Knowledge and management of chronic spontaneous urticaria in Latin America: a cross-sectional study in Ecuador

Bilastine for the treatment of allergic rhinoconjunctivitis and urticaria: results from an international Delphi study

Background

Second-generation oral H1-antihistamines, including bilastine, represent the emerging treatments of allergic rhinitis (including rhinoconjunctivitis) and chronic urticaria in both adults and children. This study analyses available evidence supporting the use of bilastine amongst second-generation antihistamines for the symptomatic treatment of allergic rhinitis and urticaria in adults and children.

Methods

Consensus amongst experts from 17 countries on the ideal treatment of rhinitis and urticaria, and the specific role of bilastine was measured by means of a modified Delphi process. A total of 12 statements were voted on by the experts using a five-point Likert scale (1 = strongly disagree; 2 = disagree; 3 = undecided; 4 = agree; 5 = strongly agree). The definition of consensus was set at a minimum of 80% concordance for 4+5 scores (agree or strongly agree).

Results

All proposed statements reached consensus, with a concordance of ≥98% for five statements and ≥96% for seven.

Conclusions

The wide consensus obtained for the proposed statements suggests a prominent role for bilastine in the management of allergic rhinitis and urticaria.

A Patient Charter for Chronic Urticaria

Chronic urticaria (CU) is the recurring development of wheals (aka "hives" or "welts"), angioedema, or both for more than 6 weeks. Wheals and angioedema occur with no definite triggers in chronic spontaneous urticaria, and in response to known and definite physical triggers in chronic inducible urticaria. Approximately 1.4% of individuals globally will have CU during their lifetime. The itching and physical discomfort associated with CU have a profound impact on daily activities, sexual function, work or school performance, and sleep, causing significant impairment in a patient's physical and mental quality of life. CU also places a financial burden on patients and healthcare systems. Patients should feel empowered to self-advocate to receive the best care. The voice of the patient in navigating the journey of CU diagnosis and management may improve patient-provider communication, thereby improving diagnosis and outcomes. A collaboration of patients, providers, advocacy organizations, and pharmaceutical representatives have created a patient charter to define the realistic and achievable principles of care that patients with CU should expect to receive. Principle (1): I deserve an accurate and timely diagnosis of my CU; Principle (2): I deserve access to specialty care for my CU; Principle (3): I deserve access to innovative treatments that reduce the burden of CU on my daily life; Principle (4): I deserve to be free of unnecessary treatment-related side-effects during the management of my CU; and Principle (5): I expect a holistic treatment approach to address all the components of my life impacted by CU. The stated principles may serve as a guide for healthcare providers who care for patients with CU and translate into better patient-physician communication. In addition, we urge policymakers and authors of CU treatment guidelines to consider these principles in their decision-making to ensure the goals of the patient are achievable.

Urticaria

Urticaria is an inflammatory skin disorder that affects up to 20% of the world population at some point during their life. It presents with wheals, angioedema or both due to activation and degranulation of skin mast cells and the release of histamine and other mediators. Most cases of urticaria are acute urticaria, which lasts ≤6 weeks and can be associated with infections or intake of drugs or foods. Chronic urticaria (CU) is either spontaneous or inducible, lasts >6 weeks and persists for >1 year in most patients. CU greatly affects patient quality of life, and is linked to psychiatric comorbidities and high healthcare costs. In contrast to chronic spontaneous urticaria (CSU), chronic inducible urticaria (CIndU) has definite and subtype-specific triggers that induce signs and symptoms. The pathogenesis of CSU consists of several interlinked events involving autoantibodies, complement and coagulation. The diagnosis of urticaria is clinical, but several tests can be performed to exclude differential diagnoses and identify underlying causes in CSU or triggers in CIndU. Current urticaria treatment aims at complete response, with a stepwise approach using second-generation H1 antihistamines, omalizumab and cyclosporine. Novel treatment approaches centre on targeting mediators, signalling pathways and receptors of mast cells and other immune cells. Further research should focus on defining disease endotypes and their biomarkers, identifying new treatment targets and developing improved therapies.

Multicentric and Observational Study of Omalizumab for Chronic Spontaneous Urticaria in Real-Life in Colombia

Background

Although chronic urticaria (CU) is a common, cause of medical consulting both in general practitioners and allergist specialists worldwide, there is little information about its behavior and management in Latin America. Currently, national and international guidelines recommend using Omalizumab for cases refractory to management with antihistamines. Despite advances in the knowledge of Omalizumab for the management of CU, although there are few studies in underdeveloped countries, there are many studies evaluating the impact of Omalizumab treatment. There is not clinical information related with CSU-Omalizumab in patient settled in the Caribbean area. This research aims to evaluate the management of CU with Omalizumab in a real-life scenario in Colombia.

Methodology

We conducted an observational, descriptive, and retrospective study with patient recruitment between 2014 and 2017 of individuals diagnosed with Chronic Urticaria (CU) treating allergology specialists in five Colombian cities. We included patients with CU who failed to achieve disease control after treatment for 4 weeks with fourfold doses of second-generation H1-antihistamines, as recommended by the EAACI/GA²LEN/EDF/WAO guidelines and who received treatment with Omalizumab.

Results

We included 123 patients, 73.1% (n = 90) were women. The mean age was 47.1 years (Standard Deviation, SD: 16.2). The median of the total months of disease evolution was 30 (IQR = 13–58). 81.3 % (n = 100) of patients were diagnosed with chronic spontaneous urticarial (CSU). 4.8% (n = 6) had inducible CU (CIndU), and 13.8% (n = 17) reported mixed urticaria (spontaneous CU with at least one inducible component). Regarding emotional factors, 34.9% (n = 43) of subjects indicated anxiety symptoms, 34.1% (n = 42) had exacerbations associated with stress, and 14.6% (n = 18) manifested episodes of sadness. The percentage of patients with CSU controlled according to medical criteria at 3 months with Omalizumab were 80% (n = 80/100) and at 6 months 87% (n = 87/100). The frequency of adverse events was 29.2% (n = 36), with headache being the most frequent adverse event.

Conclusions

This real-life study with Omalizumab at CU describes percentages of effectiveness and safety similar to those observed in pivotal and real-life studies conducted in other regions around the world.

Clinical characteristics of patients with chronic urticaria and adherence to management guidelines by postgraduate students in dermatology: A retrospective single center study

Background:

Chronic urticaria is a heterogenous skin disorder representing one of the important reasons for consultation with a dermatologist. Dermatology post-graduate students play an importanrt role in the treatment of patients with chronic urticaria.

Objective:

The objective of the study was to describe clinical characteristics of patients with chronic urticaria and assess adherence to the guidelines by postgraduate students in the department of dermatology of a tertiary care center.

Materials and Methods:

In this retrospective study, prescriptions of patients with chronic urticaria and/or angioedema presenting to the outpatient department for 5 months were analyzed. Percentage of prescriptions adhering to international urticaria management guidelines was calculated. Urticaria Activity Score, percentage of patients receiving second-generation antihistamines, first-generation antihistamines, and other drugs was recorded. Comorbidities in patients with chronic urticaria were also noted.

Results:

A total of 60 patients (mean age 32.1 years; 58.3% male) were included in. Mean (SD) duration of urticaria at the time of study was 4.7 (2.7) months. Demographism and history of allergy to drugs was present in 45 (75%) and 4 (6.7%) patients. Mean (SD) Urticaria Activity Score was 12.5 (6.5). A total of 12 (20%) patients had comorbidities. Mean number of drugs received per patient was 1.7 (0.5). A total of 47 (78.3%) patients received second-generation antihistamines, whereas 11 (18.3%) received first-generation antihistamines. Two (3.3%) patients received combination of first-generation and second-generation antihistamines. Fexofenadine, levocetirizine, bilastine, and cetirizine was prescribed to 24 (40%), 26 (43.3%), 18 (30%), and 14 (23.3%) patients. There was no significant difference in male and female patients receiving fexofenadine (P = 0.59) or levocetirizine (P = 0.13).

Conclusion:

Adherence to urticaria management guidelines by resident doctors in dermatology department in our institute was satisfactory.

Clinical characteristics and management of chronic spontaneous urticaria in patients refractory to H1-Antihistamines in Asia, Middle-East and Africa: Results from the AWARE-AMAC study

Background

Chronic urticaria (CU) is a condition characterized by recurrent itchy hives and/or angioedema for ≥6 weeks. Most of the data about CU come from western countries with very little information available about CU in Asia, Africa, and the Middle East.

Methods

AWARE-AMAC is a 24-month prospective, observational, real-world, non-interventional study in patients aged ≥18 years from Asia, the Middle East, and Africa (AMAC) with CU refractory to H1-antihistamines (H1-AH). The main objective was to describe the real-world experience with CU, including clinical characteristics, presence of angioedema, treatment patterns (shifts between treatment classes and changes within a treatment class), investigator-assessed disease control, and the impact on quality of life. Subgroups of interest were type of CU at Baseline and treatment class (based on 2013 urticaria guidelines). There were no mandatory visits and diagnostic/monitoring procedures additional to routine practice, except the patient diary (7-day Urticaria Activity Score) and patient reported outcome assessments.

Results

The focus of the current manuscript is on patients with chronic spontaneous urticaria (CSU), who formed 98% of the sample. Patients were predominantly female (69.6% female, mean age ± SD 39.8 ± 13.29 years). Time since current diagnosis (Mean ± SD) was 28.6 ± 49.06 months. Amongst patients with CSU, 31.0% had comorbid chronic inducible urticaria (CINDU) and 46.4% had a history of angioedema. 91.9% received H1-AH therapy (±other treatments). The most frequently prescribed treatment classes at Baseline were any/combination of medications, not classified under the other 7 treatment classes, named “Others” (30.5%) followed by, omalizumab (OMA; 23.6%) and second-generation H1-AH monotherapy (sgAH; 15.1%). At Month 12, the most prescribed treatment classes (>15%) for patients were OMA (23.5%) and "Other" (21.3%); 19.7% received "No drug". At Month 24, OMA (22.5%), and "Other" (17.9%) were most frequently prescribed; 28.6% received "No drug". Overall, 79.5% of patients had some type of change in treatment. Over the study period, improvement in self-reported QoL increased, which was mirrored by better disease control.

Conclusion

In AMAC countries, the non-recommended "Other" treatment class played a major role in the initial management of CU patients. High usage of H1-AH (±other treatments) and OMA was observed. Treatment changes were observed in a majority of patients. Treatment escalation from sgAH was mostly via OMA. Improvement of disease control and QoL was achieved during the study period.

Trial registration

Observational study (NA).

Real-life approach and treatment of chronic urticaria in Argentina: A National Survey

The management of chronic urticaria (CU) has been controversial. Recently updated international guidelines propose evidence-based diagnosis and treatment. Nevertheless, dermatologists have heterogeneous approaches to managing CU. To estimate the percentage of dermatologists who have an optimal approach to CU according to the international guidelines, and to explore the variables associated with optimal management a cross-sectional study using a 17-question survey was delivered by email to dermatologists from Argentina. Optimal first, second, and third line treatment were considered when dermatologists chose a nonsedative antihistamine; increased the dosage of nonsedative antihistamines, and added omalizumab, respectively. Logistic regression was used to identify variables associated with optimal management. A total of 165 questionnaires were available for analysis. An optimal first, second, and third-line treatment approach was identified in 50%, 35%, and 15% of the dermatologists, respectively. The dermatologists' age being above 55 years old (OR: 0.12, 95% CI: 0.01-0.99, p .005) and having more than 5 years of expertise (OR: 0.4, 95% CI: 0.19-0.81, p .001) were significantly associated with a suboptimal approach in second-line treatment. We could not find variables associated with an optimal first or third-line treatment. The real-life management of CU in Argentina is partly suboptimal according to the international guidelines.

A retrospective analysis omalizumab treatment patterns in patients with chronic spontaneous urticaria: a real-world study in Belgium

Background

Chronic spontaneous urticaria (CSU) is characterized by the repeated occurrence of persistent hives and/or angioedema for ≥6 weeks, without specific external stimuli. H₁‐antihistamines have long been the standard of care of CSU, but many patients remain uncontrolled even at 4× the approved dose. Add‐on therapy with omalizumab has proven effective in clinical trials, but little is known about omalizumab treatment in Belgium.

Objective

To collect real‐world clinical data on omalizumab treatment in adults with CSU in Belgium.

Methods

This was an observational, retrospective chart review of adults with CSU, who initiated omalizumab treatment between August 2014 and December 2016 (maximum 28 months follow‐up).

Results

In total, 235 patients were included (median time from symptom onset to diagnosis, 5.4 months; median time from diagnosis to commencing omalizumab, 6.7 months). Treatments used before/after commencing omalizumab did not always adhere to guidelines; many patients (26.4%/11.1%) received first‐generation H₁‐antihistamines, while 20.4% used omalizumab monotherapy after initiating treatment. The mean interval between omalizumab administrations was 4.8 (SD 1.7) weeks; 67.8% of patients had ≥1 interval prolongation and/or shortening. Mean baseline 7‐day Urticaria Activity Score (UAS7) was 32.0 (SD 6.05); this improved to 12.6 (SD 11.2) after 1 month of omalizumab. About 67.2% of patients reached UAS7 ≤ 6 (well controlled) during the study. A total of 87 patients stopped omalizumab and never restarted before the end of the observation period; the most prevalent reason was remission of symptoms (49.4% of patients), followed by lack of effect (12.6%), lost to follow‐up (6.9%) and adverse events (3.4%). Headache was the most common adverse event (n = 8/82). No anaphylaxis was reported.

Conclusions

This study revealed that patients initiated on omalizumab in Belgium had severe CSU at baseline, and showed substantial improvements after 1 month of treatment. Greater adherence to the prescription of guideline‐recommended medications is needed for the treatment of CSU.

Learnings from real-life experience of using omalizumab for chronic urticaria in Latin America

Background

Updated urticaria guidelines recommend that patients should be assessed for disease activity, severity, control, and quality of life at baseline and follow up. Regarding treatment, guidelines consider second generation antihistamines as the cornerstone in therapy for chronic urticaria (CU), while other drugs, such as omalizumab, are conceived as second-line alternatives. In regards to omalizumab, despite advances in the management of CU, there are still open questions about timing, dosing, and objective measures for clinical response. This study was designed to portray the use of patient-reported outcomes (PROs) in chronic urticaria management, as well as the effectiveness and treatment patterns of omalizumab in CU, as seen in a real-life setting in Latin America.

Methods

This is a retrospective observational study, involving 72 Latin American patients with chronic urticaria treated with omalizumab. Patient reported outcomes and treatment patterns, response, quality of life improvement and discontinuation were analyzed.

Results

From the 72 patients, 91.7% (n = 66) were assessed through PROs, where urticaria control test (UCT) was the most used (79.2%; n = 57). Overall, 80.0% (n = 44) responded to omalizumab at some point of the treatment. Omalizumab 300 mg was associated with earlier response compared to lower doses. Regardless of dosage, most patients assessed with CU-Q2oL improved quality of life (80.8%; n = 21). With respect to omalizumab discontinuation, 20.8% (n = 15) patients interrupted omalizumab before the 3rd month of treatment (p = .000).

Conclusions

The present study highlights how the use of PROs and omalizumab in Latin America differ from guidelines' recommendations and clinical trials. Even though most patients were initiated under omalizumab 300 mg, most of them finished with lower doses. Regardless of dosage, most patients responded to omalizumab and improved quality of life at some point during treatment. However, such features were seen earlier with omalizumab 300 mg. Regarding treatment discontinuation, one-fifth of patients interrupted omalizumab before the third month.

Differences in chronic spontaneous urticaria between Europe and Central/South America: results of the multi-center real world AWARE study

Background

Global chronic urticaria (CU) disease experience and management is not well documented. This study descriptively compares these aspects among CU patients residing in Europe (EU) and Central and South America (C/SA).

Methods

AWARE (A World-wide Antihistamine-Refractory chronic urticaria patient Evaluation) is a global prospective, non-interventional study of CU in the real-world setting. Patients were ≥ 18 years with a diagnosis of H1-antihistamine-refractory CU for > 2 months. Differences between the EU and C/SA regions in demographic and clinical characteristics, quality of life (QoL), work and activity impairment, pharmacological treatment, and healthcare resource use were examined.

Results

In total, 4224 patients were included in the analysis (C/SA 492; EU 3732). Rates of untreated patients were greater in the C/SA region (45.1% vs. 31.9%; P < 0.005) and escalation to third-line therapy was rare in both regions. Differences in disease experience emerged, with C/SA patients more commonly experiencing angioedema (C/SA 50.8% vs. EU 46.1%; P = 0.03) or comorbid chronic inducible urticaria (C/SA 30% vs. EU 22%; P < 0.001). Correspondingly, rates of uncontrolled urticaria were higher among C/SA patients (82.8% vs. 77.5%; P = 0.017) and patients in the C/SA region showed significantly greater work and activity impairment (absenteeism: 10.4 ± 19.7 vs. 6.7 ± 19.0, P = 0.004; presenteeism: 30.3 ± 31.9 vs. 24.4 ± 25.8, P = 0.001; work productivity loss: 33.9 ± 33.9 vs. 26.5 ± 27.5, P < 0.001; activity impairment: 37.7 ± 34.7 vs. 32.7 ± 30.1, P = 0.001). However, QoL impairment was greater in the EU region (Dermatology Life Quality Index: C/SA 6.5 ± 5.9 vs. EU 8.3 ± 7.0; P < 0.001). There was a significant difference in use of healthcare resources, including emergency services (39.6% vs. 29.3%; P < 0.001), hospitalization (7.7% vs 21.9%; P < 0.001) general practitioners (31.7% vs 57.3%; P < 0.001), and additional allergists or dermatologists (50.6% vs. 47.3%, P < 0.001), among patients in the C/SA and EU region, respectively. In both regions, patients with a primary diagnosis of CU with angioedema had significantly greater impairment in work and non-work activities and healthcare resource utilization compared to those without angioedema.

Conclusions

This study revealed that CU is a heterogeneous condition with differences in healthcare utilization and outcomes between EU and C/SA. However, overall there is a high unmet need of H1-antihistamine-refractory CU patients, which is associated with high use of healthcare resources, and has a large negative effect on QoL and work productivity.

Management of chronic spontaneous urticaria: a worldwide perspective

Background

The approaches to the diagnosis and treatment of chronic spontaneous urticaria (CSU) differ in various parts of the world. We sought to determine the adherence to international and national urticaria guidelines as well as the motives to deviate from the guidelines among physicians worldwide.

Methods

A web-based questionnaire was created and launched via e-mail by the World Allergy Organization (WAO) to representatives of all WAO Member Societies, the members of the American Academy of Allergy, Asthma & Immunology (AAAAI) and the members of the WAO Junior Members Group (JMG), regardless of the specialty, affiliation, or nationality in March 2017.

Results

We received 1140 completed surveys from participating physicians from 99 countries. Virtually all participants (96%) were aware of at least one urticaria guideline and reported that they follow a guideline. However, one in five physicians who follow a guideline (22%) reported to deviate from it. Reliance on own clinical experience is the most frequent reason for deviation from guidelines or not following them (44%). Young (< 40 years) and less experienced physicians more often follow a guideline and less often deviate than older and experienced ones. Physicians who follow a urticaria guideline showed higher rates of routinely ordering a complete blood count, the erythrocyte sedimentation rate, C-reactive protein, anti-thyroid antibodies, and thyroid-stimulating hormone and of performing the autologous serum skin test as compared to those who do not. Physicians who follow a urticaria guideline showed higher rates of using second generation antihistamines as their first-line treatment of CSU (p = 0.001) and more frequently observed higher efficacy of these drugs (or had more confidence that it would work, p < 0.019) as compared to those who do not follow the guidelines.

Conclusions

Physicians’ characteristics (e.g. age, clinical experience, and specialty) and country specifics and regional features (e.g. availability of drugs for CSU treatment) importantly influence adherence to urticaria guidelines and CSU patient care and should be addressed in more detail in future research.

Electronic supplementary material

The online version of this article (10.1186/s40413-018-0193-4) contains supplementary material, which is available to authorized users.

Etiology of chronic urticaria: the Ecuadorian experience

Background

The purpose of this study was to identify chronic urticaria (CU) etiologies and treatment modalities in Ecuador. We propose that the sample distribution fits the expected one, and that there is an association between the etiology and its treatment.

Methods

We performed a retrospective study involving 112 patients diagnosed with CU using a Checklist for a complete chronic urticaria medical history. Demographic and clinical variables were collected. The etiology of CU was classified using the EAACI/GA2LEN/EDF/WAO guideline. Descriptive analyses were performed for demographical and clinical variables. Chi square tests were applied to analyze the fit of distribution and the independence of variables. P values less than 0.05 were considered significant.

Results

Among all the patients, 76.8% were diagnosed with chronic spontaneous urticaria (CSU), of which 22.3% had a known etiology or possible exacerbating condition. Food allergy was identified as the most common accompanying condition in patients with CSU (10.7%) (p < 0.01).. On the other hand, 23.2% inducible urticarias (CIndU) were indentified; dermographism was the most common (10.7%) (p < 0.01).

Regarding treatment regimens, sg-H1-antihistamines alone represented the highest proportion (44.6%). The combination of any H1-antihistamine plus other drug was a close second (42.0%) (p < 0.01). Almost 48% of CSUs of unknown etiology were treated with any antihistamine plus another drug. In patients with known etiology, sg-antihistamines alone (44.0%) was the most common management. In addition, 53.8% of CIndUs were treated with sg-antihistamines alone. Though, these associations were not statistically significant.

Conclusion

CSU is the most frequent subtype of CU. Modern non-sedating antihistamines in licensed doses are the drug of choice. Nevertheless, a great proportion of patients require the addition of another type of medication.