Impact of Pharmacological Treatments for Chronic Spontaneous Urticaria with an Inadequate Response to H1-Antihistamines on Health-Related Quality of Life: A Systematic Review and Network Meta-Analysis

Chronic Spontaneous Urticaria: A Review

Importance

Chronic spontaneous urticaria affects approximately 1% of the general population worldwide, including approximately 3 million people in the US, impairs patients' quality of life, and is associated with multiple comorbidities.

Observations

Chronic spontaneous urticaria affects patients of any age but is most common in females aged 30 to 50 years. Diagnosis is based on clinical presentation, ie, spontaneously recurring wheals, angioedema, or both. Chronic spontaneous urticaria persists for more than 1 year in most patients (1 or repeated episodes) and may present with comorbidities including chronic inducible urticaria (>10%), autoimmune thyroiditis (approximately 20%), metabolic syndrome (6%-20%), and anxiety (10%-31%) and depression (7%-29%). Known autoimmune endotypes (subtypes of urticaria defined by distinct pathogenesis) of chronic spontaneous urticaria are mediated by mast cell-activating IgE and/or IgG autoantibodies (>50%). Approximately 40% of patients with chronic spontaneous urticaria have a Dermatology Life Quality Index of more than 10, corresponding to a very large or extremely large negative effect on quality of life. Second-generation H1 antihistamines are first-line treatment; partial or complete response, defined as a reduction in urticaria symptoms of greater than 50%, is observed in approximately 40% of patients. The 2022 international urticaria guideline recommends the monoclonal anti-IgE antibody omalizumab as second-line treatment for antihistamine-refractory chronic spontaneous urticaria. However, at least 30% of patients have an insufficient response to omalizumab, especially those with IgG-mediated autoimmune urticaria. Cyclosporine, used off-label, can improve symptoms in approximately 54% to 73% of patients, especially those with autoimmune chronic spontaneous urticaria and nonresponse to omalizumab, but has adverse effects such as kidney dysfunction and hypertension.

Conclusions and Relevance

Chronic spontaneous urticaria is an inflammatory skin disease associated with medical and psychiatric comorbidities and impaired quality of life. Second-generation H1 antihistamines are first-line treatment, omalizumab is second-line treatment, and cyclosporine is third-line treatment for chronic spontaneous urticaria.

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

Importance

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

Objective

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

Evidence Review

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

Findings

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

Conclusions and Relevance

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

Evaluation of Pharmacological Treatments for Acute Urticaria: A Systematic Review and Meta-Analysis

BACKGROUND

The effectiveness and safety of pharmacological treatments for acute urticaria remain unclear.

OBJECTIVE

To systematically review and meta-analyze the efficacy and safety of pharmacological treatments for acute urticaria in emergency department (ED) and non-ED settings.

METHODS

We searched electronic databases and gray literature up to July 8, 2023, without language restrictions. Randomized clinical trials (RCTs) relating to pharmacological interventions in patients with acute urticaria, regardless of age, were eligible for inclusion. The relevant outcomes of interest were the treatment efficacy and safety profiles. The results are presented as standardized mean differences (SMDs) or odds ratios (ORs).

RESULTS

We identified 8 RCTs comprising 680 patients. Regarding the ED setting (2 trials, n = 118), intramuscular first-generation H1-antihistamine (fgAH) was more efficacious in decreasing pruritus symptoms (SMD, -0.38; 95% confidence interval [CI], -0.75 to -0.02) but had higher sedative effects than H2-blockers. With comparable pruritus symptom improvement (2 trials, n = 295), intravenous second-generation H1-antihistamine (sgAH) had favorable clinical outcomes compared with intravenous fgAH in the ED setting with a lower risk of return to any ED/clinic (OR, 0.31; 95% CI, 0.12-0.83) and lower risk of any adverse event (OR, 0.24; 95% CI, 0.09-0.63). The efficacy of adjunctive therapy with a short course of systemic glucocorticosteroids in ED and non-ED settings remains unclear. No serious concerns regarding the safety profiles were observed in any of the treatment comparisons.

CONCLUSIONS

H1-antihistamine is a crucial and effective component of acute urticaria treatment, and intravenous sgAH is preferred as an initial treatment option.

Comparative effectiveness of glucagon-like peptide-1 receptor agonists on body composition and anthropometric indices: A protocol for a systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

To date, no studies have addressed the comparative efficacy of glucagon-like peptide-1 receptor agonists (GLP1-RAs) therapy on body composition and anthropometric indices among adult overweight or obese patients with or without type 2 diabetes. To provide evidence-based recommendations, we will conduct a traditional pairwise and network meta-analysis of all available randomized clinical trials that evaluated the effects of GLP1-RAs interventions for adult overweight or obese patients with or without type 2 diabetes.

METHODS AND DESIGN

Electronic databases, including Medline, Embase, PubMed, Cochrane Library (CENTRAL), Scopus, and CINAHL, will be searched from inception without language restriction. Grey literature will be searched, including Google Scholar, ongoing clinical trial registries, and preprint reports. Reference lists of included trials, relevant major endocrinology scientific meetings, and manual hand searches from key general medicine and obesity and endocrinology journals will also be browsed. Two authors will screen, select, extract, appraise the risk of bias, and rate the evidence findings. Any disagreement will be resolved through team discussion. Based on a random-effects model, we will employ a two-step approach of traditional pairwise meta-analysis and network meta-analysis for quantitative synthesis. The pooled effect estimates using a frequentist approach with 95% confidence intervals for continuous endpoints will be expressed as the standardized mean difference, whereas odds ratios will be used for categorical endpoints. The quality of included trials will be evaluated using the Cochrane risk-of-bias version 2 assessment tool. Certainty of evidence for each outcome will be assessed using the modified confidence in network meta-analysis approach and the Grading of Recommended Assessment, Development, and Evaluation approach. The magnitude of the effect size, prediction intervals, surface under the cumulative ranking curve values, and certainty of evidence will be incorporated to draw evidence-based conclusions.

CONCLUSION

This systematic review and network meta-analysis will summarize the comparative efficacy of GLP1-RAs therapy on body composition and anthropometric indices. Evidence identified from this review will promote the rational use of interventions for adult overweight or obese patients with or without type 2 diabetes and will serve as an important step for evidence-based practice within this area.

TRIAL REGISTRATION

PROSPERO registration number: CRD42023458228.

Comparative effectiveness and safety of drug therapy for chronic urticaria: a network meta-analysis and risk-benefit assessment

BACKGROUND

Chronic urticaria (CU) is a prevalent chronic skin condition characterized by recurrent wheals. Clinical guidelines recommend multiple drugs for CU treatment. Our study aims to compare the effectiveness and safety of drug therapy for CU.

METHODS

We conducted a comprehensive search of randomized controlled trials (RCTs) and real-world studies (RWSs) in PubMed, EMBASE, and Cochrane. A network meta-analysis (NMA) was conducted to assess the response rate, decline in Urticaria Activity Score over 7 Days (UAS7), Dermatology Life Quality Index (DLQI), and adverse event rates of standard-dose and high-dose H1 antihistamine (H1AH), omalizumab (OMA) 75, 150, and 300 mg, cyclosporine and placebo. The risk-benefit assessment was conducted by probabilistic simulation and stochastic multicriteria acceptability analysis (SMAA).

RESULTS

A total of 39 studies were identified, including 37 RCTs and 2 RWSs. OMA 300 mg and 150 mg both had significantly higher response rate than standard-dose H1AH (p < 0.05, respectively). OMA 300 mg and 150 mg both consistently led to a huge drop in UAS7 and DLQI compared to standard-dose H1AH and high-dose H1AH (p < 0.05).

CONCLUSION

Regarding risk-benefit assessment, OMA 300 mg emerges as the optimal pharmacological intervention for CU, while OMA 150 mg stands as a secondary alternative compared to H1 antihistamines and cyclosporine.

Comparative Safety Profiles of Individual Second-Generation H1-Antihistamines for the Treatment of Chronic Urticaria: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

BACKGROUND

The comparative safety and/or dosing regimens of individual second-generation H1-antihistamines (sgAHs) in patients with chronic urticaria (CU) remain poorly elucidated.

OBJECTIVE

To compare the safety profiles of individual sgAHs and/or dosing regimens in adolescents or adult patients with CU using a systematic review and network meta-analysis of all available evidence.

METHODS

With limited English publications, electronic databases and gray literature were searched for randomized clinical trials from inception, with searches last updated on January 20, 2023. Relevant safety outcomes included treatment unacceptability (all-cause discontinuation), tolerability (discontinuation due to any adverse events), adverse events, serious adverse events, central nervous system (CNS) side effects, and anticholinergic side effects. Regarding the network estimates, the probability of being associated with the highest adverse outcome risk was estimated for each treatment comparison.

RESULTS

Fifty-one randomized clinical trials with 14 individual sgAHs and different dosing regimens, involving 7502 participants, were included. On the basis of the findings from network meta-analyses, variations in sgAH treatment comparisons were observed regarding the unacceptability of treatment, tolerability, adverse events, and CNS side effects. There were no statistically significant differences between the results of sgAH treatment for serious adverse events and those for anticholinergic side effects. On the basis of the ranking of safety profiles, emedastine 4 mg, mizolastine 10 mg, and cetirizine 10 mg were the top 3 ranked treatments with unfavorable safety profiles associated with CNS side effects and any adverse events.

CONCLUSIONS

These findings suggest evidence of variations in safety profiles among sgAHs for CU treatment, particularly in terms of adverse events and CNS side effects.

Clinical Outcomes, Patient-Reported Outcomes, and Economic Burden for Thai People Living with Chronic Urticaria (CORE-CU) in routine practice: A study protocol for a monocentric prospective longitudinal study

BACKGROUND

Few prospective longitudinal studies have been conducted in Thailand to account for the long-term response to chronic urticaria (CU) treatment, clinical outcomes, and patient-reported outcomes (PROs) among people living with CU based on routine practice. As such, a prospective longitudinal study will be conducted to better understand the long-term responses to treatment options and the burden of disease in Thai CU patients.

METHODS AND DESIGN

This study is a routine clinical practice registry-based, monocentric, prospective, observational longitudinal study in the northern region of Thailand. Adult patients in an outpatient clinic diagnosed with CU, including both chronic spontaneous urticaria and chronic inducible urticaria will be recruited for this study. The cohort will be collected and registered using the joint routine clinical practice data based on multiple datasets including claims outpatient and inpatient data, routine laboratory results, medication utilization, health care costs, clinical characteristics, long-term urticaria care and monitoring, and PRO measures. The point prevalence of adverse health outcomes will be estimated and reported corresponding to 95% confidence intervals (95% CIs). The overall trend analysis will be analyzed to explore the effect of over time across the cohort time frame.

CONCLUSION

This prospective longitudinal study will report the clinical outcomes, PROs, and economic burden among Thai people living with CU based on routine clinical practice. Findings will provide comprehensive evidence and could facilitate best practices for CU care management for health care professionals, researchers, policymakers, and public society.

TRIAL REGISTRATION

Thai Clinical Trials Registry (TCTR, thaiclinicaltrials.org) registration TCTR20210706005. Registered on July 6, 2021.

Evidence Gaps in Clinical Trials of Pharmacologic Treatment for H1-Antihistamine-Refractory Chronic Spontaneous Urticaria: A Systematic Review and Future Perspectives

No data addressing issues concerning disparities in participant and trial characteristics and trial outcome reporting have been established in clinical trials for H1-antihistamine-refractory chronic spontaneous urticaria (CSU). To better harmonize and compare the different treatment interventions, we systematically evaluated the overall landscape of pharmacological treatments for H1-antihistamine-refractory CSU clinical trials published between 2000 and 2021. This systematic review included 23 randomized clinical trials involving 2480 participants from 22 countries. We found significant increases in the number of globally published and newly tested drugs, especially biologic drugs. Regarding relatively small trials, we found that people living with H1-antihistamine-refractory CSU who were identified as members of minority groups (non-white population), populations of regions other than North America/Europe, and populations of low- to lower/upper-middle-income countries are underrepresented. Most trials were designed to evaluate treatment efficacy and safety profiles; however, less than half of the included trials reported the patient’s perspective in terms of patient-reported outcomes. Disparities in outcome reporting, including clinimetric tools for assessing treatment response and outcome sets, were observed. To close the evidence gap in H1-antihistamine-refractory CSU trials, strategies for improving trial and participant enrollment and standardizing core outcome sets for trial reporting are needed.

Urticaria

Urticaria is an inflammatory skin disorder that affects up to 20% of the world population at some point during their life. It presents with wheals, angioedema or both due to activation and degranulation of skin mast cells and the release of histamine and other mediators. Most cases of urticaria are acute urticaria, which lasts ≤6 weeks and can be associated with infections or intake of drugs or foods. Chronic urticaria (CU) is either spontaneous or inducible, lasts >6 weeks and persists for >1 year in most patients. CU greatly affects patient quality of life, and is linked to psychiatric comorbidities and high healthcare costs. In contrast to chronic spontaneous urticaria (CSU), chronic inducible urticaria (CIndU) has definite and subtype-specific triggers that induce signs and symptoms. The pathogenesis of CSU consists of several interlinked events involving autoantibodies, complement and coagulation. The diagnosis of urticaria is clinical, but several tests can be performed to exclude differential diagnoses and identify underlying causes in CSU or triggers in CIndU. Current urticaria treatment aims at complete response, with a stepwise approach using second-generation H1 antihistamines, omalizumab and cyclosporine. Novel treatment approaches centre on targeting mediators, signalling pathways and receptors of mast cells and other immune cells. Further research should focus on defining disease endotypes and their biomarkers, identifying new treatment targets and developing improved therapies.

Pharmacological interventions for hidradenitis suppurativa: a protocol for systematic review and network meta-analysis of randomised trials and non-randomised studies

INTRODUCTION

Therapeutic recommendations for hidradenitis suppurativa (HS) have recently shifted towards non-invasive pharmacological options. Recent evidence has shown promising efficacy for specific treatments. However, data regarding the comparative efficacy of these treatments in patients with HS are still limited. Therefore, we plan to conduct a systematic review and network meta-analysis (NMA) to summarise the benefits and harms of different pharmacological interventions for treating people living with HS.

METHODS AND ANALYSIS

We will search electronic databases, including Medline, Embase, PubMed, Web of Science, Scopus, CINAHL and Cochrane Library beginning from their inception dates with no language restrictions. A grey literature search will be performed to supplement the electronic databases. Both randomised trials and non-randomised studies using validated measurement tools that investigated the benefits and harms of pharmacological interventions among people living with HS will be included. The predefined primary outcomes will include treatment responses that reflect the patient's perspective and all-cause discontinuation. Screening, selection, extraction, assessment of the risk of bias and analysis of the strength of the evidence will be performed independently by a pair of reviewers. A two-step approach of traditional pairwise and NMA will be performed. Based on a random-effects model, standardised weighted mean differences and ORs with corresponding 95% CIs will be pooled as effect estimates for the continuous and categorical endpoints, respectively. Statistical and methodological heterogeneities will be assessed. Preplanned subgroup analyses and univariate meta-regression will be conducted to quantify the potential sources of heterogeneity. Evidence-based synthesis will be based on the magnitudes of effect size, evidence certainty and the surface under the cumulative ranking curve values.

ETHICS AND DISSEMINATION

Ethical approval is not required because this study is based on existing published data. These findings will be disseminated through scientific meetings and publications in peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42022302795.