Urticaria: impact on quality of life and economic cost

Combination of H1 and H2 Histamine Receptor Antagonists: Current Knowledge and Perspectives of a Classic Treatment Strategy

Histamine receptor antagonists, which can bind to specific histamine receptors on target cells, exhibit substantial therapeutic efficacy in managing a variety of histamine-mediated disorders. Notably, histamine H1 and H2 receptor antagonists have been extensively investigated and universally acknowledged as recommended treatment agents for numerous allergic diseases and acid-related disorders, respectively. Historically, the combination of H1 and H2 receptor antagonists has been considered a classic treatment strategy, demonstrating relatively superior efficacy compared with single-drug therapies in the treatment of diverse histamine-mediated diseases. The latest emerging studies have additionally suggested the underlying roles of histamine and H1R and H2R in the development of anxiety disorders, arthritic diseases, and postexercise hypotension. Nevertheless, there is still a lack of systematic reviews on the clinical efficacy of combination therapy, greatly limiting our understanding of its clinical application. Here, we present a comprehensive overview of the current knowledge and perspectives regarding the combination of H1 and H2 histamine receptor antagonists in various histamine-mediated disorders. Furthermore, we critically analyze the adverse effects and limitations associated with combination therapy while suggesting potential solutions. Our review can offer a systematic summary and promising insights into the in-depth and effective application of the combination of H1 and H2 receptor antagonists.

Bridging knowledge gaps in paediatric chronic urticaria through a video-based educational tool

BACKGROUND

There is a lack of patient educational resources about chronic urticaria (CU).

AIMS

To develop and test the effectiveness of an education tool to help paediatric patients and their families better understand CU and its management.

METHODS

From July 2020 to May 2022, paediatric patients with a history of CU who presented to the allergy outpatient clinics at our institution were recruited. Consenting families and patients were asked to complete five questions related to the definition, causes and management of CU at the time of presentation to the clinic. Participants were shown a 5-min animated video addressing the main knowledge gaps about CU. At the end of the video, participants were redirected to the same five questions to respond again. The scores were recorded as a proportion of correct answers (range 0·0-1·0).

RESULTS

In total, 53 patients [30 girls (56·6%), 23 boys (43·4%); mean age 9·7 ± 5·1 years, range 1·4-18·5 years] were recruited. The mean baseline pre-video education questionnaire score was 0·67 ± 0·2 (range 0·2-1·0), while the mean post-video score was 0·94 ± 0·1 (range 0·4-1·0), a mean score difference of 0·27, which was statistically significant (P < 0·001). At the 1-year follow-up, 14 (26·4%) patients answered the questionnaire again to assess retention of knowledge; the mean score was 0·83 ± 0·2 (range 0·2-1·0).

CONCLUSIONS

Our educational video was successful in educating patients and their families to better understand urticaria. Future studies should aim to optimize patient education through nontraditional tools such as videos, and compare knowledge gain using different methods of education.

Unveiling chronic spontaneous urticaria pathophysiology through systems biology

BACKGROUND

Chronic spontaneous urticaria (CSU) is a rare, heterogeneous, severely debilitating, and often poorly controlled skin disease resulting in an itchy eruption that can be persistent. Antihistamines and omalizumab, an anti-IgE mAb, are the only licensed therapies. Although CSU pathogenesis is not yet fully understood, mast cell activation through the IgE:high-affinity IgE receptor (FcεRI) axis appears central to the disease process.

OBJECTIVE

We sought to model CSU pathophysiology and identify in silico the mechanism of action of different CSU therapeutic strategies currently in use or under development.

METHODS

Therapeutic performance mapping system technology, based on systems biology and machine learning, was used to create a CSU interactome validated with gene expression data from patients with CSU and a CSU model that was used to evaluate CSU pathophysiology and the mechanism of action of different therapeutic strategies.

RESULTS

Our models reflect the known role of mast cell activation as a central process of CSU pathophysiology, as well as recognized roles for different therapeutic strategies in this and other innate and adaptive immune processes. They also allow determining similarities and differences between them; anti-IgE and Bruton tyrosine kinase inhibitors play a more direct role in mast cell biology through abrogation of FcεRI signaling activity, whereas anti-interleukins and anti-Siglec-8 have a role in adaptive immunity modulation.

CONCLUSION

In silico CSU models reproduced known CSU and therapeutic strategies features. Our results could help advance understanding of therapeutic mechanisms of action and further advance treatment research by patient profile.

Remibrutinib, a novel BTK inhibitor, demonstrates promising efficacy and safety in chronic spontaneous urticaria

BACKGROUND

Chronic spontaneous urticaria (CSU) is inadequately controlled in many patients and greatly affects quality of life. Remibrutinib, a highly selective, oral, novel covalent Bruton tyrosine kinase inhibitor, might be effective in CSU.

OBJECTIVE

This first-in-patient trial aimed to evaluate the efficacy and safety of remibrutinib in CSU treatment and characterize the dose-response.

METHODS

This randomized, double-blind, placebo-controlled, phase 2b dose-finding trial evaluated remibrutinib (12 weeks) in patients inadequately controlled with second-generation H₁-antihistamines, with at least moderately active CSU, with or without prior anti-IgE treatment (NCT03926611). Patients received remibrutinib 10 mg once daily, 35 mg once daily, 100 mg once daily, 10 mg twice daily, 25 mg twice daily, 100 mg twice daily, or placebo (1:1:1:1:1:1:1 ratio). The main end points were weekly Urticaria Activity Score change from baseline at week 4 and safety.

RESULTS

Overall, 311 patients were randomized. Reduced symptom score was observed for all remibrutinib doses from week 1 until week 12, with weekly Urticaria Activity Score change from baseline at week 4: -19.1 (10 mg once daily), -19.1 (35 mg once daily), -14.7 (100 mg once daily), -16.0 (10 mg twice daily), -20.0 (25 mg twice daily), -18.1 (100 mg twice daily), and -5.4 for placebo (nominal P < .0001 for all doses vs placebo). Most adverse events were mild or moderate, with no dose-dependent pattern.

CONCLUSION

Remibrutinib was highly effective in the treatment of CSU over the entire dose range, with a rapid onset of action and a favorable safety profile.

New transcriptome and clinical findings of platelet-activating factor in chronic spontaneous urticaria: Pathogenic and treatment relevance

The objective of the study was to assess the pathogenic and treatment relevance of Platelet Activating factor (PAF) in chronic spontaneous urticaria (CSU). The expression and cellular location of PAF receptor (PAFR) and serum levels of PAF and PAF acetylhydrolase (PAF-AH) in patients with moderate/severe CSU (n = 45) and healthy controls (HCs, n = 17) were studied. Skin samples from the active wheal (LS-CSU, 13 samples for qPCR and 33 for immunohistochemistry) and non-lesional skin (NLS-CSU, 13 samples) of CSU patients and HCs (13 samples and 5 for immunohistochemistry) were analyzed. Serum PAF and PAF-AH levels were measured by ELISA and compared between HC (10 samples) and CSU patients (25 samples) and, among them, between those refractory and non-refractory to second-generation H₁ -antihistamines (sgAH). PAFR mRNA expression was significantly higher in LS-CSU versus HCs (p = 0.014). PAFR positive staining in immunohistochemistry was mainly found in the epidermal basal layer in HCs, whereas it was broadly present along the epidermis in LS-CSU samples. Endothelial cells showed PAFR expression exclusively in LS-CSU and NLS-CSU samples. PAFR expression was observed in the nerves of HC, LS-CSU, and NLS-CSU samples. Double PAFR/CD43 expression showed that T-lymphocytes were the main cell type from the wheal inflammatory infiltrate expressing PAFR. A significantly lower PAF-AH/PAF ratio was observed in sgAH non-responders versus responders (6.1 vs. 12.6; p = 0.049). Our study confirms that PAF is a mediator of wheal pathogenesis in CSU. The significantly lower PAF-AH/PAF ratio in sgAH non-responders vs responders suggests that PAF could be a potential biomarker of sgAH refractoriness.

Plasma D-Dimer Level in Vietnamese Patients with Chronic Urticaria

Background

Chronic Urticaria (CU) is one of the most common skin diseases, affecting 2-3% of the population. Many studies have demonstrated that plasma D-dimer levels could be considered as a biomarker for disease activity and treatment response in patients with CU.

Aim

To evaluate plasma D-dimer levels in patients with CU and their correlation with disease severity.

Methods

The present study was a case-controlled study conducted in 97 patients with CU and 40 healthy subjects. Plasma D-dimer levels were measured using the enzyme-linked immunosorbent assay.

Results

The mean plasma D-dimer level in patients with CU (807.76 ng/mL) was significantly higher than that in normal subjects (424.63 ng/mL) (P < 0.001). A significant correlation was observed between plasma D-dimer levels and the urticaria active score (P = 0.005, r = 0.28). Our study also suggested a significant difference in plasma D-dimer levels between patients with CU with and without angioedema.

Conclusions

Patients with CU had higher plasma D-dimer levels than the control group. A positive statistical correlation was observed between plasma D-dimer levels and severity of CU.

High prevalence and little awareness in patients with chronic inflammatory skin diseases and genital involvement

BACKGROUND

Genital involvement in patients with chronic inflammatory skin diseases is frequent, yet insufficiently acknowledged.

OBJECTIVE

To evaluate the prevalence of genital symptoms in psoriasis and chronic urticaria patients, effects on quality of life, physician-patient relations and disease management.

PATIENTS AND METHODS

100 patients with psoriasis and 100 with chronic urticaria from our outpatient clinic, as well as 50 healthy controls were included. Data was collected using questionnaires developed by dermatological experts.

RESULTS

Out of 250 subjects, 74 % had already experienced genital symptoms - 70 % of psoriasis patients and 58 % of urticaria patients. Seven out of ten even complained about recurrent genital involvement. 50 % of psoriasis and 41 % of urticaria patients reported an impact on quality of life. 41 % identified genital pruritus as the main symptom, with one out of three expecting a better management for this specific problem. Furthermore, 74 % complained about a lack of awareness among physicians: 79 % of urticaria patients and 58 % of psoriasis patients reported never having been questioned about genital symptoms by their physicians.

CONCLUSIONS

The majority of patients with psoriasis and chronic urticaria suffer from genital involvement and an impaired quality of life. Patient and physician reported outcomes should include genital symptoms as an influencing factor for quality of life.

Health-related quality of life in children with hereditary angioedema compared with patients with histaminergic angioedema

Background: Hereditary angioedema (HAE) is a potentially life-threatening disease that remarkably impacts patients' health-related quality of life (HRQoL). This study evaluated the HRQoL in children with HAE and compared it with healthy controls and patients with histaminergic angioedema (HA). Methods: Fifty-nine children with HAE (median [interquartile range {IQR}], ages, 8.9 years [5.4-12.6 years]), 60 children with HA (median [IQR] ages, 10.3 years [8-15.4 years]), and 72 healthy controls (median [IQR] ages, 10.3 years [6.6-13.9 years]) were recruited. All the children and their families completed the age-adapted KINDL generic instrument for assessing health-related quality of life in children and adolescents. Results: The total HRQoL score and other subscales scores of both the patients with HAE and patients with HA, and the parent-proxy reports were significantly lower than those of the healthy children (p < 0.05). In the patients with HAE, the age at symptom onset was positively correlated with physical well-being (r = 0.335; p = 0.043) and negatively correlated with self-esteem (r = -0.324; p = 0.049). In addition, the physical well-being scores were affected by the site of attacks, which was significantly lower in the patients with abdominal pain attacks (p = 0.045). The family scores and total scores were statistically significantly higher in the HA group than the HAE group (p < 0.001 and p = 0.009, respectively). A significant correlation was found between self-report and parent-proxy HRQoLs in total and all subscales scores in the patients with HAE. For HA, there were no significant correlations for family scores. Conclusion: HAE caused significant impairment of the HRQoL of children and their families, and affected their lifestyle and quality of life. In pediatric patients with HAE, the HRQoL is mainly related to age at symptom onset and the site of attacks. Although patients with HAE are affected more negatively than the patients with HA, HA affected the quality of life as well.

The challenges of chronic urticaria part 1: Epidemiology, immunopathogenesis, comorbidities, quality of life, and management

This is Part 1 of an updated follow-up review of a World Allergy Organization (WAO) position paper published in 2012 on the diagnosis and treatment of urticaria and angioedema. Since 2012, there have been advances in the understanding of the pathogenesis of chronic urticaria, and greater experience with the use of biologics, such as omalizumab, in patients with severe refractory disease. For these reasons, the WAO decided to initiate an update targeted to general practitioners around the world, incorporating the most recent information on epidemiology, immunopathogenesis, comorbidities, quality of life, clinical case presentations, and the management of chronic spontaneous and chronic inducible urticaria, including urticaria in special situations such as childhood and pregnancy. A special task force of WAO experts was invited to write the different sections of the manuscript, and the final document was approved by the WAO Board of Directors. This paper is not intended to be a substitute for current national and international guidelines on the management of urticaria and angioedema but to provide an updated, simplified guidance for physicians around the world who manage patients with this common ailment.

Efficacy of NB-UVB as Add-on Therapy to Antihistamine in the Treatment of Chronic Urticaria: A Systematic Review and Meta-analysis

INTRODUCTION

Narrow-band ultraviolet B (NB-UVB) phototherapy has been used for the treatment of chronic urticaria (CU), but the clinical efficacy of this treatment modality requires further evidence. A systematic review and meta-analysis of randomized clinical trials were conducted to evaluate the efficacy and safety of NB-UVB as add-on therapy in the treatment of CU.

METHODS

A literature search was conducted in the Cochrane, Embase, PubMed, Web of Science, CNKI, CBM, VIP and WanFang databases up to October 2020. A total of nine studies involving 713 participants met the inclusion criteria.

RESULTS

Two trials showed a significant difference in the Urticaria Activity Score between therapy with NB-UVB + antihistamines and that with antihistamines alone (mean difference 8.23, 95% confidence interval [CI] 5.78-10.68, p < 0.00001). Six trials (563 participants) showed a significant benefit of NB-UVB as add-on therapy to antihistamines in the total effective rate (risk ratio [RR] 1.56, 95% CI 1.39-1.75, p < 0.00001). In terms of adverse events, no statistically significant differences were found for NB-UVB + antihistamines versus antihistamines alone (RR 1.10, 95% CI 0.67-1.79, p = 0.71). Combination therapy of NB-UVB + antihistamines yielded a significantly lower risk of recurrence (RR 0.25, 95% CI 0.14-0.44, p < 0.00001).

CONCLUSION

Our meta-analysis suggests that combination therapy of NB-UVB + antihistamines is significantly more effective in treating CU than antihistamines alone.

Epidemiology of urticaria in German children

BACKGROUND

To date, robust epidemiological metrics as well as data on comorbidity in pediatric urticaria are lacking. They form the basis for the design of efficient healthcare.

METHODS

Retrospective study to analyze epidemiological data in pediatric urticaria. The analysis is based on routine data of a health insurance company operating throughout Germany (DAK-Gesundheit). Insured people under 18 years of age who received at least one confirmed outpatient or inpatient urticaria diagnosis according to the ICD-10 classification in the years 2010 to 2015 were included in the analysis and compared to children without a corresponding diagnosis.

RESULTS

Of 2.3 million insured individuals, 313,581 (13.5 %) were under 18 years of age (153,214 female). Urticaria was diagnosed in 1.7 % of the 313,581 patients. The prevalence of urticaria decreased with age from 3.0 % in the 0-3-year age group to 1.0 % in the 14-18-year age group. Boys and girls were almost equally affected in all age groups. Atopic diseases as comorbidity occurred more frequently in children with urticaria than in the control group (16.0 % vs. 8.0 %). Autoimmune diseases, mental health problems, and obesity also occurred more frequently in children with urticaria than in the control group.

CONCLUSIONS

The increased prevalence of specific comorbidities in children with urticaria suggests an increased need for screening. Multimodal treatment strategies need to be developed and interdisciplinary collaboration promoted.

Feasibility assessment of an 8-week attention-based training programme in the management of chronic spontaneous urticaria

BACKGROUND

Chronic spontaneous urticaria is a common disorder that is poorly understood and frequently misdiagnosed. Psychological difficulties are a significant factor in dermatological diseases and may also aggravate symptom burden. Mind-body interventions are used as a complementary approach to alleviate symptoms in chronic diseases and may represent a valuable non-pharmacological approach in CSU.

METHODS

We sought to develop and evaluate the feasibility of an 8-week attention-based training (ABT) programme, coupled to biofeedback technology for CSU. Through convergent interviews, we gathered information from individuals with urticaria about possible links between stress, mood and skin symptoms. Using these data, we recruited 12 participants to engage in an amended ABT programme for patients with CSU, comprising eight 90-min sessions held weekly. Participants completed psychometric measures and measures of urticaria symptomatology as assessed by the urticaria control test, prior to and after the intervention. Adherence to ABT practice was measured using individual inner balance devices which tracked heart rate variability. We completed qualitative interviews after the intervention to obtain feedback on participant experience of the programme.

RESULTS

Participants with CSU described how their psychological wellbeing can be linked to skin symptoms, poor sleep and difficulty concentrating. An amended ABT programme was found to be an acceptable component of care in the management of CSU. Retention of participants in the programme was challenging with 33% participants dropping out of the programme. For those who did complete the programme, three participants exceeded weekly practice at week 8. A decrease in severity of urticaria symptomatology as measured by the urticaria control test was observed upon completion of the intervention. The most commonly cited barrier to implementation of the programme was the time commitment required.

CONCLUSIONS

Integrating an ABT programme into routine clinical care for CSU patients is feasible and was deemed acceptable and valuable by individuals who took part. Further formal evaluation of ABT for CSU including the analysis of biochemical parameters is required to determine its role in the management of this distressing condition.

TRIAL REGISTRATION

This trial is registered with ISRCTN with study ID ISRCTN13672947 . Registration took place on 22/09/2020 (retrospectively registered).

Use of biologics in chronic spontaneous urticaria - beyond omalizumab therapy?

In chronic spontaneous urticaria (CSU), itchy wheals, angioedema, or both occur regularly, often daily, and for years. An effective therapy for CSU aims at achieving complete symptom control. The current guideline for the management of CSU patients recommends non-sedative anthistamines in standard or up to 4-fold higher dosages as 1 and 2 line treatment. For most CSU patients this treatment is not sufficient; for them, the anti-IgE antibody omalizumab is the therapy of choice. Although good to very good symptom control can be achieved in most cases, there are many patients with insufficient response. For these patients, but also as an alternative to therapy with omalizumab, numerous other biologicals are currently under development. In this review, we provide an overview of possible future biologic therapies for chronic urticaria.

Economic considerations on the usage of biologics in the allergy clinic

The advent of biologic therapies has transformed care for severe atopic disorders but their high cost poses new challenges with regard to long-term sustainability and fair allocation of resources. This article covers the basic concepts of cost-utility analyses and reviews the available literature on cost utility of biologic drugs in atopic disorders. When used within their limits as part of a multi-dimensional assessment, economic analyses can be extremely useful to guide decision-making and prioritization of care. Despite the good quality of most cost-utility analyses conducted for the use of biologics in asthma and other atopic diseases, their conclusions regarding cost-effectiveness are extremely variable. This is mainly due to the use of inconsistent estimates of health utility benefit with therapy. Development of reliable and validated instruments to measure disutility in atopic disorders and measure of indirect costs in atopic disease are identified as a priority for future research.

Association of Chronic Spontaneous Urticaria With Anxiety and Depression in Adolescents: A Mediation Analysis

Background: Chronic spontaneous urticaria (CSU) is related to psychiatric comorbidities. It is not clear whether the relationship is affected by modifiable factors. Objectives: To investigate whether the effect of CSU on anxiety and depression in adolescents is mediated by the symptoms of itching and sleep disturbance. Methods: Questionnaire survey was conducted among newly enrolled college students. Dermatologists diagnose skin diseases, including CSU, during health examination. Anxiety and depression were measured by the Generalized Anxiety Disorder Scale and Patient Health Questionnaire, respectively. Sleep quality was measured by the Pittsburgh Sleep Quality Index. The symptoms of itching were measured by the numeric rating scale. According to the hypothesis, the mediating effect model was put forward and the structural equation model is used to build the mediation effect model. The mediation effect model was proposed according to the hypothesis and established using a structural equation model. Results: A total of 2,358 students with no history of systemic disease and no pruritus disease (except CSU) were included in the analysis. A total of 393 CSU patients were included, and 1,965 healthy controls were selected based on age and sex matching. CSU was significantly associated with both anxiety and depression when the symptoms of itching and sleep quality were not modeled. A mediation model was proposed as CSU → itching → sleep disturbance → anxiety or depression. Itching and sleep quality mediated 65.4 and 77.6% of CSU's effects on anxiety and depression, respectively, and CSU had no significant direct effect on anxiety or depression in the mediation models. Conclusions: The associations of CSU with anxiety and depression were mediated by the symptoms of itching and sleep disturbance. Effectively reducing the symptoms of itching thereby could increase natural sleep, which can further treat the emotional disorders among patients with CSU.

Efficacy of Bloodletting Therapy in Patients with Chronic Idiopathic Urticaria: A Randomized Control Trial

Objective

To assess the efficacy of bloodletting therapy (acupoint pricking and cupping) in patients with chronic idiopathic urticaria (CIU) in a randomized, control, parallel-group trial.

Methods

A total of 174 patients with CIU enrolled from March 2018 to October 2019 were randomized into three groups: group A treated with bloodletting therapy and ebastine, group B treated with placebo treatment (acupoint pseudopricking and cupping) and ebastine, and group C treated with ebastine only. The intention-to-treat analysis was conducted, and the primary outcome was the effective rate of UAS7 score being reduced to 7 or below after treatment phase.

Results

The effective rates at the end of treatment phase were different among the three groups (P < 0.05), which were 73.7% in group A, 45.6% in group B, and 42.9% in group C. Multiple analysis indicated differences between groups A and B (P < 0.0125) and groups A and C (P < 0.0125) and no difference between groups B and C (P > 0.0125). No severe bloodletting therapy-related adverse events were observed.

Conclusions

In this study on patients with CIU, one month of bloodletting therapy combined with ebastine is clinically beneficial compared with placebo treatment combined with ebastine and treatment with ebastine only. Thus, bloodletting therapy can be an effective complementary treatment in CIU. This trial is registered with ChiCTR1800015294.

Compound glycyrrhizin combined with antihistamines for chronic urticaria: A protocol for systematic review and meta analysis

BACKGROUND

To investigate the efficacy and safety of compound glycyrrhizin (CG) combined with antihistamines in the treatment of chronic urticaria (CU).

METHODS

We will use computers to search all databases including Medline, Embase, Pubmed, Web of Science and Cochrane Central Register of Controlled Trials and China's 4 databases: China National Knowledge Infrastructure Database, China Biomedical Literature Database, China Science Journal Database, and Wanfang Database. Find data from creation date to July 2020. In addition, we will manually search the list of medical journals as a supplement. The scope of the search included randomized controlled clinical studies related to CG combined with antihistamines for CU. The primary outcome is the disease activity control. Secondary outcomes include response rate, adverse events, and recurrence rates. The Cochrane RevMan V5.3 Deviation Assessment Tool will be used to assess bias assessment risk, data integration risk, meta-analysis risk, and subgroup analysis risk (if conditions are met). The average difference, standard mean difference, and binary data will be used to represent continuous results.

RESULTS

This study will comprehensively review the existing evidence on CG combined with antihistamines for CU.

CONCLUSION

This systematic review will provide a basis for judging the effectiveness and safety of CG combined with antihistamines in the treatment of CU.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42020156153.

Clinically significant differences in patient-reported outcomes evaluations in chronic spontaneous urticaria

PURPOSE OF REVIEW

The aim of this review is to highlight the conceptual and practical knowledge for interpreting score changes in patient-reported outcomes (PROs) that have been validated for chronic spontaneous urticaria (CSU).

RECENT FINDINGS

The urticaria guidelines recommends to assess PROs as Health-Related Quality of Life, disease activity and disease control, to detect the CSU impact and the overall treatment effect. To this aim it is crucial to determine the minimal important difference (MID) to assess if changes in questionnaire scores represent either perceived improvement or deterioration for patients. Methods for establishing the MID are well defined and are clustered into two broad categories: distribution-based and anchor-based.

SUMMARY

For the majority of the available questionnaires for CSU, an MID has been defined, according to the results of various approaches. In most of the studies in our review, anchor-based methods, either alone or in combination with distribution ones, were used. The available information regarding MIDs across validated tools for CSU patients helps to interpret measurement scores and allows the implementation of PROs in routine practices.

The association of chronic spontaneous urticaria (CSU) with anxiety and depression: a nationwide cohort study

Chronic spontaneous urticaria (CSU) is a dermatological disease associated with significant impairment of overall quality of life as well as psychological distress. Previous studies have demonstrated significant comorbidity between CSU and a wide range of mental illnesses. In this study we aimed to focus on the association between CSU and anxiety and depression, using an optimized matched controlled design. A nationwide matched control study was conducted using the Clalit Health Services (CHS) database. The study included 12,539 CSU patients and 60,510 age and sex matched controls. Three multiple logistic regression models were conducted to assess the association between CSU and anxiety and depression, while adjusting for age, sex, socioeconomic status (SES), diabetes, obesity, hypertension, and smoking status. A higher frequency of anxiety and depression was found in CSU patients compared to that in controls (anxiety frequency of 9.6% vs. 5.7%, p < 0.001; depression frequency of 11% vs 7.9%, p < 0.001, respectively) after adjustment for demographic and clinical factors. The association of CSU with anxiety was the strongest in the 18-29 age group, and in the high SES group, while the association of CSU with depression was the highest in the 50-69 age group, and in the low SES group. Chronic spontaneous urticaria is associated with anxiety and depression. In light of the clinical implications of a comorbid mental disorder, dermatologists should consider employing mental health screening procedures, especially for patients from specific risk groups.

Approach to the Patient with Hives

Urticaria is a common presenting problem to the primary care provider. Acute urticaria lasting less than 6 weeks may be associated with a drug or food allergens. Chronic urticaria lasting more than 6 weeks is often associated without a known underlying cause. Inducible stimuli causing hives should be excluded using specific provocation testing. Treatment follows a standardized algorithmic approach as outlined by the Joint Task Force Practice Parameter and/or International Urticaria guidelines. Patients not responsive to steps 1 or 2 should be referred to an urticaria specialist for further evaluation and treatment. The prognosis and outcome of urticaria is generally very favorable for most patients.

New treatments for chronic urticaria

OBJECTIVE

Chronic urticaria (CU) is a common, heterogeneous, and debilitating disease. Antihistamines and omalizumab are the mainstay therapies of CU. Additional treatment options are needed. Here, we review the off and beyond label use of licensed drugs, novel treatments that are currently under development, and promising new targets.

DATA SOURCES

MEDLINE was searched for recent reports of the successful use of treatments in CU and promising targets for the development of novel treatment options. We also searched ClinicalTrials.gov for recent and ongoing randomized clinical trials in CU.

STUDY SELECTIONS

Relevant articles were selected and reviewed.

RESULTS

Omalizumab, the treatment of choice in patients with antihistamine-resistant chronic spontaneous urticaria (CSU), should be explored for use in chronic inducible urticaria in children younger than 12 years with CSU and at higher doses. The off-label use of dupilumab, reslizumab, mepolizumab, and benralizumab can be effective in CU. Ligelizumab and UB-221, 2 novel anti-IgE monoclonal antibodies, are in clinical trials for CU. Other promising drugs that are currently under development for CU are a chemoattractant receptor-homologous molecule expressed on T_H2 cell antagonist, a monoclonal antibody to Siglec-8 (AK002), Bruton tyrosine kinase inhibitors (fenebrutinib and Lou064), a spleen tyrosine kinase inhibitor, and dupilumab. Promising targets of future therapies include the Mas-related G-protein-coupled receptor X2; the histamine₄ receptor; C5a and its receptor; inhibitory mast cell receptors other than Siglec-8; interleukin 33, interleukin 25, and thymic stromal lymphopoietin, and stem cell factor.

CONCLUSION

Novel and better treatments for CU are very much needed. Some agents are in clinical trials already (eg, ligelizumab), and additional ones should be developed, making use of the many promising targets recently identified and characterized.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Autologous whole-blood or autologous serum acupoint injection therapy for chronic urticaria: A systematic review protocol

BACKGROUND

Chronic urticaria (CU) is a common and easily recurring skin disease in the world. Many trials have shown that autologous whole-blood or autologous serum acupoint injection therapy is effective in treating CU. There is currently no systematic review of this therapy. The program aims to evaluate the effectiveness and safety of this therapy in patients with CU.

METHODS

Literature search will be conducted at Medline, PubMed, Excerpt Medica Database, Springer, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Chinese Scientific Journal Database, and other databases. The search date is until May 2019. We will search for popular terms including CU and this therapy. Import the literature electronically. Duplicate documents will be deleted. The primary outcome is the urticaria activity score or other validated scales. Secondary outcomes included response rate, quality of life scale, recurrence rate, and adverse events. A systematic review and search for a randomized controlled trial of this therapy for CU. Implement the Cochrane RevMan V5.3 bias assessment tool to assess bias assessment risk, data integration risk, meta-analysis risk, and subgroup analysis risk (if conditions are met). The mean difference, standard MD, and binary data will be used to represent continuous results.

RESULTS

This study will provide a comprehensive review of the available evidence for the treatment of CU with this therapy.

CONCLUSION

This study will provide new evidence for assessing the effectiveness and side effects of this therapy for CU. Since the data is not individualized, there is no need for formal ethical approval.

PROSPERO REGISTRATION NUMBER

CRD42019128364.

Bloodletting Therapy for Patients with Chronic Urticaria: A Systematic Review and Meta-Analysis

Background

Many trials have reported that bloodletting therapy is effective when treating chronic urticaria. There are currently no systematic reviews of bloodletting therapy for chronic urticaria.

Objective

The aim of this review is to assess the effectiveness and safety of bloodletting therapy for chronic urticaria.

Methods

A systematic review and meta-analysis of randomized controlled trials were performed. Disease activity control was assessed as the primary outcome. Response rate, recurrence rate, and adverse events were assessed as secondary outcomes.

Results

Seven studies with 512 participants were included. One trial showed a significant difference between bloodletting therapy plus medicine and medicine alone in disease activity control (MD 0.67; 95% CI 0.03 to 1.31; p=0.04). Six trials (372 participants) showed a significant difference between bloodletting therapy and pharmacological medication in response rate (RR 1.10; 95% CI 0.97-1.26; P =0.15). Two studies (170 participants) showed a significant difference between bloodletting therapy plus pharmacological medication and pharmacological medication in response rate (RR 1.34; 95% CI 1.10-1.63; p=0.003). Two studies (126 participants) reported a statistically significant difference between bloodletting therapy and pharmacological medication in recurrence rate. No serious adverse events related to bloodletting therapy were reported.

Conclusions

Bloodletting therapy might be an effective and safe treatment for chronic urticaria, but the evidence is scarce. More high quality trials are needed in the future.

Efficacy and safety of Xiaofeng powder (xiao feng san) in treating urticaria: A protocol for a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Urticaria is a common skin disease that has a high impact on a patient's daily life. Xiaofeng powder (XFP) is one of the most commonly used Chinese herbal formula in China for urticaria. However, due to the lack of systematic evaluations, its clinical efficacy remains controversial. This meta-analysis was performed to evaluate the effect and safety of XFP for urticaria.

METHODS

Seven databases, including Cochrane Central Register of Controlled Trials, PubMed, Embase, the Chinese National Knowledge Infrastructure (CNKI), the Chinese Scientific Journal Database (VIP), the Chinese Biomedical Literature Database (CBM), and the Wanfang Database. The period will be from their inception to September 2018. Randomized controlled trials of XFS used separately against conventional Western medicine therapy in patients with urticarial were included. After the methodologic quality was assessed and the valid data were extracted, RevMan 5.3 software was used for the final meta-analysis.

RESULTS

The results will provide evidence regarding the efficacy and safety of XFP in treating urticaria.

CONCLUSION

The conclusion of our systematic review will provide evidence to judge whether XFP is an effective intervention for patient with urticaria. This systematic review will be disseminated in peer-reviewed publications. The results of the study will provide evidence concerning the efficacy and safety of Xiaofeng Powder (xiao feng san) in treating urticaria.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD 42018087260.

Managing chronic spontaneous urticaria (hives) in primary care

Chronic spontaneous urticaria is characterised by the spontaneous appearance of hives or wheals, and/or angioedema, lasting for at least six weeks. The condition may be associated with significant physical and emotional burden for patients. Nurses have an important role in the differential diagnosis of chronic spontaneous urticaria, assessing patients' quality of life, providing advice on non-pharmacological measures, monitoring the patient's response to treatment, and referring the patient for specialist care, where appropriate. This article describes the presentation, diagnosis and management of chronic spontaneous urticaria in primary care.

Stress, itch and quality of life in chronic urticaria females

Introduction

Chronic urticaria (CU) belongs to a group of psychodermatological disorders, thus stress can play a significant role in this dermatosis onset and/or exacerbation. On the other hand, the disease itself accompanied by itch, may be a source of distress and could worsen patients' quality of life (QoL).

Aim

The first goal of our study was to compare stress intensity between CU subjects and the control group. The second aim was to investigate the relationships between disease-related parameters (CU severity, itch) and psychological variables (stress and QoL) in CU patients.

Material and methods

Forty-six female patients with CU participated in our study. Thirty-three healthy females constituted a control group. The following methods were applied: Urticaria Activity Score (UAS), Itch Severity Evaluation Questionnaire, Visual analogue scale (VAS), Social Readjustment Rating Scale (SRRS) and the Chronic Urticaria Quality of Life Questionnaire (CU-Q2oL).

Results

Chronic urticaria patients demonstrated a significantly higher stress level in comparison to the control group (z = 2.699; p < 0.001). Regarding the total pruritus score, all CU-Q2oL dimensions were affected, except for subscale swelling/mental status. The strongest link was revealed between global itch and QoL subscale embarrassment (r = 0.51, p < 0.001). There were also statistically significant correlations between stress (VAS scale and SRRS) and QoL (all at least p < 0.05).Conclusions: Taking into account the significant pruritus contribution to QoL impairment, it would be worth employing itch-coping trainings in the CU group. As a consequence, feeling of self-control and self-efficacy could be enhanced, thus resulting in the well-being improvement.

Integrated behavioral health care for management of stress in allergic diseases

OBJECTIVE

This article reviews current findings regarding the management of stress in allergic disease.

DATA SOURCES

The authors use articles and books published between 1995 and 2017. Approximately 85% of sources used were published in the last 10 years, and 60% were published in the last 5 years. Most of the sources are peer-reviewed articles.

STUDY SELECTIONS

Articles that focused on allergic diseases such as allergic rhinitis, food allergies, urticaria, and allergic asthma were included. Articles in which whether the underlying disorder was allergic in nature (for example, nonspecified asthma) were not included. Preference was given to articles published within the past five years.

RESULTS

Patients with allergic diseases, particularly those with chronic or co-occurring allergic diseases, often experience stress and, in turn, this experience of stress can exacerbate disease presentation. High rates of treatment nonadherence in patients with allergic disease also can increase disease burden and stress. Research supports the benefit of behavioral health interventions for patients with allergic disease. Interventions with multidisciplinary teams, which include behavioral health, as well as interventions at the school, workplace, and community level, are recommended.

CONCLUSION

Medical providers working with patients with allergic disease need to address patients' experience of stress and nonadherence to treatment recommendations. This could be done through routine screening and referrals to behavioral health or, ideally, through incorporation of a behavioral health provider within a multidisciplinary patient team.

Burden of Illness and Quality-of-Life Measures in Angioedema Conditions

Burden of illness studies and evaluation of health-related quality of life using validated questionnaires have become an important task in the comprehensive management of angioedema conditions, mainly angioedema associated with chronic spontaneous urticaria and hereditary angioedema caused by C1-inhibitor deficiency. A review of the principal tools and studies is presented. Both diseases present a higher proportion of psychiatric disorders, impair work and studies productivity, and produce high direct and indirect costs. These assessments also have been useful to evaluate the positive impact of new drugs and interventions. More studies are desirable, especially in other types of angioedema disorders, such as hereditary angioedema with normal C1 inhibitor.

Validity and responsiveness of the Urticaria Activity and Impact Measure: A new patient-reported tool

BACKGROUND

Chronic spontaneous urticaria (CSU), also known as chronic idiopathic urticaria, may produce hives, itch, and angioedema. The Urticaria Activity and Impact Measure (U-AIM) is a newly developed 9-item patient-reported measure designed for use in routine clinical practice to assess CSU activity and impact during the previous 7 days.

OBJECTIVE

To evaluate validity, responsiveness, and clinically meaningful change of the U-AIM.

METHODS

Data from a 24-week, open-label, single-arm period of a randomized, placebo-controlled study of omalizumab were used to assess the psychometric properties of U-AIM items for itch, hives, and angioedema.

RESULTS

A total of 206 patients (75% female; mean age, 44.6 years) were enrolled. At baseline, U-AIM results included prevalent severe itch (55%) and more than 12 hives (67%), angioedema (15%), and bother by itch (84%), hives (84%), and angioedema (49%). The Urticaria Patient Daily Diary (UPDD) mean weekly scores were 15.4 (itch severity), 16.8 (number of hives), and 32.2 (Urticaria Activity Score [UAS7]). At baseline, week 12, and week 24, U-AIM itch and hives items and UAS7 proxy scores (the sum of itch severity and number of hives during 7 days) demonstrated strong correlation coefficients with their corresponding measures from the UPDD (itch severity: 0.634-0.806; hives number: 0.735-0.843; UAS7 proxy: 0.724-0.852). Changes in U-AIM scores differentiated patients by their perspective of symptom improvement. Meaningful change thresholds were established for itch severity and number of hives scores (range, 0.8-1.0 for both) and the UAS7 proxy score (range, 10.5-12.5).

CONCLUSION

The U-AIM is valid and responsive to change and may help clinicians monitor CSU activity and track treatment effectiveness.

Disease-specific impairment of the quality of life in adult patients with chronic spontaneous urticaria

BACKGROUND/AIMS

Chronic urticaria (CU) is a common skin disorder characterized by wheals and pruritus lasting more than 6 weeks. Due to its long duration and changeable symptoms, the quality of life (QOL) of patients with CU can be impaired substantially. We evaluated the CU-QOL, a previously validated CU-specific QOL measure, and investigated factors influencing QOL in chronic spontaneous urticaria (CSU) patients.

METHODS

A hospital-based cross-sectional study was performed on 390 adult patients diagnosed with CSU from March 2009 to December 2012 at the Allergy and Clinical Immunology Clinic at Ajou University Hospital. The CU-QOL questionnaire, urticaria activity score (UAS), combined angioedema, and serum total immunoglobulin E (IgE) levels were investigated.

RESULTS

The average CU-QOL score obtained from the questionnaire was 70.6 (of 100 points). The CU-QOL scores correlated significantly with the UAS, particularly with the 15-point UAS (UAS-15; coefficient -0.532, p < 0.01) rather than the 6-point UAS (-0.502, p < 0.01). The patients presenting with angioedema and urticaria had poorer scores in the urticaria symptom domain than those with urticaria alone (37.4 vs. 46.9, p = 0.004). Log-transformed serum total IgE levels correlated significantly with CU-QOL (-0.131, p < 0.05). Multivariate regression models indicated that severe CU (UAS-15 score ≥ 13), log (total IgE), and the presence of angioedema were significant predictors of impaired CU-QOL (< 85 points).

CONCLUSIONS

CU has a substantial negative impact on QOL. The assessment of UAS-15, total IgE, and the presence of angioedema can be useful to predict QOL of the patients with CSU.

Chronic Urticaria Patient Perspective (CUPP): The First Validated Tool for Assessing Quality of Life in Clinical Practice

BACKGROUND

There is a need for validated tools to assess health-related quality of life (HRQoL) in routine clinical practice.

OBJECTIVE

The aim of this study was to validate the Chronic Urticaria Patient Perspective (CUPP) for assessment of patients with chronic urticaria (CU) in clinical practice.

METHODS

A provisional CUPP was developed from candidate items identified by following an iterative process in a retrospective analysis of 249 Chronic Urticaria Quality of Life Questionnaire questionnaires. The psychometric properties of the CUPP were then tested on a sample of patients enrolled in 13 Italian centers.

RESULTS

The study population in the validation phase comprised 152 patients. The 10-item version of the CUPP showed satisfactory internal consistency (Cronbach's alpha values of 0.76 at visit 1 and 0.90 at visit 2), good criteria, and discriminative and convergent validity. Reliability was assessed in 34 patients with no changes in health (Global Rating Scale = 0 at visit 2) and was satisfactory (CCC [concordance correlation coefficient] = 0.9). Changes in CUPP scores were significantly associated with changes in Urticaria Activity Score (UAS)-Hive count (r = 0.36, P < .001), UAS-Itch severity (r = 0.48, P < .001), and UAS-Total score (r = 0.342, P < .001), all of which indicated good responsiveness. The minimal important difference was 1.5.

CONCLUSIONS

CUPP is a simple 10-question tool with good psychometric properties that provides a valid, reliable, and standardized measurement of HRQoL in patients with CU.

The Expanding Field of Biologics in the Management of Chronic Urticaria

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.

Omalizumab substantially improves dermatology-related quality of life in patients with chronic spontaneous urticaria

Background

Chronic spontaneous/idiopathic urticaria (CSU/CIU) has substantial detrimental effects on health‐related quality of life (HRQoL) with an effect comparable to or worse than many other skin diseases.

Objective

To assess the effect of omalizumab on CSU patients' HRQoL, measured by the Dermatology Life Quality Index (DLQI) in three phase III studies ASTERIA I, ASTERIA II and GLACIAL.

Methods

A post hoc analysis examined changes in DLQI scores, distribution of patients across DLQI bands and the proportion reaching minimal clinically important difference (MCID) following omalizumab vs. placebo.

Results

Omalizumab 300 mg significantly improved total DLQI scores vs. placebo, with a mean decrease from baseline to week 12 of −10.3 vs. −6.1 (P < 0.0001) in ASTERIA I, −10.2 vs. −6.1 (P = 0.0004) in ASTERIA II and −9.7 vs. −5.1 (P < 0.0001) in GLACIAL. A significant shift from high disease impact on life at baseline towards less impact at week 12 was seen with omalizumab 300 mg vs. placebo (P < 0.001; all studies). The proportion of patients where change in mean total DLQI score from baseline to week 12 reached an MCID of ≥4 was 74.1%, 76.0% and 77.2% in ASTERIA I, II and GLACIAL, respectively (P < 0.01; all studies).

Limitations

Maximum duration of omalizumab treatment was 24 weeks.

Conclusion

This additional analysis assessed the impact of CSU and benefit of treatment with omalizumab by exploring different facets of DLQI data by treatment arm at multiple assessment points. The original aspects of analysis included applying the concept of the recently validated score for the MCID of the DLQI, changes in DLQI domain scores and in the distribution of subjects based on validated total DLQI score bands. It showed consistently that omalizumab provides significant and clinically relevant improvements in many aspects of HRQoL that are important to patients with CSU. These results contribute to a better understanding of the impact of CSU and its treatment on patients and can support clinical decision‐making in routine medical practice.

Chronic urticaria in the real-life clinical practice setting in Sweden, Norway and Denmark: baseline results from the non-interventional multicentre AWARE study

BACKGROUND

Chronic urticaria (CU) is characterized by the recurrence of itchy hives and/or angioedema for more than 6 weeks. AWARE (A World-wide Antihistamine-Refractory Chronic Urticaria Patient Evaluation) is a multinational study designed to document the real-life treatment situation, burden of disease and clinical resource usage of H1-antihistamine-refractory CU patients.

OBJECTIVE

To examine baseline data from Scandinavian AWARE patients.

METHODS

AWARE is a prospective, non-interventional, multinational, umbrella design study, which includes adults (≥18 years) with a confirmed CU diagnosis (>2 months) that is refractory to H1-antihistamines. Baseline patient characteristics, disease activity (urticaria control test [UCT]), pharmacological treatment, comorbidities and healthcare usage were documented by the treating physician. Quality of life (QoL; dermatology life quality index [DLQI]; chronic urticaria quality of life questionnaire [CU-Q₂ oL; Danish patients only]) and work productivity and activity impairment (WPAI) scores were also assessed.

RESULTS

Overall, 158 CU patients from seven centres in Denmark (n = 80), Norway (n = 50) and Sweden (n = 28) were included in this baseline analysis. Mean age and BMI were 40.3 years and 26.5 kg/m² , respectively. The majority of patients were female (69.6%), had uncontrolled CU (75.6%; UCT score <12) and had a 'spontaneous' component to their CU (61.4% CSU; 20.3% both CSU and chronic inducible urticaria). Common comorbidities included asthma (19.6%), allergic rhinitis (16.5%) and food allergies (8.2%). Overall, 60.1% of patients reported using treatments for CU including non-sedative H1-antihistamines (40.5%), corticosteroids (19%), montelukast (14.6%) and omalizumab (8.2%). Pharmacological treatment rates increased to 96.2% during the baseline visit. On average, patient QoL was moderately affected (mean DLQI score 7.7) and healthcare resource usage was high.

CONCLUSION

Adult Scandinavian H1-antihistamine-refractory CU patients reported high rates of healthcare usage and QoL impairment. Rates of pharmacological treatment use were low before study enrolment but increased to almost 100% during the baseline visit.

Positive impact of omalizumab on angioedema and quality of life in patients with refractory chronic idiopathic/spontaneous urticaria: analyses according to the presence or absence of angioedema

Background

Approximately 50% of patients with chronic idiopathic/spontaneous urticaria (CIU/CSU) report hives and angioedema; some experience hives/angioedema only.

Objective

Assess omalizumab's effect on angioedema and quality of life (QoL) in subgroups with refractory CIU/CSU: those with and without angioedema.

Methods

Patients received omalizumab (75, 150 or 300 mg) or placebo every 4 weeks for 12/24 weeks. Angioedema and QoL were assessed [Urticaria Patient Daily Diary and Dermatology Quality of Life Index (DLQI)]. Subgroups were based on the presence/absence of baseline angioedema 7 days prior to randomization.

Results

Patients with baseline angioedema randomized to omalizumab 300 mg had a greater reduction in mean weekly incidence of angioedema and mean number of days/week with angioedema vs. placebo at 12 and 24 weeks. A 3.3‐ to 4.5‐point greater mean reduction in DLQI score was achieved with omalizumab 300 mg treatment vs. placebo, above the minimal clinically important difference threshold. Results with lower doses vs. placebo were variable.

Conclusion

Compared with placebo, omalizumab 300 mg treatment over 12–24 weeks resulted in marked reduction in incidence and number of days/week with angioedema accompanied by clinically relevant improvement in QoL.

Biologics in Chronic Urticaria

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.

The Impact of Chronic Urticaria from the Patient's Perspective: A Survey in Five European Countries

Background

Chronic spontaneous urticaria (CSU) is associated with considerable burden, but data from European patients are limited.

Methods

This study is a retrospective, cross-sectional analysis of National Health and Wellness Survey data from the five largest EU countries (5EU: France, Germany, Italy, Spain, and the UK) collected between 2010 and 2013. Burden of disease for patients with CSU was estimated by comparing individuals currently treated for chronic urticaria (proxy CSU cases) with controls selected from respondents without chronic urticaria. Matching and regression models were used to quantify the impact of chronic urticaria on health-related quality of life, self-reported psychological complaints, work and activity impairment, and healthcare use.

Results

The sample included 175,923 respondents. Prevalence of diagnosed chronic urticaria was 0.5 and 0.2 % were treating the condition with a prescription. Cases (N = 369) had substantially lower (worse) regression-adjusted mean Mental Component Summary (40.2 vs. 45.4), Physical Component Summary (44.6 vs. 49.9), and SF-6D health utility scores (0.63 vs. 0.71; all p < 0.001) relative to controls (N = 1476), differences that exceed accepted minimally important differences for these measures. Depression, anxiety, and sleep difficulties were approximately twice as prevalent among those currently receiving treatment for chronic urticaria (all p < 0.001). Cases also had elevated presenteeism (31 vs. 17 %), overall work impairment (37 vs. 20 %), and impairment in non-work activities (42 vs. 26 %; all p < 0.01) relative to controls. Physician visits (9.1 vs. 4.9), emergency room visits (0.8 vs. 0.3), and hospitalizations (0.3 vs. 0.2) were more frequent than in controls (all p < 0.01).

Conclusions

This research adds to the existing evidence showing significant burden of CSU.

Electronic supplementary material

The online version of this article (doi:10.1007/s40271-015-0145-9) contains supplementary material, which is available to authorized users.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Effectiveness and Safety of Acupuncture for Patients with Chronic Urticaria: A Systematic Review

Background. Acupuncture might have effectiveness in relieving the symptoms of chronic urticaria. There are currently no systematic reviews of acupuncture for chronic urticaria published in English. Objective. We conducted a systematic review to assess the effectiveness and safety of acupuncture for chronic urticaria. Methods. A systematic review and meta-analysis of randomized, controlled trials were performed. The primary outcome was global symptom improvement. Results. We included 6 studies with 406 participants. Three trials showed significant difference between acupuncture and drugs in global symptom improvement (relative risk 1.37; 95% CI 1.11-1.70; P = 0.003). As an adjuvant to medication, acupuncture was also beneficial for global symptom improvement (relative risk 1.77; 95% CI 1.41-2.22; P < 0.01). There were no severe adverse events related to acupuncture. Limitations. Some methodological limitations were observed. The overall risk of bias in the 6 included trials was high and all included RCTs were conducted in China and published in Chinese. Besides, the lack of proper control groups and the use of different rating methods and cut-offs in the included trials also made the evidence of this review limited. Conclusions. Acupuncture might be effective and safe for chronic urticaria in relieving symptoms, based on a low level of evidence. To draw a reliable conclusion, more high quality trials are needed in the future. This trial is registered with PROSPERO CRD42015015702.

Economic burden of refractory chronic spontaneous urticaria on Kuwait's health system

Background

Chronic spontaneous urticaria (CSU) is a common problem worldwide. We evaluated the direct medical costs of treating patients with refractory CSU and the budget effect of omalizumab use in these patients in Kuwait.

Methods

The prevalence of CSU was estimated using the Delphi method. Medical records of patients with refractory CSU in Kuwait were reviewed. Costs were calculated from a health system perspective. One-way sensitivity analyses were conducted on the price and utilization of each cost component.

Results

Before omalizumab use, the total direct costs of treating 1,293 patients with refractory CSU were estimated to be USD 3,650,733 per year. This estimation was principally generated by outpatient visits. After omalizumab use, the cost was sensitive to price variation and estimated to be USD 15,828,612 per year. All other direct costs were reduced.

Conclusion

The economic burden of refractory CSU in Kuwait is high. Omalizumab use is costly, but its administration reduces all other direct costs.