What are the guideline sources, guidelines and references for Chronic urticaria ?
Guideline sources The following summarized guidelines for the evaluation and management of chronic urticaria are prepared by our editorial team based on guidelines from the British Association of Dermatologists (BAD 2022) and the Asia Pacific Association of Allergy, Asthma and Clinical Immunology (APAAACI/GA LEN/EDF/EAACI 2022). 1 2 Pathway Chronic urticaria Management of chronic urticaria Guidelines 1. Classification and risk stratification Classification (based on duration): classify urticaria as acute ( 6 weeks) or chronic (> 6 weeks). A https://web.pathway.md/diseases/recnnkbrhQjdCxtFY 1/7 6/23/23, 3:26 AM Chronic urticaria Pathway Classification (based on trigger): classify urticaria as spontaneous (no definite eliciting factor involved) or inducible (specific definite factor involved). A Differential diagnosis: Include the following in the differential diagnosis of patients with signs or symptoms suggestive of chronic urticaria: acquired angioedema due to C1 inhibitor deficiency ACEI-induced angioedema hereditary angioedema chronic spontaneous urticaria chronic inducible urticaria urticarial vasculitis acquired/hereditary autoinflammatory disorders. A 2. Diagnostic investigations Clinical assessment: Use the urticaria activity score 7 and/or angioedema activity score to assess disease activity in patients with chronic spontaneous urticaria. A Show 2 more Use provocation threshold measurements and the urticaria control test to measure disease activity and control in patients with chronic inducible urticaria, respectively. A Consider using appropriate validated scoring systems to assess disease activity and impact, for example DLQI, weekly Urticaria Activity Score 7, Angioedema Activity Score and/or Urticaria Control Test. E Initial evaluation: As per EAACI 2022 guidelines, obtain limited investigations as part of the initial evaluation of patients with chronic spontaneous urticaria, including a CBC, CRP and/or ESR, and in specialized care total IgE and IgG-anti-TPO, and more biomarkers as appropriate. A Show 2 more As per BAD 2022 guidelines, consider obtaining baseline investigations if clinically indicated. C Show 5 more Provocation tests: Obtain provocation testing to diagnose chronic inducible urticaria. A Use provocation threshold measurements and the urticaria control test to measure disease activity and control in patients with chronic inducible urticaria, respectively. A 3. Medical management https://web.pathway.md/diseases/recnnkbrhQjdCxtFY 2/7 6/23/23, 3:26 AM Chronic urticaria Pathway Goals of treatment: target complete symptom control in patients with urticaria, considering as much as possible the safety and the quality of life of each individual patient. A Avoidance of inciting agents: As per EAACI 2022 guidelines, advise patients with chronic spontaneous urticaria to discontinue medications suspected to worsen the disease, such as NSAIDs. A As per BAD 2022 guidelines, advise avoiding identified triggers or exacerbating factors, such as drugs, and in particular triggers for inducible urticarias. E Show 4 more Histamine-1 receptor antagonists: As per EAACI 2022 guidelines, offer a second generation H1RA as first-line therapy in patients with all types of urticaria. A Show 4 more As per BAD 2022 guidelines, offer a second-generation H1RA using a regular daily licensed dose in patients with chronic urticaria. A Show 6 more Histamine-2 receptor antagonists: As per EAACI 2022 guidelines, insufficient evidence to recommend for or against the combined use of H1RAs and H2RAs in patients with chronic urticaria. I As per BAD 2022 guidelines: Insufficient evidence to recommend routine addition of H2RAs to second-generation H1RAs in patients with chronic spontaneous urticaria with inadequately controlled symptoms. Consider adding H2RAs to second-generation H1RAs if urticaria is associated with dyspepsia. Obtain appropriate evaluation for dyspepsia. Leukotriene receptor antagonists: consider offering montelukast in addition to a second- generation H1RA in patients with chronic spontaneous urticaria inadequately controlled by standard and increased doses of second-generation H1RAs. C Show 2 more Systemic corticosteroids: As per EAACI 2022 guidelines: Consider offering a short course of rescue systemic corticosteroids in patients with an acute exacerbation of chronic urticaria. C Do not use systemic corticosteroids for long-term in patients with chronic urticaria. D As per BAD 2022 guidelines: Consider offering oral prednisolone (0.5 mg/kg), in addition to continued use of a second- generation H1RA, for short, infrequent courses of a few days as rescue treatment to control severe exacerbations in patients with chronic spontaneous urticaria. C Do not use long-term systemic corticosteroids in patients with chronic spontaneous urticaria unless there is no other option. Administer the lowest effective dose for the shortest possible period. D https://web.pathway.md/diseases/recnnkbrhQjdCxtFY 3/7 6/23/23, 3:26 AM Chronic urticaria Pathway Omalizumab: As per EAACI 2022 guidelines, offer add-on omalizumab for the treatment of patients with chronic urticatia unresponsive to high-dose second generation H1RAs. A As per BAD 2022 guidelines: Offer omalizumab in addition to a second-generation H1RA in patients with chronic spontaneous urticaria inadequately controlled by first-line therapy. A Consider offering omalizumab in addition to a second-generation H1RA in patients with chronic inducible urticaria inadequately controlled by first-line therapy. C Cyclosporin: As per EAACI 2022 guidelines, consider offering cyclosporin for the treatment of patients with chronic urticaria unresponsive to high-dose of second generation H1RAs and omalizumab. C As per BAD 2022 guidelines: Offer cyclosporin for 3-6 months in addition to a second-generation H1RA in patients with chronic spontaneous urticaria inadequately controlled by first-line therapy. A Avoid using long-term cyclosporin, if possible, in patients with chronic spontaneous urticaria inadequately controlled by first-line therapy. Administer at the lowest effective dose if avoidance is not possible, interrupt treatment periodically to confirm continued requirement, and consider switching to alternative agents. D Epinephrine autoinjector: prescribe self-injectable epinephrine, if appropriate, in patients at risk of anaphylaxis, for example in association with cold or cholinergic urticaria. E Third-line therapy (chronic spontaneous urticaria): Consider offering the following options in patients with chronic spontaneous urticaria inadequately controlled by first- and second-line treatment options or where the latter are contraindicated or inappropriate (in alphabetical order): azathioprin dapsone doxepin (recognize that there are concerns about CNS effects, as for first-generation antihistamines) hydroxychloroquine (particularly for urticaria occurring with SLE) IVIGs methotrexate mycophenolate mofetil narrowband UV B (typically a course of around 30 treatments, repeated after 12 months if necessary, but not for continual treatment) oral tacrolimus sulfasalazine tranexamic acid (only if predominantly angioedema). C Insufficient evidence to recommend the following options in patients with chronic spontaneous urticaria inadequately controlled by first- and second-line treatment options: https://web.pathway.md/diseases/recnnkbrhQjdCxtFY 4/7 6/23/23, 3:26 AM Chronic urticaria Pathway colchicine cyclophosphamide dipyridamole IL-1 antagonists (such as anakinra) plasmapheresis psychological interventions rituximab thyroxine TNF antagonists warfarin. I Third-line therapy (chronic inducible urticaria): consider offering anticholinergic drugs (such as oxybutynin) or -blockers (such as propranolol) or danazol or possibly phototherapy in patients with cholinergic urticaria. E Show 10 more 4. Nonpharmacologic interventions Dietary modifications: Do not advise routine dietary exclusion in patients with chronic spontaneous urticaria. Obtain appropriate evaluation if food appears to play a role, based on a detailed history, in patients with chronic spontaneous urticaria. D Insufficient evidence regarding dietary supplementation in patients with chronic spontaneous urticaria. I Emollients: consider offering topical antipruritic agents such as a menthol-containing emollient in patients with chronic urticaria. E Psychosocial support: offer access to support and treatment for anxiety, depression and the psychosocial impact of the disease, where appropriate. Consider assessing the psychological impact using the Hospital Anxiety and Depression Scale. E 5. Specific circumstances Pediatric patients: consider using the same treatment algorithm with caution (weight-adjusted dosage) in pediatric patients with chronic urticaria. C Pregnant patients: As per EAACI 2022 guidelines, consider using the same treatment algorithm with caution both in pregnant and lactating patients after risk-benefit assessment. Do not use drugs contraindicated or not suitable in pregnancy. C As per BAD 2022 guidelines: https://web.pathway.md/diseases/recnnkbrhQjdCxtFY 5/7 6/23/23, 3:26 AM Chronic urticaria Pathway Insufficient evidence regarding the safety of use of antihistamines during pregnancy and breastfeeding. Consider offering cetirizine or loratadine in patients with active disease and after counseling the female patient with any type of urticaria, where necessary. 6. Patient education Patient education: provide patients with educational material or a patient information leaflet on urticaria and angioedema. E 7. Follow-up and surveillance Indications for referral: Refer patients with chronic urticaria to secondary care in the following situations: diagnostic doubt urticaria is not adequately controlled by first-line therapy high levels of inflammatory markers marked or persistent associated systemic symptoms, or if the patient is systemically unwell urticaria is having a significant impact on quality of life, such as depression, anxiety, marked psychosocial impact, reduced work/school attendance or sleep disturbance angioedema without weals not controlled by first-line therapy. E Serial clinical assessment: assess disease activity, impact and control at every follow-up visit in patients with chronic urticaria. A References 1. Juhani Knuuti, William Wijns, Antti Saraste et al. British Association of Dermatologists guidelines for the management of people with chronic urticaria 2021. Br J Dermatol. 2022 Mar;186 3 398 413. Open 2. Torsten Zuberbier, Amir Hamzah Abdul Latiff, Mohamed Abuzakouk et al. The international EAACI/GA LEN/EuroGuiDerm/APAAACI guideline for the definition, classification, diagnosis, and management of urticaria. Allergy. 2022 Mar;77 3 734 766. Open 3. Fine LM, Bernstein JA. Guideline of Chronic Urticaria Beyond. Allergy Asthma Immunol Res. 2016 Sep;8 5 396 403. Open 4. American Academy of Allergy, Asthma & Immunology. Choosing Wisely AAAAI recommendations. Choosing Wisely. 2012. Open 5. Jonathan A Bernstein, David M Lang, David A Khan et al. The diagnosis and management of acute and chronic urticaria: 2014 update. J Allergy Clin Immunol. 2014 May;133 5 1270 7. Open 6. Paul Schaefer. Acute and Chronic Urticaria: Evaluation and Treatment. Am Fam Physician. 2017 Jun 1;95 11 717 724. Open https://web.pathway.md/diseases/recnnkbrhQjdCxtFY 6/7 6/23/23, 3:26 AM Chronic urticaria Pathway https://web.pathway.md/diseases/recnnkbrhQjdCxtFY 7/7