Azathioprine in autologous serum skin test positive chronic urticaria: A case-control study in a tertiary care hospital of eastern India

Abstract

Context:Urticaria, also referred to as hives or wheals is a common and distinctive reaction pattern characterized by spontaneous eruption of wheals. About 30–50% of patients categorized as idiopathic urticaria have autoimmune urticaria, needing immunosuppressive agents. Immunosuppressive agents are either too costly or have serious side effects. Azathioprine seems to address both these issues, being less costly.Aims:The aim was to evaluate the role of azathioprine in autologous serum skin test (ASST) positive chronic urticaria (CU).Settings and Design:A single-blind randomized control trial of ASST positive patients of CU.Materials and Methods:Patients with positive ASST were allotted into two treatment groups, named group A and group B. Patients in group A were administered azathioprine (50 mg/day) for a period of 8 weeks and followed up till 36 weeks, while patients in group B were given placebo pills. All patients were directed to take levocetirizine (5 mg) on as and when basis, in addition. Urticaria was assessed by total severity score.Statistical Analysis Used:MedCalc statistical software (v 12.5 for Windows) to calculate P values in independent samples by t-test, Mann–Whitney test, Friedmann test, and ANOVA.Results:Administration of azathioprine in group A resulted in a significant diminution of the intensity of the disease as well as in the requirement of rescue antihistamine (positive primary and secondary outcome).Conclusion:Azathioprine not only had immunomodulatory properties during the treatment period, but also had lasting therapeutic effect as well. There were some gastrointestinal side effects in the initial stages but no incidence of hematological or biochemical disturbances.

Comparing azathioprine with cyclosporine in the treatment of antihistamine refractory chronic spontaneous urticaria: A randomized prospective active-controlled non-inferiority study

“…In the present study, adequate monitoring was routinely performed, and both agents were found to be safe, and serious adverse effects warranting the discontinuation of treatment were not noticed. This can be attributed to low doses of cyclosporine and azathioprine employed (comparable to prior study on azathioprine 8 ). Both agents rendered antihistamine-resistant disease adequately responsive to antihistamines for the intended study duration and scored comparably on global patient satisfaction score at the end of the study.…”

“…There are only 2 prior publications stating the efficacy of azathioprine in CU. A placebo-controlled study by Bhanja et al., 8 found low-dose azathioprine (50 ​mg/day) to be effective in a cohort of ASST positive CSU patients and the remission lasted till 36 weeks. Azathioprine was also employed successfully in 2 patients having resistant urticaria who had failed high-dose cyclosporine 7 …”

“…Cyclosporine is the next line treatment option for these patients, but its use is restricted owing to high costs (especially in resource poor settings) and associated adverse effects 2 . Azathioprine was found to be beneficial in cyclosporine resistant CSU in 2 patients 7 (in a dosage of 150 ​mg/day) and also responded fairly in autologous serum skin test (ASST) positive CSU in a prior placebo-controlled study (in a dosage of 50 ​mg/day) 8 . In the absence of any previous study, we attempted to compare azathioprine with cyclosporine (an established agent in the management of antihistamine refractory CSU) in this prospective, active-controlled, non-inferiority study.…”

Effectiveness and Safety of Immunosuppressants and Biological Therapy for Chronic Spontaneous Urticaria: A Network Meta-Analysis

“…In total, 14 records met the inclusion criteria and were included in the NMA ( Figure 1 ) [ 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ]. Detailed information on all studies included in the NMA is presented in Table 1 , and Table S2 shows information of studies excluded from the NMA [ 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ].…”

“…Treatments that were eligible for the evidence network were cyclosporin, methotrexate, hydroxychloroquine, omalizumab, and montelukast. We excluded the trials with azathioprine due to insufficient outcome evaluations and no placebo comparator [ 31 , 32 ]. Based on the overall risk-of-bias assessment, 12 trials had a low risk of bias, 2 trials had some concerns, and no trials had a high risk of bias ( Table S3 ).…”