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Sánchez-Borges M, Díaz SG, Ortega-Martell JA, Rojo MI, Ansotegui IJ. Current and Potential Biologic Drugs for the Treatment of Chronic Urticaria. Immunol Allergy Clin North Am 2020; 40:609-623. [PMID: 33012323 DOI: 10.1016/j.iac.2020.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article reviews biologic treatments that are currently applied for the treatment of severe chronic urticaria. Monoclonal anti-immunoglobulin E (omalizumab) is effective and safe in many patients, but accessibility and cost constitute barriers to its wider use. Questions on the optimal duration of the treatment and possible symptom recurrences after discontinuing the drug are still raised. A discussion is presented about several other biologics currently under investigation with potential to be incorporated in the near future in patients with severe chronic urticaria.
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Affiliation(s)
- Mario Sánchez-Borges
- Allergy and Clinical Immunology Department, Centro Médico Docente La Trinidad, Caracas, Venezuela; Allergy and Clinical Immunology Department, Clínica El Avila, Caracas, Venezuela.
| | - Sandra González Díaz
- Centro Regional de Excelencia CONACYT/WAO en Alergia Asma e Inmunologia Clìnica, Hospital Universitario, Facultad de Medicina, Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo León, Mexico; San Francisco Centro de Especialistas Médicos 27196008(82)
| | - Jose Antonio Ortega-Martell
- Universidad Autónoma del Estado de Hidalgo, Artículo 27 # 102. Col. Constitución, Pachuca, Hidalgo CP 42080, Mexico
| | | | - Ignacio J Ansotegui
- Department of Allergy and Immunology, Hospital Quironsalud Bizkaia, Carretera Leioa-Unbe 33 bis, Erandio-Bilbao 48950, Spain
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2
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Yao Y, Ravn Jørgensen AH, Thomsen SF. Biologics for chronic inflammatory skin diseases: an update for the clinician. J DERMATOL TREAT 2019; 31:108-130. [DOI: 10.1080/09546634.2019.1589643] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Yiqiu Yao
- Department of Dermato-Venereology and Wound Healing Centre, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Simon Francis Thomsen
- Department of Dermato-Venereology and Wound Healing Centre, Bispebjerg Hospital, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
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3
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de Montjoye L, Herman A, Nicolas JF, Baeck M. Treatment of chronic spontaneous urticaria: Immunomodulatory approaches. Clin Immunol 2017; 190:53-63. [PMID: 29129806 DOI: 10.1016/j.clim.2017.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 09/12/2017] [Accepted: 11/07/2017] [Indexed: 02/01/2023]
Abstract
This paper summarizes and reviews the mechanisms of action and data concerning efficacy of recommended treatments as well as other treatments that have been tested, independently of the outcomes, in the management of chronic spontaneous urticaria. Due to the central role of mast cells, basophils and histamine in the pathophysiology of this disease, H1-antihistamines remain the first-line treatment. However, current knowledge about this complex disease, also recognizes an important role for T lymphocytes, B lymphocytes, and autoantibodies. Implications of these others mediators thus provide further targets for treatment. Indeed, agents previously used to treat other autoimmune and inflammatory diseases, have demonstrated efficacy in chronic spontaneous urticaria and are therefore potential therapeutic alternatives for antihistamine unresponsive patients.
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Affiliation(s)
- Laurence de Montjoye
- Department of Dermatology, Saint-Luc University Hospital, Université catholique de Louvain, Brussels, Belgium; Institute of Experimental and Clinical Research, Pole of Pneumology, ENT and Dermatology, Université catholique de Louvain, Brussels, Belgium.
| | - Anne Herman
- Department of Dermatology, Saint-Luc University Hospital, Université catholique de Louvain, Brussels, Belgium; Institute of Experimental and Clinical Research, Pole of Pneumology, ENT and Dermatology, Université catholique de Louvain, Brussels, Belgium
| | - Jean-François Nicolas
- Department of Allergy and Clinical Immunology, Hospital Center Lyon Sud, Lyon, France; CIRI- INSERM U1111 - CNRS UMR5308, Université Lyon 1, Université de Lyon, Lyon, France
| | - Marie Baeck
- Department of Dermatology, Saint-Luc University Hospital, Université catholique de Louvain, Brussels, Belgium; Institute of Experimental and Clinical Research, Pole of Pneumology, ENT and Dermatology, Université catholique de Louvain, Brussels, Belgium
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4
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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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Holm JG, Ivyanskiy I, Thomsen SF. Use of nonbiologic treatments in antihistamine-refractory chronic urticaria: a review of published evidence. J DERMATOL TREAT 2017; 29:80-97. [DOI: 10.1080/09546634.2017.1329505] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | - Ilya Ivyanskiy
- Department of Dermatology, Bispebjerg Hospital, Copenhagen, Denmark
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Simon Francis Thomsen
- Department of Dermatology, Bispebjerg Hospital, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
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6
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Perez EE, Orange JS, Bonilla F, Chinen J, Chinn IK, Dorsey M, El-Gamal Y, Harville TO, Hossny E, Mazer B, Nelson R, Secord E, Jordan SC, Stiehm ER, Vo AA, Ballow M. Update on the use of immunoglobulin in human disease: A review of evidence. J Allergy Clin Immunol 2016; 139:S1-S46. [PMID: 28041678 DOI: 10.1016/j.jaci.2016.09.023] [Citation(s) in RCA: 376] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 09/12/2016] [Accepted: 09/23/2016] [Indexed: 12/20/2022]
Abstract
Human immunoglobulin preparations for intravenous or subcutaneous administration are the cornerstone of treatment in patients with primary immunodeficiency diseases affecting the humoral immune system. Intravenous preparations have a number of important uses in the treatment of other diseases in humans as well, some for which acceptable treatment alternatives do not exist. We provide an update of the evidence-based guideline on immunoglobulin therapy, last published in 2006. Given the potential risks and inherent scarcity of human immunoglobulin, careful consideration of its indications and administration is warranted.
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Affiliation(s)
- Elena E Perez
- Allergy Associates of the Palm Beaches, North Palm Beach, Fla.
| | - Jordan S Orange
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Francisco Bonilla
- Department of Pediatrics, Clinical Immunology Program, Children's Hospital Boston and Harvard Medical School, Boston, Mass
| | - Javier Chinen
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Ivan K Chinn
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Morna Dorsey
- Department of Pediatrics, Allergy, Immunology and BMT Division, Benioff Children's Hospital and University of California, San Francisco, Calif
| | - Yehia El-Gamal
- Department of Pediatrics, Pediatric Allergy and Immunology Unit, Children's Hospital and Ain Shams University, Cairo, Egypt
| | - Terry O Harville
- Departments of Pathology and Laboratory Services and Pediatrics, University of Arkansas, Little Rock, Ark
| | - Elham Hossny
- Department of Pediatrics, Pediatric Allergy and Immunology Unit, Children's Hospital and Ain Shams University, Cairo, Egypt
| | - Bruce Mazer
- Department of Pediatrics, Allergy and Immunology, Montreal Children's Hospital and McGill University, Montreal, Quebec, Canada
| | - Robert Nelson
- Department of Medicine and Pediatrics, Division of Hematology and Oncology and Stem Cell Transplantation, Riley Hospital, Indiana University School of Medicine and the IU Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Elizabeth Secord
- Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Detroit, Mich
| | - Stanley C Jordan
- Nephrology & Transplant Immunology, Kidney Transplant Program, David Geffen School of Medicine at UCLA and Cedars-Sinai Medical Center, Los Angeles, Calif
| | - E Richard Stiehm
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Ashley A Vo
- Transplant Immunotherapy Program, Comprehensive Transplant Center, Kidney Transplant Program, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Mark Ballow
- Department of Pediatrics, Division of Allergy & Immunology, University of South Florida, Morsani College of Medicine, Johns Hopkins All Children's Hospital, St Petersburg, Fla
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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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Asero R, Pinter E, Marra AM, Tedeschi A, Cugno M, Marzano AV. Current challenges and controversies in the management of chronic spontaneous urticaria. Expert Rev Clin Immunol 2015; 11:1073-82. [DOI: 10.1586/1744666x.2015.1069708] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Mehta A, Godse K, Patil S, Nadkarni N, Gautam M. Treatment of Refractory Chronic Urticaria. Indian J Dermatol 2015; 60:230-7. [PMID: 26120147 PMCID: PMC4458932 DOI: 10.4103/0019-5154.156325] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Chronic spontaneous urticaria is a distressing disease encountered frequently in clinical practice. The current mainstay of therapy is the use of second-generation, non-sedating antihistamines. However, in patients who do not respond satisfactorily to these agents, a variety of other drugs are used. This article examines the available literature for frequently used agents including systemic corticosteroids, leukotriene receptor antagonists, dapsone, sulfasalazine, hydroxychloroquine, H2 antagonists, methotrexate, cyclosporine A, omalizumab, autologous serum therapy, and mycophenolate mofetil, with an additional focus on publications in Indian literature.
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Affiliation(s)
- Aayushi Mehta
- Department of Dermatology, Dr. DY Patil Medical College and Hospital, Nerul, Navi Mumbai, Maharashtra, India
| | - Kiran Godse
- Department of Dermatology, Dr. DY Patil Medical College and Hospital, Nerul, Navi Mumbai, Maharashtra, India
| | - Sharmila Patil
- Department of Dermatology, Dr. DY Patil Medical College and Hospital, Nerul, Navi Mumbai, Maharashtra, India
| | - Nitin Nadkarni
- Department of Dermatology, Dr. DY Patil Medical College and Hospital, Nerul, Navi Mumbai, Maharashtra, India
| | - Manjyot Gautam
- Department of Dermatology, Dr. DY Patil Medical College and Hospital, Nerul, Navi Mumbai, Maharashtra, India
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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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Bernstein JA, Lang DM, Khan DA, Craig T, Dreyfus D, Hsieh F, Sheikh J, Weldon D, Zuraw B, Bernstein DI, Blessing-Moore J, Cox L, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CR, Schuller DE, Spector SL, Tilles SA, Wallace D. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol 2014; 133:1270-7. [DOI: 10.1016/j.jaci.2014.02.036] [Citation(s) in RCA: 320] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 02/10/2014] [Accepted: 02/12/2014] [Indexed: 12/13/2022]
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13
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Asero R, Tedeschi A, Cugno M. Treatment of refractory chronic urticaria: current and future therapeutic options. Am J Clin Dermatol 2013; 14:481-8. [PMID: 24085572 DOI: 10.1007/s40257-013-0047-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Chronic urticaria is a distressing disease that affects up to 1 % of the general population at a time point in life and may severely worsen the quality of life. First-line treatment has been based on antihistamines, and presently relies on the use of non-sedating, second-generation antihistamines; following the recommendations of the recent international guidelines, in patients who do not respond to antihistamines at licensed doses, the daily dosage of these drugs can be increased up to fourfold. Nonetheless, a significant proportion of patients with chronic urticaria remain poorly controlled; in these cases, alternative therapeutic approaches have to be considered. This article critically reviews all of the third- and fourth-line treatment options suggested for patients whose disease is refractory to antihistamines, including systemic corticosteroids, leukotriene receptor antagonists, several different anti-inflammatory drugs (dapsone, sulfasalazine, hydroxychloroquine), various immunosuppressive drugs (calcineurin inhibitors, methotrexate, cyclophosphamide, azathioprine, mycophenolate mofetil), intravenous immunoglobulin, and newer treatment options, such as omalizumab and other biologic drugs. In addition, the article examines possible future treatment options based on recent findings about pathogenic mechanisms, and considers the treatment of antihistamine-unresponsive urticaria in special conditions such as children and pregnancy/lactation. The evidence supporting the use of several of the discussed drugs is presently limited and thus insufficient to recommend their routine use; as a consequence, such compounds should be considered only in specific cases and in adequate settings.
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Affiliation(s)
- Riccardo Asero
- Ambulatorio di Allergologia, Clinica San Carlo, Paderno Dugnano, Milan, Italy,
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Sánchez-Borges M, Asero R, Ansotegui IJ, Baiardini I, Bernstein JA, Canonica GW, Gower R, Kahn DA, Kaplan AP, Katelaris C, Maurer M, Park HS, Potter P, Saini S, Tassinari P, Tedeschi A, Ye YM, Zuberbier T. Diagnosis and treatment of urticaria and angioedema: a worldwide perspective. World Allergy Organ J 2012; 5:125-47. [PMID: 23282382 PMCID: PMC3651155 DOI: 10.1097/wox.0b013e3182758d6c] [Citation(s) in RCA: 126] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
: Urticaria and angioedema are common clinical conditions representing a major concern for physicians and patients alike. The World Allergy Organization (WAO), recognizing the importance of these diseases, has contributed to previous guidelines for the diagnosis and management of urticaria. The Scientific and Clinical Issues Council of WAO proposed the development of this global Position Paper to further enhance the clinical management of these disorders through the participation of renowned experts from all WAO regions of the world. Sections on definition and classification, prevalence, etiology and pathogenesis, diagnosis, treatment, and prognosis are based on the best scientific evidence presently available. Additional sections devoted to urticaria and angioedema in children and pregnant women, quality of life and patient-reported outcomes, and physical urticarias have been incorporated into this document. It is expected that this article will supplement recent international guidelines with the contribution of an expert panel designated by the WAO, increasing awareness of the importance of urticaria and angioedema in medical practice and will become a useful source of information for optimum patient management worldwide.
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Affiliation(s)
- Mario Sánchez-Borges
- Department of Allergy and Clinical Immunology, Centro Médico-Docente La Trinidad, Caracas, Venezuela
| | - Riccardo Asero
- Ambulatorio di Allergologia, Clinica San Carlo, Paderno-Dugnano, Milan, Italy
| | - Ignacio J Ansotegui
- Department of Allergy and Immunology, Hospital Quirón Bizkaia, Bilbao, Spain
| | - Ilaria Baiardini
- Allergy and Respiratory Disease Clinic, University of Genova, Ospedale S.Martino di Genova, Genoa, Italy
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology/Allergy Section University of Cincinnati, Cincinnati, OH
| | - G Walter Canonica
- Allergy and Respiratory Disease Clinic, University of Genova, Ospedale S.Martino di Genova, Genoa, Italy
| | - Richard Gower
- Department of Medicine, University of Washington, Spokane, WA
| | - David A Kahn
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Allen P Kaplan
- Division of Pulmonary and Critical Care Medicine and Allergy and Immunology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Connie Katelaris
- Department of Allergy and Immunology, University of Western Sydney and Campbelltown Hospital, Sydney, Australia
| | - Marcus Maurer
- Universitätsmedizin Berlin. Allergie-Centrum-Charité, Berlin, Germany
| | - Hae Sim Park
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, South Korea
| | - Paul Potter
- Allergy Diagnostic & Clinical Research Unit, University of Cape Town Lung Institute, Groote Schuur, South Africa
| | - Sarbjit Saini
- Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Paolo Tassinari
- Immunology Institute, Faculty of Medicine, Universidad Central de Venezuela, Caracas, Venezuela
| | - Alberto Tedeschi
- U.O. Allergologia e Immunologia Clinica, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Young Min Ye
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, South Korea
| | - Torsten Zuberbier
- Universitätsmedizin Berlin. Allergie-Centrum-Charité, Berlin, Germany
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Hrabak T, Calabria CW. Multiple treatment cycles of high-dose intravenous immunoglobulin for chronic spontaneous urticaria. Ann Allergy Asthma Immunol 2010; 105:245; author reply 245-6. [PMID: 20800796 DOI: 10.1016/j.anai.2010.05.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2010] [Accepted: 05/23/2010] [Indexed: 10/19/2022]
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Effect of high-dose intravenous immunoglobulin treatment in therapy-resistant chronic spontaneous urticaria. Ann Allergy Asthma Immunol 2010; 104:253-8. [PMID: 20377115 DOI: 10.1016/j.anai.2009.12.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Chronic spontaneous urticaria (CSU) lasting more than 6 weeks is one of the most disabling types of urticaria and often results in severely impaired quality of life. Patients with CSU are often unsatisfied with the standard treatment. Another treatment option recommended for patients with so-called nonresponding CSU according to the newest guidelines is intravenous immunoglobulin (IVIG). OBJECTIVE To assess the efficacy and safety of high-dose IVIG as a treatment option in patients with therapy-resistant CSU. METHODS Six patients with severe CSU unresponsive to other treatment options according to the newest guidelines for several weeks were treated with high-dose IVIG (2 g/kg every 4-6 weeks). The response to treatment was observed on the basis of clinical signs and reduction of co-medications using a special treatment score. Patients were studied during the treatment period and were followed up for an average of 16 months. Adverse events were assessed. RESULTS Patients showed an improvement in symptoms and a reduction in co-medication use just after the first cycle. Symptoms such as itching, wheals, and edema were reduced after the first or second cycle of IVIG treatment. Four of 6 patients had complete remission after 2 to 4 cycles. One patient needed a longer continuation of treatment to reach a stable state of improvement, and another patient had a slight relapse after the seventh cycle. Adverse effects, such as headache and increased blood pressure, were observed only at the beginning of treatment. CONCLUSION High-dose IVIG represents an important therapeutic option in patients with severe CSU.
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Abstract
Chronic urticaria is heterogenous, long-persisting and has a severe impact on quality of life and daily work. Effective treatment is essential but remains a confounding problem. This review summarizes available treatment strategies for chronic urticaria and their strength of evidence. Besides treatment of identified triggering factors such as chronic persistent bacterial infections (e.g., with Helicobacter pylori, streptococci, staphylococci or yersinia), standard treatment consists of nonsedating H1-antihistamines. Most patients require increasing (off-label) dosages that should be taken daily and regularly, however, this still fails in a third of cases. Reliable alternatives in the world literature are rare and the level of evidence is low. Certain subgroups may display benefit from additional treatment with cyclosporine A, cysteinyl leukotriene receptor antagonists, chloroquine, dapsone or other alternatives. A practicable step-wise treatment approach is given to optimize and individualize the treatment of patients with chronic urticaria.
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Affiliation(s)
- Bettina Wedi
- Department of Dermatology and Allergology, Hannover Medical University, Ricklinger Str. 5, D-30449 Hannover, Germany.
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18
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Abstract
Urticaria is often classified as acute, chronic, or physical based on duration of symptoms and the presence or absence of inducing stimuli. Urticarial vasculitis, contact urticaria, and special syndromes are also included under the broad heading of urticaria. Recent advances in our understanding of the pathogenesis of chronic urticaria include the finding of autoantibodies to mast cell receptors in nearly half of patients with chronic idiopathic urticaria. These patients may have more severe disease and require more aggressive therapies. Extensive laboratory evaluation for patients with chronic urticaria is typically unrevealing and there are no compelling data that associate urticaria with chronic infections or malignancy. Pharmacologic therapy consists primarily of the appropriate use of first- and second-generation histamine H(1) receptor antihistamines. Additional therapy may include leukotriene receptor antagonists, corticosteroids, and immunomodulatory agents for severe, unremitting disease. Despite our greater understanding of the pathogenesis of urticaria, the condition remains a frustrating entity for many patients, particularly those with chronic urticaria.
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Morgan M, Khan DA. Therapeutic alternatives for chronic urticaria: an evidence-based review, Part 2. Ann Allergy Asthma Immunol 2008; 100:517-26; quiz 526-8, 544. [PMID: 18592813 DOI: 10.1016/s1081-1206(10)60047-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the use of alternative therapies for chronic urticaria refractory to first-line treatments in an evidence-based manner. DATA SOURCES MEDLINE searches were performed cross-referencing urticaria with the names of multiple therapies. Articles were then reviewed for additional citations. Articles published after 1950 were considered. STUDY SELECTION All articles, including case reports, were reviewed for soundness and relevance. RESULTS Experience has been reported for a wide variety of alternative therapies in the treatment of chronic idiopathic and physical urticarias. Evidence for most agents is limited to anecdotal reports. The therapies reviewed are also categorized based on criteria of safety, efficacy, convenience, and cost. The less preferred alternative agents in the second part of this review are divided between third-line therapies and others that are unable to be firmly recommended or that seem promising but lack substantial evidence. CONCLUSIONS Third-line alternative agents should be considered in patients with chronic urticaria who are severely affected and unresponsive to antihistamines and second-line therapies. Although monitoring for toxicity is important in management with third-line agents, safety remains favorable for most agents compared with corticosteroids.
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Affiliation(s)
- Matt Morgan
- Division of Allergy and Immunology, University of Texas Southwestern, Dallas, Texas 75390-8859, USA
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20
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Smith AA, Humphrey J, McAuley JB, Tharp MD. Common variable immunodeficiency presenting as chronic urticaria. J Am Acad Dermatol 2008; 59:S40-1. [DOI: 10.1016/j.jaad.2007.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2007] [Revised: 09/04/2007] [Accepted: 09/12/2007] [Indexed: 10/21/2022]
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Abstract
Patients with urticaria make up a large proportion of the referrals to allergy clinics. There are many causes of urticaria and it is the clinical history which is most important when attempting to identify potential causes; however, urticaria is very often idiopathic. In a small minority of patients urticaria may be a symptom of a serious underlying medical illness or the allergic symptoms may progress to cause systemic reactions, and it is important to identify these patients and to remember that severe urticaria is a distressing and disabling condition. This review will discuss classification, investigation and treatment of urticaria and will consider some of the more unusual types of urticaria that may be encountered in the out-patient clinic.
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Affiliation(s)
- S J Deacock
- Royal Surrey County Hospital NHS Trust, Guildford, Surrey, UK.
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22
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Abstract
The intravenous administration of exogenous pooled human immunoglobulin (i.v. IG) was originally licensed as antibody replacement therapy in patients with primary immunodeficiencies and there are currently six FDA-approved uses for this agent. Despite a current lack of FDA approval, off-label treatment of a multitude of dermatologic disorders with i.v. IG has shown exciting potential for this unique treatment modality. The diseases successfully treated with i.v. IG include autoimmune bullous diseases, connective tissue diseases, vasculitides, toxic epidermal necrolysis, and infectious disorders (such as streptococcal toxic shock syndrome). Currently the biggest drawback in the consideration of i.v. IG therapy in dermatologic disorders is the lack of randomized controlled trials. Nevertheless, there is a significant body of evidence demonstrating the efficacy of i.v. IG in patients with dermatologic disorders that are resistant to treatment with standard agents. In summary, i.v. IG constitutes a valuable and potentially life-saving agent in managing patients with a variety of dermatologic disorders under the appropriate circumstances.
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Affiliation(s)
- Anthony P Fernandez
- Department of Dermatology and Cutaneous Surgery, Unversity of Miami Miller School of Medicine, Miami, Florida, USA
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23
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Smith DI, Swamy PM, Heffernan MP. Off-label uses of biologics in dermatology: Interferon and intravenous immunoglobulin (Part 1 of 2). J Am Acad Dermatol 2007; 56:e1-54. [PMID: 17190617 DOI: 10.1016/j.jaad.2006.06.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2005] [Revised: 05/04/2006] [Accepted: 06/19/2006] [Indexed: 11/29/2022]
Abstract
The introduction of a number of biologic therapies into the market has revolutionized the practice of dermatology. These therapies include interferons, intravenous immunoglobulin, infliximab, adalimumab, etanercept, efalizumab, alefacept, and rituximab. Most dermatologists are familiar with the Food and Drug Administration-approved indications of these medications. However, numerous off-label uses have evolved. As part 1 of a 2-part series, this article will review the literature regarding the off-label uses of the interferons and intravenous immunoglobulin in dermatology.
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24
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Kerns MJJ, Graves JE, Smith DI, Heffernan MP. Off-Label Uses of Biologic Agents in Dermatology: A 2006 Update. ACTA ACUST UNITED AC 2006; 25:226-40. [PMID: 17174843 DOI: 10.1016/j.sder.2006.08.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The introduction of a number of biologic therapies into the market has revolutionized the practice of dermatology. These therapies include adalimumab, alefacept, efalizumab, etanercept, infliximab, IVIg, omalizumab, and rituximab. Most dermatologists are familiar with the indications of these medications that have been approved by the Food and Drug Administration; however, numerous off-label uses have evolved. To update the reader on more recent uses of the biologics for off-label dermatologic use, this article will emphasize more recent published data from 2005 through the date of submission in May 2006.
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25
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Abstract
Chronic urticaria (CU), with or without angioedema, is a frequent disorder defined as the occurrence of pruritic wheals for > 6 weeks. Studies carried out in the last two decades showed that the origin of the disease is autoimmune in up to 50% of cases. Currently available treatments include antihistamines, corticosteroids and ciclosporin; recently, leukotriene receptor antagonists proved effective in a subset of patients as well. For patients with an unremitting and extremely severe disease unresponsive to standard treatments, plasmapheresis and immunosuppressive drugs have been successfully attempted. Recent findings that the autologous plasma skin test scores positive in nearly all patients and that plasmas from patients with both autoimmune and 'idiopathic' chronic urticaria are frequently characterised by signs of thrombin activation (plasma levels of prothrombin fragment F(1.2) are significantly increased) suggest that clotting cascade might be somehow involved in the pathogenesis of CU. These findings put under a new light some rather sparse studies of the effect of drugs active on the coagulation system (heparin and oral anticoagulants) in patients with CU.
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Affiliation(s)
- Riccardo Asero
- Ambulatorio di Allergologia, Allergy Unit, Clinica San Carlo, Via Ospedale 2120037 Paderno Dugnano (MI), Italy.
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26
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Affiliation(s)
- S Jolles
- Department of Clinical Immunology, Royal Free Hospital London, UK.
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27
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Jolles S, Hughes J. Use of IGIV in the treatment of atopic dermatitis, urticaria, scleromyxedema, pyoderma gangrenosum, psoriasis, and pretibial myxedema. Int Immunopharmacol 2005; 6:579-91. [PMID: 16504920 DOI: 10.1016/j.intimp.2005.11.017] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
There has been a rapid expansion in the use of IGIV for an ever-growing number of conditions. It is a product with an excellent safety record without the side effects of steroids or other immunosuppressive agents. There have been numerous recent advances in our understanding of the mechanisms of action of IGIV in many of the conditions for which it is being used, but there is still much to be learned. IGIV has had a major impact in neurology, haematology, immunology, rheumatology and dermatology. The limitations for IGIV are cost of the preparation itself and the logistical problems associated with its administration. Here we describe the published evidence for the use of high-dose IGIV in the dermatological conditions atopic dermatitis, urticaria, scleromyxedema, pyoderma gangrenosum, psoriasis and pretibial myxedema. These conditions have an emerging evidence base for hdIGIV which is relatively small consisting mainly of case reports and small case series. The outcomes in a number of these conditions appear encouraging, but as the reports are likely to reflect a bias for positive results, one must be cautious about drawing firm conclusions.
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Affiliation(s)
- Stephen Jolles
- National Institute for Medical Research, Mill Hill, London and University Hospital of Wales, Cardiff, UK.
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28
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Tedeschi A, Airaghi L, Lorini M, Asero R. Chronic urticaria: a role for newer immunomodulatory drugs? Am J Clin Dermatol 2003; 4:297-305. [PMID: 12688835 DOI: 10.2165/00128071-200304050-00001] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Chronic urticaria is now recognized as an autoreactive disorder in a substantial fraction of patients. A serologic mediator of whealing has been demonstrated in 50-60% of patients with chronic urticaria, and autoantibodies against the high affinity IgE receptor or IgE have been detected in about half of these patients. The demonstration that chronic urticaria is frequently autoimmune has encouraged a more aggressive therapeutic approach, with the use of immunomodulatory drugs.A step-by-step approach to the management of chronic urticaria is proposed, based on our personal experience and review of current medical literature, identified through Medline research and hand searching in medical journals. The non- or low-sedating H(1) receptor antagonists (antihistamines), such as cetirizine, fexofenadine, loratadine, mizolastine and, more recently, levocetirizine, desloratadine and ebastine, represent the basic therapy for all chronic urticaria patients. Older sedating antihistamines, such as hydroxyzine and diphenhydramine, may be indicated if symptoms are severe, are associated with angioedema, and if the patient is anxious and disturbed at night.Corticosteroid therapy with prednisone or methylprednisolone can be administered for a few days (7-14) if urticarial symptoms are not controlled by antihistamines and a rapid clinical response is needed. In cases of relapse after corticosteroid suspension, leukotriene receptor antagonists, such as montelukast and zafirlukast, should be tried. In our experience, remission of urticarial symptoms can be achieved in 20-50% of chronic urticaria patients unresponsive to antihistamines alone. When urticaria is unremitting and is not controlled by combined therapy with antihistamines and leukotriene receptor antagonists, prolonged corticosteroid therapy may be needed. Long-term corticosteroid therapy should be administered at the lowest dose able to control urticarial symptoms, in order to minimize adverse effects. In a few patients, however, high-dose corticosteroid therapy may have to be administered for long periods. In these patients, immunosuppressive treatment with low-dose cyclosporine can be started. This type of treatment has a corticosteroid-sparing effect and is also generally effective in patients with severe, unremitting urticaria, but requires careful monitoring of cyclosporine plasma concentration and possible adverse effects. Other immunomodulating drugs that have been tried in chronic urticaria patients include hydroxychloroquine, dapsone, sulfasalazine and methotrexate, but their efficacy has not been proven in large controlled studies. Warfarin therapy may also be considered in some patients with chronic urticaria and angioedema unresponsive to antihistamines.
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Affiliation(s)
- Alberto Tedeschi
- Allergy and Immunopharmacology Unit, First Division of Internal Medicine, IRCCS Ospedale Maggiore Policlinico, Milan, Italy.
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29
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Altschul A, Cunningham-Rundles C. Chronic urticaria and angioedema as the first presentations of common variable immunodeficiency. J Allergy Clin Immunol 2002; 110:664-5. [PMID: 12373278 DOI: 10.1067/mai.2002.127002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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