Management of Urticaria 2012

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Mnagement of acute and chronic urticaria.

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بسم الله الرحمن الرحیم

Management of Acute & Chronic Urticaria :

Slide Number: 2 Management of Acute & Chronic Urticaria Mostafa Moin M.D Professor of Allergy & Clinical Immunology Immunology , Asthma and Allergy Research Institute (IAARI) Tehran University of Medical Sciences I.R.IRAN 2012

Quality of Life in Patients with Urticaria:

Quality of Life in Patients with Urticaria Prevalence : 15 % of the population at some time in their lives (0.5 – 1 % at any single time) Some patients with chronic urticaria have their life compromised to the extent of those awaiting coronary bypass surgery or children with severe skin eczema . - Sheldon J, Matthews K, Lovell R. J Allergy 1954; 25: 525-60 - O’Donnell BF, et al. Br J Dermatol 1997; 136: 197-201 Slide Number: 3

Education(oral and written) Reassurance for the parents Removal of the inciting agent (when identifiable , if possible) Symptomatic relief Close cooparation & an individual approach “Cinderella disease!” :

Education(oral and written) Reassurance for the parents Removal of the inciting agent (when identifiable , if possible) Symptomatic relief Close cooparation & an individual approach “ Cinderella disease! ” Slide Number: 4 Management of Acute & Chronic Urticaria Treatment Strategies :

Management of Acute & Chronic Urticaria:

Management of Acute & Chronic Urticaria General & Preventive Measures Avoidance of : Alcohol, spicy foods , additives ASA & NSAIDS , ACE inh , β -blockers, codeine, morphine Overtiredness and stress Wearing of tightly fitting garments, footwear Strenuous physical exercise Overheated ambient temperature Slide Number: 5

Pharmaco-therapy of Acute Urticaria :

Pharmaco-therapy of Acute Urticaria Many attacks of acute urticaria are solitary , and the cause is evident and avoidable - Mild urticaria needs no R x. 2 nd generation AH for daytime symptoms 1 st generation AH for nighttime symptoms Facial / labial/ buccal angioedema should respond to AH and/or oral CS X3-7 days – 2% ephedrine useful Severe oropharyngeal angioedema should prompt overnight admission -Adrenaline may be required Diphenhydramine or Promethazine by IM injection (avoid IV administration because of hupotension) . Prednisolone or IM/IV hydrocortisone can be given. Slide Number: 6

Algorithm for Acute Urticaria/Angioedema:

Algorithm for Acute Urticaria/Angioedema Acute Presentation Detailed Hx & ROS : drug , food, physical , Infection , Occupational , insects , Physical Examination Any Underlying Cause? Limited Evaluation & Intervention CBC , ESR , U/A , LFTs Treatment ER Rx if appropriate Remove cause or trigger Antihistamines other treatments F.U. & Consultation If > 6w Specific Evaluation Undelying Etiology? Specific Rx. 1 2 3 5 4 6 7 8 yes No

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Slide Number: 8 Chronic urticaria is a disabling disease Treat it until it is gone !

Classification of Chronic Urticaria:

Classification of Chronic Urticaria Chronic Urticaria Physical urticaria Ordinary chronic urticaria Urticarial vasculitis Contact urticaria Schnitzler’s syndrome Autoimmune urticaria Idiopathic chronic urticaria Slide Number: 9

Pharmaco-therapy of Chronic Urticaria:

Pharmaco-therapy of Chronic Urticaria H 1 receptor antagonists H 2 receptor antagonists Leukotriene antagonists Alternate-day corticosteroids Cyclosporin Slide Number: 10

First-line Thrapy for Chronic Urticaria:

First-line Thrapy for Chronic Urticaria 2 nd generation AH up to 2 weeks Updosing 2 nd generation AH (up to 4x) Add 1 st generation AH at night Add H2 AH (Ranitidine , Famotidine , Nizatidine) Add Doxepin (H1 & H2 AH) at night Important notes : 1- Always dose on a schedule (not prn)! 2- Topical AH & CS should not be used ! Slide Number: 11

Second-line Thrapy for Refractory Chronic Urticaria:

Second-line Thrapy for Refractory Chronic Urticaria Add montelukast :5-10mg daily : It helps some but not all patients and adverse effects are rarely a problem Prednisolone : Short courses (3-7 d) are useful to deal with the occasional temporary flare-up Impotant note: Use CS as PO & not depot! Slide Number: 12

Third-line Thrapy for Refractory Chronic Urticaria:

Third-line Thrapy for Refractory Chronic Urticaria Add Cyclosporin-A with monitoring of B.P. & renal function & chest x-ray Intravenous immunoglobulin and plasmapheresis have proved highly effective in some selected refractory cases Omalizumab in both autoimmne and non-autoimmune chronic urticaria Epipen for oropharyngeal angioedema Slide Number: 13

Management of Chronic Urticaria:

Follow up & Consultation To refer again if urticaria &/or angioedema get worse To refer again if no response to R x in 2w Allergy consultation if urticaria continues or recur after 6w of R x . Allergy consultation if oro-pharyngeal angioedema develops Slide Number: 14 Management of Chronic Urticaria

Guideline : Management of Chronic Urticaria:

Guideline : Management of Chronic Urticaria

Treatment of Dermatographia:

Treatment of Dermatographia 2 nd generation AH :loratadin,desloratidine,cetirizine levocetirizine,fexophenadine May combine agents for more severe cases , e.g., fexofendadine in the morning , Promethasine at bedtime For unresponsive cases to the above : add Doxepin at night – risk of sedation the next day Slide Number: 16

Treatment of Contact Urticaria:

Treatment of Contact Urticaria Treatment consists of identification of culprit , avoidance and patient education Sever reactors (eg peanut contact urticaria) Should wear an inscribed bracelet listing the culprit plus cross reacting substances Should carry antihistamines and self administration adrenaline (Epipen) Slide Number: 17

Other physical urticarias ::

Cholinergic Urticaria : Treatment : Usually responds to H1 antihistamines , anabolic steroids eg , danazol effective in severly affected cases Cold Urticaria : Treatment : Usually responds to avoidance + H1 antihistamines . Cold tolerance treatment (“cold desensitization”) is effective in selectes cases Slide Number: 18 Other physical urticarias :

Other physical urticarias ::

Other physical urticarias : Solar Urticaria : Treatment : Avoidance , H1 antihistamines , light tolerance treatment in selected patients Heat Contact Urticaria : Treatment : Avoidance and H1 antihistamine Slide Number: 19

Other physical urticarias ::

Other physical urticarias : Aquagenic Urticaria : Treatment : Avoidance and H1 antihistamines Vibratory Angioedema : Treatment : Avoidance and H1 antihistamines Slide Number: 20

Treatment of urticarial vasculitis:

Treatment of urticarial vasculitis Antihistamines are usually ineffective ; the following may be effective : Dapsone (screen for G6-PD deficiency) Colchicine Hydroxychloroquine Prednisolone (especially in patients with systemic involement) Intravenous immunoglobulin plasmapheresis Slide Number: 21

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Close cooperation needed to Promote QOL of the Patient. The 1 st goal of R x is identification & elimination of the cause(s) &/or trigger(s). The 2 nd goal of R x is to achieve complete symptom relief. An individual approach is necessary for each patient (high variability). 1 st line of R x : Second generation AH up to 4-fold higher dose. 2 nd line of R x : Corticosteroids in severely affected patients. 3ird line of R x : Ciclosporin for patients refractory to other modalities. Re-evaluation of R x - Every 3-6 months. Maintanance Rx at least 1-3 month after relief. Zuberbier T et al , Position paper , ESSCI/ GALEN/EDF/WAO guideline: 2009,management of urticaria Conclusions

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Slide Number: 23 Kaplan AP , urticaria and angioedema : synopsis , sept 2004 , www.worldallergy.org Kaplan AP , chronic urticaria and angioedema , Jan 2002 , Negl J Med , Vol 346 , No3 Kaplan AP , urticaria and angioedema . In : Middleton et al. Allergy : Principles & Practice , 2011 Finn AJ, Kaplan A, Fretwell R. J Allergy Clin Immunol 103:1071-1078, 1999. Nelson H, Reynolds R, Mason J. Annals Allergy Asthma Immunol 84:517-522, 2000. LaRosa M, Leonardi S, Marchese G, et. al. Annals Allergy Asthma Immunol 87:48-53, 2001. Clough B, Boutsiouki P, Church M. Allergy 56:985-988, 2001. Simons FVerster J, Volkerts E Annals Allergy Asthma Immunol 92:294-303, 2004. N Eng J Med 351:2203-2217, 2004. Grattan C, O’Donnell B, Francis D, et. al. Br J Dermatol 143:365-372, 2000 Kaplan A, Joseph K, Maykut R, et. al. J Allergy Clin Immunol 122:569-573, 2008. Athanasiadis GI, Pfab F, Kollman A. Allergy 61:1484-1485, 2006 Kanani et al. Allergy , Asthma & Clinical Immunology 2011 , 7( suppl 1) : sq Safar B , Cone DC , Pham KT . Subcutaneous epinephrine in the prehospital setting. Prehosp Emerg Care 2001 ; 5:200-7 Maurer M et al , Unmet needs in chronic urticaria . A GALEN task force report , Allergy ,,(2011)317-330 Zuberbier T.et al , EAACI / GALEN/EDF/WAO guidline : management of urticaria , Allergy 2009:64:1427-1443 References

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