Challenges in the management of chronic urticaria.

Todor A Popov

doi:10.1097/wox.0b013e3181f8dabb

Abstract

The term "chronic idiopathic urticaria" denotes a spectrum of conditions with different poorly understood pathogenetic mechanisms in which the release of histamine plays a role. Nonsedating second-generation H1 antihistamines are postulated to be the first line of treatment of chronic idiopathic urticaria by national and international guidelines, but as control is not always achievable with the usually recommended doses, first-generation sedating antihistamines like hydroxyzine and diphenhydramine at high daily doses (200 mg) have been proposed as an alternative before resorting to treatment with systemic corticosteroids and other potentially hazardous agents. Our long time experience and recent research give us grounds to believe that increasing the doses of nonsedating H1 antihistamines up to fourfold improves significantly the chances of successful treatment. Our data suggest that the urticaria-associated discomfort is relieved by higher than conventional doses of levocetirizine and desloratadine in about 75% of the patients and that sedation/somnolence does not seem to be a major deterrent. The dose increase also improves the urticaria-specific quality of life. Contrary to the belief that individual patients may benefit from one antihistamine or another, we demonstrate that the drug with better ability to suppress the histamine skin effects in experiments in healthy volunteers (levocetirizine) is also superior in improving the different aspects of control of chronic urticaria (subjective and objective symptoms, quality of life) and that increasing its dose of up to fourfold may even paradoxically reduce the sense of sedation/somnolence in parallel with the relief of urticaria discomfort.

Highlights

The term “chronic idiopathic urticaria” denotes a spectrum of conditions with different poorly understood pathogenetic mechanisms in which the release of histamine plays a role
When the wheals with or without angioedema recur for longer than 6 weeks, they fall within the definition of chronic urticaria (Fig. 1)
The starting point for pharmacological treatment is the prescription of nonsedating H1 antihistamines

Summary

DEFINING THE TOPIC

A wide spectrum of different conditions share a seemingly common clinical feature: appearance of urticarial lesions. The latter are described as red, raised, itchy wheals (“nettle rash,” “hives”) resulting from vasodilatation, increased blood flow, and increased vascular permeability.[1] They have fleeting character and disappear without a trace in less than 24 hours. Chronic urticaria (CU) is a relatively common condition, which has a profound effect on the quality of life of those suffering.[2] The need to establish an optimal approach to this class of disorders resulted in working out of national and international guidelines for its diagnosis, classification, pathogenetic mechanisms, and management.[3,4] As opposed to other types of urticaria like acute urticaria, physical urticaria, and urticarial vasculitis that may have identifiable causes and triggers, the nature of chronic spontaneous urticaria remains elusive, which is reflected in the commonly accepted term chronic idiopathic urticaria (CIU). Histamine is intimately implicated in the pathogenesis of allergic and other

Urticaria Challenges

PICKING THE BEST ANTIHISTAMINE FOR THE TREATMENT OF CIU

Findings

CONCLUSIONS