Non-sedating antihistamines in the treatment of chronic idiopathic urticaria using patient-reported outcomes

A qualitative research study on the illness perception of chronic pruritus in older Asian adults based on the Common-Sense Model of self-regulation

Background

Chronic pruritus (CP), itch lasting more than 6 weeks, is common in community‐dwelling older adults. Understanding their illness perception allows the attending physician to develop a personalised care plan to mitigate CP.

Aim

This study explores the illness perception of CP among older Asian adults in an urban community.

Design

Qualitative research was conducted, framed by the Common‐Sense Model of self‐regulation (CSM). Through in‐depth interviews (IDIs), qualitative data were gathered from Asian patients with CP, and then a thematic analysis was carried out. The emergent themes were grouped according to the five domains of CSM: ‘identity’, ‘cause’, ‘time’, ‘controllability’ and ‘consequence’.

Setting and Patients

IDIs were conducted in a Singapore public primary care clinic before the data were saturated.

Results

The CSM domains illustrate the illness perception of CP. CP was identified as a ‘problem’ rather than a disease and was often described in metaphor. Patients' perception of the cause was diverse due to the lack of provision of a clear explanation by their physicians. They opined that CP continued indefinitely. Without definite time to resolution, patients adapted their help‐ and health‐seeking behaviours to control it. The consequences included therapeutic experimentation, alternative therapy, self‐isolation, avoidance behaviours, emotional disturbance and dermatological complications.

Conclusion and Patient Contribution

Patients provided information on their perception of CP, which aligned with the CSM. A multipronged approach is needed to deliver holistic and personalised care to patients with CP, providing clarity on its natural progression, to set their expectations on its timeline, treatment effectiveness and undertake appropriate behaviour modification to adapt to its chronicity.

Chronic Pruritus in the Geriatric Population

Chronic pruritus (>6 week's duration) in the geriatric population (≥65 years old), is an increasing health care problem. The pathophysiologic predisposing factors are abnormalities of the epidermal barrier, immune system, and nervous system. Causes can be dichotomized into histaminergic and nonhistaminergic pruritus. Topical treatments are generally safe. Systemic treatments are chosen depending on the condition, comorbid diseases, and drug interactions. Treatment options are limited. Progress has been made in identifying itch-selective mediators over the last decade. Numerous new medications are currently undergoing clinical trials and they are anticipated to enter the clinics in the near future.

Urticaria and its subtypes: the role of second-generation antihistamines

Urticaria is a heterogeneous group of debilitating skin disorders characterized by wheals, pruritus, and frequently angioedema. The various forms of urticaria are often chronic and can exact a toll on quality of life. New diagnostic criteria and management guidelines are available to assist primary care physicians in the identification and proper treatment of different subtypes of urticaria. Second-generation antihistamines are recommended as first-line therapy because of their high degree of efficacy and safety. It is important to note, however, that European indications for most agents in this class are limited to specific forms of urticaria. The exception is desloratadine, the only second-generation antihistamine approved for the treatment of all urticaria subtypes in the European Union. Guidelines and best practice suggest that doses of antihistamines up to 4 times higher than those normally recommended for urticaria may benefit patients who do not respond to standard doses of antihistamines. Adjunctive therapy with leukotriene receptor antagonists may be advantageous in certain subgroups of patients who have suboptimal responses to antihistamine monotherapy. In all cases, physicians should work closely with patients to ensure proper adherence to prescribed regimens-a component that is often lacking but holds the key to successful outcomes.

Chronic urticaria: a comparison of management guidelines

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Recommendations for assessing patient-reported outcomes and health-related quality of life in patients with urticaria: a GA(2) LEN taskforce position paper

The aim of this Global Allergy and Asthma European Network (GA(2)LEN) consensus report is to provide recommendations and suggestions for assessing patient-reported outcomes (PROs) including health-related quality of life in patients with urticaria. We recommend that PROs should be used both in clinical trials and routine practice for the evaluation of urticaria patients. We suggest that PROs should be considered as the primary outcome of future clinical trials. Two validated and disease-specific instruments for assessing PROs are available, the urticaria activity score (for symptoms) and the chronic urticaria questionnaire on quality of life CU-Q(2)oL. This latter tool, CU-Q(2)oL, is available in many languages and should be preferred, where available, over more generic instruments for assessing urticaria-specific effects on quality of life. CU-Q(2)oL is only suited for the investigation of patients with chronic spontaneous urticaria. Similar instruments for other forms of urticaria have yet to be developed and validated. Also, tools for assessing other chronic spontaneous urticaria PROs besides quality of life and symptoms are needed.