The KAAACI/KDA Evidence-Based Practice Guidelines for Chronic Spontaneous Urticaria in Korean Adults and Children: Part 2. Management of H1-Antihistamine-Refractory Chronic Urticaria

Abstract

Quite a few patients with chronic spontaneous urticaria (CSU) are refractory to H 1 -antihistamines, even though the dose of H 1 -antihistamines is increased up to 4-fold. CSU that is not controlled with H 1 -antihistamines results in increased disease burden. Several immunomodulators have been used to manage these patients. The guidelines reported herein are connected to Part 1 of the KAAACI/KDA Evidence-Based Practice Guidelines for Chronic Spontaneous Urticaria in Korean Adults and Children, and aimed to provide evidence-based recommendations for the management of H 1 -antihistamine-refractory CSU. Part 2 focuses on the more commonly used additional treatment options for refractory CSU, including omalizumab, cyclosporine, leukotriene receptor antagonist, dapsone, methotrexate, and phototherapy. The evidence to support their efficacy, dosing, safety, and selection of these agents is systematically reviewed. To date, for patients with refractory CSU, the methodologically sound data to evaluate the use of omalizumab has been growing; however, the evidence of other immunomodulators and phototherapy is still insufficient. Therefore, an individualized stepwise approach with a goal of achieving complete symptom control and minimizing side effects can be recommended. Larger controlled studies are needed to elevate the level of evidence to select a rational therapeutic agent for patients with refractory CSU.

Efficacy of NB-UVB as Add-on Therapy to Antihistamine in the Treatment of Chronic Urticaria: A Systematic Review and Meta-analysis

“…Bishnoi et al [29] published a randomized prospective observer-blinded comparative study and found that after 90 days of treatment with NB-UVB, there was a decrease in the UAS to a mean value of 1.4, which was statistically significant. Although only very low-quality evidence is available, the KAAACI/KDA Evidence-Based Practice Guideline [15] suggests that NB-UVB phototherapy be used as add-on therapy in patients unresponsive to H1-antihistamines. Despite the growing acceptance of NB-UVB as an effective treatment modality in CU, few studies have systematically reviewed the advantages of NB-UVB phototherapy added to guideline-recommended antihistamine drugs.…”

“…Other plausible mechanisms include apoptosis of dermal mast cells, immunomodulatory action and the production of anti-inflammatory cytokine [14]. The Korean Academy of Asthma, Allergy and Clinical Immunology (KAAACI) and the Korean Dermatological Association (KDA) Evidence-Based Practice Guideline suggests that narrowband UVB (NB-UVB) phototherapy can be added to H1-antihistamine treatment for the treatment of chronic spontaneous urticaria (CSU) and symptomatic dermographism [15]. However, to date, there has been no systematic review of NB-UVB phototherapy for treating CU.…”

The Use of Omalizumab in Chronic Urticaria: Available Data and Future Aspects of Anti-IgE Treatment

“…Management guidelines for CU in past included omalizumab, cyclosporine, dapsone, hydroxychloroquine, methotrexate, montelukast, colchine, and phototherapy as alternative treatment for antihistamine-refractory CU [1,2]. However, most of recent guidelines recommend omalizumab for the first of choice among various immunomodulating agents based on lots of study results [3,4].…”

Moxibustion therapy for chronic spontaneous urticaria

“…[ 8 – 10 ] Therefore, it is difficult to carry out targeted treatment of the cause, and only symptomatic treatment is currently available. [ 11 , 12 ] However, sometimes symptomatic treatment such as antihistamines cannot completely control the symptoms of CSU, [ 13 , 14 ] it will lead to a serious influence on the quality of life of patients, [ 15 ] and also greatly increase the pressure on public health. [ 16 , 17 ] Therefore, more effective and optimized treatments are required.…”