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Bhowmik R, Shaharyar MA, Sarkar A, Mandal A, Anand K, Shabana H, Mitra A, Karmakar S. Immunopathogenesis of urticaria: a clinical perspective on histamine and cytokine involvement. Inflamm Res 2024; 73:877-896. [PMID: 38555555 DOI: 10.1007/s00011-024-01869-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/28/2024] [Accepted: 03/05/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Urticaria is a clinical condition characterized by the appearance of wheals (hives), angioedema, or both. Over the last several decades, a better understanding of the mechanisms at play in the immunopathogenesis of urticaria has underscored the existence of numerous urticaria subtypes. Separating the different kinds of urticaria explicitly helps find the best detection method for the management of this skin disorder. Subtypes of urticaria also include both spontaneous and physical types. The conventional ones include spontaneous urticaria, constituting both acute and chronic urticaria. Therefore, a broad and effective therapy is essential for the diagnosis and treatment of urticaria. METHODS To understand the immunopathogenesis of urticaria, various databases, including PubMed, Scopus, and Web of Science, were used to retrieve original articles and reviews related to urticaria. While information on several clinical trials were obtained from clinicaltrials.gov database. RESULTS This article highlights the immunopathogenesis involved in the intricate interaction between cellular infiltration, immune reactions, coagulation cascades, and autoantibodies that underlie urticaria's pathophysiology. CONCLUSION The recent progress in understanding urticaria can help to understand the intricate characteristics in the immunopathogenesis of urticaria and could play a beneficial role in the management of urticaria.
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Affiliation(s)
- Rudranil Bhowmik
- Bioequivalence Study Centre, Department of Pharmaceutical Technology, Jadavpur University, Kolkata, 700032, India
| | - Md Adil Shaharyar
- Bioequivalence Study Centre, Department of Pharmaceutical Technology, Jadavpur University, Kolkata, 700032, India
| | - Arnab Sarkar
- Bioequivalence Study Centre, Department of Pharmaceutical Technology, Jadavpur University, Kolkata, 700032, India
| | - Avishek Mandal
- Bioequivalence Study Centre, Department of Pharmaceutical Technology, Jadavpur University, Kolkata, 700032, India
| | - Kumar Anand
- Bioequivalence Study Centre, Department of Pharmaceutical Technology, Jadavpur University, Kolkata, 700032, India
| | - Humira Shabana
- Chaudhary Charan Singh University, Formerly, Meerut University, Meerut, Uttar Pradesh, India
| | - Achintya Mitra
- Regional Ayurveda Research Institute (RARI) CCRAS Under Ministry of AYUSH, Thapla, Ganiyadeoli, Ranikhet Almora, Uttarakhand, India
| | - Sanmoy Karmakar
- Bioequivalence Study Centre, Department of Pharmaceutical Technology, Jadavpur University, Kolkata, 700032, India.
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Sulk M, Hammers CM, Heine G. [Spontaneous remission of urticaria: does it exist and if so, when?]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2024; 75:303-308. [PMID: 38466406 DOI: 10.1007/s00105-024-05320-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Urticaria mostly occurs acutely with a very high probability of spontaneous remission. When it persists for more than 6 weeks a chronic urticaria is manifest, which occurs either spontaneously or inducible by specific triggers. The underlying mechanisms are not fully understood but recent research points to defined pathogenetic factors. QUESTION AND AIM Whether spontaneous remission is possible in urticaria is summarized descriptively in this review, and suggestions are given for the "step down" of urticaria treatment after remission. The mechanisms including autoallergic, immunoglobulin E (IgE)-dependent type I reactions and autoimmune, activating IgG-dependent type IIb reactions are presented. These are discussed in the context of spontaneous remission and the possibilities of induced remission.
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Affiliation(s)
- Mathias Sulk
- Klinik für Hautkrankheiten, Universitätsklinikum Münster, Münster, Deutschland
| | - Christoph M Hammers
- Klinik und Poliklinik für Dermatologie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Guido Heine
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Deutschland.
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Türk M, Kocatürk E, Ertaş R, Ensina LF, Mariel Ferrucci S, Grattan C, Vestergaard C, Zuberbier T, Maurer M, Giménez‐Arnau AM. A global perspective on stepping down chronic spontaneous urticaria treatment: Results of the Urticaria Centers of Reference and Excellence SDown-CSU study. Clin Transl Allergy 2024; 14:e12343. [PMID: 38353300 PMCID: PMC10865765 DOI: 10.1002/clt2.12343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/29/2024] [Accepted: 02/04/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Although there have been significant advances in the treatment of chronic spontaneous urticaria (CSU) in recent years, there remains a lack of clear guidance on when and how to step down treatment in responders. This study aims to investigate stepping down approaches of different steps of CSU treatment from a global perspective. METHODS "Stepping down chronic spontaneous urticaria treatment" (SDown-CSU) is an international, multicenter, observational, cross-sectional, survey-based study of the Urticaria Centers of Reference and Excellence (UCARE) network. The questionnaire included 48 questions completed by physicians in the UCARE network. RESULTS Surveys completed by 103 physicians from 81 UCAREs and 34 countries were analyzed. Seventy-eight percent of the participants responded that they had a national urticaria management guideline written by their professional societies and 28% responded that they had to operate under a regulatory guideline proposed by central health funding organizations. Seventy-two and 58.7% of these national recommendations do not contain any detailed information on when and/or how CSU treatment should be discontinued. There was a lack of detailed information on antihistamines and cyclosporine in particular. A predefined maximum duration was generally not applicable to omalizumab and cyclosporine (81% and 82%, respectively). Nearly all UCAREs step down omalizumab within 6 months from the first controlled status and 42% discontinue cyclosporine after 6 months regardless of the control status. CONCLUSIONS The findings from the SDown-CSU study clearly highlight a global need for guidance on the process of stepping down treatment in CSU. Additionally, the study offers a step-down algorithm applicable to all stages of CSU treatment.
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Affiliation(s)
- Murat Türk
- Department of Chest DiseasesDivision of Allergy and Clinical ImmunologyErciyes University School of MedicineKayseriTurkey
- Clinic of Allergy and Clinical ImmunologyKayseri City Education and Research HospitalKayseriTurkey
| | - Emek Kocatürk
- Institute of AllergologyCharité – Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMPAllergology and ImmunologyBerlinGermany
| | - Ragıp Ertaş
- Department of DermatologyChronic Skin Diseases UnitUniversity of Health SciencesKayseri City Education and Research HospitalKayseriTurkey
| | - Luis Felipe Ensina
- Division of Allergy, Immunology, RheumatologyFederal University of São PauloSao PauloBrazil
| | | | - Clive Grattan
- St John's Institute of DermatologyGuy's HospitalLondonUK
| | | | - Torsten Zuberbier
- Institute of AllergologyCharité – Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMPAllergology and ImmunologyBerlinGermany
| | - Marcus Maurer
- Institute of AllergologyCharité – Universitätsmedizin BerlinCorporate Member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMPAllergology and ImmunologyBerlinGermany
| | - Ana Maria Giménez‐Arnau
- Department of DermatologyHospital del Mar & Research InstituteBarcelonaSpain
- Universitat Pompeu FabraBarcelonaSpain
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Weller K, Gimenez-Arnau AM, Baron J, Brehler R, Ferrer M, Groffik A, Grundmann S, Jakob T, Labrador-Horrillo M, Müller S, Staubach P, Wurpts G, Metz M, Maurer M. Efficacy and safety of on-demand versus daily rupatadine in chronic spontaneous urticaria: A randomized trial. Allergy 2024; 79:93-103. [PMID: 37597162 DOI: 10.1111/all.15854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/25/2023] [Accepted: 06/16/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND Non-sedating H1 -antihistamines (nsAH) are the most commonly used treatment for chronic spontaneous urticaria (CSU). Many patients use them as on-demand (OD) therapy rather than a maintenance treatment. Here, we compared OD versus daily maintenance treatment with the nsAH rupatadine, assessed the efficacy of rupatadine updosing, and investigated potential long-term disease-modifying effects. METHODS This multicenter, randomized study consisted of 2 weeks of screening, 8 weeks of double-blind treatment, and 6 weeks of treatment-free follow-up (OD allowed). Adult patients were randomized to 10 mg rupatadine OD or 10 mg rupatadine daily. At Week 4, if patients did not have a complete response, they switched from 10 to 20 mg rupatadine daily or underwent sham updosing (patients on 10 mg rupatadine OD). The primary aim was to compare CSU disease activity at the end of follow-up between daily versus OD. Additionally, we assessed the efficacy of rupatadine updosing. Major outcomes were disease activity, CSU-related quality of life (QoL), and disease control. RESULTS At Week 4, disease activity and QoL significantly improved in daily versus OD-treated patients. Updosing of rupatadine did not improve the mean disease activity, but the number of complete responders increased during updosing from 5% to 22%. At the end of follow-up, the disease activity of patients treated OD versus daily was not significantly different. CONCLUSIONS Daily rupatadine treatment significantly improved CSU disease activity and QoL during treatment versus OD treatment but not after discontinuation of rupatadine, indicating the benefits of a daily maintenance nsAH schedule.
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Affiliation(s)
- Karsten Weller
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ana Maria Gimenez-Arnau
- Department of Dermatology, Hospital del Mar, IMIM, Universitat Pompeu Fabra, Barcelona, Spain
| | - Jens Baron
- Department of Dermatology and Allergy, University Hospital, RWTH Aachen, Aachen, Germany
| | - Randolf Brehler
- Department of Dermatology, University Hospital Muenster, Muenster, Germany
| | - Marta Ferrer
- Department of Allergy, Clinica Universidad de Navarra, Pamplona, Spain
- RICORS Red De Enfermedades Inflamatorias (REI)-RD21/0002/0028, Madrid, Spain
| | - Adriane Groffik
- Department of Dermatology, University Medical Center Mainz, Mainz, Germany
| | | | - Thilo Jakob
- Department of Dermatology and Allergy, University Medical Center, Justus Liebig University Gießen, Giessen, Germany
| | - Moisés Labrador-Horrillo
- Allergy Department, Hospital Universitario Vall d'Hebron, VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sabine Müller
- Department of Dermatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Petra Staubach
- Department of Dermatology and Allergy, University Medical Center, Mainz, Germany
| | - Gerda Wurpts
- Clinic for Dermatology and Allergology, Aachen Comprehensive Allergy Center (ACAC), Uniklinik RWTH Aachen, Aachen, Germany
| | - Martin Metz
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Marcus Maurer
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Zheng H, Xiao XJ, Shi YZ, Zhang LX, Cao W, Zheng QH, Zhong F, Hao PS, Huang Y, Chen ML, Zhang W, Zhou SY, Wang YJ, Wang C, Zhou L, Chen XQ, Yang ZQ, Zou ZH, Zhao L, Liang FR, Li Y. Efficacy of Acupuncture for Chronic Spontaneous Urticaria : A Randomized Controlled Trial. Ann Intern Med 2023; 176:1617-1624. [PMID: 37956431 DOI: 10.7326/m23-1043] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND The effectiveness of acupuncture for patients with chronic spontaneous urticaria (CSU), reported in a few small-scale studies, is not convincing. OBJECTIVE To investigate whether acupuncture leads to better effects on CSU than sham acupuncture or waitlist control. DESIGN A multicenter, randomized, sham-controlled trial. (Chinese Clinical Trial Registry: ChiCTR1900022994). SETTING Three teaching hospitals in China from 27 May 2019 to 30 July 2022. PARTICIPANTS 330 participants diagnosed with CSU. INTERVENTION Participants were randomly assigned in a 1:1:1 ratio to receive acupuncture, sham acupuncture, or waitlist control over an 8-week study period (4 weeks for treatment and another 4 weeks for follow-up). MEASUREMENTS The primary outcome was the mean change from baseline in the Weekly Urticaria Activity Score (UAS7) at week 4. Secondary outcomes included itch severity scores, self-rated improvement, and Dermatology Life Quality Index scores. RESULTS The mean change in UAS7 (range, 0 to 42) for acupuncture from baseline (mean score, 23.5 [95% CI, 21.8 to 25.2]) to week 4 (mean score, 15.3 [CI, 13.6 to 16.9]) was -8.2 (CI, -9.9 to -6.6). The mean changes in UAS7 for sham acupuncture and waitlist control from baseline (mean scores, 21.9 [CI, 20.2 to 23.6] and 22.1 [CI, 20.4 to 23.8], respectively) to week 4 (mean scores, 17.8 [CI, 16.1 to 19.5] and 20.0 [CI, 18.3 to 21.6], respectively) were -4.1 (CI, -5.8 to -2.4) and -2.2 (CI, -3.8 to -0.5), respectively. The mean differences between acupuncture and sham acupuncture and waitlist control were -4.1 (CI, -6.5 to -1.8) and -6.1 (CI, -8.4 to -3.7), respectively, which did not meet the threshold for minimal clinically important difference. Fifteen participants (13.6%) in the acupuncture group and none in the other groups reported adverse events. Adverse events were mild or transient. LIMITATION Lack of complete blinding, self-reported outcomes, limited generalizability because antihistamine use was disallowed, and short follow-up period. CONCLUSION Compared with sham acupuncture and waitlist control, acupuncture produced a greater improvement in UAS7, although the difference from control was not clinically significant. Increased adverse events were mild or transient. PRIMARY FUNDING SOURCE The National Key R&D Program of China and the Science and Technology Department of Sichuan Province.
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Affiliation(s)
- Hui Zheng
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China (H.Z., Y.-Z.S., W.C., Q.-H.Z., S.-Y.Z., Z.-H.Z., L.Z., F.-R.L., Y.L.)
| | - Xian-Jun Xiao
- College of Health Preservation and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, China (X.-J.X.)
| | - Yun-Zhou Shi
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China (H.Z., Y.-Z.S., W.C., Q.-H.Z., S.-Y.Z., Z.-H.Z., L.Z., F.-R.L., Y.L.)
| | - Lei-Xiao Zhang
- Internal Medicine of Integrated Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China (L.-X.Z.)
| | - Wei Cao
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China (H.Z., Y.-Z.S., W.C., Q.-H.Z., S.-Y.Z., Z.-H.Z., L.Z., F.-R.L., Y.L.)
| | - Qian-Hua Zheng
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China (H.Z., Y.-Z.S., W.C., Q.-H.Z., S.-Y.Z., Z.-H.Z., L.Z., F.-R.L., Y.L.)
| | - Feng Zhong
- The First Hospital of Hunan University of Chinese Medicine, Changsha, China (F.Z., W.Z.)
| | - Ping-Sheng Hao
- Dermatology Department, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China (P.-S.H., Y.H., M.-L.C.)
| | - Ying Huang
- Dermatology Department, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China (P.-S.H., Y.H., M.-L.C.)
| | - Ming-Ling Chen
- Dermatology Department, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China (P.-S.H., Y.H., M.-L.C.)
| | - Wei Zhang
- The First Hospital of Hunan University of Chinese Medicine, Changsha, China (F.Z., W.Z.)
| | - Si-Yuan Zhou
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China (H.Z., Y.-Z.S., W.C., Q.-H.Z., S.-Y.Z., Z.-H.Z., L.Z., F.-R.L., Y.L.)
| | - Yan-Jun Wang
- Department of Acupuncture and Moxibustion, The First Affiliated Hospital of Hebei University of Chinese Medicine, Shijiazhuang, China (Y.-J.W.)
| | - Chuan Wang
- Wuhan No. 1 Hospital, Wuhan, China (C.W., L.Z.)
| | - Li Zhou
- Wuhan No. 1 Hospital, Wuhan, China (C.W., L.Z.)
| | - Xiao-Qin Chen
- No. 3 Affiliated Hospital of Chengdu University of Traditional Chinese Medicine (West District), Chengdu Pidu District Hospital of Traditional Chinese Medicine, Chengdu, China (X.-Q.C., Z.-Q.Y.)
| | - Zuo-Qin Yang
- No. 3 Affiliated Hospital of Chengdu University of Traditional Chinese Medicine (West District), Chengdu Pidu District Hospital of Traditional Chinese Medicine, Chengdu, China (X.-Q.C., Z.-Q.Y.)
| | - Zi-Hao Zou
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China (H.Z., Y.-Z.S., W.C., Q.-H.Z., S.-Y.Z., Z.-H.Z., L.Z., F.-R.L., Y.L.)
| | - Ling Zhao
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China (H.Z., Y.-Z.S., W.C., Q.-H.Z., S.-Y.Z., Z.-H.Z., L.Z., F.-R.L., Y.L.)
| | - Fan-Rong Liang
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China (H.Z., Y.-Z.S., W.C., Q.-H.Z., S.-Y.Z., Z.-H.Z., L.Z., F.-R.L., Y.L.)
| | - Ying Li
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China (H.Z., Y.-Z.S., W.C., Q.-H.Z., S.-Y.Z., Z.-H.Z., L.Z., F.-R.L., Y.L.)
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Sekerel BE, Ilgun Gurel D, Sahiner UM, Soyer O, Kocaturk E. The many faces of pediatric urticaria. FRONTIERS IN ALLERGY 2023; 4:1267663. [PMID: 38026129 PMCID: PMC10655015 DOI: 10.3389/falgy.2023.1267663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/11/2023] [Indexed: 12/01/2023] Open
Abstract
Urticaria is a common disease that can affect individuals of all age groups, with approximately one-quarter of the population experiencing it at least once in their lifetime. Lesions characterized by erythema and itchy hives can appear anywhere on the body. These can vary in size ranging from millimeters to centimeters, and typically clear within 24 h. About 40% of patients with urticaria have accompanying angioedema, which involves localized deep tissue swelling. Urticaria usually occurs spontaneously and is classified into acute and chronic forms, with the latter referring to a condition that lasts for more than 6 weeks. The prevalence of chronic urticaria in the general population ranges from 0.5% to 5%, and it can either be inducible or spontaneous. The most common form of pediatric urticaria is acute and is usually self-limiting. However, a broad differential diagnosis should be considered in children with urticaria, particularly if they also have accompanying systemic complaints. Differential diagnoses of pediatric urticaria include chronic spontaneous urticaria, chronic inducible urticaria, serum sickness-like reaction, urticarial vasculitis, and mast cell disorders. Conditions that can mimic urticaria, including but not limited to cryopyrinopathies, hyper IgD syndrome, Periodic Fever, Aphthous Stomatitis, Pharyngitis and Adenitis (PFAPA), Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPs), and Schnitzler syndrome should also be considered. The many faces of pediatric urticaria can be both easy and confusing. A pragmatic approach relies on clinical foresight and understanding the various forms of urticaria and their potential mimickers. This approach can pave the way for an accurate and optimized diagnostic approach in children with urticaria.
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Affiliation(s)
- Bulent Enis Sekerel
- Department of Pediatric Allergy, Hacettepe University School of Medicine, Ankara, Türkiye
| | - Deniz Ilgun Gurel
- Department of Pediatric Allergy, Hacettepe University School of Medicine, Ankara, Türkiye
| | - Umit Murat Sahiner
- Department of Pediatric Allergy, Hacettepe University School of Medicine, Ankara, Türkiye
| | - Ozge Soyer
- Department of Pediatric Allergy, Hacettepe University School of Medicine, Ankara, Türkiye
| | - Emek Kocaturk
- Department of Allergology, Charite University School of Medicine, Berlin, Germany
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Fijen LM, Vera C, Buttgereit T, Bonnekoh H, Maurer M, Magerl M, Weller K. Sensitivity to change and minimal clinically important difference of the angioedema control test. Clin Transl Allergy 2023; 13:e12295. [PMID: 37746798 PMCID: PMC10472988 DOI: 10.1002/clt2.12295] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/20/2023] [Accepted: 08/07/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND The Angioedema Control Test (AECT) is a patient-reported outcome measure developed and validated for the assessment of disease control in patients with recurrent angioedema. Its sensitivity to change and minimal clinically important difference (MCID) have hitherto not been established. METHODS Patients with recurrent angioedema due to chronic spontaneous urticaria, hereditary angioedema, or acquired C1-inhibitor deficiency were repeatedly asked to complete the AECT along with the Angioedema Quality of Life Questionnaire (AE-QoL), Dermatology Life Quality Index (DLQI), and anchors for disease control and whether treatment was sufficient during routine care visits. The sensitivity to the change of the AECT was determined by correlating changes in its scores over time with changes in the applied anchors. The MCID was determined using anchor-based and distributional criterion-based approaches. RESULTS Eighty-six cases were used for this analysis. Changes in AECT scores correlated well with AE-QoL changes (but less with changes in the DLQI) as well as other applied anchors, demonstrating its sensitivity to change. The MCID was found to be three points for improvement of angioedema control. The available number of cases with meaningful deterioration in our dataset was too low to reach a definite conclusion on the MCID for deterioration of angioedema control. CONCLUSION The AECT is a valuable tool to assess changes in disease control in patients with recurrent angioedema over time. The lowest AECT score change that reflects a meaningful improvement of disease control to patients (MCID) is three points.
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Affiliation(s)
- Lauré M. Fijen
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
- Institute of AllergologyCharité ‐ Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMPImmunology and AllergologyBerlinGermany
| | - Carolina Vera
- Institute of AllergologyCharité ‐ Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMPImmunology and AllergologyBerlinGermany
| | - Thomas Buttgereit
- Institute of AllergologyCharité ‐ Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMPImmunology and AllergologyBerlinGermany
| | - Hanna Bonnekoh
- Institute of AllergologyCharité ‐ Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMPImmunology and AllergologyBerlinGermany
| | - Marcus Maurer
- Institute of AllergologyCharité ‐ Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMPImmunology and AllergologyBerlinGermany
| | - Markus Magerl
- Institute of AllergologyCharité ‐ Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMPImmunology and AllergologyBerlinGermany
| | - Karsten Weller
- Institute of AllergologyCharité ‐ Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMPImmunology and AllergologyBerlinGermany
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8
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Terhorst-Molawi D, Fox L, Siebenhaar F, Metz M, Maurer M. Stepping Down Treatment in Chronic Spontaneous Urticaria: What We Know and What We Don't Know. Am J Clin Dermatol 2023; 24:397-404. [PMID: 36810982 DOI: 10.1007/s40257-023-00761-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2023] [Indexed: 02/23/2023]
Abstract
In chronic spontaneous urticaria (CSU), wheals, angioedema, or both appear spontaneously for > 6 weeks. Current recommended treatment options for urticaria target mast cell mediators such as histamine, or activators, such as autoantibodies. The goal of CSU treatment is to treat the disease until it is gone as effectively and safely as possible. As no cure is available for CSU as of now, the treatment is aimed at continuously suppressing disease activity, with complete control of the disease and a normalization of quality of life. To achieve this, pharmacological treatment should be continued until no longer needed. Treatment of CSU should follow the basic principles of treating as much as needed and as little as possible taking into consideration that the activity of the disease may vary. Since CSU is a disease with spontaneous remission, it is hard to tell, in patients with complete control and no signs or symptoms, when medication is no longer needed. The current international guideline for urticaria suggests that the treatment can be stepped down once a patient is free of signs and symptoms. Other reasons for stepping down the treatment of CSU patients include safety concerns or issues, pregnancy or wanting to become pregnant, and economic factors. As of now, it is unclear over which period, with what intervals and with which dosages CSU treatment should be stepped down. Guidance on this is needed for all recommended therapies: (i) standard-dosed second-generation H1-antihistamine (sgAH), (ii) higher than standard-dosed sgAH, (iii) standard-dosed omalizumab, (iv) higher than standard-dosed omalizumab, and (v) cyclosporine. However, there is a lack of controlled trials on the step down and discontinuation of these treatments. Here, we aim to provide a summary of what is known and what needs to be investigated in further studies, based on our own experience and real-world evidence.
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Affiliation(s)
- Dorothea Terhorst-Molawi
- Institute of Allergology, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Paul-Ehrlich-Haus, Hindenburgdamm 27, 12203, Berlin, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany
| | - Lena Fox
- Institute of Allergology, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Paul-Ehrlich-Haus, Hindenburgdamm 27, 12203, Berlin, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany
| | - Frank Siebenhaar
- Institute of Allergology, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Paul-Ehrlich-Haus, Hindenburgdamm 27, 12203, Berlin, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany
| | - Martin Metz
- Institute of Allergology, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Paul-Ehrlich-Haus, Hindenburgdamm 27, 12203, Berlin, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany
| | - Marcus Maurer
- Institute of Allergology, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Paul-Ehrlich-Haus, Hindenburgdamm 27, 12203, Berlin, Germany.
- Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany.
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9
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Chronic spontaneous urticaria guidelines: What is new? J Allergy Clin Immunol 2022; 150:1249-1255. [PMID: 36481045 DOI: 10.1016/j.jaci.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/29/2022] [Accepted: 10/05/2022] [Indexed: 12/07/2022]
Abstract
Urticaria is a heterogeneous inflammatory disorder that can be acute or chronic and is defined by the appearance of wheals, angioedema, or both. Very recently, the newest update and revision of the international European Academy of Allergy and Clinical Immunology/Global Allergy and Asthma European Network/European Dermatology Forum/Asia Pacific Association of Allergy Asthma Clinical Immunology guideline for the definition, classification, diagnosis, and management of urticaria was published. It aims to help primary care physicians and specialists in the management of their patients with urticaria. The guideline applied the Grading of Recommendations Assessment Development and Evaluations approach to developing consensus recommendations. These recommendations were then discussed in a Delphi conference that included more than 250 specialists in the field, and they are endorsed by more than 50 international societies. Here, we highlight changes from previous versions of the international urticaria guideline and their impact on clinical practice.
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10
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Abstract
Urticaria is an inflammatory skin disorder that affects up to 20% of the world population at some point during their life. It presents with wheals, angioedema or both due to activation and degranulation of skin mast cells and the release of histamine and other mediators. Most cases of urticaria are acute urticaria, which lasts ≤6 weeks and can be associated with infections or intake of drugs or foods. Chronic urticaria (CU) is either spontaneous or inducible, lasts >6 weeks and persists for >1 year in most patients. CU greatly affects patient quality of life, and is linked to psychiatric comorbidities and high healthcare costs. In contrast to chronic spontaneous urticaria (CSU), chronic inducible urticaria (CIndU) has definite and subtype-specific triggers that induce signs and symptoms. The pathogenesis of CSU consists of several interlinked events involving autoantibodies, complement and coagulation. The diagnosis of urticaria is clinical, but several tests can be performed to exclude differential diagnoses and identify underlying causes in CSU or triggers in CIndU. Current urticaria treatment aims at complete response, with a stepwise approach using second-generation H1 antihistamines, omalizumab and cyclosporine. Novel treatment approaches centre on targeting mediators, signalling pathways and receptors of mast cells and other immune cells. Further research should focus on defining disease endotypes and their biomarkers, identifying new treatment targets and developing improved therapies.
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Affiliation(s)
- Pavel Kolkhir
- Urticaria Center of Reference and Excellence (UCARE), Institute of Allergology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
- Allergology and Immunology, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Berlin, Germany.
| | - Ana M Giménez-Arnau
- Urticaria Center of Reference and Excellence (UCARE), Department of Dermatology, Hospital del Mar, Institut Mar d'Investigacions Mediques, Universitat Autònoma, Barcelona, Spain
| | - Kanokvalai Kulthanan
- Urticaria Center of Reference and Excellence (UCARE), Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jonny Peter
- Urticaria Center of Reference and Excellence (UCARE), Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Urticaria Center of Reference and Excellence (UCARE), Allergy and Immunology Unit, University of Cape Town, Lung Institute, Cape Town, South Africa
| | - Martin Metz
- Urticaria Center of Reference and Excellence (UCARE), Institute of Allergology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Allergology and Immunology, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Berlin, Germany
| | - Marcus Maurer
- Urticaria Center of Reference and Excellence (UCARE), Institute of Allergology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
- Allergology and Immunology, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Berlin, Germany.
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