EAACI/GA²LEN/EDF/WAO guideline: management of urticaria

Abstract

This guideline, together with its sister guideline on the classification of urticaria (Zuberbier T, Asero R, Bindslev-Jensen C, Canonica GW, Church MK, Giménez-Arnau AM et al. EAACI/GA(2)LEN/EDF/WAO Guideline: definition, classification and diagnosis of urticaria. Allergy 2009;64: 1417-1426), is the result of a consensus reached during a panel discussion at the Third International Consensus Meeting on Urticaria, Urticaria 2008, a joint initiative of the Dermatology Section of the European Academy of Allergology and Clinical Immunology (EAACI), the EU-funded network of excellence, the Global Allergy and Asthma European Network (GA(2)LEN), the European Dermatology Forum (EDF) and the World Allergy Organization (WAO). As members of the panel, the authors had prepared their suggestions regarding management of urticaria before the meeting. The draft of the guideline took into account all available evidence in the literature (including Medline and Embase searches and hand searches of abstracts at international allergy congresses in 2004-2008) and was based on the existing consensus reports of the first and the second symposia in 2000 and 2004. These suggestions were then discussed in detail among the panel members and with the over 200 international specialists of the meeting to achieve a consensus using a simple voting system where appropriate. Urticaria has a profound impact on the quality of life and effective treatment is, therefore, required. The recommended first line treatment is new generation, nonsedating H(1)-antihistamines. If standard dosing is not effective, increasing the dosage up to four-fold is recommended. For patients who do not respond to a four-fold increase in dosage of nonsedating H(1)-antihistamines, it is recommended that second-line therapies should be added to the antihistamine treatment. In the choice of second-line treatment, both their costs and risk/benefit profiles are most important to consider. Corticosteroids are not recommended for long-term treatment due to their unavoidable severe adverse effects. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS).

Challenges in the Management of Chronic Urticaria

“…It appears, though, that identifiable autoimmune mechanisms do not alter the subsequent treatment approach. The latest EAACI/GA(2)LEN/EDF/WOA management guideline grades the strength and quality of the experimental evidence when formulating recommendations[8]. The starting point for pharmacological treatment is the prescription of nonsedating H 1 antihistamines (nsAH) (table 1, adapted from Table in reference 8).…”

“…In a recent overview of his extensive experience in urticaria treatment, Allen Kaplan, a leading expert in the field of urticaria, lists a number of misconceptions among the medical community and the lay public related to urticaria management and pinpoints controversies relating to the use of AH, which need to be addressed by specifically designed clinical studies[9]. The present paper is focusing exclusively on the treatment of chronic urticaria with nsAH, as these drugs are suggested as the first line of treatment, but unresolved issues still remain because of the relative paucity of reliable evidence[8]. …”

“…A cellular infiltrate similar to a late-phase IgE-mediated allergic reaction with ensuing therapeutic implications has been extensively reviewed[15]. Still, in most cases histamine has a leading role in the pathogenesis of chronic urticaria, which is the reason for H 1 AH to be proposed as first-line and mainstay treatment (Table 1)[8]. …”

Urticaire chronique et corticothérapie générale, les liaisons dangereuses

“…Une étude portant sur 139 urticariens chroniques a ainsi montré la persistance de la maladie dans 52 % des cas à deux ans, 43 % à trois ans et 14 % à cinq ans [5]. Le recours répétitif à la corticothérapie par méconnaissance du diagnostic peut générer une corticodépendance et des effets secondaires non négligeables dans une pathologie cutanée, certes invalidante en termes de qualité de vie, mais bénigne ;• la corticothérapie générale n'est pas un traitement curatif de l'UC, aucun n'étant d'ailleurs validé dans cette pathologie [6]. Le traitement symptomatique repose sur la prise continue d'antihistaminiques H1 qui permettent dans un grand nombre de cas de soulager suffisamment les patients.…”

Omalizumab: now licensed as adjunct for urticaria

“…1 Secondline therapies include a leukotriene receptor antagonist (LRTA) or a triple regimen of an H 1 -and H 2 -antihistamine and an LTRA. Steroids are not recommended for long-term use due to their adverse effects.…”