Management of Chronic Idiopathic Urticaria Supported by Proactive Pharmacist Outreach
The name “chronic idiopathic urticaria” couldn’t be any more accurate. It conjures the image of never-ending, itchy hives in a patient whose misery is amplified because they never know when the rash will come or go. It also doesn’t help that treatment options are hindered by lack of an obvious cause.
Pharmacists are key health care professionals for patients with chronic idiopathic urticaria, as they need OTC and prescription products to relieve symptoms. You’ll be prepared to counsel these patients when you’re armed with knowledge about the condition, prognostic factors, and the medications that help.
What Pharmacists Should Know About Chronic Urticaria
Health professionals and most patients are quite familiar with the everyday variety of hives that affect 20 percent of people at some point in their lives. Acute cases of hives are short-lived and often associated with allergies, triggered by foods, medications, insect bites, latex, pets, pollen, poison ivy, and physical triggers such as cold, heat and exercise, to name just a few. However, chronic hives are different because duration is a key characteristic and even though physical triggers may be identified, they are seldom caused by a food allergy.
Chronic hives are defined as episodic or daily hives that last for at least six weeks and may recur over months or years. The lifetime prevalence of chronic urticaria is estimated to be 1.8 percent of the adult population and 0.1 to 0.3 percent in children.1 Based on the duration of chronic urticaria, it’s easy to understand how it can impact quality of life and cause lost days at work:
- 53 percent of adults with chronic urticaria have the condition for 6 to 12 weeks
- In 18.5 percent, duration is 3 to 6 months
- 4 percent have hives for 7 to 12 months
- Nearly 9 percent have hives for 1 to 5 years
- In 11 percent of patients, duration is longer than 5 years
There are several primary subtypes of chronic urticaria, but once physical causes and urticarial vasculitis are ruled out, 45 percent of the remaining cases have autoimmune chronic urticaria and 55 percent have chronic idiopathic urticaria.2 In November 2014, the World Allergy Association Journal published a table of unfavorable prognostic factors. It’s good background information for pharmacists to have on hand when they counsel patients who are frustrated by their long-term condition and lack of response to treatment.
The following factors predict longer duration of hives or chronic idiopathic urticaria that’s more likely to resist treatment:
- Failure of a single labeled dose of an H1 receptor blocker to control chronic urticaria—predicts poor quality of life
- Duration of 6 months or longer at time of diagnosis
- Angioedema—occurs in 40 percent of patients
- Physical urticaria comorbid with chronic idiopathic urticaria
- Autoimmune disease
- Evidence of fibrinolysis or prothrombin fragments
- Positive autologous serum test—positive results are found in about one-third of patients
Patients with a positive autologous serum test are more likely to develop urticaria due to endogenous causes. A positive test correlates with disease severity and duration, and may indicate the need for a higher antihistamine dose or an additional immunomodulatory agent. Positive results are also associated with a higher chance of intolerance to nonsteroidal anti-inflammatory drugs.3
Management of Chronic Idiopathic Urticaria
The persistent nature of chronic idiopathic urticaria affects the mental health of many patients. They can also become wary of treatment changes if the medications already tried have produced minimal relief. Keep their frustrations and concerns in mind, ask how they’re doing, and don’t hesitate to suggest they talk about their psychological health with their physician or a psychologist.
Pharmacists should also be aware that about one-third of patients with chronic idiopathic urticaria may develop angioedema after they take aspirin or other nonsteroidal anti-inflammatory drugs, so counsel patients about pain relief options when they pick up medications. Here’s a short list of agents used to treat chronic urticaria:
- Antihistamines – Non-sedating anti-H1 antihistamines are first-line treatment. A second dose at night is sometimes needed because pruritus becomes more troublesome at night. Ultimately, about 75 percent need higher than the recommended dose.
- Higher dosages of H1 receptor antagonists – Patients who don’t respond to the usual dose may need up to four times the labeled adult dosages of the second generation H1 receptor antagonists, levocetirizine and desloratadine. If patients don’t respond to an initial regimen using desloratadine, switching to levocetirizine may help.
- Biologic therapy – Omalizumab is approved for patients aged 12 years and older whose chronic idiopathic urticaria doesn’t respond to treatment with an H1 receptor antagonist. In some patients, pruritus and urticarial lesions are reduced within one week of subcutaneous injection.
- Leukotriene antagonists – These agents are better than placebo, but less effective than non-sedating antihistamines. Combining antihistamines and leukotriene antagonists is especially beneficial for patients with flare-ups caused by aspirin or other NSAIDs.
- Corticosteroids – May be used as second-line agents but most physicians will try higher doses of antihistamines before prescribing systemic corticosteroids. Topical corticosteroid creams are not very effective for chronic urticaria.
- Topical tricyclic antidepressants – Topical doxepin and other tricyclic antidepressants are potent H1 receptor antagonists that resulted in total clearing of pruritus and urticarial lesions in 43 percent of patients, compared to 5 percent in those using topical diphenhydramine.
A variety of other agents such as dapsone, sulfasalazine, and colchicine may reduce the frequency and severity of lesions in treatment-resistant chronic idiopathic urticaria, but they’re not acceptable for all patients due to adverse effects. Vitamin D used as adjunctive treatment may improve results, but only in high doses that reach or exceed the tolerable upper intake level, so advise patients to only take this vitamin under the supervision of their physician.
Pharmacist Outreach Offers Reassuring Support
Any type of chronic disease creates a unique set of challenges for patients and their doctors, but the issues are notably insidious when the condition is chronic idiopathic urticaria. At first it’s shrugged off as a typical and transient rash. Then patients live for months or years with an unpredictable yet persistent rash that’s itchy, sometimes painful, affects their appearance, and is hard to treat. Pharmacists who proactively reach out can help ease the burden and promote better outcomes.
Pharmaceutica North America provides prescription drug products such as diclofenac sodium and lidocaine, as well as high-quality active pharmaceutical ingredients. We also have a line of OTC supplements, including natural Sintralyne-PM, which is a blend of melatonin and gamma-aminobutyric acid that may help patients with chronic urticaria get a good night’s sleep. Contact us today to talk about how we can support your pharmaceutical needs.
- “Urticaria: New Management Options,” November 2014, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4223736/ ↩
- “Chronic Urticaria,” August 2016, http://emedicine.medscape.com/article/1050052-overview ↩
- “Autologous Serum Skin Test,” January 2009, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800884/ ↩