Successful sulfasalazine treatment of severe chronic idiopathic urticaria associated with pressure urticaria

Evaluating and managing chronic idiopathic urticaria in adults

Chronic idiopathic urticaria (CIU), also known as chronic spontaneous urticaria, is characterized by the presence of hives on most days of the week, for 6 weeks or longer, and without an identifiable or consistent cause. Evaluation is clinical and based on the presence of episodic urticarial lesions. Although patients are subject to overtesting during the diagnosis of CIU, guidelines suggest starting with three basic laboratory tests. Treatment is a stepwise approach, involving second-generation antihistamines, histamine2 antagonists, leukotriene receptor antagonists, first-generation antihistamines, and potent antihistamines. Refractory CIU requires adding alternative agents such as omalizumab, anti-inflammatory agents, and immunosuppressants.

Sulfasalazine-Related Hypersensitivity Reactions in Patients With Rheumatic Diseases

BACKGROUND

Sulfasalazine (SSZ), which has an arylamine sulfonamide structure, is an anti-inflammatory drug used in the treatment of many rheumatic diseases. Various adverse effects have been reported related to SSZ. In the present study, we aimed to define the frequency of SSZ-related hypersensitivity reaction in patients with rheumatoid arthritis and ankylosing spondylitis.

METHODS

A total of 136 patients were included in this study. During follow-ups, reaction type, reaction duration, and drug doses were recorded in patients who developed hypersensitivity reactions. Drugs were discontinued in patients who developed reactions, and they were treated with antihistaminics and/or corticosteroids, according to requirements. Drug provocation tests with the drugs and aminosalicylic acid were performed in patients with negative skin prick test individually.

RESULTS

A total of 136 patients, with ages ranging from 19 to 71 years (mean, 41.97 [SD, 12.04] years), were included in the study. Hypersensitivity reactions according to the drug provocation test were found against SSZ in 12 patients (8.8%). The SSZ-related hypersensitivity reaction types were urticaria in 7 patients, urticaria and angioedema in 4 patients, and pruritus in 1 patient.

CONCLUSIONS

Sulfasalazine is widely used by rheumatologists in the treatment of rheumatic diseases. Whereas the frequency of sulfonamide-related hypersensitivity reactions was reported as 3.0% in the population, we detected hypersensitivity reactions to be 8.8% with SSZ usage in rheumatic diseases.

Therapy of antihistamine-resistant chronic spontaneous urticaria

INTRODUCTION

Chronic urticaria affects up to 1-3% of the general population and contributes to significant direct and indirect medical costs as well as decreased quality of life, which has a significant economic impact on our health care system. Areas covered: Given the prevalence of this condition on a large sector of the population, finding lasting relief for refractory cases is essential and is the focus of this review. Expert commentary: The choice of appropriate therapy in chronic refractory urticaria is not a 'one-size fits all' approach. Treatment should take multiple factors into consideration including the chronicity of hives, presence of physical urticaria, type of cellular infiltrate on skin histopathology, patient age, concomitant comorbid conditions, as well as patient preference and cost.

Anaphylaxis and urticaria

Anaphylaxis and urticaria are common presenting allergic complaints. Affecting up to 2% of the population, anaphylaxis is a serious, life-threatening allergic reaction. Although not life-threatening, urticaria is a rash of transient, erythematous, pruritic wheals that can be bothersome and affects up to 25% of the population. All cases of anaphylaxis warrant thorough clinical evaluation by the allergist-immunologist, although most cases of urticaria are self-limited and do not require specialist referral. This article offers an overview of our current knowledge on the epidemiology, pathogenesis, triggers, diagnosis, and treatment of anaphylaxis and urticaria.

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.

Update on the treatment of chronic urticaria

Chronic spontaneous urticaria, also known as chronic idiopathic urticaria or simply chronic urticaria, is a common disorder that has a prevalence in the general population that ranges between 0.5% and 1%. This condition negatively affects the patient's quality of life and has considerable impact on direct and indirect health-related costs. Chronic urticaria is difficult to manage. Nonsedating H1 antihistamines are the first line of therapy, but fewer than 50% of patients experience relief at recommended dosages. Although guidelines call for increasing the dosage when response is inadequate, some patients still do not achieve adequate control of symptoms. New treatment alternatives, with proven efficacy under the standards of evidence-based medical practice, must therefore be developed.

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.

Chronic urticaria: assessment of current treatment

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.

Therapeutic alternatives for chronic urticaria: an evidence-based review, part 1

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 second-line therapies reviewed are also categorized based on criteria of safety, efficacy, convenience, and cost, in relation to the first-line antihistamines.

CONCLUSIONS

Alternative agents should be considered in patients with chronic urticaria who are both severely affected and unresponsive to antihistamines. Although monitoring for toxicity is important in management with many alternative agents, safety is favorable compared with corticosteroids.

Emerging drugs for chronic urticaria

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.

Bullous delayed pressure urticaria: pathogenic role for eosinophilic granulocytes?

Bullous delayed pressure urticaria (DPU) is a rare variant of DPU. Treatment of DPU is difficult and the underlying pathogenic mechanism of DPU remains elusive. We report a 72-year-old man with DPU and associated chronic urticaria as well as delayed urticarial dermographism. Pressure challenge gave rise to a deep weal covered by multiple vesicles and bullae after 24 h. Histological examination of a skin biopsy specimen obtained 24 h after pressure challenge demonstrated intraepidermal bullae filled with eosinophils accompanied by a dense, predominantly eosinophilic infiltrate in the dermis. Whereas the numbers and morphology of mast cells were unaltered, the extracellular deposition of eosinophil cationic protein revealed evidence for eosinophil activation. Concomitantly, both CD4+ and CD8+ T lymphocytes were present in the infiltrate and expressed interleukin 5. As bullous DPU may represent the maximal variant of DPU, the investigation of the cellular infiltrate and the chemokines/cytokines released may reveal potential pathogenic mechanisms. A possible effector role of eosinophilic granulocytes, T-cell subsets and mast cells is discussed.

[Urticaria. Classification and diagnosis]

Urticaria belongs to the most frequent dermatologic diseases. Although the pathogenesis of urticaria is not fully understood, systematic studies in recent years have identified the most important triggering factors of the different forms of urticaria. Based on these results, it is recommended to restrict diagnostic procedures in acute urticaria to history and physical examination, while in chronic urticaria, one should exclude drugs, infections, pseudoallergic reactions, and autoimmune processes as causes. For the diagnosis of physical urticaria, standardized provocation test are recommended.

Urticaria

Urticaria has been known as a disease since antiquity. However, in the last decades an increasing understanding of the mechanisms involved in its pathogenesis has shown the high heterogeneity of different urticaria subtypes. Clear distinction of the subtypes is required not only to choose the correct measures in diagnosis and management, but also to interpret the available data in research. The subtypes can be grouped into spontaneous urticaria, which includes acute urticaria and chronic urticaria, the physical urticarias, special types of urticaria including, e.g. contact urticaria, and diseases related to urticaria for historical reasons, e.g. urticaria pigmentosa. Most urticaria subtypes have a profound impact on the quality of life and effective treatment is thus required in case the diagnostic procedures do not reveal a cause which can be treated. Although, for symptomatic relief, nonsedating H1-antihistamines are the first choice in most subtypes of urticaria, double-blind controlled studies have shown that dosages required may exceed those recommended for other diseases, e.g. allergic rhinitis. Alternative treatments should be reserved for unresponsive patients.

Chronic urticaria: a role for newer immunomodulatory drugs?

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.