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Chang J, Cattelan L, Ben-Shoshan M, Le M, Netchiporouk E. Management of Pediatric Chronic Spontaneous Urticaria: A Review of Current Evidence and Guidelines. J Asthma Allergy 2021; 14:187-199. [PMID: 33727832 PMCID: PMC7955742 DOI: 10.2147/jaa.s249765] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 01/14/2021] [Indexed: 12/27/2022] Open
Abstract
Chronic urticaria (CU) is associated with debilitating symptoms such as pruritic wheals and/or angioedema, which can significantly affect patients’ sleep, productivity and quality of life. Chronic spontaneous urticaria (CSU) is defined in cases in which no triggering factor is identified. Various guidelines directing the optimal management of CU in the adult population were published and updated over the recent years with the most accepted and widely used being the EAACI/GA2LEN/EDF/WAO 2017 guidelines. Meanwhile, guidelines specific to the pediatric population are scarce, mainly due to the fact that high quality evidence is lacking for many treatment options in this age group. The objective of this article is to review and synthesize the existing literature regarding the management of pediatric CSU. Our review highlights evidence supporting the EAACI/GA2LEN/EDF/WAO 2017 treatment guidelines with non-sedating second-generation antihistamines (sgAHs) as the mainstay of treatment for pediatric CSU, considering their demonstrated efficacy and reassuring safety profile. Additionally, the use of omalizumab in adolescents is well supported by the current literature. There is limited data available regarding the updosing of sgAHs, omalizumab in children with CSU under 12 years of age and the treatment with cyclosporine and leukotriene receptor antagonists (LTRAs) in pediatric patients of all ages. However, the results from currently available case series and case reports are promising for omalizumab and cyclosporine use in children with CSU, although large and well-designed randomized control trials (RCTs) assessing these treatment options are needed in order to formulate strong recommendations for their use. First-generation antihistamines (fgAHs) remain commonly used in pediatric CSU treatment despite a lack of studies assessing their efficacy and safety in the pediatric population and their widely known inferior safety profile compared to sgAHs.
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Affiliation(s)
- Jasmine Chang
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Leila Cattelan
- Division of Dermatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Moshe Ben-Shoshan
- Division of Allergy Immunology and Dermatology, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Michelle Le
- Division of Dermatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Elena Netchiporouk
- Division of Dermatology, McGill University Health Centre, Montreal, Quebec, Canada
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Asfour L, Yiu ZZN, Warren RB. How is safety of dermatology drugs assessed: trials, registries, and spontaneous reporting. Expert Opin Drug Saf 2020; 19:449-457. [PMID: 32228187 DOI: 10.1080/14740338.2020.1746267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Introduction: Skin conditions are common and highly varied in their etiology; therefore, a diverse array of therapeutics are utilized. Drug safety studies in dermatology can be challenging as there are over 3000 diagnoses to consider. As a result, dermatologists rely on data from multiple sources including clinical trials and real-world evidence.Areas covered: In this review, we cover the main sources of safety data available, their strengths and weaknesses and how dermatologists should utilize such data. We use real-world examples of the different types of adverse events reported and how they are best captured by either randomized controlled trials or post-marketing pharmacovigilance methods. With multiple new therapies in dermatology, such as dupilumab for atopic dermatitis and janus-kinase inhibitors for alopecia areata the specialty is awash with evolving high-level evidence for their use. It is important to understand the optimal way to assess safety from trials but also appreciate the need for ongoing capture of safety data in clinical practice.Expert opinion: In dermatology, there is a plethora of conditions to treat and clinical trials, post-marketing surveillance, such as drug registries and spontaneous reporting, all enable dermatologists to gain a more comprehensive understanding of the safety profiles of drugs being used.
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Affiliation(s)
- Leila Asfour
- Dermatology Centre, Salford Royal NHS Foundation Trust, the University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester, UK
| | - Zenas Z N Yiu
- Dermatology Centre, Salford Royal NHS Foundation Trust, the University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester, UK
| | - Richard B Warren
- Dermatology Centre, Salford Royal NHS Foundation Trust, the University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester, UK
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Weller K, Maurer M. Antihistamine updosing in chronic urticaria - is there enough evidence? Br J Dermatol 2016; 175:1134-1135. [DOI: 10.1111/bjd.15104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- K. Weller
- Department of Dermatology and Allergy; Charité - Universitätsmedizin Berlin; Charitéplatz 1 10117 Berlin Germany
| | - M. Maurer
- Department of Dermatology and Allergy; Charité - Universitätsmedizin Berlin; Charitéplatz 1 10117 Berlin Germany
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de Silva NL, Damayanthi H, Rajapakse AC, Rodrigo C, Rajapakse S. Leukotriene receptor antagonists for chronic urticaria: a systematic review. Allergy Asthma Clin Immunol 2014; 10:24. [PMID: 24817895 PMCID: PMC4016797 DOI: 10.1186/1710-1492-10-24] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 04/13/2014] [Indexed: 11/29/2022] Open
Abstract
A significant proportion of patients with chronic urticaria respond inadequately to first line treatment with antihistamines. Leukotreine receptor antagonists (LTRA) are also used for chronic urticaria, although firm recommendations on their use are lacking. We performed a systematic review of randomised trials to determine the role of LTRA in treatment of chronic urticaria. A search of PUBMED, EMBASE, SCOPUS, LILACS, the Cochrane Central Register of Controlled Trials, and the Web of Science for relevant randomized control trials or cross over studies yielded 10 eligible studies. The heterogeneity of trials were high, preventing valid meta-analysis of data. Most trials indicated that LTRA are not superior to placebo or antihistamine therapy, while combination therapy of LTRA and antihistamines appear to be more efficacious compared to antihistamine alone. The side effect profile and tolerability of this group of drugs is acceptable. The use of LTRA as monotherapy cannot be recommended. LTRA are effective add-on therapy to anti-histamines, and their use in patients responding poorly to antihistamines is justifiable. Further well designed randomized controlled trials with clear and standardized outcome measures are needed to determine the role of LTRA in chronic urticaria.
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Affiliation(s)
- Nipun Lakshitha de Silva
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, 25 Kynsey Road, Colombo 08, Sri Lanka
| | | | - Anoja Chamarie Rajapakse
- Department of Geriatrics, Kings Mill Hospital, Sherwood Forest NHS Foundation Trust, Sutton-in-Ashfield, Nottinghamshire, UK
| | - Chaturaka Rodrigo
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, 25 Kynsey Road, Colombo 08, Sri Lanka
| | - Senaka Rajapakse
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, 25 Kynsey Road, Colombo 08, Sri Lanka
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Ortonne JP. Urticaria and its subtypes: the role of second-generation antihistamines. Eur J Intern Med 2012; 23:26-30. [PMID: 22153526 DOI: 10.1016/j.ejim.2011.09.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Revised: 09/07/2011] [Accepted: 09/11/2011] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Jean-Paul Ortonne
- Department of Dermatology, Hôpital de L'Archet 2-BP 3079, 151 Route St.-Antoine de Ginestière, 06202, Nice, France.
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Abstract
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.
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Affiliation(s)
- Jean-Paul Ortonne
- Service de Dermatologie, Hôpital de l'Archet, 151, route de Saint-Antoine-de-Ginèstre, F-06202, Nice cedex 03, France.
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Wan KS. Efficacy of leukotriene receptor antagonist with an anti-H1 receptor antagonist for treatment of chronic idiopathic urticaria. J DERMATOL TREAT 2009; 20:194-7. [PMID: 19085267 DOI: 10.1080/09546630802607495] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Chronic idiopathic urticaria (CIU) is often difficult to treat. Although histamine-releasing activity is detectable for up to 50% of CIU patients, antihistamine therapy provides only a limited response. OBJECTIVE This study aimed to assess the clinical efficacy of combined leukotriene receptor antagonist (LRA) and H1 antihistamine, H1 and H2 antihistamine, and two H1 antihistamines as a synergistic therapeutic regimen for treating CIU compared with a matched placebo modality. METHODS A total of 120 newly diagnosed adult patients were evaluated. Patients were single blinded and randomly assigned to one of four medication groups that received the following regimens for 4 weeks: Group A, combination of sedating H1 antihistamine and non-sedating H1 antihistamine; Group B, combination of H1 antihistamine and H2 antihistamine; Group C, combination of H1 antihistamine and LRA; and Group D, matched placebo medication. The primary measure of treatment efficacy was the daily urticaria activity score (UAS) of 'wheal and itch'. A positive therapeutic response was defined as a reduction to < 25% of baseline weekly UAS, while a relapse was a return to > 75% of baseline weekly UAS. RESULTS In all, 107 patients completed the trial medication. At the end of 4 weeks, the UAS score as a response to treatment was 23.3% for Group A, 63.3% for Group B, 53.3% for Group C, and no real change for the placebo treatment group. CONCLUSIONS The combination of LRA and H1 receptor antagonist is promising for CIU treatment and is reasonably well tolerated by patients. The combination of H1- and H2-receptor antagonists provided the greatest treatment efficacy by the measures used in this small study.
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Affiliation(s)
- Kong-Sang Wan
- Department of Pediatric, Taipei City Hospital, Renai Branch, Taipei City 106, Taiwan.
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Abstract
Chronic urticaria, a major health problem causing patient's distress, induces often physicians' dilemma while dealing with its etiology, investigations and management. Clinical approach of such cases should include apart from clinical history and physical examination laboratory investigations like routine blood test, thyroid profile, etc. as well as sometimes special test like autologous serum skin test. Management includes reassurance, avoidance of precipitating factors, treatment of underlying disorders, and non-pharmacological approach along with pharmacotherapy. First line drug therapy comprises non-sedative and sedative antihistamines, second line doxepin, nifedipine, leukotriene-inhibitors, sulfasalazine, etc. and third line cyclosporine, dapsone, colchicin, etc.
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Affiliation(s)
- Sudha Yadav
- From the Departments of Skin, Veneral Disease, and Leprosy, M.L.N. Medical College, Allahabad, UP, India.
| | - A K Bajaj
- From the Departments of Skin, Veneral Disease, and Leprosy, M.L.N. Medical College, Allahabad, UP, India.
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