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Pathania YS. Treatment options in refractory chronic spontaneous urticaria. Curr Opin Allergy Clin Immunol 2024; 24:416-418. [PMID: 38920335 DOI: 10.1097/aci.0000000000001006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
PURPOSE OF REVIEW Chronic spontaneous urticaria (CSU) patients sometimes do not respond to second-generation antihistamine, and 10-50% patients do not even respond to four-fold the usual dose of nonsedating H1 antihistamine, which further leads to repeated courses of oral corticosteroids to abate the symptoms. There are third-line agents approved by EAACI guidelines, which include omalizumab and cyclosporine. Certain patients are even resistant to the third-line agents. In this review, various other treatment options will be discussed in patients of refractory CSU. RECENT FINDINGS Recently, we demonstrated azathioprine as a possible third-line option, which was found noninferior to cyclosporine in antihistamine refractory CSU. There have been trials, studies, case series and reports, which suggest other putative options for refractory CSU management. SUMMARY Studies on the management of refractory CSU are accumulating thereby expanding the armamentarium of dermatologists and allergologist against difficult-to-treat urticaria patients.
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Affiliation(s)
- Yashdeep Singh Pathania
- Department of Dermatology, Venereology and Leprology, All India Institute of Medical Sciences, Rajkot, Gujarat, India
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2
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Mocanu M, Procopciuc D, Gheucă-Solovăstru DF, Popescu IA, Olinici DT, Pătrașcu AI, Vâță D, Gheucă-Solovăstru L. An Overview of Methotrexate Indications in Skin Diseases. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1024. [PMID: 39064453 PMCID: PMC11279115 DOI: 10.3390/medicina60071024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Revised: 06/14/2024] [Accepted: 06/17/2024] [Indexed: 07/28/2024]
Abstract
Methotrexate is an immunosuppressive drug with remarkable therapeutic results in the treatment of autoimmune and proliferative skin diseases. Although it has been more than half a century since it was first introduced into the therapeutic arsenal of dermatologists, there are currently no standardized therapeutic protocols regarding the prescription of methotrexate in dermatology, with the exception of psoriasis treatment. This review aims to highlight the indications and benefits of methotrexate beyond psoriasis, with a focus on a wide range of inflammatory, vesiculobullous, and proliferative dermatological pathologies.
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Affiliation(s)
- Mădălina Mocanu
- Department of Dermatology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (I.A.P.); (L.G.-S.)
- Dermatology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700115 Iasi, Romania; (D.P.); (D.T.O.); (A.I.P.)
| | - Dorina Procopciuc
- Dermatology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700115 Iasi, Romania; (D.P.); (D.T.O.); (A.I.P.)
| | | | - Ioana Adriana Popescu
- Department of Dermatology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (I.A.P.); (L.G.-S.)
- Dermatology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700115 Iasi, Romania; (D.P.); (D.T.O.); (A.I.P.)
| | - Doinița Temelie Olinici
- Dermatology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700115 Iasi, Romania; (D.P.); (D.T.O.); (A.I.P.)
- Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Adriana Ionela Pătrașcu
- Dermatology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700115 Iasi, Romania; (D.P.); (D.T.O.); (A.I.P.)
| | - Dan Vâță
- Department of Dermatology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (I.A.P.); (L.G.-S.)
- Dermatology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700115 Iasi, Romania; (D.P.); (D.T.O.); (A.I.P.)
| | - Laura Gheucă-Solovăstru
- Department of Dermatology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (I.A.P.); (L.G.-S.)
- Dermatology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700115 Iasi, Romania; (D.P.); (D.T.O.); (A.I.P.)
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Zuberbier T, Peter J, Staubach P, Chularojanamontri L, Kulthanan K. Potential Therapeutic Approaches for Chronic Urticaria: Beyond H1-Antihistamines and Biologics. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2265-2273. [PMID: 37356753 DOI: 10.1016/j.jaip.2023.06.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/31/2023] [Accepted: 06/14/2023] [Indexed: 06/27/2023]
Abstract
Chronic urticaria is a disease that can significantly impact a patient's quality of life and ability to function. There are effective treatment options, such as nonsedating antihistamines or biologics, but some patients do not respond to these therapies, or the therapies are not available or affordable to all patients. This review aims to summarize potential treatment strategies for patients (1) who do not respond to antihistamines and (2) cannot readily access or do not respond to biologics. The review emphasizes the importance of sound clinical practice, including correct diagnosis of chronic urticaria phenotypes, treatment of associated comorbidities, and consideration of add-on pharmacological and nonpharmacological approaches. Although some treatments may lack high-quality evidence, they may still be justifiable in certain cases, provided that there is shared decision-making, regular reassessment, and early recognition of adverse events.
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Affiliation(s)
- Torsten Zuberbier
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany.
| | - Jonny Peter
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa; Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Petra Staubach
- Department of Dermatology, University Medical Center Mainz, Mainz, Germany
| | - Leena Chularojanamontri
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kanokvalai Kulthanan
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Kocaturk E, Saini SS, Rubeiz CJ, Bernstein JA. Existing and Investigational Medications for Refractory Chronic Spontaneous Urticaria: Safety, Adverse Effects, and Monitoring. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:3099-3116. [PMID: 36241154 DOI: 10.1016/j.jaip.2022.09.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/14/2022] [Accepted: 09/27/2022] [Indexed: 11/13/2022]
Abstract
Treatment of chronic spontaneous urticaria (CSU) is responsive to H1 antihistamines administered up to four times the recommended US Food and Drug Administration dose in approximately 50% of patients. However, when patients do not respond to these first-line agents, evidence-based guidelines using Grading of Recommendations, Assessment, Development, and Evaluations methodology have provided direction for second- and third-line treatments that can effectively treat patients with CSU. Some patients remain refractory to these advanced treatments; therefore, alternative treatments with a lower certainty of evidence may be necessary. Regardless of the therapies used to treat CSU patients, it is essential for clinicians to be knowledgeable about the mechanism of action, efficacy, and safety and monitoring recommendations of the treatments prescribed. This review provides a comprehensive review of the adverse effects and monitoring recommendations for agents in use for CSU treatment as well as those currently undergoing investigation for CSU treatment.
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Affiliation(s)
- Emek Kocaturk
- Department of Dermatology, Koç University School of Medicine, Istanbul, Turkey; Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Department of Allergology and Immunology, Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Berlin, Germany
| | | | - Christine J Rubeiz
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jonathan A Bernstein
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Internal Medicine, Division of Rheumatology, Allergy, and Immunology, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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Kulthanan K, Rujitharanawong C, Munprom K, Trakanwittayarak S, Phumariyapong P, Prasertsook S, Ungprasert P. Prevalence, Clinical Manifestations, Treatment, and Clinical Course of Chronic Urticaria in Elderly: A Systematic Review. J Asthma Allergy 2022; 15:1455-1490. [PMID: 36299736 PMCID: PMC9590340 DOI: 10.2147/jaa.s379912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/23/2022] [Indexed: 11/05/2022] Open
Abstract
Purpose Data specific to the epidemiology, clinical features, and management of chronic urticaria (CU) in the geriatric population remain limited and not well understood. We aim to systematically review the prevalence, clinical manifestations, treatment, and clinical course of elderly patients with CU. Patients and methods Original articles that included data of elderly (aged >60 years) with CU that were published until February 2021 were searched in PubMed, Scopus, and Embase using predfefined search terms. Related articles were evaluated according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. Results Among the included 85 studies and 1,112,066 elderly CU patients, most (57.4%) were women. The prevalence of elderly CU in the general population ranged from 0.2–2.8%, and from 0.7–33.3% among all CU patients. Compared to adult CU, elderly CU patients had a higher percentage of wheal alone (73.9%), and lower rate of positive autologous serum skin test and atopy. Gastrointestinal diseases were the most common comorbidity (71.9%), and there was a high rate of malignancies and autoimmune diseases. Second generation H1-antihistamines were commonly used, and achievement of complete control was most often reported. Omalizumab was prescribed in 59 refractory patients, and a significant response to treatment was reported in most patients. The treatment of comorbidities also yielded significant improvement in CU. Conclusion Elderly CU was found to be different from adult CU in both clinical and laboratory aspects. H1- antihistamines are effective as first-line therapy with minimal side-effects at licensed doses. Treatment of secondary causes is important since the elderly usually have age-related comorbidities.
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Affiliation(s)
- Kanokvalai Kulthanan
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chuda Rujitharanawong
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kanyalak Munprom
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Phumithep Phumariyapong
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Suthasanee Prasertsook
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Patompong Ungprasert
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA,Correspondence: Patompong Ungprasert, Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA, Tel +1 216 986 4000, Fax +1 216 986 4953, Email
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Ünsel M. Therapeutic Challenges in Chronic Spontaneous Urticaria. CYPRUS JOURNAL OF MEDICAL SCIENCES 2022. [DOI: 10.4274/cjms.2021.2021-231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Sandhu J, Kumar A, Gupta SK. The therapeutic role of methotrexate in chronic urticaria: A systematic review. Indian J Dermatol Venereol Leprol 2021; 88:313-321. [PMID: 34623059 DOI: 10.25259/ijdvl_1145_20] [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: 08/01/2020] [Accepted: 06/01/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Chronic urticaria, in many cases, has an unsatisfactory response to antihistamines. The current recommendations in urticaria do not mention the dose and duration for methotrexate. AIMS This study aims to systematically review the use/efficacy of methotrexate in chronic urticaria. METHODS A systematic search in four databases, that is, PubMed/Medline, Cochrane central, Google Scholar and Clinicaltrials.gov was done to identify studies on the use of methotrexate in chronic urticaria using key words "methotrexate [MeSH terms]" and "urticaria" or "urticaria, chronic" or "urticaria, chronic spontaneous." RESULTS Nine articles (study participants 127), including three randomized control trials, one prospective interventional trial without control, three retrospective reviews and two case reports, were identified and finally included in the systematic review. There was a paucity of literature and the three randomized control trials did not show any benefit of methotrexate over antihistamines alone. However, in studies where steroid-dependent cases were given methotrexate, marked benefit was reported with steroid-sparing effect, particularly on methotrexate dose escalation. LIMITATIONS Due to a paucity of published literature on methotrexate in urticaria, a meta-analysis could not be done. CONCLUSION In chronic recalcitrant or steroid-dependent cases, methotrexate may be a therapeutic agent of interest; however, current evidence does not point to any added advantage in efficacy over antihistamines. More evidence based on larger, well-executed randomized control trials is needed in the future to get more definitive answers.
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Affiliation(s)
- Jaspriya Sandhu
- Department of Dermatology, Venereology and Leprology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Arushi Kumar
- Department of Dermatology, Venereology and Leprology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Sunil K Gupta
- Department of Dermatology, Venereology and Leprology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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van Huizen AM, Vermeulen FM, Bik CMJM, Borgonjen R, Karsch SAT, Kuin RA, Gerbens LAA, Spuls PI. On which evidence can we rely when prescribing off-label methotrexate in dermatological practice? - a systematic review with GRADE approach. J DERMATOL TREAT 2021; 33:1947-1966. [PMID: 34425719 DOI: 10.1080/09546634.2021.1961999] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
If an authorized drug is prescribed for a use that is not described in the Summary of Product Characteristics, this is defined as 'off-label use.' Methotrexate is often used off-label for dermatological indications. Off-label use is permitted if physicians can justify the treatment based on scientific evidence available to them. Our objective here was therefore to summarize the evidence for the effectiveness, efficacy, and safety of the dermatological off-label use of methotrexate in a systematic review. We searched MEDLINE, EMBASE, and CENTRAL for studies for evidence on the effectiveness, efficacy, and safety of the off-label use of methotrexate in dermatological indications up to November 2019. We used the GRADE system to rate the quality of the evidence. The search retrieved 34,583 hits of which 3566 were selected after the title and abstract screening. After the full-text screening, 143 studies were included, which involved 3688 patients in total. We found low-quality evidence for the effectiveness, efficacy, and safety of the off-label use of methotrexate in 31 dermatological diseases. To optimize the quality of evidence to support off-label use, we need high-quality studies in which well-characterized patients are treated with standardized treatments regimens using well-validated outcomes relevant to patients and physicians.
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Affiliation(s)
- Astrid M van Huizen
- Department of Dermatology, Amsterdam Public Health, Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Francisca M Vermeulen
- Department of Dermatology, Amsterdam Public Health, Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Rinke Borgonjen
- Department of Dermatology, Gelderland Valley Hospital, Ede, The Netherlands
| | - Saskia A T Karsch
- Department of Family Medicine, UMC Utrecht, Utrecht, The Netherlands
| | - Rosanna A Kuin
- Department of Dermatology, Amsterdam Public Health, Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Louise A A Gerbens
- Department of Dermatology, Amsterdam Public Health, Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Phyllis I Spuls
- Department of Dermatology, Amsterdam Public Health, Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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What's New in the Treatment of Urticaria and Angioedema. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2170-2184. [PMID: 34112473 DOI: 10.1016/j.jaip.2021.03.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 12/26/2022]
Abstract
Chronic urticaria and angioedema are diseases often managed by Allergy and Immunology specialists. Recent international guidelines have outlined a stepwise approach to management of patients using dose escalation of second-generation antihistamines followed by use of omalizumab and finally cyclosporine in more refractory cases. In select patients (those with refractory chronic urticaria), nonbiologic alternative medications with anti-inflammatory or immunosuppressant activity may be considered. Angioedema without wheals may have several different pathophysiologic mechanisms. Optimal management of mast cell-mediated angioedema is less clear but is often managed similar to chronic spontaneous urticaria. Drug-induced angioedema due to angiotensin-converting enzyme inhibitors is a common cause of angioedema in the emergency department. Although bradykinin is thought to be a primary mediator for this type of angioedema, studies of targeted therapies have been generally disappointing. In contrast, several targeted therapies have been proven successful using acute and preventive approaches for management of hereditary angioedema. Further developments, including novel biologics, novel oral therapies, and gene therapy approaches, may hopefully continue to broaden therapeutic options to ensure optimal individual management of patients with hereditary angioedema.
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10
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Çildağ S, Yenisey Ç, Ünübol M, Şentürk T. Comparison of immunoglobulin E anti-thyroid peroxidase antibodies in patients with Hashimoto thyroiditis and chronic spontaneous urticaria. Med Pharm Rep 2021; 94:53-57. [PMID: 33629049 PMCID: PMC7880074 DOI: 10.15386/mpr-1598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 07/27/2020] [Accepted: 09/30/2020] [Indexed: 12/04/2022] Open
Abstract
Background and aim Chronic spontaneous urticaria (CSU) is a disease of unknown etiology and autoimmunity has been thought to be an etiological factor. Immunoglobulin E (IgE)-anti-thyroid peroxidase antibodies (anti-TPO) may play a role in the pathogenesis of certain cases of urticaria. The aim of this study is to investigate IgE-anti-TPO in patients with chronic spontaneous urticaria and in patients with Hashimoto’s thyroiditis. Methods A total of 175 subjects were included in this study. 59 patients had chronic spontaneous urticaria without history of Hashimoto’s thyroiditis, while 58 patients had Hashimoto’s thyroiditis without history of urticaria. The control group consisted of 58 participants without history of Hashimoto’s thyroiditis and urticaria. Serum IgE-anti-TPO levels were analyzed by site-directed IgE capture Enzyme-Linked Immunosorbent Assay technique. We used this technique by modifying it. Results IgE-anti-TPO antibodies were detected in all three groups and in all subjects. There was no significant difference between the three groups in terms of IgE-anti-TPO levels. Although total IgE and IgE-anti-TPO levels were higher in the IgG-anti-TPO positive chronic spontaneous urticaria, there was no significant difference. Conclusions IgE-anti-TPO antibodies do not play a pathogenic role in the majority of patients with chronic spontaneous urticaria.
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Affiliation(s)
- Songül Çildağ
- Department of Immunology and Allergy, Adnan Menderes University, Turkey
| | - Çiğdem Yenisey
- Department of Biochemistry, Adnan Menderes University, Turkey
| | - Mustafa Ünübol
- Department of Endocrinology and Metabolism, Adnan Menderes University, Turkey
| | - Taşkın Şentürk
- Department of Immunology and Allergy, Adnan Menderes University, Turkey
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Hon KL, Li JTS, Leung AKC, Lee VWY. Current and emerging pharmacotherapy for chronic spontaneous Urticaria: a focus on non-biological therapeutics. Expert Opin Pharmacother 2021; 22:497-509. [PMID: 32990110 DOI: 10.1080/14656566.2020.1829593] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Chronic spontaneous urticaria (CSU) refers to urticaria (wheals) or angioedema, which occur for a period of six weeks or longer without an apparent cause. The condition may impair the patient's quality of life. AREAS COVERED Treatment for CSU is mainly symptomatic. Both AAAAI/ACAAI practice parameters and EAACI/GA2LEN/EDF/WAO guidelines suggest CSU management in a stepwise manner. First-line therapy is with second-generation H1-antihistamines. Treatment should be stepped up along the algorithm if symptoms are not adequately controlled. Increasing the dosage of second-generation H1-antihistamines, with the addition of first-generation H1-antihistamines, H2 antagonist, omalizumab, ciclosporin A, or short-term corticosteroid may be necessary. New medications are being developed to treat refractory CSU. They include spleen tyrosine kinase inhibitor, Bruton tyrosine kinase inhibitor, prostaglandin D2 receptor inhibitor, H4-antihistamine, and other agents. The authors discuss these treatments and provide expert perspectives on the management of CSU. EXPERT OPINION Second-generation H1-antihistamines remain the first-line therapeutic options for the management of CSU. For patients not responding to higher-dose H1-antihistamines, international guidelines recommend the addition of omalizumab. Efficacy and safety data for newer agents are still pending. Large-scale, well-designed, randomized, double-blind, placebo-controlled trials will further provide evidence on the safety profile and efficacy of these agents in patients with CSU.
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Affiliation(s)
- Kam Lun Hon
- Department of Paediatrics, The Chinese University of Hong Kong, Shatin, Hong Kong & Department of Paediatrics and adolescent Medicine, the Hong Kong Children's Hospital, Shatin, Hong Kong
| | - Joyce T S Li
- Centre for Learning Enhancement and Research, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Alexander K C Leung
- Department of Pediatrics, The University of Calgary and The Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Vivian W Y Lee
- Centre for Learning Enhancement and Research, The Chinese University of Hong Kong, Shatin, Hong Kong
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Patil AD, Bingewar G, Goldust M. Efficacy of methotrexate as add on therapy to
H1
antihistamine in difficult to treat chronic urticaria: A systematic review and meta‐analysis of randomized clinical trials. Dermatol Ther 2020; 33:e14077. [DOI: 10.1111/dth.14077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 07/15/2020] [Accepted: 07/18/2020] [Indexed: 01/30/2023]
Affiliation(s)
- Anant D. Patil
- Department of Pharmacology, Dr. DY Patil Medical College Navi Mumbai India
| | - Ganesh Bingewar
- Burjeel Medical Center, Al Shahama Abu Dhabi United Arab Emirates
| | - Mohamad Goldust
- Department of Dermatology University Hospital Basel Basel Switzerland
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Maurer M, Eyerich K, Eyerich S, Ferrer M, Gutermuth J, Hartmann K, Jakob T, Kapp A, Kolkhir P, Larenas-Linnemann D, Park HS, Pejler G, Sánchez-Borges M, Schäkel K, Simon D, Simon HU, Weller K, Zuberbier T, Metz M. Urticaria: Collegium Internationale Allergologicum (CIA) Update 2020. Int Arch Allergy Immunol 2020; 181:321-333. [PMID: 32224621 DOI: 10.1159/000507218] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 03/11/2020] [Indexed: 12/13/2022] Open
Abstract
This update on chronic urticaria (CU) focuses on the prevalence and pathogenesis of chronic spontaneous urticaria (CSU), the expanding spectrum of patient-reported outcome measures (PROMs) for assessing CU disease activity, impact, and control, as well as future treatment options for CU. This update is needed, as several recently reported findings have led to significant advances in these areas. Some of these key discoveries were first presented at past meetings of the Collegium Internationale Allergologicum (CIA). New evidence shows that the prevalence of CSU is geographically heterogeneous, high in all age groups, and increasing. Several recent reports have helped to better characterize two endotypes of CSU: type I autoimmune (or autoallergic) CSU, driven by IgE to autoallergens, and type IIb autoimmune CSU, which is due to mast cell (MC)-targeted autoantibodies. The aim of treatment in CU is complete disease control with absence of signs and symptoms as well as normalization of quality of life (QoL). This is best monitored by the use of an expanding set of PROMs, to which the Angioedema Control Test, the Cholinergic Urticaria Quality of Life Questionnaire, and the Cholinergic Urticaria Activity Score have recently been added. Current treatment approaches for CU under development include drugs that inhibit the effects of signals that drive MC activation and accumulation, drugs that inhibit intracellular pathways of MC activation and degranulation, and drugs that silence MCs by binding to inhibitory receptors. The understanding, knowledge, and management of CU are rapidly increasing. The aim of this review is to provide physicians who treat CU patients with an update on where we stand and where we will go. Many questions and unmet needs remain to be addressed, such as the development of routine diagnostic tests for type I and type IIb autoimmune CSU, the global dissemination and consistent use of PROMs to assess disease activity, impact, and control, and the development of more effective and well-tolerated long-term treatments for all forms of CU.
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Affiliation(s)
- Marcus Maurer
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,
| | - Kilian Eyerich
- Division of Dermatology and Venerology, Department of Medicine Solna and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Stefanie Eyerich
- Center for Allergy and Environment, Technical University and Helmholtz Center Munich, Munich, Germany
| | - Marta Ferrer
- Department of Allergy and Clinical Immunology, Clínica Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra Pamplona, Spain, RETIC de Asma, Reacciones Adversas y Alérgicas, Madrid, Spain
| | - Jan Gutermuth
- Department of Dermatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Karin Hartmann
- Division of Allergy, Department of Dermatology, University of Basel, Basel, Switzerland
| | - Thilo Jakob
- Department of Dermatology and Allergy, University Medical Center Giessen, Justus-Liebig University Giessen, Giessen, Germany
| | - Alexander Kapp
- Department of Dermatology and Allergy, Hannover Medical School, Hannover, Germany
| | - Pavel Kolkhir
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Division of Immune-Mediated Skin Diseases, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Désirée Larenas-Linnemann
- Center of Excellence in Asthma and Allergy, Médica Sur, Clinical Foundation and Hospital, Mexico City, Mexico
| | - Hae-Sim Park
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Gunnar Pejler
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Mario Sánchez-Borges
- Allergy and Clinical Immunology Department, Centro Médico Docente La Trinidad, Caracas, Venezuela
| | - Knut Schäkel
- Department of Dermatology, Heidelberg University, Heidelberg, Germany
| | - Dagmar Simon
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hans-Uwe Simon
- Institute of Pharmacology, University of Bern, Bern, Switzerland.,Department of Clinical Immunology and Allergology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Karsten Weller
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Torsten Zuberbier
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Martin Metz
- Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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14
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Choi JH, Lee DH, Song WJ, Choi M, Kwon JW, Kim GW, Kim MH, Kim MA, Kim MH, Kim BK, Kim S, Kim JS, Kim JE, Kim JY, Kim JH, Kim HJ, Kim HO, Kim HB, Roh JY, Park KH, Park KY, Park HK, Park H, Bae JM, Byun JY, Song DJ, Ahn YM, Lee SE, Lee YB, Lee JS, Lee JH, Lim KH, Youn SW, Chang YS, Jeon YH, Jeon J, Jue MS, Choi SH, Hur GY, Lim DH, Ye YM, Park YM. The KAAACI/KDA Evidence-Based Practice Guidelines for Chronic Spontaneous Urticaria in Korean Adults and Children: Part 2. Management of H1-Antihistamine-Refractory Chronic Urticaria. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2020; 12:750-770. [PMID: 32638557 PMCID: PMC7346997 DOI: 10.4168/aair.2020.12.5.750] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 02/25/2020] [Indexed: 01/19/2023]
Abstract
Quite a few patients with chronic spontaneous urticaria (CSU) are refractory to H₁-antihistamines, even though the dose of H₁-antihistamines is increased up to 4-fold. CSU that is not controlled with H₁-antihistamines results in increased disease burden. Several immunomodulators have been used to manage these patients. The guidelines reported herein are connected to Part 1 of the KAAACI/KDA Evidence-Based Practice Guidelines for Chronic Spontaneous Urticaria in Korean Adults and Children, and aimed to provide evidence-based recommendations for the management of H₁-antihistamine-refractory CSU. Part 2 focuses on the more commonly used additional treatment options for refractory CSU, including omalizumab, cyclosporine, leukotriene receptor antagonist, dapsone, methotrexate, and phototherapy. The evidence to support their efficacy, dosing, safety, and selection of these agents is systematically reviewed. To date, for patients with refractory CSU, the methodologically sound data to evaluate the use of omalizumab has been growing; however, the evidence of other immunomodulators and phototherapy is still insufficient. Therefore, an individualized stepwise approach with a goal of achieving complete symptom control and minimizing side effects can be recommended. Larger controlled studies are needed to elevate the level of evidence to select a rational therapeutic agent for patients with refractory CSU.
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Affiliation(s)
- Jeong Hee Choi
- Department of Pulmonology and Allergy, Hallym University Dongtan Sacred Heart Hospital, Allergy and Clinical Immunology Research Center, Hallym University College of Medicine, Chuncheon, Korea
| | - Dong Hun Lee
- Department of Dermatology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Woo Jung Song
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Mira Choi
- Department of Dermatology, Inje University Ilsan Paik Hospital, Ilsan, Korea
| | - Jae Woo Kwon
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Gun Woo Kim
- Department of Internal Medicine, St. Carollo General Hospital, Suncheon, Korea
| | - Myung Hwa Kim
- Department of Dermatology, Dankook University College of Medicine, Cheonan, Korea
| | - Mi Ae Kim
- Department of Pulmonology, Allergy and Critical Care Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Min Hye Kim
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Byung Keun Kim
- Department of Internal Medicine, Korea University Medical Center Anam Hospital, Seoul, Korea
| | - Sujeong Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Joung Soo Kim
- Department of Dermatology, Hanyang University Guri Hospital, Guri, Korea
| | - Jung Eun Kim
- Department of Dermatology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ju Young Kim
- Division of Pulmonology and Allergy, Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Joo Hee Kim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Hyun Jung Kim
- Institute for Evidence-based Medicine, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Hye One Kim
- Department of Dermatology, Hallym University College of Medicine, Seoul, Korea
| | - Hyo Bin Kim
- Department of Pediatrics, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Joo Young Roh
- Department of Dermatology, Gil Medical Center, Gachon University School of Medicine, Incheon, Korea
| | - Kyung Hee Park
- Division of Allergy and Immunology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kui Young Park
- Department of Dermatology, Chung-Ang University College of Medicine, Seoul, Korea
| | - Han Ki Park
- Department of Allergy and Clinical Immunology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hyunsun Park
- Department of Dermatology, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Jung Min Bae
- Department of Dermatology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Ji Yeon Byun
- Department of Dermatology, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Dae Jin Song
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Young Min Ahn
- Department of Pediatrics, Eulji General Hospital, Eulji University School of Medicine, Seoul, Korea
| | - Seung Eun Lee
- Division of Pulmonology and Allergy, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Young Bok Lee
- Department of Dermatology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joong Sun Lee
- Department of Dermatology, School of Medicine, Eulji University, Daejeon, Korea
| | - Ji Hyun Lee
- Department of Dermatology, Seoul St. Mary's Hospital, Brain Korea 21 PLUS Project for Medical Science, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | | | - Sang Woong Youn
- Department of Dermatology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Yoon Seok Chang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - You Hoon Jeon
- Department of Pediatrics, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Jiehyun Jeon
- Department of Dermatology, Korea University College of Medicine, Seoul, Korea
| | - Mihn Sook Jue
- Department of Dermatology, Veterans Health Service Medical Center, Seoul, Korea
| | - Sun Hee Choi
- Department of Pediatrics, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Gyu Young Hur
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Dae Hyun Lim
- Department of Pediatrics, School of Medicine, Inha University, Incheon, Korea
| | - Young Min Ye
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea.
| | - Young Min Park
- Department of Dermatology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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15
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Efficacy and safety of methotrexate versus placebo as add-on therapy to H1 antihistamines for patients with difficult-to-treat chronic spontaneous urticaria: A randomized, controlled trial. J Am Acad Dermatol 2020; 82:240-243. [DOI: 10.1016/j.jaad.2019.07.097] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 07/24/2019] [Accepted: 07/25/2019] [Indexed: 11/19/2022]
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16
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Criado PR, Maruta CW, Alchorne ADODA, Ramos AMC, Gontijo B, Santos JBD, Martins LEAM, Rivitti-Machado MC, Silvares MRC, Pires MC, Souza PKD, Orfali RL, Bonamigo RR, Bedrikow RB, Criado RFJ, Oliveira ZNPD. Consensus on the diagnostic and therapeutic management of chronic spontaneous urticaria in adults - Brazilian Society of Dermatology. An Bras Dermatol 2019; 94:56-66. [PMID: 31166404 PMCID: PMC6544033 DOI: 10.1590/abd1806-4841.2019940209] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 12/07/2018] [Indexed: 11/22/2022] Open
Abstract
Background Urticarias are frequent diseases, with 15% to 20% of the population
presenting at least one acute episode in their lifetime. Urticaria are
classified in acute ( ≤ 6 weeks) or chronic (> 6 weeks). They may
be induced or spontaneous. Objectives To verify the diagnostic and therapeutic recommendations in chronic
spontaneous urticaria (CSU), according to the experience of Brazilian
experts, regarding the available guidelines (international and US). Methods A questionnaire was sent to Brazilian experts, with questions concerning
diagnostic and therapeutic recommendations for CSU in adults. Results Sixteen Brazilian experts answered the questionnaire related to diagnosis and
therapy of CSU in adults and data were analyzed. Final text was written,
considering the available guidelines (International and US), adapted to the
medical practices in Brazil. Diagnostic work up in CSU is rarely necessary.
Biopsy of skin lesion and histopathology may be indicated to rule out other
diseases, such as, urticarial vasculitis. Other laboratory tests, such as
complete blood count, CRP, ESR and thyroid screening. Treatment of CSU
includes second-generation anti-histamines (sgAH) at licensed doses, sgAH
two, three to fourfold doses (non-licensed) and omalizumab. Other drugs,
such as, cyclosporine, immunomodulatory drugs and immunosuppressants may be
indicated (non-licensed and with limited scientific evidence). Conclusions Most of the Brazilian experts in this study partially agreed with the
diagnostic and therapeutic recommendations of the International and US
guidelines. They agreed with the use of sgAH at licensed doses. Increase in
the dose to fourfold of sgAH may be suggested with restrictions, due to its
non-licensed dose. Sedating anti-histamines, as suggested by the US
guideline, are indicated by some of the Brazilian experts, due to its
availability. Adaptations are mandatory in the treatment of CSU, due to
scarce or lack of other therapeutic resources in the public health system in
Brazil, such as omalizumab or cyclosporine.
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Affiliation(s)
| | - Celina Wakisaka Maruta
- Department of Dermatology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Andréa Machado Coelho Ramos
- Dermatology Service, Hospital das Clinicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Bernardo Gontijo
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Josemir Belo Dos Santos
- Centro de Ciências Médicas, Faculdade de Medicina, Universidade Federal de Pernambuco, Recife, PE, Brazil
| | | | | | | | | | - Patricia Karla de Souza
- Urticaria Outpatient Clinic, Department of Dermatology, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Raquel Leão Orfali
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Renan Rangel Bonamigo
- Hospital de Clínicas de Porto Alegre, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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17
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Temiz SA, Ataseven A, Ozer I, Dursun R, Findik S. Refractory Urticarial Vasculitis Responsive to Methotrexate: Could It Be a New Treatment Option? CLINICAL AND EXPERIMENTAL HEALTH SCIENCES 2019. [DOI: 10.33808/marusbed.546841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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18
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Antia C, Baquerizo K, Korman A, Alikhan A, Bernstein JA. Urticaria: A comprehensive review: Treatment of chronic urticaria, special populations, and disease outcomes. J Am Acad Dermatol 2019; 79:617-633. [PMID: 30241624 DOI: 10.1016/j.jaad.2018.01.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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).
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Affiliation(s)
- Camila Antia
- Department of Dermatology, University of Cincinnati, Cincinnati, Ohio.
| | | | - Abraham Korman
- College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Ali Alikhan
- Department of Dermatology, University of Cincinnati, Cincinnati, Ohio
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19
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Abstract
Non-hereditary angioedema (AE) with normal C1 esterase inhibitor (C1INH) can be presumably bradykinin- or mast cell-mediated, or of unknown cause. In this systematic review, we searched PubMed, EMBASE, and Scopus to provide an overview of the efficacy of different treatment options for the abovementioned subtypes of refractory non-hereditary AE with or without wheals and with normal C1INH. After study selection and risk of bias assessment, 61 articles were included for data extraction and analysis. Therapies were described for angiotensin-converting enzyme inhibitor-induced AE (ACEi-AE), for idiopathic AE, and for AE with wheals. Described treatments consisted of ecallantide, icatibant, C1INH, fresh frozen plasma (FFP), tranexamic acid (TA), and omalizumab. Additionally, individual studies for anti-vitamin K, progestin, and methotrexate were found. Safety information was available in 26 articles. Most therapies were used off-label and in few patients. There is a need for additional studies with a high level of evidence. In conclusion, in acute attacks of ACEi-AE and idiopathic AE, treatment with icatibant, C1INH, TA, and FFP often leads to symptom relief within 2 h, with limited side effects. For prophylactic treatment of idiopathic AE and AE with wheals, omalizumab, TA, and C1INH were effective and safe in the majority of patients.
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20
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Wang SH, Tang SE, Li YH, Wei KY, Chang CY. Pneumocystis jirovecii pneumonia induced by low-dose methotrexate in a patient with chronic urticaria. An Bras Dermatol 2018; 92:401-403. [PMID: 29186259 PMCID: PMC5514587 DOI: 10.1590/abd1806-4841.20175392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 02/15/2016] [Indexed: 11/21/2022] Open
Abstract
Methotrexate has immunosuppressive effects and is administered for refractory
chronic urticaria. We present a case of Pneumocystis jirovecii
pneumonia in a patient with refractory chronic urticaria managed by low-dose
weekly methotrexate treatment (total cumulative dose 195mg). Our study
highlights the importance of providing prompt diagnosis and treatment of
Pneumocystis jirovecii pneumonia in patients with chronic
urticaria under methotrexate therapy.
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Affiliation(s)
- Sheng-Huei Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center - Taipei, Taiwan, Republic of China
| | - Shih-En Tang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center - Taipei, Taiwan, Republic of China
| | - Yu-Huei Li
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center - Taipei, Taiwan, Republic of China
| | - Kuang-Yu Wei
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center - Taipei, Taiwan, Republic of China
| | - Chan-Yuan Chang
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center - Taipei, Taiwan, Republic of China
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21
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Rutkowski K, Grattan CEH. How to manage chronic urticaria 'beyond' guidelines: a practical algorithm. Clin Exp Allergy 2018; 47:710-718. [PMID: 28452145 DOI: 10.1111/cea.12944] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Chronic urticaria (CU) is a disease characterized by pruritic weals, angio-oedema or both occurring for at least 6 weeks. It encompasses spontaneous and inducible urticarias. The national and international guidelines outline the principles of treatment. Omalizumab, an anti-immunoglobulin E monoclonal antibody, has transformed the management of many severe and treatment-refractory patients. However, current UK guidance on its use does not address the needs of those with less severe disease, inducible urticarias, idiopathic histaminergic angio-oedema without weals as a presentation of CU and omalizumab non-responders. Our algorithm and a summary of the evidence to support its principles offers guidance and a more systematic targeted approach to using a range of 'off-label' agents for specific phenotypes of CU. It will be of use when guideline-recommended mast cell mediator antagonists fail to control symptoms and/or using omalizumab is ineffective, not practical or unfunded.
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Affiliation(s)
- K Rutkowski
- Urticaria Clinic, St John's Institute of Dermatology, London, UK.,Department of Allergy, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - C E H Grattan
- Urticaria Clinic, St John's Institute of Dermatology, London, UK
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22
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Godse K, De A, Zawar V, Shah B, Girdhar M, Rajagopalan M, Krupashankar DS. Consensus Statement for the Diagnosis and Treatment of Urticaria: A 2017 Update. Indian J Dermatol 2018. [PMID: 29527019 PMCID: PMC5838750 DOI: 10.4103/ijd.ijd_308_17] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Kiran Godse
- Department of Dermatology, D Y Patil Hospital, Navi Mumbai, Maharastra, India
| | - Abhishek De
- Department of Dermatology, Calcutta National Medical College, Kolkata, West Bengal, India
| | - Vijay Zawar
- Department of Dermatology, Skin Diseases Center, Nashik, India
| | - Bela Shah
- Department of Dermatology, BJ Medical College, Ahmedabad, Gujarat, India
| | - Mukesh Girdhar
- Department of Dermatology, Max Super Speciality Hospital, New Delhi, India
| | | | - D S Krupashankar
- Department of Dermatology, Krupa Shankar Skin Care Center, Mallige Hospital, Bengaluru, Karnataka, India
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23
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Leis-Dosil V, Prats-Caelles I. Practical Management of Immunosuppressants in Dermatology. ACTAS DERMO-SIFILIOGRAFICAS 2018. [DOI: 10.1016/j.adengl.2017.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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24
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de Montjoye L, Herman A, Nicolas JF, Baeck M. Treatment of chronic spontaneous urticaria: Immunomodulatory approaches. Clin Immunol 2017; 190:53-63. [PMID: 29129806 DOI: 10.1016/j.clim.2017.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 09/12/2017] [Accepted: 11/07/2017] [Indexed: 02/01/2023]
Abstract
This paper summarizes and reviews the mechanisms of action and data concerning efficacy of recommended treatments as well as other treatments that have been tested, independently of the outcomes, in the management of chronic spontaneous urticaria. Due to the central role of mast cells, basophils and histamine in the pathophysiology of this disease, H1-antihistamines remain the first-line treatment. However, current knowledge about this complex disease, also recognizes an important role for T lymphocytes, B lymphocytes, and autoantibodies. Implications of these others mediators thus provide further targets for treatment. Indeed, agents previously used to treat other autoimmune and inflammatory diseases, have demonstrated efficacy in chronic spontaneous urticaria and are therefore potential therapeutic alternatives for antihistamine unresponsive patients.
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Affiliation(s)
- Laurence de Montjoye
- Department of Dermatology, Saint-Luc University Hospital, Université catholique de Louvain, Brussels, Belgium; Institute of Experimental and Clinical Research, Pole of Pneumology, ENT and Dermatology, Université catholique de Louvain, Brussels, Belgium.
| | - Anne Herman
- Department of Dermatology, Saint-Luc University Hospital, Université catholique de Louvain, Brussels, Belgium; Institute of Experimental and Clinical Research, Pole of Pneumology, ENT and Dermatology, Université catholique de Louvain, Brussels, Belgium
| | - Jean-François Nicolas
- Department of Allergy and Clinical Immunology, Hospital Center Lyon Sud, Lyon, France; CIRI- INSERM U1111 - CNRS UMR5308, Université Lyon 1, Université de Lyon, Lyon, France
| | - Marie Baeck
- Department of Dermatology, Saint-Luc University Hospital, Université catholique de Louvain, Brussels, Belgium; Institute of Experimental and Clinical Research, Pole of Pneumology, ENT and Dermatology, Université catholique de Louvain, Brussels, Belgium
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25
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Leis-Dosil VM, Prats-Caelles I. Practical Management of Immunosuppressants in Dermatology. ACTAS DERMO-SIFILIOGRAFICAS 2017; 109:24-34. [PMID: 28964393 DOI: 10.1016/j.ad.2017.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 03/24/2017] [Accepted: 05/14/2017] [Indexed: 12/17/2022] Open
Abstract
The treatment of inflammatory and autoimmune diseases is challenging because of their frequency and complexity. Treatment of these diseases is based on the suppression of the patient's immune system using corticosteroids, corticosteroid-sparing immunosuppressive agents, and biologic drugs, making an understanding of the management of immunosuppressive therapy essential. Before an immunosuppressive agent is prescribed, a study must be carried out to identify contraindications, detect latent infections, and determine the most appropriate dose. During treatment, regular monitoring is required to detect adverse effects. The clinician must be familiar with the time lag between start of treatment and onset of the immunosuppressive effect as well as the maximum recommended duration of treatment and cumulative dose for each drug. As dermatologists we are accustomed to using these immunosuppressive agents, but we should have a good knowledge of the guidelines for their use and the monitoring required in each case if we are to reduce variability and avoid potentially serious adverse effects.
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Affiliation(s)
- V M Leis-Dosil
- Sección de Dermatología, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, España.
| | - I Prats-Caelles
- Sección de Dermatología, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, España
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26
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Autoimmune chronic spontaneous urticaria: What we know and what we do not know. J Allergy Clin Immunol 2017; 139:1772-1781.e1. [DOI: 10.1016/j.jaci.2016.08.050] [Citation(s) in RCA: 171] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/02/2016] [Accepted: 08/12/2016] [Indexed: 11/19/2022]
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27
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Holm JG, Ivyanskiy I, Thomsen SF. Use of nonbiologic treatments in antihistamine-refractory chronic urticaria: a review of published evidence. J DERMATOL TREAT 2017; 29:80-97. [DOI: 10.1080/09546634.2017.1329505] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | - Ilya Ivyanskiy
- Department of Dermatology, Bispebjerg Hospital, Copenhagen, Denmark
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Simon Francis Thomsen
- Department of Dermatology, Bispebjerg Hospital, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
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Rajesh G, Keerthi S, Karthikeyan K, Venkatesan M. Weekly injection of histaglobulin produces long-term remission in chronic urticaria: A prospective clinical study. Indian J Pharmacol 2017; 48:292-7. [PMID: 27298500 PMCID: PMC4900003 DOI: 10.4103/0253-7613.182884] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Treatment of chronic urticaria (CU) can be difficult in many patients. Achieving long-term remission and reducing the requirement of antihistamines are vital in CU. The objective of this study was to assess the effectiveness of injection histaglobulin, a complex of histamine and human immunoglobulin, in producing relief in patients with CU. MATERIALS AND METHODS Fifty-one patients with CU were enrolled into this prospective clinical study. Patients were administered 1 ml of injection histaglobulin subcutaneous for 8 consecutive weeks. They were also prescribed tablet levocetirizine 5 mg to be taken when required (but not more than the permitted dosage). Efficacy was assessed using urticaria activity score (UAS) which has a maximum score of 33/day, during each weekly visit. Final assessment was done after 24 weeks. RESULTS Twenty-nine patients had completed the entire 8-week drug regimen. Mean basal UAS was 18.9 ± 6.3 and it reduced to 80.4% by 8 weeks. The angioedema sub-score reduced by 89.8%. Anti-histamine pill burden also reduced significantly. By 24 weeks of starting the therapy, 23 patients (45%) had attained complete remission. No adverse effects to the drug were observed. CONCLUSIONS Histaglobulin was found to be effective in producing long-term remission and it reduced the antihistamine requirement as well. Thus, it can serve as an effective alternative to existing treatment modalities.
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Affiliation(s)
- Gurumoorthy Rajesh
- Department of Dermatology, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
| | - Subramaniam Keerthi
- Department of Dermatology, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
| | - Kaliaperumal Karthikeyan
- Department of Dermatology, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
| | - Murugan Venkatesan
- Department of Community Medicine, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
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29
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Healthcare Services Utilization and Drug Use in Patients with Chronic Urticaria. J Invest Dermatol 2015; 135:3187-3189. [DOI: 10.1038/jid.2015.330] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Vestergaard C, Deleuran M. Chronic spontaneous urticaria: latest developments in aetiology, diagnosis and therapy. Ther Adv Chronic Dis 2015; 6:304-13. [PMID: 26568807 PMCID: PMC4622315 DOI: 10.1177/2040622315603951] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
| | - Mette Deleuran
- Department of Dermatology, Aarhus University Hospital, Aarhus, Denmark
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31
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Criado PR, Criado RFJ, Maruta CW, Reis VMSD. Chronic urticaria in adults: state-of-the-art in the new millennium. An Bras Dermatol 2015; 90:74-89. [PMID: 25672302 PMCID: PMC4323701 DOI: 10.1590/abd1806-4841.20153509] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 06/04/2014] [Indexed: 11/21/2022] Open
Abstract
Chronic urticaria has been explored in several investigative aspects in the new
millennium, either as to its pathogenesis, its stand as an autoimmune or
auto-reactive disease, the correlation with HLA-linked genetic factors, especially
with class II or its interrelation with the coagulation and fibrinolysis systems. New
second-generation antihistamines, which act as good symptomatic drugs, emerged and
were commercialized over the last decade. Old and new drugs that may interfere with
the pathophysiology of the disease, such as cyclosporine and omalizumab have been
developed and used as treatments. The purpose of this article is to describe the
current state of knowledge on aspects of chronic urticaria such as, pathophysiology,
diagnosis and the current therapeutic approach proposed in the literature.
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32
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Asero R, Pinter E, Marra AM, Tedeschi A, Cugno M, Marzano AV. Current challenges and controversies in the management of chronic spontaneous urticaria. Expert Rev Clin Immunol 2015; 11:1073-82. [DOI: 10.1586/1744666x.2015.1069708] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Mehta A, Godse K, Patil S, Nadkarni N, Gautam M. Treatment of Refractory Chronic Urticaria. Indian J Dermatol 2015; 60:230-7. [PMID: 26120147 PMCID: PMC4458932 DOI: 10.4103/0019-5154.156325] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Chronic spontaneous urticaria is a distressing disease encountered frequently in clinical practice. The current mainstay of therapy is the use of second-generation, non-sedating antihistamines. However, in patients who do not respond satisfactorily to these agents, a variety of other drugs are used. This article examines the available literature for frequently used agents including systemic corticosteroids, leukotriene receptor antagonists, dapsone, sulfasalazine, hydroxychloroquine, H2 antagonists, methotrexate, cyclosporine A, omalizumab, autologous serum therapy, and mycophenolate mofetil, with an additional focus on publications in Indian literature.
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Affiliation(s)
- Aayushi Mehta
- Department of Dermatology, Dr. DY Patil Medical College and Hospital, Nerul, Navi Mumbai, Maharashtra, India
| | - Kiran Godse
- Department of Dermatology, Dr. DY Patil Medical College and Hospital, Nerul, Navi Mumbai, Maharashtra, India
| | - Sharmila Patil
- Department of Dermatology, Dr. DY Patil Medical College and Hospital, Nerul, Navi Mumbai, Maharashtra, India
| | - Nitin Nadkarni
- Department of Dermatology, Dr. DY Patil Medical College and Hospital, Nerul, Navi Mumbai, Maharashtra, India
| | - Manjyot Gautam
- Department of Dermatology, Dr. DY Patil Medical College and Hospital, Nerul, Navi Mumbai, Maharashtra, India
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Maurer M, Church M, Gonçalo M, Sussman G, Sánchez-Borges M. Management and treatment of chronic urticaria (CU). J Eur Acad Dermatol Venereol 2015; 29 Suppl 3:16-32. [DOI: 10.1111/jdv.13198] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 04/14/2015] [Indexed: 12/22/2022]
Affiliation(s)
- M. Maurer
- Department of Dermatology and Allergy; Allergie-Centrum-Charité; Charité - Universitatsmedizin Berlin; Berlin Germany
| | - M.K. Church
- Department of Dermatology and Allergy; Allergie-Centrum-Charité; Charité - Universitatsmedizin Berlin; Berlin Germany
| | - M. Gonçalo
- Clinic of Dermatology; University Hospital and Faculty of Medicine; University of Coimbra; Coimbra Portugal
| | - G. Sussman
- Division of Allergy and Clinical Immunology; St. Michael's Hospital and University of Toronto; Toronto ON Canada
| | - M. Sánchez-Borges
- Allergy and Clinical Immunology Department; Centro Médico-Docente La Trinidad; Caracas Venezuela
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35
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Wieder S, Maurer M, Lebwohl M. Treatment of severely recalcitrant chronic spontaneous urticaria: a discussion of relevant issues. Am J Clin Dermatol 2015; 16:19-26. [PMID: 25452254 DOI: 10.1007/s40257-014-0103-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Chronic spontaneous urticaria (CSU) is a common disorder with a prevalence of 1% that is characterized by recurrent wheals, angioedema, or both. CSU is self-limited but in many patients symptoms recur for several years and can be refractory to standard therapies. In this review, we present an illustrative case of a female patient with CSU who, despite taking 15 antihistamines a day in addition to a number of second-line therapies, continued to be refractory to treatment. However, once we initiated subcutaneous treatment with omalizumab 300 mg every 4 weeks, she experienced rapid relief of her CSU symptoms. Through this case, we present a review of the relevant issues, including the efficacy of laboratory tests to identify the cause of a patient's CSU, the association between CSU and thyroid disease and its relevance to treatment options, the recommendation to increase antihistamine dose up to fourfold and possible adverse events associated with this treatment option. We also include a discussion of the use of second-line therapies as well as omalizumab in refractory CSU patients.
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Affiliation(s)
- Shira Wieder
- Albert Einstein College of Medicine, Bronx, NY, USA
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36
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Greenberger PA. Chronic urticaria: new management options. World Allergy Organ J 2014; 7:31. [PMID: 25383135 PMCID: PMC4223736 DOI: 10.1186/1939-4551-7-31] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 09/30/2014] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Paul A Greenberger
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, 676 N. St. Clair Street, # 14108, 60611 Chicago, IL USA
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37
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Marrouche N, Grattan C. Update and insights into treatment options for chronic spontaneous urticaria. Expert Rev Clin Immunol 2014; 10:397-403. [PMID: 24527948 DOI: 10.1586/1744666x.2014.892416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Nadine Marrouche
- Department of Dermatology, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, UK
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38
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Soria A, Francès C. Urticaires : diagnostic, prise en charge et traitement. Rev Med Interne 2014; 35:586-94. [DOI: 10.1016/j.revmed.2014.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Revised: 12/30/2013] [Accepted: 01/27/2014] [Indexed: 01/31/2023]
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39
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Tal Y, Toker O, Agmon-Levin N, Shalit M. Azathioprine as a therapeutic alternative for refractory chronic urticaria. Int J Dermatol 2014; 54:367-9. [DOI: 10.1111/ijd.12536] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Yuval Tal
- Allergy and Clinical Immunology Unit; Department of Medicine; Hadassah-Hebrew University Medical Center; Jerusalem Israel
| | - Ori Toker
- Allergy and Clinical Immunology Unit; Department of Medicine; Hadassah-Hebrew University Medical Center; Jerusalem Israel
| | - Nancy Agmon-Levin
- Sackler Faculty of Medicine; Tel-Aviv University; Tel-Aviv Israel
- Zabludowicz Center for Autoimmune Diseases; Sheba Medical Center; Tel-Hashomer Israel
| | - Meir Shalit
- Allergy and Clinical Immunology Unit; Department of Medicine; Hadassah-Hebrew University Medical Center; Jerusalem Israel
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40
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Sabroe R. Commentary: Omalizumab for the treatment of chronic idiopathic or spontaneous urticaria. Br J Dermatol 2014; 171:13-5. [DOI: 10.1111/bjd.13074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- R.A. Sabroe
- Royal Hallamshire Hospital; Sheffield Teaching Hospitals NHS Foundation Trust; Glossop Road Sheffield S10 2JF U.K
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41
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Kuo CL, Chen CY, Huang HL, Chen WL, Lee HC, Chang CY, Chou CC, Ho SY, Wu HP, Lin YR. Increased risk of major depression subsequent to a first-attack and non-infection caused urticaria in adolescence: a nationwide population-based study. BMC Pediatr 2014; 14:181. [PMID: 25012668 PMCID: PMC4105518 DOI: 10.1186/1471-2431-14-181] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 07/09/2014] [Indexed: 12/13/2022] Open
Abstract
Background Non-infection caused urticaria is a common ailment in adolescents. Its symptoms (e.g., unusual rash appearance, limitation of daily activities, and recurrent itching) may contribute to the development of depressive stress in adolescents; the potential link has not been well studied. This study aimed to investigate the risk of major depression after a first-attack and non-infection caused urticaria. Methods This study used the Taiwan Longitudinal Health Insurance Database. A total of 5,755 adolescents hospitalized for a first-attack and non-infection caused urticaria from 2005 to 2009 were recruited as the study group, together with 17,265 matched non-urticarial enrollees who comprised the control group. Patients who had any history of urticaria or depression prior to the evaluation period were excluded. Each patient was followed for one year to identify the occurrence of depression. Cox proportional hazards models were generated to compute the risk of major depression, adjusting for the subjects’ sociodemographic characteristics. Depression-free survival curves were also analyzed. Results Thirty-four (0.6%) adolescents with non-infection caused urticaria and 59 (0.3%) non-urticarial control subjects suffered a new-onset episode of major depression during the study period. The stratified Cox proportional analysis showed that the crude hazard ratio (HR) of depression among adolescents with urticaria was 1.73 times (95% CI, 1.13-2.64) than that of the control subjects without urticaria. Moreover, the HR were higher in physical (HR: 3.39, 95% CI 2.77-11.52) and allergy chronic urticaria (HR: 2.43, 95% CI 3.18-9.78). Conclusion Individuals who have a non-infection caused urticaria during adolescence are at a higher risk of developing major depression.
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Affiliation(s)
| | | | | | | | | | | | | | - Shinn-Ying Ho
- Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan.
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42
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43
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Curto-Barredo L, Silvestre J, Giménez-Arnau A. Update on the Treatment of Chronic Urticaria. ACTAS DERMO-SIFILIOGRAFICAS 2014. [DOI: 10.1016/j.adengl.2014.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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44
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Pathogenic intracellular and autoimmune mechanisms in urticaria and angioedema. Clin Rev Allergy Immunol 2014; 45:47-62. [PMID: 22674016 DOI: 10.1007/s12016-012-8326-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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45
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46
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Asero R, Tedeschi A, Cugno M. Treatment of refractory chronic urticaria: current and future therapeutic options. Am J Clin Dermatol 2013; 14:481-8. [PMID: 24085572 DOI: 10.1007/s40257-013-0047-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Chronic urticaria is a distressing disease that affects up to 1 % of the general population at a time point in life and may severely worsen the quality of life. First-line treatment has been based on antihistamines, and presently relies on the use of non-sedating, second-generation antihistamines; following the recommendations of the recent international guidelines, in patients who do not respond to antihistamines at licensed doses, the daily dosage of these drugs can be increased up to fourfold. Nonetheless, a significant proportion of patients with chronic urticaria remain poorly controlled; in these cases, alternative therapeutic approaches have to be considered. This article critically reviews all of the third- and fourth-line treatment options suggested for patients whose disease is refractory to antihistamines, including systemic corticosteroids, leukotriene receptor antagonists, several different anti-inflammatory drugs (dapsone, sulfasalazine, hydroxychloroquine), various immunosuppressive drugs (calcineurin inhibitors, methotrexate, cyclophosphamide, azathioprine, mycophenolate mofetil), intravenous immunoglobulin, and newer treatment options, such as omalizumab and other biologic drugs. In addition, the article examines possible future treatment options based on recent findings about pathogenic mechanisms, and considers the treatment of antihistamine-unresponsive urticaria in special conditions such as children and pregnancy/lactation. The evidence supporting the use of several of the discussed drugs is presently limited and thus insufficient to recommend their routine use; as a consequence, such compounds should be considered only in specific cases and in adequate settings.
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Affiliation(s)
- Riccardo Asero
- Ambulatorio di Allergologia, Clinica San Carlo, Paderno Dugnano, Milan, Italy,
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47
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Abstract
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.
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Affiliation(s)
- Karen Rance
- Allergy Partners of Central Indiana, Indianapolis, Indiana
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48
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Cotes MES, Swerlick RA. Practical guidelines for the use of steroid-sparing agents in the treatment of chronic pruritus. Dermatol Ther 2013; 26:120-34. [PMID: 23551369 DOI: 10.1111/dth.12026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Chronic pruritus in the adult patient is both an underappreciated and a difficult to treat condition. In the vast majority of cases, itch is the result of inflammatory skin disease and therefore may be responsive to systemic anti-inflammatory therapies. Urticarial dermatitis is an under-recognized cause of chronic itch in the adult population. Patients with this disorder are characterized by prolonged, prednisone-responsive pruritus, often in the absence of substantial cutaneous findings. Skin findings, when present, can range from subtle, persistent urticarial lesions to excoriated papules, often intermixed with urticaria, eczematous change, and lichenification secondary to chronic scratching. Hereby, we describe our algorithm for evaluation and management of adult patients with refractory pruritus (urticarial dermatitis in particular), including evaluation for other etiologies of pruritus, pre-immunosuppression workup, and the use of azathioprine and other steroid-sparing agents for treatment of recalcitrant itch.
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Affiliation(s)
- Maren E S Cotes
- Emory Department of Dermatology, Emory University, Atlanta, Georgia 30322, USA
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49
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[Chronic spontaneous urticaria: An autoimmune disease?]. Hautarzt 2013; 64:675-82; quiz 683-4. [PMID: 24022631 DOI: 10.1007/s00105-013-2612-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The identification of the causes of chronic spontaneous urticaria (CSU) is difficult. The recognition of functional autoantibodies against FcεRI and/or against IgE in some patients with CSU led to the concept of autoimmune etiology of the disease. Clinical and laboratory features in a subpopulation of CSU patients also point to an autoimmune etiology of the disease. This review will present and discuss the relevance of functional autoantibodies in CSU pathogenesis and their implications for treatment and prognosis.
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50
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Khan DA. Alternative agents in refractory chronic urticaria: evidence and considerations on their selection and use. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2013; 1:433-440.e1. [PMID: 24565613 DOI: 10.1016/j.jaip.2013.06.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 06/02/2013] [Accepted: 06/19/2013] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- David A Khan
- Division of Allergy & Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Tex.
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