|
baths or vigorous exercise in hot
weather . Patients with symptomatic
|
of first-generation antihistamines is likely because of their sedative |
score as discussed earlier ) and treatment under the care of a specialist |
complete remission in patients with refractory disease . 51 |
benefit . 54 Studies have trialled thyroid replacement therapy in euthy- |
||||
dermographism should avoid tight |
effect ; however , a blinded trial did |
with expertise in managing chronic |
Published evidence for systemic |
roid patients , but evidence suggests |
||||
clothing and irritating materials . Educate patients with CIndU about the possibility of anaphylaxis and its |
not find significant differences in enhanced sleep . 45 Adverse effects include drug interactions ; reduc- |
spontaneous urticaria . Omalizumab is administered by subcutaneous injection , with a large proportion of |
corticosteroid use in chronic spontaneous urticaria is limited . A short course of oral prednisone , as rescue |
that benefit is limited to patients with abnormal thyroid profiles . 55 Methotrexate , sulfasalazine , phototherapy |
||||
emergency management . There are |
tion in REM sleep ; impaired learn- |
patients responding to the standard |
therapy , has been widely accepted |
( very low-quality evidence ), IV immu- |
||||
no published guidelines regarding |
ing ; and impaired performance in |
dose of 300mg monthly . In non-re- |
in clinical practice . A typical dose |
noglobulin and plasmapheresis have |
||||
adrenaline autoinjector prescription |
sensorimotor tasks , such as driving . |
sponsive patients , up-titrating the |
is prednisone 25mg orally , rapidly |
been studied , resulting in low-grade |
||||
in CIndU , so this is considered on an |
Second-generation antihistamines |
dose ( maximum 600mg ) or increas- |
tapered over 10 days . Unsurpris- |
case report or case series evidence . |
||||
individual basis . Anaphylaxis may |
are thus strongly recommended over |
ing the frequency ( maximum fort- |
ingly , a study in patients prescribed |
These therapies are rarely required |
||||
be more prevalent in those with cold |
first generation . 2 |
nightly ) can be considered . 47 |
oral corticosteroid for the condition |
when effective second-generation |
||||
urticaria . 42 |
Several second-line pharmaco- |
Anaphylaxis is a rare complica- |
found an increased risk of newly |
antihistamines and anti-IgE pharma- |
||||
Certain medications , such as |
therapies can be used in conjunction |
tion of omalizumab , so initial treat- |
diagnosed hypertension , diabetes , |
cotherapy are available . |
||||
NSAIDs and opiates , can trigger mast cell degranulation in patients with chronic spontaneous urti- |
with oral non-sedating antihistamines in refractory disease . These include H2-receptor antagonists , |
ment should be administered under supervision . Subsequent doses may be self-administered by patients |
obesity , neuropsychiatric disorders and skeletal conditions . 52 Oral corticosteroid should only be consid- |
Targeting the bradykinin pathway is effective in cases of non-histaminergic angioedema . Icatibant , a brad- |
||||
caria and should be avoided . Mini- |
such as nizatidine and famotidine , |
or suitable carers after supervised |
ered in conjunction with high-dose |
ykinin type 2 – receptor antagonist , |
||||
mise alcohol and heat as these may |
or a leukotriene receptor antagonist |
training . |
H1-antihistamine and other thera- |
can be administered as rescue ther- |
||||
amplify urticaria by dilating der- |
( montelukast ). Doxepin , a first-gen- |
pies as described earlier . |
apy in angioedema but is currently |
|||||
mal blood vessels . Periods of pro- |
eration tricyclic antidepressant , can |
ALTERNATIVE AGENTS |
only PBS approved for HAE . Icatibant |
|||||
longed stress can increase urticaria |
reduce pruritis . Doxepin is not suit- |
Ciclosporin can be used where omal- |
ERADICATION OF INFECTIOUS |
can be useful in recurrent idiopathic |
||||
severity , so patients should reduce this where possible . 43 In the absence of IgE-mediated food allergy , spe- |
able for patients whose occupation may be affected by drowsiness . The evidence to support H2-receptor |
izumab is contraindicated or not efficacious . Ciclosporin is administered orally at a dose of 2-5mg / kg / day . A |
AGENTS Chronic H . Pylori infection has been implicated as a factor in the sever- |
angioedema that has not responded to antihistamines and in severe cases of ACEI-associated angioedema . Fol- |
||||
cific food avoidance is rarely useful . |
antagonist , montelukast and dox- |
systematic review and meta-analysis |
ity and frequency of urticaria . A |
lowing an episode of ACEI-associated |
||||
Elimination diets , including low-his- |
epin treatment in chronic sponta- |
found it significantly decreased the |
meta-analysis noted very low-grade |
angioedema , the switch to an ARB |
|
tamine diets , have been examined , but there is a paucity of evidence to support any dietary modifications . 44
Pharmacological
Oral H1-antihistamines are effective first-line therapy for urticaria ,
|
neous urticaria is of low quality . As there is limited evidence for efficacy , these second-line therapies are absent from recent international guidelines . 2 They are included here as current PBS subsidy arrangements require treatment failure on a combi- |
Oral H1-antihistamines are effective first-line therapy for urticaria , with second-generation drugs preferred . |
is generally acceptable as the incidence of angioedema with ARBs is very low . 56 Patients should be advised that angioedema can recur for up to six months following cessation of the ACEI . 57 H1 and H2 antihistamines , oral corticosteroid and adrenaline are gen- |
|
with second-generation ( non-sedat- |
nation of first- and second-line regi- |
UAS , with the caveat that there were |
evidence for H . Pylori eradication |
erally ineffective in treating bradykin- |
ing ) antihistamines preferred . These include loratadine , fexofenadine , cetirizine , desloratadine , levoceti- |
men for anti-IgE therapy eligibility . Anti-IgE therapy is an effective agent for persistent symptoms . |
a limited number and overall lower quality of studies . 48 Patients require close monitoring for adverse effects , |
therapy in chronic spontaneous urticaria . 53 Nonetheless , eradication therapy is often prescribed if H . Pylori |
in-mediated angioedema . 58
OPTIMISING COMORBID
|
rizine and bilastine . Standard doses |
Omalizumab is an anti-IgE mono- |
including hypertension , hyperlipi- |
is detected for the added benefit of |
CONDITIONS |
are adequate initially but should be up-titrated if symptom control is |
clonal antibody that binds free IgE . Postulated mechanisms of action |
48 , 49
daemia and nephrotoxicity . An Australian study showed that
|
reducing risk of peptic ulceration and malignant disease . Treatment |
Hypothyroidism can exacerbate the frequency and severity of urticaria ; |
|
inadequate . Guidelines support the up-titration of second-generation antihistamines to fourfold standard dosing before considering second-line treatment . 2
First-generation antihista-
|
include downregulation of mast cell activation by prevention of IgE receptor binding , reducing activity of autoantibodies and reversing eosinophilia and basopenia . 46 Patients with active urticaria despite six weeks of |
hydroxychloroquine was beneficial in chronic idiopathic urticaria . 50 A recent retrospective study investigated the efficacy of hydroxychloroquine compared with , and combined with , anti-IgE therapy . Omalizumab |
of chronic parasitic infections , such as strongyloidiasis , can be useful in improving control of urticaria . 35 Additionally , eradication of chronic parasitic infections is important prior to commencement of anti-IgE therapy . |
therefore , normalisation of thyroid parameters with thyroid replacement therapy is recommended . 59 Weaker evidence supports the correction of other parameters , such vitamin D and iron deficiency when detected , |
mines — such as promethazine , |
therapy can access omalizumab via |
was superior to hydroxychloroquine |
38 , 39 to improve disease activity . |
|
cyproheptadine and diphenhy- |
the PBS . |
in achieving remission of chronic |
OTHER PHARMACOTHERAPIES |
|
dramine — can be used , but their |
Current PBS criteria require doc- |
spontaneous urticaria . Omalizumab |
Small studies have trialled warfarin |
SPECIAL POPULATIONS |
side-effect profile makes them |
umentation of severe urticaria activ- |
plus hydroxychloroquine ther- |
and heparin , particularly in patients |
In pregnant and lactating women , |
less desirable . Perceived efficacy |
ity ( demonstrated by a high UAS-7 |
apy resulted in increased rates of |
with elevated D-dimer , with some |
second-generation oral antihistamines |