The leukotriene receptor antagonist montelukast in the treatment of chronic idiopathic urticaria: a single-blind, placebo-controlled, crossover clinical study

Leukotriene receptor antagonists as add-on therapy to antihistamines for urticaria: Systematic review and meta-analysis of randomized clinical trials

BACKGROUND

The benefits and harms of adding antileukotrienes to H1 antihistamines (AHs) for the management of urticaria (hives, itch, and/or angioedema) remain unclear.

OBJECTIVE

We sought to systematically synthesize the treatment outcomes of antileukotrienes in combination with AHs versus AHs alone for acute and chronic urticaria.

METHODS

As part of updating American Academy of Allergy, Asthma & Immunology and American College of Allergy, Asthma, and Immunology Joint Task Force on Practice Parameters urticaria guidelines, we searched Medline, Embase, Central, LILACS, WPRIM, IBECS, ICTRP, CBM, CNKI, VIP, Wanfang, US Food and Drug Administration, and European Medicines Agency databases from inception to December 18, 2023, for randomized controlled trials (RCTs) evaluating antileukotrienes and AHs versus AHs alone in patients with urticaria. Paired reviewers independently screened citations, extracted data, and assessed risk of bias. Random effects models pooled effect estimates for urticaria activity, itch, wheal, sleep, quality of life, and harms. The GRADE approach informed certainty of evidence ratings. The study was registered at the Open Science Framework (osf.io/h2bfx/).

RESULTS

Thirty-four RCTs enrolled 3324 children and adults. Compared to AHs alone, the combination of a leukotriene receptor antagonist with AHs probably modestly reduces urticaria activity (mean difference, -5.04; 95% confidence interval, -6.36 to -3.71; 7-day urticaria activity score) with moderate certainty. We made similar findings for itch and wheal severity as well as quality of life. Adverse events were probably not different between groups (moderate certainty); however, no RCT reported on neuropsychiatric adverse events.

CONCLUSION

Among patients with urticaria, adding leukotriene receptor antagonists to AHs probably modestly improves urticaria activity with little to no increase in overall adverse events. The added risk of neuropsychiatric adverse events in this population with leukotriene receptor antagonists is small and uncertain.

Effectiveness of Hydroxychloroquine and Omalizumab in Chronic Spontaneous Urticaria: A Real-World Study

BACKGROUND

Chronic spontaneous urticaria (CSU) not controlled by optimized doses of antihistamines is referred to as refractory CSU. Add-on therapies recommended by guidelines include omalizumab, immunosuppressive, and anti-inflammatory agents.

OBJECTIVES

The objective of the study was to assess the real-world effectiveness of different add-on treatment options for refractory CSU in 2 large clinical practices.

METHODS

A retrospective chart review was conducted in 264 patients with refractory CSU not adequately controlled for ≥6 weeks with optimized doses of second-generation histamine-1 blockers. Omalizumab and hydroxychloroquine were the most frequently prescribed add-on therapies, allowing comparisons of clinical outcomes for these 2 agents. Complete response included absent or infrequent urticaria and patient satisfaction with treatment. Partial response was reduced hives, but requiring a second add-on therapy. Sustained response was complete response to an add-on therapy for ≥1 year.

RESULTS

Omalizumab add-on treatment was significantly more likely to be associated with a complete response versus hydroxychloroquine. Complete sustained response at 1 year was observed in 82% (111 of 134) of patients on omalizumab and 66% (73 of 111) on hydroxychloroquine as the first add-on therapy (P < .01). Patients with thyroid disease had a poorer response to add-on treatments (45% responded vs 63%; P = .03). In patients with incomplete responses to first add-on interventions (n = 45), 65% and 62% subsequently had complete responses to omalizumab and hydroxychloroquine, respectively.

CONCLUSIONS

Although omalizumab was superior, hydroxychloroquine achieved a complete response in two-thirds of treated patients. Given a favorable safety profile, hydroxychloroquine should be considered as an add-on treatment for refractory CSU.

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.

Effectiveness and Safety of Immunosuppressants and Biological Therapy for Chronic Spontaneous Urticaria: A Network Meta-Analysis

Chronic spontaneous urticaria (CSU) is the most common phenotype of chronic urticaria. We compared treatment effects and safety profiles of the medications in patients with CSU. We searched PubMed, MEDLINE, and Web of Science for randomized control trials (RCTs), from 1 January 2000 to 31 July 2021, which evaluated omalizumab and immunosuppressants. Network meta-analyses (NMAs) were performed with a frequentist approach. Outcome assessments considered the efficacy (Dermatology Life Quality Index (DLQI) and weekly urticaria activity score (UAS7)) and tolerability profiles with evaluations of study quality, inconsistencies, and heterogeneity. We identified 14 studies which we included in our direct and indirect quantitative analyses. Omalizumab demonstrated better efficacy in DLQI and UAS7 outcomes compared to a placebo, and UAS7 assessments also demonstrated better outcomes compared to cyclosporine. Alongside this, omalizumab demonstrated relatively lower incidences of safety concerns compared to the other immunosuppressants. Cyclosporin was also associated with higher odds of adverse events than other treatment options. Our findings indicate that omalizumab resulted in greater improvements in terms of the DLQI and UAS7 with good tolerability in CSU patients compared to the other immunosuppressants.

Causal Relationship between D-Dimers and Disease Status in Chronic Spontaneous Urticaria and Adjuvant Effect of Oral Tranexamic Acid

Introduction:

Besides autoimmunity, recent studies have reported a role of the coagulation cascade in the pathogenesis of urticaria. However, the real-world data regarding the utility of measuring D-dimer levels in patients chronic spontaneous urticaria (CSU) is missing. This study was done to evaluate the D-dimer levels of CSU patients and study the relationship between raised D-dimer levels and disease severity and treatment response.

Methods:

A retrospective chart review of all adult (>18 years) CSU patients was done. Complete clinicodemographic data regarding the disease duration and treatment response were noted. Urticaria activity score over 7 days (UAS7) was used to assess disease severity.

Results:

Of total 141 patients, D-dimer levels were raised in 46 CSU patients (32.6%) with mean D-dimer levels at baseline in these patients being 329.53 ± 546.94 ng/ml. The proportion of patients with raised plasma D-dimer levels was higher in patients with severe CSU (12.9%, 27.2%, 54.5% in mild, moderate, and severe disease, respectively P < 0.001). No significant differences were found between those with raised D-dimers and those having normal D-dimer levels with respect to age, gender, presence of angioedema, history of atopy, presence of thyroid abnormality, ASST/APST positivity, and serum IgE.

Conclusion:

D-dimer levels parallels the disease severity and can help predict the need for higher dose of antihistamines and second-line therapy in CSU patients.

Chronic Urticaria: Advances in Understanding of the Disease and Clinical Management

Chronic urticaria (CU) is a common skin condition characterized by the recurrence of wheals, with or without angioedema, which lasts for at least 6 weeks. Owing to its pruritus and incurability, this disease adversely affects the patients' physical and mental health and diminishes the quality of life. CU is generally classified into two subtypes based on the relevance of eliciting factors: chronic spontaneous urticaria (CSU) and chronic inducible urticaria (CIndU), the latter of which is further divided into several subtypes. To improve the understanding and clinical management of this highly heterogeneous disorder, the EAACI/GA²LEN/EDF/WAO guideline was developed and published in 2018 based on evidence and expert consensus. The diagnostic and treatment algorithms proposed by the guideline have largely facilitated dermatologists in clinical practice. However, several questions remained unsolved and have been widely investigated in the recent years. First, a better understanding of the association between chronic urticaria and its potential underlying causes or eliciting factors such as autoimmunity, infections, coagulation aberrance, and vitamin D deficiency is warranted. This would lead to updates in the diagnostic and treatment procedures of different subtypes of chronic urticaria. Secondly, treatment for recalcitrant cases, especially those resistant to or intolerant of second-generation antihistamines and (or) omalizumab, calls for novel therapeutic measures or strategies. In the present review, we summarized recent advances in the understanding and management of both CSU and CIndU, with special emphasis on their underlying causes or eliciting factors, pathogenic mechanisms, potential targets for intervention, and advances in treatment strategies.

Evaluation of Pharmacologic Treatments for H1 Antihistamine-Refractory Chronic Spontaneous Urticaria: A Systematic Review and Network Meta-analysis

Importance

The comparative benefits and harms of all available treatments for H1 antihistamine-refractory chronic spontaneous urticaria (CSU) have not been established.

Objective

To evaluate different treatment effects of pharmacologic treatments among patients with H1 antihistamine-refractory CSU.

Data Sources

Searches were conducted of MEDLINE, Embase, PubMed, Cochrane Library, Web of Science, Scopus, and CINAHL from inception to April 19, 2021, with no language restrictions. Gray literature from Google Scholar, ongoing trial registers, and preprint reports was added to the searches of electronic databases.

Study Selection

Randomized clinical trials using validated measurement tools that investigated the benefits and harms of pharmacologic treatments among adolescent or adult patients with CSU who had an inadequate response to H1 antihistamines were screened for inclusion independently by 2 investigators.

Data Extraction and Synthesis

Two investigators independently extracted study data according to the predefined list of interests. A random-effects model was used to calculate the network estimates reported as standardized mean differences and odds ratios with corresponding 95% CIs.

Main Outcomes and Measures

The primary outcomes that reflect the patient's perspective included changes in urticaria symptoms from baseline and unacceptability of treatment (all-cause dropouts).

Results

Twenty-three randomized clinical trials with 2480 participants that compared 18 different interventions or dosages and placebo were included. The standardized mean differences for change in urticaria symptoms were -1.05 (95% CI, -1.37 to -0.73) for ligelizumab, 72 mg; -1.07 (95% CI, -1.39 to -0.75) for ligelizumab, 240 mg; -0.77 (95% CI, -0.91 to -0.63) for omalizumab, 300 mg; and -0.59 (95% CI, -1.10 to -0.08) for omalizumab, 600 mg. No significant differences in treatment unacceptability were observed. With respect to benefits and harms, the network estimates illustrated that the most efficacious treatments were achieved with ligelizumab, 72 or 240 mg (large beneficial effect) and omalizumab, 300 or 600 mg (moderate beneficial effect).

Conclusions and Relevance

The findings in this meta-analysis suggest that the biologic agents ligelizumab, 72 or 240 mg, and omalizumab, 300 or 600 mg, can be recommended as effective treatments for patients with CSU who have had an inadequate response to H1 antihistamines. Head-to-head trials with high methodologic quality and harmonized design and outcome definitions are needed to help inform subsequent international guidelines for the management of CSU.

The Addition of Montelukast for the Treatment of Chronic Idiopathic Urticaria

Introduction Chronic urticaria (CU) is a common disorder that can significantly affect the quality of life. The goal of treatment is complete symptomatic relief. Conventional therapy, with antihistamines, is not always effective in all patients. Leukotrienes are believed to be involved in the pathogenesis of urticaria. Leukotriene receptor antagonists (LTRAs), such as montelukast, have been suggested as useful agents in patients with chronic idiopathic urticaria. Our objective is to document the efficacy of montelukast in our patients. Materials and methods Patients who received montelukast were identified from clinic letters. Data including clinical features were collected and analyzed. The main endpoint was adequate disease control. Results A total of nine patients who met the inclusion criteria were included in this study. Four patients reported having a good response to montelukast and three patients reported full control of the disease. Conclusion These findings suggest that leukotriene antagonists, such as montelukast, are effective as an add-on therapy to anti-histamines and their use in histamine resistant patients is justifiable.

SELE Downregulation Suppresses Mast Cell Accumulation to Protect against Inflammatory Response in Chronic Idiopathic Urticaria

BACKGROUND

Chronic idiopathic urticaria (CIU) represents a common skin disorder often characterized by mast cell activation and secretion of histamine and other proinflammatory factors. E-selectin (SELE) has been implicated in the pathogenesis of common inflammatory cutaneous disorders, while the role of SELE in CIU is yet to be fully understood. Thus, we aimed to investigate the mechanism by which SELE influences CIU in connection with the involvement of mast cells.

METHODS

SELE expression was measured in blood samples obtained from CIU patients and normal individuals. A CIU mouse model was subsequently established by intradermally injecting a normal saline solution with ovalbumin IgE antiserum into the mice. Loss- and gain-of-function investigations were conducted on the mouse models. The number of degranulated mast cells and the amount of histamine release in vitro were determined. The levels of SELE, tumor necrosis factor (TNF)-α, homologous restriction factor (HRF), and interleukin (IL)-6 levels were determined.

RESULTS

The CIU clinical samples exhibited upregulated SELE, while the CIU mice showed increased mast cell degranulation and an increased rate of histamine directional release, as well as an elevated expression of SELE, TNF-α, HRF, and IL-6. SELE silencing was found to decrease the number of degranulated mast cells and reduce the rate of histamine directional release, along with suppressed TNF-α, HRF, and IL-6 expression, in the serum of CIU mice. Ketotifen was observed to rescue the increased expression of TNF-α, HRF, and IL-6 caused by SELE overexpression.

CONCLUSIONS

This study highlights the potential of SELE downregulation to repress inflammatory factor secretion caused by the accumulation of mast cells, which ultimately inhibits the development of CIU.

Chronic Urticaria: An Overview of Treatment and Recent Patents

Background:

Up to 1% of the general population in the USA and Europe suffer from chronic urticaria (CU) at some point in their lifetime. CU has an adverse effect on the quality of life.

Objective:

This study aims to provide an update on the epidemiology, pathogenesis, clinical manifesta-tions, diagnosis, aggravating factors, complications, treatment and prognosis of CU.

Methods:

The search strategy included meta-analyses, randomized controlled trials, clinical trials, reviews and pertinent references. Patents were searched using the key term “chronic urticaria” at the following links: www.google.com/patents, www.uspto.gov, and www.freepatentsonline.com.

Results:

CU is a clinical diagnosis, based on the episodic appearance of characteristic urticarial lesions that wax and wane rapidly, with or without angioedema, on most days of the week, for a period of six weeks or longer. Triggers such as medications, physical stimuli, and stress can be identified in 10 to 20% of cases. C-reactive protein/erythrocyte sedimentation rate, and complete blood cell count with differential are the screening tests that may be used to rule out an underlying disorder. The mainstay of therapy is reassurance, patient education, avoidance of known triggers, and pharmacotherapy. Second-generation H1 antihistamines are the drugs of choice for initial therapy because of their safety and efficacy profile. If satisfactory improvement does not occur after 2 to 4 weeks or earlier if the symptoms are intolerable, the dose of second-generation H1 antihistamines can be increased up to fourfold the manufacturer’s recom-mended dose (all be it off license). If satisfactory improvement does not occur after 2 to 4 weeks or earlier if the symptoms are intolerable after the fourfold increase in the dosage of second-generation H1 antihis-tamines, omalizumab should be added. If satisfactory improvement does not occur after 6 months or earli-er if the symptoms are intolerable after omalizumab has been added, treatment with cyclosporine and sec-ond-generation H1 antihistamines is recommended. Short-term use of systemic corticosteroids may be considered for acute exacerbation of CU and in refractory cases. Recent patents for the management of chronic urticaria are also discussed. Complications of CU may include skin excoriations, adverse effect on quality of life, anxiety, depression, and considerable humanistic and economic impacts. On average, the duration of CU is around two to five years. Disease severity has an association with disease duration.

Conclusion:

CU is idiopathic in the majority of cases. On average, the duration of CU is around two to five years. Treatment is primarily symptomatic with second generation antihistamines being the first line. Omalizumab has been a remarkable advancement in the management of CU and improves the quality of life beyond symptom control.

Urticaria: A comprehensive review: Treatment of chronic urticaria, special populations, and disease outcomes

Second-generation antihistamines are considered first-line agents in the treatment of chronic urticaria because of their safety and efficacy profile. Some patients require higher doses of H₁ antihistamines alone or in combination with other classes of medications, including H₂ antihistamines, leukotriene receptor antagonists, or first-generation H₁ antihistamines. One major therapeutic advance has been omalizumab, a humanized monoclonal anti-immunoglobulin E that was recently approved by the US Food and Drug Administration for the treatment of chronic urticaria that is unresponsive to H₁ antagonists. In addition, the second article in this continuing medical education series outlines several evidence-based alternative treatments for urticaria and the differences in recommendations between 2 major consensus groups (the European Academy of Allergy and Clinical Immunology/World Allergy Organization and the American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force).

The effect of levocetirizine and montelukast on clinical symptoms, serum level and skin expression of COX-1 and COX-2 enzymes in patients suffering from chronic autoimmune urticaria - a pilot study

Introduction

Chronic autoimmune urticaria (CAU) lasts over 6 weeks and is characterized by circulating IgE autoantibodies or IgG against IgE or IgE receptor.

Aim

To assess the clinical, laboratory and histological effects of 4-week levocetirizine and montelukast therapy in patients suffering from CAU.

Material and methods

Of 296 tested patients with chronic urticaria 40 had a positive ASST test. Only 17 (16 female/1 male; medium age: 44 years) fulfilled all study inclusion/exclusion criteria. The study was designed as an open, randomized trial with two arms: levocetirizine or montelukast treatment for 4 weeks following a 2-week wash-out period. All participants completed urticaria activity score (UAS) and visual analogue scale (VAS) questionnaires before and after both therapies. Blood samples and skin bioptats were obtained before and after treatment to evaluate COX-1 and COX-2 serum concentrations and skin expression.

Results

Clinical response to therapy measured with the UAS and VAS was better in the levocetirizine group. Both drugs caused a significant decrease in COX-1 and COX-2 serum level. COX-1 and COX-2 expression in epidermal and dermal inflammatory infiltration did not change significantly in either study group, but a significant decrease of COX-1 expression was observed when the groups were combined for analysis, and the decrease in COX-2 expression in the epidermis was of borderline significance.

Conclusions

The effectiveness of levocetirizine and montelukast in treating CAU may be partly related to the reduction of COX-1 and COX-2 serum level and tissue expression, but further studies on a larger group of patients are needed to support this observation.

Consensus Statement for the Diagnosis and Treatment of Urticaria: A 2017 Update

This article is developed by the Skin Allergy Research Society of India for an updated evidence-based consensus statement for the management of urticaria, with a special reference to the Indian context. This guideline includes updated definition, causes, classification, and management of urticaria. Urticaria has a profound impact on the quality of life and causes immense distress to patients, necessitating effective treatment. One approach to manage urticaria is by identification and elimination of the underlying cause(s) and/or eliciting trigger(s) while the second one is by treatment for providing symptomatic relief. This guideline recommends the use of second-generation nonsedating H1-antihistamines as the first-line treatment. The dose can be increased up to four times to meet the expected results. In case patients still do not respond, appropriate treatment options can be selected depending on the associated medical condition, severity of the symptoms, affordability of the drugs, and accessibility of modern biologics such as omalizumab.

Treatment of chronic spontaneous urticaria: Immunomodulatory approaches

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.

Lipid Mediators of Allergic Disease: Pathways, Treatments, and Emerging Therapeutic Targets

Bioactive lipids are critical regulators of inflammation. Over the last 75 years, these diverse compounds have emerged as clinically-relevant mediators of allergic disease pathophysiology. Animal and human studies have demonstrated the importance of lipid mediators in the development of asthma, allergic rhinitis, urticaria, anaphylaxis, atopic dermatitis, and food allergy. Lipids are critical participants in cell signaling events which influence key physiologic (bronchoconstriction) and immune phenomena (degranulation, chemotaxis, sensitization). Lipid-mediated cellular mechanisms including: (1) formation of structural support platforms (lipid rafts) for receptor signaling complexes, (2) activation of a diverse family of G-protein coupled receptors, and (3) mediating intracellular signaling cascades by acting as second messengers. Here, we review four classes of bioactive lipids (platelet activating factor, the leukotrienes, the prostanoids, and the sphingolipids) with special emphasis on lipid synthesis pathways and signaling, atopic disease pathology, and the ongoing development of atopy treatments targeting lipid mediator pathways.

Chronic Spontaneous Urticaria: Pathogenesis and Treatment Considerations

The treatment of chronic spontaneous urticaria begins with antihistamines; however, the dose required typically exceeds that recommended for allergic rhinitis. Second-generation, relatively non-sedating H₁-receptor blockers are typically employed up to 4 times a day. First-generation antihistamines, such as hydroxyzine or diphenhydramine (Atarax or Benadryl), were employed similarly in the past. Should high-dose antihistamines fail to control symptoms (at least 50%), omalizumab at 300 mg/month is the next step. This is effective in 70% of antihistamine-refractory patients. H₂-receptor blockers and leukotriene antagonists are no longer recommended; they add little and the literature does not support significant efficacy. For those patients who are unresponsive to both antihistamines and omalizumab, cyclosporine is recommended next. This is similarly effective in 65%–70% of patients; however, care is needed regarding possible side-effects on blood pressure and renal function. Corticosteroids should not be employed chronically due to cumulative toxicity that is dose and time dependent. Brief courses of steroid e.g., 3–10 days can be employed for severe exacerbations, but should be an infrequent occurrence. Finally, other agents, such as dapsone or sulfasalazine, can be tried for those patients unresponsive to antihistamines, omalizumab, and cyclosporine.

Guideline of Chronic Urticaria Beyond

Urticaria is a relatively common condition that if chronic can persist for weeks, months or years and affect quality of life significantly. The etiology is often difficult to determine, especially as it becomes chronic. Many cases of chronic urticaria are thought to be autoimmune, although there is no consensus that testing for autoimmunity alters the diagnostic or management strategies or outcomes. Many times, urticaria is easily managed with antihistamines and/or short courses of oral corticosteroids, but too often control is insufficient and additional therapies must be added. For years, immune modulating medications, such as cyclosporine and Mycophenolate Mofetil, have been used in cases refractory to antihistamines and oral corticosteroids, although the evidence supporting their efficacy and safety has been limited. Omalizumab was recently approved for the treatment of chronic urticaria unresponsive to H1-antagonists. This IgG anti-IgE monoclonal antibody has been well demonstrated to safely and effectively control chronic urticaria at least partially in approximately 2/3 of cases. However, the mechanism of action and duration of treatment for omalizumab is still unclear. It is hoped that as the pathobiology of chronic urticaria becomes better defined, future therapies that target specific mechanistic pathways will be developed that continue to improve the management of these often challenging patients.

BSACI guideline for the management of chronic urticaria and angioedema

This guidance for the management of patients with chronic urticaria and angioedema has been prepared by the Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI). The guideline is based on evidence as well as on expert opinion and is aimed at both adult physicians and paediatricians practising in allergy. The recommendations are evidence graded. During the development of these guidelines, all BSACI members were included in the consultation process using a Web-based system. Their comments and suggestions were carefully considered by the Standards of Care Committee. Where evidence was lacking, a consensus was reached by the experts on the committee. Included in this management guideline are clinical classification, aetiology, diagnosis, investigations, treatment guidance with special sections on children with urticaria and the use of antihistamines in women who are pregnant or breastfeeding. Finally, we have made recommendations for potential areas of future research.

Chronic spontaneous urticaria: latest developments in aetiology, diagnosis and therapy

Chronic urticaria is a debilitating disease characterized by itching and hives with or without angioedema lasting for more than 6 weeks. The disease carries a significant emotional and economic burden for the patient and often results in an odyssey between doctors of different specialities. Patients suffering from chronic urticaria are considered more difficult to satisfy, treat and to have a bigger emotional burden than the average patient in dermatology, paediatric and general practice settings. A joint initiative under the Dermatology section of the European Academy of Allergy and Clinical immunology (EAACI), the Global Allergy and Asthma European Network (GA(2)LEN), the European Dermatology Forum (EDF) and the World Allergy Organization (WAO) has resulted in recently published guidelines for the diagnosis, classification and treatment of chronic urticarial: these guidelines are clinically useful and have a high success rate when followed in daily clinical practice. The treatment of choice for chronic urticaria is still nonsedating antihistamines although other treatments are available, with omalizumab (humanized IgG anti IgE antibodies) as the newest therapy. The pathogenesis of urticaria is poorly understood but autoimmunity is considered as one of the major underlying causes for this disease, although other theories exist.

Urticaria Guidelines: Consensus and Controversies in the European and American Guidelines

Urticaria can present acutely and be self-limiting or become chronic and persist for weeks, months, or years. In either case, the condition may have a significant impact on the patient's quality of life. Two major consensus groups, the EAACI/WAO and the AAAAI/ACAAI Joint Task Force, have written guidelines on the diagnosis and management of urticaria. While both agree on most points regarding the definition, general evaluation, and treatment, there are some differences which exist. The guidelines, which are written to assist both primary practitioners and specialists in managing their patients with urticaria, have been developed based on scientific evidence, and when insufficient evidence is available, then recommendations are based on expert consensus opinion. The majority of the differences between the two guidelines pertain to recommendations based on expert opinion because of weak scientific evidence. Within this document, we compare the recommendations of these two groups, highlighting the key similarities and differences.

Chronic urticaria: new management options

Chronic urticaria is defined as episodic or daily hives lasting for at least 6 weeks and impairs quality of life. Two main subtypes include chronic idiopathic (spontaneous) urticaria and inducible (physical) urticaria, but some patients have urticarial vasculitis. “Autoimmune chronic urticaria” implies the presence of histamine releasing or mast cell activating autoantibodies to IgE or FcϵRI, the high affinity receptor on mast cells and basophils. In patients not readily controlled with labeled dosages of second generation H₁ receptor antagonists (antihistamines), there is evidence for reduction of urticaria using up to 4 fold increases in labeled dosages. The biologic modifier, omalizumab, helps to reduce lesions of chronic urticaria within 1–2 weeks.

Update and insights into treatment options for chronic spontaneous urticaria

Chronic spontaneous urticaria (CSU) is defined as itchy weals, angio-oedema, or both, arising spontaneously without external physical stimuli. Symptoms of the disease continue to develop for more than 6 weeks. It carries a high socioeconomic burden with considerable health care costs. Second generation H1-antihistamines are the mainstay of urticaria treatment and are the only licensed option. However, many patients are resistant to H1-antihistamine therapy. Omalizumab has proven to be an effective therapeutic option in patients with recalcitrant chronic urticaria. Ciclosporin appears to be more beneficial in patients with functional histamine releasing autoantibodies as a cause of their disease. This review article will highlight the major therapeutic options available today for the management of CSU knowing that good quality evidence for efficacy of many agents is scarce except for H1-antihistamines and omalizumab.

Autologous serum therapy in chronic urticaria: a promising complement to antihistamines

Background:

Chronic urticaria (CU) is a vexing problem and patients of CU suffer from the morbidity that arise from irritable itch and weals and are also subjected to a huge antihistamine pill burden. The symptoms are more in autoreactive urticaria (AU) where auto-antibodies in blood flares-up the condition. Search for newer effective modalities which can reduce pill burden is a felt need.

Aims:

This study evaluates the effectiveness of autologous serum therapy (AST) in CU and also determines its usefulness in AU.

Materials and Methods:

Double blind, parallel group, randomized, controlled study. Fifty four patients were given AST and 57 patients were given injection normal saline (placebo), along with cetirizine in an on-demand basis in both groups. AST/Placebo was given weekly for nine weeks and followed-up for a total period of 24 weeks. AU was diagnosed by autologous serum skin test. Urticaria total severity score (TSS), Urticaria activity score (UAS), Dermatologic life quality index (DLQI) was used as primary effectiveness variables. Safety parameters assessed were the spontaneously reported adverse events and laboratory parameters.

Results:

TSS showed significant improvement from baseline, 7^th week and 8^th week onwards in AST group and placebo group respectively. Group comparison showed significant improvement 4^th week onwards. UAS showed similar results. DLQI showed significant improvement in AST group compared to placebo at the end of study. Both AU and non-AU patients showed comparable improvement of TSS.

Conclusion:

AST shows promise in treatment of urticaria regardless of the autoreactive nature.

Methods report on the development of the 2013 revision and update of the EAACI/GA2 LEN/EDF/WAO guideline for the definition, classification, diagnosis, and management of urticaria

This methods report describes the process of guideline development in detail. It is the result of a systematic literature review using the 'Grading of Recommendations Assessment, Development and Evaluation' (GRADE) methodology and a structured consensus conference held on 28 and 29 November 2012, in Berlin. It is a joint initiative of the Dermatology Section of the European Academy of Allergy and Clinical Immunology (EAACI), the EU-funded network of excellence, the Global Allergy and Asthma European Network (GA(2) LEN), the European Dermatology Forum (EDF), and the World Allergy Organization (WAO) with the participation of delegates of 21 national and international societies. This guideline covers the definition and classification of urticaria, taking into account the recent progress in identifying its causes, eliciting factors and pathomechanisms. In addition, it outlines evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS) and is published in Allergy 2014; 69:868-887.

Treatment of chronic urticaria in children with antihistamines and cyclosporine

BACKGROUND

Chronic idiopathic urticaria, daily hives that last >6 weeks, can be resistant to antihistamines, even when higher than conventional doses are used. Other pharmacologic agents have been associated with inconsistent benefit.

OBJECTIVE

We examined the relationship of clinical characteristics and the presence of autoimmune antibodies to antihistamine resistance in children. We further examined the efficacy and safety of cyclosporine in children whose urticaria was resistant to antihistamine.

METHODS

Patients referred to the pediatric allergy and pulmonary specialty clinic at the University of Iowa Children's Hospital and diagnosed as having chronic idiopathic urticaria were identified during the period from August 2008 to July 2013. A retrospective examination of treatment and outcome was performed.

RESULTS

Forty-six patients, 26 female patients and 20 male patients, with chronic idiopathic urticaria were identified. The ages of 16 patients who were antihistamine resistant ranged from 9 to 18 years (median, 12.5 years). Those patients who were antihistamine responsive had a median age of 6 years, significantly lower than those who were antihistamine resistant (P = .0001). There was no significant association between autoimmune antibodies and antihistamine resistance. All the patients who were antihistamine resistant were treated with cyclosporine; all experienced complete resolution of urticaria at times that ranged from 2 days to 3 months (median, 7 days). Relapses responsive to repeated cyclosporine occurred in 5 of the patients after 1 week to 15 months (median, 6 months). Adverse effects were not seen in these patients.

CONCLUSION

Our data were consistent with efficacy and safety of cyclosporine for chronic urticaria in children when even high doses of antihistamines are ineffective.

Leukotriene receptor antagonists for chronic urticaria: a systematic review

A significant proportion of patients with chronic urticaria respond inadequately to first line treatment with antihistamines. Leukotreine receptor antagonists (LTRA) are also used for chronic urticaria, although firm recommendations on their use are lacking. We performed a systematic review of randomised trials to determine the role of LTRA in treatment of chronic urticaria. A search of PUBMED, EMBASE, SCOPUS, LILACS, the Cochrane Central Register of Controlled Trials, and the Web of Science for relevant randomized control trials or cross over studies yielded 10 eligible studies. The heterogeneity of trials were high, preventing valid meta-analysis of data. Most trials indicated that LTRA are not superior to placebo or antihistamine therapy, while combination therapy of LTRA and antihistamines appear to be more efficacious compared to antihistamine alone. The side effect profile and tolerability of this group of drugs is acceptable. The use of LTRA as monotherapy cannot be recommended. LTRA are effective add-on therapy to anti-histamines, and their use in patients responding poorly to antihistamines is justifiable. Further well designed randomized controlled trials with clear and standardized outcome measures are needed to determine the role of LTRA in chronic urticaria.

Pathogenic intracellular and autoimmune mechanisms in urticaria and angioedema

Urticaria and angioedema are common disorders. Chronic urticaria is defined as lasting longer than 6 weeks. Causes of chronic urticaria fall into the following categories: physical, allergic, hereditary, autoimmune, and idiopathic. Basophils and mast cells are the primary effector cells responsible for clinical symptoms and signs. These cells produce and secrete a variety of mediators including histamine, leukotrienes, prostaglandins, cytokines, chemokines, and other pro-inflammatory mediators. This leads to vasodilation, fluid exudation, increased vascular permeability, and accumulation of additional secondary inflammatory cells. Two mechanisms have been investigated as possibly contributing to the pathogenesis of chronic urticaria. One is the development of autoantibodies to FcεRI or IgE on mast cells and basophils. This appears to be responsible for 30-50 % of cases. The other is dysregulation of intracellular signaling pathways involving Syk, SHIP-1, or SHIP-2 in basophils and mast cells. The primary treatment for chronic urticaria is to treat the underlying pathology, if any can be identified. Otherwise, in idiopathic cases, H1 antihistamines, H2 antihistamines, antileukotrienes, and corticosteroids constitute the main pharmacologic treatment modalities. In severe and recalcitrant cases of chronic and autoimmune urticaria, immunosuppressive drugs have been used, most commonly cyclosporin. More recent experimental studies have also suggested that omalizumab, an anti-IgE therapy, may be of benefit. Currently, inhibitors of Syk are also being developed and tested in the laboratory and in animal models. As our understanding of the pathogenesis of idiopathic urticaria increases, development of additional drugs targeting these pathways may provide relief for the significant physical and psychological morbidity experienced by patients with this disorder.

Therapy of chronic urticaria: a simple, modern approach

OBJECTIVE

To examine the available treatment choices for chronic spontaneous urticaria (CSU) and discuss a new paradigm for treating such patients.

DATA SOURCES

The literature regarding treatment is reviewed, including considerations of published guidelines. Attention is focused on the most recent evidence indicating particular efficacy of omalizumab.

RESULTS

Omalizumab has been found to have considerable efficacy in phase 2 and phase 3 trials in which more than 900 patients have been studied. A response rate of 65% is seen in patients resistant to antihistamines as well as to histamine2 blockers and leukotriene antagonists, and 40% of patients are completely free of hives as long as therapy is continued. In addition, serious adverse events have not been seen. Only cyclosporine can match this response rate (excluding steroids), but the adverse effect profile (blood pressure and renal function) is substantial by comparison. Double-blind, placebo-controlled studies of other agents often listed as alternatives are lacking (ie, whether their success rate exceeds the 25%-30% placebo response is uncertain). The mechanism by which omalizumab works in CSU is not clear because the response rate is unrelated to the autoimmune profile and can occur rapidly (ie, within a few days).

CONCLUSION

Omalizumab has exceptional efficacy for antihistamine-resistant CSU with an excellent adverse effect profile.

Treatment of refractory chronic urticaria: current and future therapeutic options

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.

The Management and Treatment of Chronic Urticaria

Chronic urticaria (CU) is a challenging and frequently encountered diagnosis characterized by the presence of evanescent wheals that persist for greater than 6 weeks. It is estimated that 15% to 25% of the US population are affected at some time in their lives with urticaria and that 33% of all urticaria cases are considered to be chronic. Although acute urticaria is generally benign and self-limiting, serious medical illness may occur with CU. The incidence of CU is estimated to be as high as 5% in the general population and greater than 10% when surveying allergy and dermatology patients. CU is an episodic, pruritic disorder in which 45% to 90% of patients will not have an identifiable cause and occurs 4 times more often in females than males. The average disease duration of CU is between 2 and 5 years, and its typical onset is in the third to fourth decade of life. CU is thought to have the most impact on quality of life than any other allergic disease. This article will provide a clinical update and review on the management and treatment of CU.

Chronic urticaria: Indian context-challenges and treatment options

Urticaria is a common condition that occurs in both children and adults. Most cases have no specific allergic trigger and the aetiology of urticaria remains idiopathic and occasionally spontaneous in nature. Inappropriate advice such as avoidance of foods (milk, egg, prawn, and brinjal) is common place in certain sections of India mostly by nonspecialists that should not be routinely recommended. It is important to look for physical urticarias such as pressure urticaria in chronic cases, which may be present either alone or in combination with other causes. Autoimmune causes for chronic urticaria have been found to play an important role in a significant proportion of patients. Long-acting nonsedating antihistamines at higher than the standard doses is safe and effective. Quality of life is affected adversely in patients with chronic symptomatic urticaria and some may require multidisciplinary management.

Alternative agents in refractory chronic urticaria: evidence and considerations on their selection and use

Patients with chronic urticaria (CU) who are refractory to antihistamines are frequently encountered by allergy specialists. Several alternative agents have been used to treat these patients; however, the evidence to support these agents is generally limited. This review focuses on some of the more commonly used alternative agents in refractory CU, including anti-inflammatory agents (montelukast, hydroxychloroquine, dapsone, sulfasalazine, methotrexate, colchicine), immunosuppressants (cyclosporine, tacrolimus, mycophenolate), and immunomodulatory agents (omalizumab, immune globulin). The evidence to support their use, dosing, potential toxicity, monitoring, and selection of these alternative agents is reviewed. Although numerous knowledge gaps exist for alternative agents in refractory CU, a rational, patient-based approach can be used with a goal of improving control and quality of life and minimizing adverse medication effects.

Diagnosis and treatment of urticaria and angioedema: a worldwide perspective

: 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.

Add-on montelukast in antihistamine-resistant chronic idiopathic urticaria

BACKGROUND

Antihistamines (AH) alleviate pruritus and decrease the incidence of hives in patients with chronic idiopathic urticaria (CU). However, some patients do not respond completely to this therapy. We hypothesized that some of them might benefit from the addition of leukotriene receptor antagonists (LA).

METHODS

We screened patients diagnosed and treated for CU and selected those that had symptoms despite antihistamine treatment. In a double-blind crossover study, patients took the leukotriene antagonist montelukast (10 mg per day) or placebo. Efficacy was assessed by a symptom score.

RESULTS

In a group of 22 patients, the symptom score was not significantly different between periods using montelukast (48.8; 0-214) or placebo (68.5; 0-230). However in the subgroup of five patients with the most severe urticaria, defined as patients with symptom scores in the upper quartile at inclusion in the study, montelukast (41; 11 214) was superior to placebo (95.5; 48 230; p < 0.05), but only when using an in-house symptom score questionnaire and not when using a validated urticaria activity score questionnaire.

CONCLUSIONS

We showed that in patients with antihistamine-resistant CU the addition of montelukast significantly diminished symptoms in only a small minority of patients. However, response to add-on montelukast was seen in the subgroup of patients with particularly severe disease. To confirm this observation, a study with a larger group of patients is warranted.

Urticaria and angioedema

Urticaria (hives) is a common disorder that often presents with angioedema (swelling that occurs beneath the skin). It is generally classified as acute, chronic or physical. Second-generation, non-sedating H1-receptor antihistamines represent the mainstay of therapy for both acute and chronic urticaria. Angioedema can occur in the absence of urticaria, with angiotensin-converting enzyme (ACE) inhibitor-induced angioedema and idiopathic angioedema being the more common causes. Rarer causes are hereditary angioedema (HAE) or acquired angioedema (AAE). Although the angioedema associated with these disorders is often self-limited, laryngeal involvement can lead to fatal asphyxiation in some cases. The management of HAE and AAE involves both prophylactic strategies to prevent attacks of angioedema (i.e., trigger avoidance, attenuated androgens, tranexamic acid, and plasma-derived C1 inhibitor replacement therapy) as well as pharmacological interventions for the treatment of acute attacks (i.e., C1 inhibitor replacement therapy, ecallantide and icatibant). In this article, the authors review the causes, diagnosis and management of urticaria (with or without angioedema) as well as the work-up and management of isolated angioedema, which vary considerably from that of angioedema that occurs in the presence of urticaria.

Chronic urticaria

Chronic urticaria (CU) is a disturbing allergic condition of the skin. Although frequently benign, it may sometimes be a red flag sign of a serious internal disease. A multitude of etiologies have been implicated in the causation of CU, including physical, infective, vasculitic, psychological and idiopathic. An autoimmune basis of most of the 'idiopathic' forms is now hypothesized. Histamine released from mast cells is the major effector in pathogenesis and it is clinically characterized by wheals that have a tendency to recur. Laboratory investigations aimed at a specific etiology are not always conclusive, though may be suggestive of an underlying condition. A clinical search for associated systemic disease is strongly advocated under appropriate circumstances. The mainstay of treatment remains H1 antihistaminics. These may be combined with complementary pharmacopeia in the form of H2 blockers, doxepin, nifedipine and leukotriene inhibitors. More radical therapy in the form of immunoglobulins, plasmapheresis and cyclophosphamide may be required for recalcitrant cases. Autologous transfusion and alternative remedies like acupuncture have prospects for future. A stepwise management results in favorable outcomes. An update on CU based on our experience with patients at a tertiary care centre is presented.

Chronic urticaria: a comparison of management guidelines

INTRODUCTION

Chronic urticaria is characterized by recurring episodes of spontaneous transient dermal wheals and pruritus, with or without angioedema, which can persist for ≥ 6 weeks. Chronic urticaria impairs quality of life, emphasizing the need for effective treatments. Professional societies and clinical experts have issued evidence-based recommendations for the management of chronic urticaria, including recommending the use of second-generation antihistamines as a first-line therapy.

AREAS COVERED

A Medline search was conducted from 2000 to 2011 using the following terms, alone or in combination: 'chronic urticaria', 'management guidelines', 'consensus guidelines' and 'expert opinions'. Ten management guidelines/expert opinions met the inclusion criteria.

EXPERT OPINION

There was a universal agreement among the articles reviewed, that low-sedating, second-generation antihistamines should be prescribed as a first-line treatment of chronic urticaria. For refractory urticaria, however, recommendations varied and included dose escalation of second-generation antihistamines and adjunctive treatments with other agents of the same class, such as sedating antihistamines or leukotriene receptor antagonists. More research into effective second-line treatments and consistent implementation of current guidelines is needed, to ensure that treatment is based on clinical evidence.