International Urticaria Guideline 2021: An Overview

The International Urticaria Guideline 2021 is a joint initiative of various medical societies, including the European Academy of Allergology and Clinical Immunology, Global Allergy and Asthma European Network, European Dermatology Forum, and the Asia Pacific Association of Allergy, Asthma and Clinical Immunology. It aims to provide guidance on the diagnosis, classification, and treatment of urticaria – a condition characterized by the sudden appearance of wheals, itching, and swelling on the skin. The guideline focuses on chronic spontaneous urticaria (CSU), which is a type of urticaria that persists for six weeks or more.

Diagnostic and Therapeutic Algorithm Simplified

The guideline introduces a simplified algorithm for the diagnosis and management of CSU, replacing the previous four-step algorithm with a three-step process based on continuous assessment of disease activity, quality-of-life impairment, and disease control. This approach helps physicians make treatment decisions tailored to individual patients. Patients are assessed for disease activity, impact, and control during the first visit and every follow-up visit. Six validated patient-reported outcome measures are recommended to facilitate this assessment.

Importance of Quality-of-Life Improvement

The overall treatment goal in CSU remains complete control of symptoms. However, the guideline emphasizes the importance of considering the safety and quality-of-life of patients when making treatment decisions. It recommends continuous treatment for CSU and the use of tools such as the urticaria activity score (UAS) and the 7-day urticaria activity score (UAS7) to help patients understand the need for ongoing management of their condition.

First-Line Therapy: Second-Generation Antihistamines

The guideline recommends second-generation histamine type 1 (H1) antihistamines as the first-line therapy for all types of urticaria. Several second-generation antihistamines, including cetirizine, desloratadine, fexofenadine, loratadine, and rupatadine, are considered effective and safe for the treatment of CSU at standard doses. Short-term prophylactic antihistamine treatment prior to trigger exposure is also useful in patients with chronic inducible urticaria (CIndU).

Updosing of Antihistamines

In patients with CSU unresponsive to standard second-generation antihistamines dosing, the guideline recommends up to a fourfold increase in dose. However, some patients with CSU may respond incompletely to antihistamine updosing. In such cases, the guideline recommends adding second-line omalizumab, a humanized monoclonal anti-immunoglobulin E (IgE), as an alternative therapy for treating antihistamine-refractory and/or omalizumab-refractory CSU.

Use of Omalizumab

Omalizumab is approved by the FDA for antihistamine-resistant CSU. It is highly effective, safe, and improves quality of life for patients with CSU. It is also effective for treating different subtypes of CIndU. The guideline recommends shortening the interval between doses or increasing the dose to a maximum of 600 mg every 2 weeks at intervals of 2-4 weeks for patients with incomplete response to omalizumab. However, some experts caution that alternative treatment options are needed, including safer and more effective oral therapies for second- and even third-line use.

Other Therapies

The guideline notes that other treatments, such as oral dapsone, dupilumab, and tumor necrosis factor alpha inhibitors, have also been helpful for some patients. Cyclosporine is recommended as a third-line therapy in patients with severe CSU refractory to any dose of antihistamine in combination with any dose of omalizumab. However, it should be monitored for potential adverse effects such as nephrotoxicity and hypertension. The long-term use of systemic glucocorticosteroids in chronic urticaria is not recommended. A short course of rescue systemic glucocorticosteroids may be considered in patients with an acute exacerbation.

Step-Down Algorithm

The guideline provides a step-up algorithm for achieving complete disease control but does not provide a step-down algorithm for discontinuing treatment. The lack of guidance about stepping down the treatment for CSU needs to change. Physicians need to bring individual patient needs on board and implement step-down protocols with prudence and patience. When treatment step-down interferes with disease control, the guideline recommends reinstating antihistamines at the last dose that provided complete disease control.

Conclusion

The 2021 International Urticaria Guideline provides a simplified diagnostic and therapeutic algorithm, emphasizing patient assessment, safety, and quality-of-life improvement. Second-generation antihistamines remain the recommended first-line therapy for all types of urticaria, with omalizumab as a second-line therapy for treating antihistamine-refractory and/or omalizumab-refractory CSU. Other therapies, such as oral dapsone, dupilumab, and tumor necrosis factor alpha inhibitors, are helpful for some patients. A clear step-down algorithm for discontinuing treatment in CSU needs to be included in the next update and revision of the guideline.

Originally Post From https://www.medpagetoday.com/medical-journeys/urticaria/110399

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