Clinical Practice Guideline 2557 ก ก (Urticaria/Angioedema)
ก ก
ก ก ก ก ก 238 Clinical Practice Guideline Urticaria/Angioedema
Clinical Practice Guideline
ก : ก ก ก ก ก
: ก ก ก
ก ก : ก ก ก ก ก ก ก ก ก ก ก ก
ก ก ก : Clinical Practice Guideline Urticaria/Angioedema 239
ก ก / ก ก ก ก / ก / ก ก ก / / ก (spontaneous urticaria) ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก / ก ก ก ก ก ก ก ก ก 2552
ก ก ก (wheal and flare) / ก (angioedema) ก ก ก ก ก ก ก ก ก (physical) ก ก
ก ก (urticaria) ก (wheal and flare) ก ก ก ก ก ก ก (angioedema) ก ก ก ก ก ก ก 24 ก ก ก ก ก ก 24 ก ก ก anaphylaxis ก ก ก ก ก ก ก ก (anaphylactic shock) ก 2 1. (acute urticaria) ก ก ก 6 2. (chronic urticaria) ก 2 ก กก 6 240 Clinical Practice Guideline Urticaria/Angioedema
1 ก ก ( ก ก (1) (2)) ก ก ก • / ก ก (Spontaneous urticaria) (Acute spontaneous urticaria) ก 6 • / ก ก (Chronic spontaneous urticaria) กก 6 ก
ก กก • Cold urticaria ก ก • Delayed pressure urticaria ก ก ก 3 12 กก (Inducible urticaria or physical urticaria) • Heat urticaria
• Solar urticaria /
• Symptomatic dermographism (mechanical shearing forces ) ก 1 5 กก
• Vibratory angioedema (pneumatic hammer) ก 1 2
• Contact urticaria ก ก ก
ก ก ก ก ก ก 1 ก ก ก ก ก syndromes ก ก / 2 Clinical Practice Guideline Urticaria/Angioedema 241
1 ก ก ( ก (2) (3))
Urticaria Angioedema
H istory istory , , ? ก ACEI ?
+ +
hereditary ก Autoinflammatory (HAE) acquired
> 24 ? ก ? disorder ? angioedema (AAE) ? + + + +
testsDiagnostic
Histology: Inducible vasculitis ? symptoms ?
+ +
Provocation test
+
Auto Urticarial Chronic Chronic HAE I III ACEI inflammatory spontaneous inducible vasculitis AAE induced disease urticaria urticaria angioedema
Mediators
Interleukin 1 Histamine and other Bradykinin mast cell mediators
ACEI, angiotensin converting enzyme inhibitors; HAE, hereditary angioedema; AAE, acquired angioedema 242 Clinical Practice Guideline Urticaria/Angioedema
2 ก syndromes ก ก / ( ก ก (2))
ก Maculopapular cutaneous mastocytosis (urticaria pigmentosa) Urticarial vasculitis Bradykinin mediated angioedema ( hereditary angioedema) Exercise induced anaphylaxis Cryopyrin associated periodic syndromes: recurrent fever attacks, arthralgia or arthritis, eye inflammation, fatigue and headaches Muckle Wells syndrome Neonatal onset multisystem inflammatory disease Familial cold autoinflammatory syndrome Schnitzler s syndrome: monoclonal gammopathy, recurrent fever attacks, bone and muscle pain, arthralgia or arthritis, lymphadenopathy Gleich s syndrome (episodic angioedema with eosinophilia): IgM gammopathy, eosinophilia Well s syndrome (eosinophilic cellulitis): granulomatous dermatitis with eosinophilia
ก กก ก ก ก ก 3
Clinical Practice Guideline Urticaria/Angioedema 243
3 ก ก ก ก ก ก ก ( ก ก (2) (4)) ก ก (Spontaneous urticaria) routine diagnostic tests ( ก ก) (CSU) Differential blood count ** , ESR ** NSAID ก autologous serum skin test*, test Helicobacter**, gastroscopy**, ANA**, D Dimer*,†, **, ก **, specific IgE**, autoantibodies** ( ก ก 15 ก antibodies ก ) ก ก 1. Cold urticaria Cold provocation test (ice cube, cold water) *, differential blood count ** , ESR**, cryoglobulins** 2. Delayed pres sure urticaria Pressure test * ก ก 0.2 1.5 กก./ . . 10 20 ก 6.8 ก ก (15 ) ก ก ก 15 3. H eat urticaria Warm arm bath * 4. S olar urticaria visible light * 5. Symptomatic dermographism *, differential blood count ** ESR ** dermographism 6. Vibratory angioedema vortex 1 5 * 7. Aquagenic urticaria 20 8. Cholinergic urticaria Exercise ก hot bath 15 20 * 9. Contact urticaria ก immunol ogic nonimmunologic ก ก patch test, skin prick testing ก * ก ก ** ก ก † CSU ก ก coagulation pathway plasma D Dimer CSU, chronic spontaneous urticaria; NSAID, non steroidal anti inflammatory drug; ANA, antinuclear antibodies; ESR, erythrocyte sedimentation rate 244 Clinical Practice Guideline Urticaria/Angioedema
ก ก ก ก ก ก ก chronic spontaneous urticaria (CSU) ก ก spontaneous wheals ก กก ก ก autoantibodies (IgG) high affinity IgE receptor (Fc εRI) IgE 30 50 ก CSU ก ก autoimmune urticaria CSU ก ก coagulation pathway plasma D Dimer
Clinical Practice Guideline Urticaria/Angioedema 245
ก
2 ก ก
• ก ก prednisolone 20 30 ก. ก ก 10 • ก ก ก ก aspirin, NSAIDs, codeine, morphine, ACEI
NSAIDs, non steroidal anti inflammatory drugs; ACEI, angiotensin converting enzyme inhibitors
246 Clinical Practice Guideline Urticaria/Angioedema
4 ก ก anaphylaxis* anaphylaxis ก ก 1 3 1. ก ก ( ) ก ก ก ก ก 1.1. ก ก (stridor) ก ก ก ก peak expiratory flow (PEF) ก 1.2. ก hypotonia (collapse) 2. ก กก ก 2 ก ก ( ) 2.1. ก ก 2.2. ก ก (stridor) ก ก ก PEF ก 2.3. ก 2.4. ก 3. ก ก ก ( ) 3.1. ก systolic ก ก systolic กก 30 systolic * 3.2. systolic ก 90 mmHg systolic กก 30 systolic * ก ก systolic ก < 70 mmHg ก 1 1 < 70 mmHg + (2 x ) ก 1 10 < 90 mmHg ก 11 17
* ก ก (Clinical Practice Guidelines for Management Anaphylaxis) . .2551 ก ก ก ก ก ก
Clinical Practice Guideline Urticaria/Angioedema 247
3 ก ( ก ก (5) (6))
NSAIDs, non steroidal anti inflammatory drugs; SLE, systemic lupus erythematosus; SPT, skin prick testing; ESR, erythrocyte sedimentation rate; ANA, antinuclear antibodies; ASST, autologous serum skin testing
* ก ก ก ก
248 Clinical Practice Guideline Urticaria/Angioedema
ก
1. ก ก ก ก ก ก ก ก ก ก ก
4 ก ก
Response rate H1 antihistamines = 45 50%, low dose corticosteroids = 70 80%, ciclosporin = 70 80%, omalizumab = 70 80% * NSAIDs, non steroidal anti inflammatory drugs 1 ก ก ก ( 4 ) ก ก ก ก ก ก fexofenadine, rupatadine, desloratadine levocetirizine ก (2) 2 ก ก ก 2 4 3 Clinical Practice Guideline Urticaria/Angioedema 249
ก (Non pharmacotherapy to minimize skin hyper responsiveness) 1.1 ก 1.2 ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก
2. ก ก 2.1 (Antihistamines) 1 (H1 antihistamines) ก ก 2 ก. 1 1 (First generation or sedating antihistamines) , ก ก ก ก ก ก (benign prostate hypertrophy) (glaucoma) ก ก EAACI/GA2LEN/DEF/WAO Guideline 2013 ก ก ก ก ก non sedating antihistamines ก (2) ก ก ก ก ก sedating antihistamines ก ก non sedating antihistamines ก ก ก ก ก ก ก ก (7) sedating antihistamines 5
. 1 2 (Second generation or non sedating antihistamines) ( 6) ก ก ก ก
250 250 Clinical Practice Guideline Urticaria/Angioedema Clinical Practice Guideline Urticaria/Angioedema
5 1 1 (First generation or sedating antihistamines)
Pediatric dosage Age Pregnancy Grades of Strength of Drug Adult dosage Dose adjustment (mg/Kg/day) approved category evidence recommendation
Chlorpheniramine* 0.35 2 1 4 ก. ก 4 6 . B ก ก Cyproheptadine 0.25 2 4 ก. ก 6 8 . B ก 4 C* ก ก Diphenhydramine 5 2 25 50 ก. ก 4 6 . B ก ก ก Hydroxyzine* 1 2 6 10 ก. ก 6 . C ก * grades of evidence strength of recommendation ก ก ก ก ก ก ก ก ก
ClinicalClinical Practice Practice Guideline Guideline Urticaria/Angioedema Urticaria/Angioedema 251 25 1
6 1 2 (Second generation or non sedating antihistamines) ( ก ก (2) (8))
Pediatric dosage Age Pregnancy Grades of Strength of Drug Adult dosage Dose adjustment Age Dose approved category evidence* recommendation* 2.5 ก. 2 2 6 ก ก Cetirizine 5 ก. >2 10 ก. B 1a A (Ccr<30 / /1.73m 2) >6 10 ก. 6 11 1 ก. Desloratadine 1 5 1.25 ก. ก ก >6 5 ก. C 1a A 6 11 2.5 ก. (Ccr<30 / /1.73m 2) >12 5 ก. 6 < 2 15 ก. 2 180 ก. Fexofenadine 2 11 30 ก. 2 ก ก >6 60 ก. C 1a A 60 ก. 2 (Ccr< 80 / /1.73m 2) >12 ก 12 180 ก. ก Levocetirizine > 6 5 ก. >6 5 ก. B 1a A ก (Ccr<50 / /1.73m 2) Loratadine 2 12 5 ก. >2 10 ก. ก ก B 1a A >12 , >30 กก. 10 ก. 6 11 >12 ( ) ก ก Rupatadine 5 ก. 10 ก. B 1a A ( ≥ 25 กก.) >6 ( ) (Ccr<30 / /1.73m 2) * ก ก (8) 252 Clinical Practice Guideline Urticaria/Angioedema
2.2 ก ก • (Corticosteroids) prednisolone ก (acute severe urticaria), serum sickness , urticarial vasculitis delayed pressure urticaria ก ก physical urticaria prednisolone ก ก ก (acute exacerbation) ก ก • ก 1 2 ก (H1 and H2 antihistamines) quality of evidence 2 (H2 antihistamines) ก 1 (H1 antihistamines) ก ก ก ก ก 1 ก , ก ก ก ก H1 antihistamine 2 ก ก ก H1 antihistamines ก 2 4 • Leukotriene receptor antagonist ก montelukast (chronic urticaria) ก ก montelukast ก ก aspirin sensitive chronic urticaria ก quality of evidence ก montelukast ก 2 4 • Ciclosporin ก ก กก ก 2.5 5 ก./ กก./ ก ciclosporin ก 3 6 ก ก ก ก ก 18 • Omalizumab ก ก ก ก ก ก ก ก ก ก ก ก ก 12 ก ก ก ก ก ก ก (appendix II; ก ก omalizumab) ClinicalClinical Practice Practice Guideline Guideline Urticaria/Angioedema Urticaria/Angioedema 253 253 7 ก ก ก ก ก ( ก ก (2) (8)) ก ก RCT ก ก RCT ก ก RCT RCT (uncontrolled studies , Strength of ก non sedating Grades of evidence* ก case reports) recommendation* H1 antihistamines Doxepin X 3b B Ketotifen X 3b B Montelukast X 4 C Nifedipine X 4 C PUVA X 4 C Warfarin X 4 C Ciclosporin X 1a A Hydroxychloroquine X 4 C Montelukast X 3b B Narrow band UVB X 4 C Omalizumab X 1a A Stanozolol X 3b B Cromolyn X 4 C Sedating H1 antihistamines + H2 X 4 C antihistamines (cimetidine) Sedating H1 antihistamines + terbutaline X 4 C Tranexamic acid X 4 C Dapsone X 4 C Corticosteroids X 3b B Interferon X 4 C Intravenous immunoglobulins X 4 C Methotrexate X 4 C Plasmapheresis X 4 D Sulfasalazine X 4 C * ก ก (8) ; RCT, randomized controlled trial 254 Clinical Practice Guideline Urticaria/Angioedema
3. ก ก 3.1 ก calamine lotion menthol ก ก ก ก ก กก ก ก 3.2 ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก (holistic approach) ก กก ก
ก ก ก ก guidelines ก ก
ก ก 1. ก ก ก 3 ก ก ก 1 5 21 ก (9) 2. 50 1 20 กก 20 ก ก 75 ก 1 20 ก 20 1 1 3 34 (remission) 390 ก 50 ก ก 1 ( 16 ) 19 1 Clinical Practice Guideline Urticaria/Angioedema 255
ก
• ก ก ก ก ก ก ก ก (first line treatment ) 1. ก ก Complete blood count (CBC) Erythrocyte sedimentation rate (ESR) Stool examination Chest X ray Sinus X ray Antinuclear antibodies (ANA) D dimer ก Helicobacter Gastroscopy Thyroid antibodies / thyroid function test: ก autoimmune urticaria
2. ก ก (skin prick testing, SPT): ก ก IgE mediated ก กก ก allergen specific IgE ก ก ก ก กก ก ก (negative predictive accuracy) กก 95 ก IgE mediated reactions ก ก positive predictive accuracy ก 50 ก ก double blind, placebo controlled food challenge ก ก SPT SPT ก ก ก ก ก IgE acute allergic urticaria กก
3. ก ก Gold standard ก ก ก double blinded, placebo controlled food challenge ก ก ก ก IgE mediated non IgE mediated reaction ก ก IgE mediated reaction skin prick testing serum specific IgE ก ก ก specific serum IgG ก 256 Clinical Practice Guideline Urticaria/Angioedema
4. ก Autoantibodies ก chronic autoimmune urticaria ก
4.1 In vivo test • Autologous serum skin testing (ASST) screening test ก chronic autoimmune urticaria ก 70 80 ก ก 30 60 CSU ก ก ก ก
4.2 In vitro test ก • Basophil histamine release assay* ก functional autoantibodies ก fresh basophils ก ก • Direct immunoassays * ก non functional functional anti Fc εRI autoantibodies ก ก Western blotting, immunoprecipitation, enzyme linked immunosorbent assay, flow cytometry chimeric cell lines express human Fc εRI α * ก
Clinical Practice Guideline Urticaria/Angioedema 257
Appendix I. grades of evidence strength of recommendation clinical practice guideline Grades of evidence ( ก ก (8)) 1a Metaanalysis of RCT 1b Single RCTs 2a Systemic review of cohort studies 2b Single cohort studies and RCTs of limited quality 3a Systematic review of case control studies 3b Single case control study 4 Case series, case cohort series or cohort studies of limited q uality , expert committee opinion RCT, randomized controlled trial
Classification of strength of recommendation ( ก ก (8)) Recommendation s trength Evidence grade A 1a, 1b B 2a, 2b, 3a, 3b C 4 D Expert opinion
258 Clinical Practice Guideline Urticaria/Angioedema
Appendix II ก ก Omalizumab
Omalizumab omalizumab ก ก ก ก
( 12 ) ก ก omalizumab ก ก ก H1 antihistamines ก add on therapy ก ก omalizumab (anti IgE treatment) ก ก
1. ก /
2. 12
3. ก ก ก
- ก ก complete blood count (CBC), ANA, urine analysis
4. ก ก ก (chronic spontaneous urticaria)
ก ก ก
5. ก 3 ก ก ก ก ก ก ( ก ก 2557
ก ก ) ก omalizumab
ก ก (chronic spontaneous urticaria)
ก ก nonsedating H 1 antihistamines
4
ก ก
nonsedating H1 antihistamines กก 1 modern second generation H antihistamines 1 ( ก 4 ก ) 4 1
ก ก
Clinical Practice Guideline Urticaria/Angioedema 259
ก H antihistamines leukotriene receptor antagonis ts 2 (LTRAs) ก H1 antihistamines 4
ก ก absolute contraindications ciclosporin ก 3 ก ./กก ./ ciclosporin 2 4 ก 3 6
ก ก
ก omalizumab
ก ก Urticaria Activity Score 7 (UAS7) >16 Urticaria Activity Score 7 (UAS7) >16 ก ก ก ก ก ก ก ก ก ก omalizumab 1. absolute contraindications ciclosporin 2 ก UAS7 >16 * ก ก ก 1. Ciclosporin ciclosporin ก ก 18 ก - ciclosporin dependence ก ciclosporin 3 2. absolute contraindications systemic - ก ก ciclosporin ( corticosteroids 3 UAS7 30% ก ก ก 3 ก./กก./ 4 ก ก )
7 (Urticaria Activity Score 7; UAS7) - ciclosporin treatment intolerance ก ก omalizumab ก / UAS7 กก ก 16 ( ก blood pressure >140 mmHg systolic >90 mmHg 42 ) diastolic ก 2
: ก Relative 2. Corticosteroids - contraindications ciclosporin 2 systemic oral prednisolone กก ก 10 corticosteroids 3 ก ก ก 30 - corticosteroid dependence
omalizumab 260 Clinical Practice Guideline Urticaria/Angioedema
ก ก ก ก omalizumab ก ก ก 150 ก ก 4 ก ก ก ก 4 ก ก ก 7 (UAS7) ก complete response ( UAS7 90% กก ก ก ) significant improvement ( UAS7 30 90% กก ก ก ) 150 ก ก 4 3 6 4 significant improvement ( UAS7 ก 30% กก ก ก ) 300 ก ก 2 ก significant improvement ก ก ก ก ( UAS7 ก 30%) omalizumab omalizumab ก omalizumab ก 3 6 ก ก ก ก ก omalizumab omalizumab ก 150 300 ก ก 4 (deltoid) (thigh) ก ก ก omalizumab ก ก ก ก add on therapy anaphylaxis anaphylactoid reactions 0.1% ก ก ก 0.2% ก ก ก ก 3 ก ก ก anaphylaxis 2 ก ก 30 - omalizumab ก - (Pregnancy Category B) - ก anaphylaxis - ก ( ก ) - ก live attenuated vaccines ก omalizumab 1 3
Clinical Practice Guideline Urticaria/Angioedema 261
1 modern second generation non sedating H1 antihistamines ก ก ก 4 ก ก ก ก ก ก fexofenadine, rupatadine, desloratadine, levocetirizine 2 Absolute contraindications ciclosporin ก - Live attenuated vaccines 1 3 ก - Uncontrolled or severe hypertension - Serious infection - Immune compromise Relative contraindication ciclosporin ก ก ciclosporin ก ciclosporin ก methotrexate, phototherapy immunosuppressive 3 Absolute contraindications systemic corticosteroids ก - Systemic fungal infections - Herpes simplex keratitis - Hypersensitivity Relative contraindications systemic corticosteroids ก - Active tuberculosis or a positive tuberculin test (purified protein derivative [PPD]) - Active peptic ulcer disease (PUD) - Recent anastomotic surgery - Hypertension - Depression or psychosis - Diabetes mellitus (DM) - Osteoporosis - Cataracts and glaucoma
262 Clinical Practice Guideline Urticaria/Angioedema
ก ก Urticaria Activity Score 7 Diary
ก ก ก ก ก ก ก ก ก ก ก ก ก ก 1 ก 7 1. ก ก ก ก 2. ก ก ก ก ก ก ก ก ก ก ก ก
1. 2. ก * ก 0 1 2 3 0 1 2 3
24 24
50 >50 ก 24 24 24 <20 20 ก ก ก ก ก ก 1 2 3 4 5 6 7
* ก ก ก 0 ก 1 ก ( ก ก ก ก ก ก ) 2 ก ก ( ก ก ก ก ก ก ) 3 ก ก ( ก ก ก ก ก ก ก )
References Clinical Practice Guideline Urticaria/Angioedema 263
1. Sanchez Borges M, Asero R, Ansotegui IJ, Baiardini I, Bernstein JA, Canonica GW, et al. Diagnosis and treatment of urticaria and angioedema: a worldwide perspective. WAO Journal. 2012;5(11):125 47. 2. Zuberbier T, Aberer W, Asero R, Bindslev Jensen C, Brzoza Z, Canonica GW, et al. The EAACI/GA(2) LEN/EDF/WAO Guideline for the definition, classification, diagnosis, and management of urticaria: the 2013 revision and update. Allergy. 2014;69(7):868 87. 3. Maurer M, Magerl M, Metz M, Zuberbier T. Revisions to the international guidelines on the diagnosis and therapy of chronic urticaria. J Dtsch Dermatol Ges. 2013. in press, PMID:24034140. 4. Zuberbier T, Asero R, Bindslev Jensen C, Walter Canonica G, Church MK, Gimenez Arnau A, et al. EAACI/GA(2)LEN/EDF/WAO guideline: definition, classification and diagnosis of urticaria. Allergy. 2009;64(10):1417 26. 5. Wai YC, Sussman GL. Evaluating chronic urticaria patients for allergies, infections, or autoimmune disorders. Clin Rev Allergy Immunol. 2002;23(2):185 93. 6. Powell RJ, Du Toit GL, Siddique N, Leech SC, Dixon TA, Clark AT, et al. BSACI guidelines for the management of chronic urticaria and angio oedema. Clin Exp Allergy. 2007;37(5):631 50. 7. Staevska M, Gugutkova M, Lazarova C, Kralimarkova T, Dimitrov V, Zuberbier T, et al. Night time sedating H1 antihistamine increases daytime somnolence but not treatment efficacy in chronic spontaneous urticaria: a randomized controlled trial. Br J Dermatol. 2014;171(1):148 54. 8. Ring J, Alomar A, Bieber T, Deleuran M, Fink Wagner A, Gelmetti C, et al. Guidelines for treatment of atopic eczema (atopic dermatitis) part I. J Euro Acad Dermatol Venereol. 2012;26(8):1045 60. 9. Kulthanan K, Chiawsirikajorn Y, Jiamton S. Acute urticaria: etiologies, clinical course and quality of life. Asian Pac J Allergy Immunol. 2008;26(1):1 9. 10. Wedi B, Kapp A. Evidence based therapy of chronic urticaria. J Dtsch Dermatol Ges. 2007;5(2):146 57. 11. Khafagy NH, Salem SA, Ghaly EG. Comparative study of systemic psoralen and ultraviolet A and narrowband ultraviolet B in treatment of chronic urticaria. Photodermatol Photoimmunol Photomed. 2013;29(1):12 7. 12. Zuberbier T, Asero R, Bindslev Jensen C, Walter Canonica G, Church MK, Gimenez Arnau AM, et al. EAACI/GA(2)LEN/EDF/WAO guideline: management of urticaria. Allergy. 2009;64(10):1427 43. 13. Staevska M, Popov TA, Kralimarkova T, Lazarova C, Kraeva S, Papova D, et al. The effectiveness of levocetirizine and desloratadine in up to 4 times conventional doses in difficult to treat urticaria. J Allergy Clin Immunol. 2010;125:676 82. 14. Grattan CEH, Humphreys. Guidelines for evaluation and management of urticaria in adults and children. Br J Dermatol. 2007;157: 1116 23. 15. Powell RJ, Du Toit GL, Siddique N, Leech SC, Dixon TA, Clark AT, et al. BSACI guidelines for management of chronic urticaria and angio edema. Clin Exp Allergy. 2007;37:631 50. 16. Zuberbier T. Acute urticaria. In: Greaves MW, Kaplan AP, editors. Urticaria and angioedema. 1 st ed. New York: Marcel Dekker, Inc; 2004. p. 141 7. 264 Clinical Practice Guideline Urticaria/Angioedema
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