumology Department, Hospital Clinic, University of BarcelonaBarcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)Barcelona, Spain
| | - A Giménez-Arnau
- Dermatology Department, Hospital del Mar, Parc de Salut Mar, Universitat Autonoma BarcelonaBarcelona, Spain
| | - I Jauregui
- Allergy Department, Hospital Universitario BasurtoBilbao, Spain
| | - M Labrador-Horrillo
- Allergy Section, Medicine Department, Hospital Vall d'Hebron, Universitat Autònoma de BarcelonaBarcelona, Spain
| | - J Ortiz de Frutos
- Dermatology Department, Hospital Universitario 12 de OctubreMadrid, Spain
| | - J F Silvestre
- Dermatology Department, Hospital General Universitario de AlicanteAlicante, Spain
| | - J Sastre
- Allergy Department, Fundación Jiménez DiazMadrid, Spain
| | - M Velasco
- Dermatology Department, Hospital Arnau de VilanovaValencia, Spain
| | - A Valero
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)Barcelona, Spain
- Allergy Unit, Pneumology and Respiratory Department, Hospital Clínic (ICT), University of BarcelonaBarcelona, Spain
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Stokes JR, Casale TB. The Use of Anti-IgE Therapy Beyond Allergic Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:162-6. [DOI: 10.1016/j.jaip.2014.10.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Revised: 10/08/2014] [Accepted: 10/10/2014] [Indexed: 11/29/2022]
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Biologic agents and the therapy of chronic spontaneous urticaria. Curr Opin Allergy Clin Immunol 2015; 14:347-53. [PMID: 24936849 DOI: 10.1097/aci.0000000000000083] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Chronic spontaneous urticaria (CSU) has been traditionally managed with antihistamines. Over the years, studies using different formulations and dosing regimens have delineated the limits of their effectiveness, thus emphasizing the need for alternative therapeutic approaches. Data keep accumulating that the monoclonal anti-immunoglobulin E antibody omalizumab, until recently reserved for the treatment of severe atopic asthma, may have a beneficial therapeutic and safety profile for CSU cases resistant to the effect of antihistamines. RECENT FINDINGS Since the beginning of 2013, a host of studies have been published paving the way for licensing of omalizumab for the treatment of CSU. Dose-finding studies have indicated 300 mg monthly as a possible optimal treatment regimen. Efficacy proving randomized controlled trials were further supported by open-label studies confirming its effectiveness in real life. One report has been published so far presenting positive data about the use of another biologic agent, rituximab, depleting the blood stream of B cells, in patients with CSU. SUMMARY New convincing evidence in support of the efficacy and safety of omalizumab in the treatment of CSU has accumulated over the past year, providing another tool for coping with the antihistamine-resistant cases.
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