Buscar en
Allergologia et Immunopathologia
Toda la web
Inicio Allergologia et Immunopathologia Chronic idiopathic urticaria treatment
Journal Information
Vol. 29. Issue 4.
Pages 129-132 (July 2001)
Share
Share
Download PDF
More article options
Vol. 29. Issue 4.
Pages 129-132 (July 2001)
Full text access
Chronic idiopathic urticaria treatment
Visits
7288
JM. Negro-Álvareza, JC. Miralles-Lópezb
a Allergy Section.
b Allergy Section. General University Hospital.
This item has received
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Tables (1)
La urticaria crónica idiopática (UCI) es una afección común que afecta entre el 0,1 y el 3 % de la población de EE.UU. y Europa. La duración varía mucho entre pacientes, sufriéndola algunos durante décadas. La primera línea de tratamiento son los antihistamínicos no sedantes de segunda generación, aunque en algunos casos con importante componente de ansiedad puede ser beneficioso asociar un antihistamínico de primera generación por su efecto sedante sobre el paciente. En algunos casos, refractarios a los antihistamínicos, se pueden utilizar glucocorticoides, aunque sus efectos secundarios limitan su uso, debiendo ser prescritos el menor tiempo posible y a las menores dosis posibles. Los antileucotrienos pueden ser útiles en el tratamiento de algunos pacientes. También se han utilizado en algunos casos ciclosporina, colchicina, dapsona, así como plasmaféresis e inmunoglobulinas intravenosas.
Palabras clave:
Idiopatic chronic urticaria
Second generation antihistamines
Cetirizine
Desloratadine
Ebastine
Fexofenadine
Hidroxyzine
Loratadine
Mizolastine
Doxepin
Cimetidine
Ranitidine
Anti-leukotrienes
Chronic idiopathic urticaria (CIU) is a common skin condition that affects 0.1-3 % of people in the USA and Europe and accounts for nearly 75 % of all chronic urticaria cases. Up to 40 % of patients who have chronic urticaria for more than 6 months still have urticarial wheals 10 years later. The therapeutic management should first be oriented towards palliation of symptoms. A 2 % solution of ephedrine as a local spray is very useful for oropharyngeal edema. H1 antihistamines with a low potential for sedation are the most important first-line treatment. Combinations of various antihistamines may be useful in suppressing symptomatology. These include: a) First generation H1 antihistamines; b) Combinations of first and second generations using non-sedating agents in the morning and first generation drugs at night; c) Combinations of second generation antihistamines; d) Combination of doxepin with a first or second generation antihistamine; e) Combination of an H2 anti-receptor antihistamine (eg, cimetidine or ranitidine) with a first or second generation antihistamine. Preliminary reports suggest that desloratadine and anti-leukotrienes may be effective in treating some patients with chronic idiopathic urticaria.
Keywords:
Antihistamínicos de segunda generación
Antihistamínicos no sedativos
Urticaria crónica idiopática
Cetirizina
Desloratadina
Ebastina
Fexofenadina
Hidroxizina
Loratadina
Mizolastina
Doxepin
Ranitidina
Anti-leucotrienos
Full Text

INTRODUCTION

Although accurate data on the prevalence of urticaria are unavailable, 15 to 24 percent of the U.S. population may have had this condition (1, 2) which in many cases is prolonged and relapsing. On the basis of published data (3), a similar prevalence in the United Kingdom seems probable. Chronic urticaria is likely to be present at some time in about 25 percent of patients with urticaria. By chronic idiophatic urticaria, I mean the occurrence of widespread wheals daily or almost daily for at least six weeks, in the absence of a causative physical or environmental trigger (4).

Chronic urticaria affects predominantly adults. It is approximately twice as common in woman as in men (5).

Chronic idiopathic urticaria (CIU) is a common skin condition that affects 0,1-3 % of people in the USA and Europe (6) and accounts for nearly 75 % of all chronic urticaria cases (7). Therefore, the diagnosis of CIU is mainly one of exclusion, and the clinical investigative process can be lengthy. Haematologic, biochemical, immunologic, and endocrine assays are needed to provide direct or indirect evidence of systemic allergic, inflammatory, infectious, or autoimmune processes that may cause chronic urticaria. There after, sensitivity to foods, environmental agents/pollutants, and the presence of chronic infection or occult malignancy must all be excluded before a diagnosis of CIU can be finally established (8).

The duration of CIU varies greatly from patient to patient, with some individuals suffering irritating symptoms such as pruritus for decades. Up to 40 % of patients who have chronic urticaria for more than 6 months still have urticarial wheals 10 years later (9). Patients with CIU have measurable decrements in quality of life, primarily due to recurrent itch, poor sleep, and the physically unappealing nature of the lesions. The activities of daily life and social life are badly affected by CIU. Indeed, the magnitude of this impairment of quality of life approximates that of chronic heart disease (10).

DATA SOURCES

MEDLINE (1966-2001), EMBASE (Excepta Medica: 1974-2001), and other biomedical and drug directory databases were searched to identify english-language articles (basic science, clinical trial research, and review articles) and abstracts of conference proceeding on antihistamines, chronic urticaria, cetirizine, desloratadine, ebastine, fexofenadine, hidroxycine, loratadine, mizolastine, doxepin, cimetidine, ranitidine, anti-leukotrienes and releated terms.

TREATMENT

Is reasonable to define chronic urticaria/angioedema as idiopathic since this is a diagnosis by exclusion of underlying etiologies. If treatment is ineffective up to this point, referral to an allergist or dermatologist might be considered. The therapeutic management should first be oriented towards palliation of symptoms. A 2 % solution of ephedrine as a local spray is very useful for oropharyngeal edema. H1 antihistamines (11) with a low potential for sedation are the most important first-line treatment, however. The pharmacologic actions and use of H1-receptor antagonists were recently reviewed (12).

Combinations of various antihistamines may be useful in suppressing symptomatology. These include:

1. First generation H1 antihistamines. Sedation from first generation antihistamines may reduce the discomfort of pruritus associated with urticaria; however, first generation antihistamines may cause undesirable and potentially dangerous side effects (9) related to sedation, including driving impairment and risk for fatal automobile accidents, decreased workplace productivity, increase risk for occupational accidents, and impaired learning and academic performance. Doses of antihistamines that can sedate the patient, including 25 mg of hydroxyzine, are useful at bedtime.

2. Combinations of first and second generations using non-sedating agents (table I). In the morning and first generation drugs at night (13). All the new generation of H1-antihistamines have been shown to be significantly more effective than placebo in chronic urticaria (9). Several studies show the new antihistamines to be as effective as, or sometimes more effective than traditional sedating antihistamines. Second generation antihistamines, at recommended doses do not have a sedative effect. Cetirizine may have a sedative effect in a small percentage of patients (14).

3. Combinations of second generation antihistamines (9).

4. Doxepin, a tricyclic antidepressant drug with marked H1 antihistaminic activity, is particularly valuable when severe urticaria is associated with anxiety and depression. Doxepin posses more potent H1 antihistamine properties than some first generation classical antihistamines, although side effects such as dry mouth may limit their tolerability. This drug can be given at a dosage of 25 mg orally twice daily or as a single 25-mg dose at bedtime. Doxepin should not be given concurrently with monoamine oxidase inhibitors or terfenadine.

5. Combination of an H2 anti-receptor antihistamine (15) (eg, cimetidine or ranitidine) with a first or second generation antihistamine.

Antihistamines may not be entirely effective in controlling urticaria because other capillary permeability inducing mediators are released (eg, leukotrienes; prostaglandin D2; kinins; platelet activating factor, etc.). Glucocorticosteroid treatment may be appropriate when antihistamines are not effective (16). These agents are helpful in controlling the inflammatory cell influx that can potentiate the urticaria by secondary release of histamine releasing factors and cytokines. Managing physicians should explain the potential side effects associated with glucocorticosteroids. In some clinical situations, the managing physician or patient may request more evidence to justify the initiation of glucocorticosteroid therapy. A skin biopsy with perivascular predominant-polymorphonuclear cell urticaria may justify initiation and continuation of glucocorticosteroid treatment (17). In adults, these medications are best administered daily as a single oral dose of 30 mg of prednisolone or prednisone early in the morning (18). The dose should be tapered when the urticaria subsides. The course should be completed within three weeks. Prolonged use of corticosteroids is almost invariably associated with reduced efficacy and toxic side effects. As soon as possible, glucocorticosteroid therapy should be discontinued or reduced to minimal requirements such as an every other day regimen to reduce potential side effects. On rare occasions, chronic urticaria/angioedema may not respond to prednisone. Some of these patients may respond to methylprednisolone (19).

A double-blind, placebo-controlled multicenter trial (n = 190) of desloratadine in moderate-severe CIU has recently been comparated (20). Clinical experience in CIU has so far shown desloratadine to be a safe and effective treatment, providing rapid onset of action and long duration of symptoms relief.

Preliminary reports suggest that anti-leukotrienes may be effective in treating some patients with chronic idiopathic urticaria (21, 22). There are reports that oral cyclosporine (23), colchicine, or dapsone (24) may be helpful in selected cases of severe refractory chronic urticaria/angioedema.

Repeated plasmapheresis over a 2-month period may be effective in controlling refractory chronic urticaria especially in patients with circulating IgG autoantibody to IgE or the high affinity IgE receptor (25, 26).

A report described the efficacy of intravenous immunoglobulin therapy in patients with severe chronic urticaria caused by circulating autoantibodies (27).

Glossopharyngeal and laryngeal angioedema deserve special attention as they may become life threatening or present as manifestations of anaphylaxis. Patients may present with other symptoms of anaphylaxis that may require emergency treatment. The mainstay of treatment for this emergency is epinephrine in doses dependent on the patient's age (28). Intramuscular administration of epinephrine in children has been shown to produce a faster time of action than subcutaneous administration (29).

Bibliography
[1]
Sheldon JM, Mathews KP, Lovell RG..
The vexing urticaria problem: present concepts of etiology and management..
J Allergy, 25 (1954), pp. 525-60
[2]
Consensus statement on the treatment of allergic rhinithis. Allergy 2000; 55: 2: 116-34.
[3]
Champion RH, Roberts SO.B, Carpenter RG, Roger JH..
Urticaria and angio-oedema: a review of 554 patients..
Br J Dermatol, 81 (1969), pp. 588-97
[4]
Greaves MW..
Chronic urticaria..
N Engl J Med, 332 (1995), pp. 1767-72
[5]
Urticaria y angioedema. En: Alergología en Atención Primaria. Jarpio 1999; 47-65.
[6]
Sabroe RA, Greaves MW..
The pathogenesis of chronic idiopathic urticaria..
Arch Dermatol, 133 (1997), pp. 1003-8
[7]
Champion RH..
Urticaria: then and now..
Br J Dermatol, 119 (1988), pp. 427-36
[8]
Ring J, Brockow K, Ollert M, Engst R..
Antihistamines in urticaria..
Clin Exp Allergy, 29 (1999), pp. 31-7
[9]
Pharmacologic therapy for urticaria. Allergol Immunopathol 1997; 25: 1: 36-51.
[10]
O'Donell BF, Lawlor F, Simpson J, Morgan M, Greaves MW..
The impact of chronic urticaria on the quality of life..
Br J Dermatol, 136 (1997), pp. 197-201
[11]
Monroe EW..
Chronic urticaria: review of nonsedating H1 antihistamines in treatment..
J Am Acad Dermatol, 19 (1988), pp. 842-9
[12]
Simons FE.R, Simons KJ..
The pharmacology and use of H1-receptor-antagonist drugs..
N Engl J Med, 330 (1994), pp. 1663-70
[13]
Kennard CD..
Evaluation and treatment of urticaria. In: Charlesworth EN, ed..
Immunology and Allergy Clinics of North America, 15 (1995), pp. 785-801
[14]
Sedation with
[15]
Bleehen SS, Thomas SE, Greaves MW et al..
Cimetidine and chlorpheniramine in the treatment of chronic idiopathic urticaria: a multi-centre randomised double-blind study..
Br J Dermatol, 117 (1987), pp. 81-8
[16]
Urticaria and angioedema. In: Middleton E, Reed CE, Ellis EF et al, eds. Allergy, principles and practice. 5th ed. Publisher Mosby-Year Book 1998: 1104-22.
[17]
Zavadak D, Tharp MD..
Chronic urticaria as a manifestation of the late phase reaction. In: Charlesworth EN, ed..
Immunol Allergy Clin North Am, 15 (1995), pp. 745-59
[18]
Chronic urticaria: review of drug management. In: Champion RH, Greaves MW, Kobza Black A, Pye RJ, eds. The urticarias. Edinburgh: Churchill Livingstone, 1985; 205-11.
[19]
Kaplan AP..
Chronic urticaria. Possible causes, suggested treatment alternatives..
Postgrad Med, 74 (1983), pp. 209-15
[20]
Desloratadine in the treatment of chronic idiopathic urticaria. Allergy 2001; 56 (Suppl 65): 28-32.
[21]
Antileukotrienes in chronic urticaria [letter to the editor]. J Allergy Clin Immunol 1998; 572.
[22]
Ellis MH..
Successful treatment of chronic urticaria with leukotriene antagonists..
J Allergy Clin Immunol, 102 (1998), pp. 876-7
[23]
Fradin MS, Ellis CN, Goldfarb MT, Voorhees JJ..
Oral cyclosporine for severe chronic idiopathic urticaria and angioedema..
J Am Acad Dermatol, 25 (1991), pp. 1065-7
[24]
Tharp MD..
Chronic urticaria: pathophysiology and treatment approaches..
J Allergy Clin Immunol, 98 (1996), pp. S325-30
[25]
Grattan CE.H, Francis DM, Slater NGP..
Plamapheresis for severe unremitting chronic urticaria..
Lancet, 339 (1992), pp. 1078-80
[26]
Sabroe RA, Greaves MW..
The pathogenesis of chronic idiopathic urticaria..
Arch Dermatol, 133 (1997), pp. 1003-8
[27]
O'Donnell BF, Barr RM, Black AK et al..
Intravenous immunoglobulin in autoimmune chronic urticaria..
Br J Dermatol, 138 (1998), pp. 101-6
[28]
Nicklas RA, Bernstein IL, Li JT, Lee RE et al..
The diagnosis and management of anaphylaxis..
J Allergy Clin Immunol, 101 (1998), pp. S465-S528
[29]
Simons FE, Roberts JR, Gu X, Simons KJ..
Epinephrine absorption in children with a history of anaphylaxis..
J Allergy Clin Immunol, 101 (1998), pp. 33-7
Article options
Tools
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos