A Patient Charter for Chronic Urticaria.

Chronic urticaria (CU) is the recurring development of wheals (aka "hives" or "welts"), angioedema, or both for more than 6 weeks. Wheals and angioedema occur with no definite triggers in chronic spontaneous urticaria, and in response to known and definite physical triggers in chronic inducible urticaria. Approximately 1.4% of individuals globally will have CU during their lifetime. The itching and physical discomfort associated with CU have a profound impact on daily activities, sexual function, work or school performance, and sleep, causing significant impairment in a patient's physical and mental quality of life. CU also places a financial burden on patients and healthcare systems. Patients should feel empowered to self-advocate to receive the best care. The voice of the patient in navigating the journey of CU diagnosis and management may improve patient-provider communication, thereby improving diagnosis and outcomes. A collaboration of patients, providers, advocacy organizations, and pharmaceutical representatives have created a patient charter to define the realistic and achievable principles of care that patients with CU should expect to receive. Principle (1): I deserve an accurate and timely diagnosis of my CU; Principle (2): I deserve access to specialty care for my CU; Principle (3): I deserve access to innovative treatments that reduce the burden of CU on my daily life; Principle (4): I deserve to be free of unnecessary treatment-related side-effects during the management of my CU; and Principle (5): I expect a holistic treatment approach to address all the components of my life impacted by CU. The stated principles may serve as a guide for healthcare providers who care for patients with CU and translate into better patient-physician communication. In addition, we urge policymakers and authors of CU treatment guidelines to consider these principles in their decision-making to ensure the goals of the patient are achievable.

Comparative safety of tenecteplase vs alteplase for acute ischemic stroke.

INTRODUCTION: Tenecteplase has been compared to alteplase in acute stroke randomized trials, with similar outcomes and safety measures, but higher doses of tenecteplase have been associated with higher hemorrhage rates in some studies. Limited data are available on the safety of tenecteplase outside of clinical trials. METHODS: We examined the safety measures of intracranial hemorrhage, angioedema, and serious extracranial adverse events in a 21-hospital integrated healthcare system that switched from alteplase (0.9 mg/kg, maximum dose 90 mg) to tenecteplase (0.25 mg/kg, maximum dose 25 mg) for acute ischemic stroke. RESULTS: Among 3,689 subjects, no significant differences were seen between tenecteplase and alteplase in the rate of intracranial hemorrhage (ICH), parenchymal hemorrhage, or volume of parenchymal hemorrhage. Symptomatic hemorrhage (sICH) was not different between the two agents: sICH by NINDS criteria was 2.0 % for alteplase vs 2.3 % for tenecteplase (P = 0.57), and sICH by SITS criteria was 0.8 % vs 1.1 % (P = 0.39). Adjusted logistic regression models also showed no differences between tenecteplase and alteplase: the odds ratio for tenecteplase (vs alteplase) modeling sICH by NINDS criteria was 0.9 (95 % CI 0.33 - 2.46, P = 0.83) and the odds ratio for tenecteplase modeling sICH by SITS criteria was 1.12 (95 % CI 0.25 - 5.07, P = 0.89). Rates of angioedema and serious extracranial adverse events were low and did not differ between tenecteplase and alteplase. Elapsed door-to-needle times showed a small improvement after the switch to tenecteplase (51.8 % treated in under 30 min with tenecteplase vs 43.5 % with alteplase, P < 0.001). CONCLUSION: In use outside of clinical trials, complication rates are similar between tenecteplase and alteplase. In the context of a stroke telemedicine program, the rates of hemorrhage observed with either agent were lower than expected based on prior trials and registry data. The more easily prepared tenecteplase was associated with a lower door-to-needle time.

Atopy and Response to Omalizumab Treatment in Chronic Spontaneous Urticaria.

INTRODUCTION: The possible influence of sensitization to aeroallergens on omalizumab response in chronic spontaneous urticaria (CSU) has been insufficiently investigated. This study's aim was to investigate atopy's influence on omalizumab response in CSU patients. METHOD: Retrospective study of CSU patients followed at a Portuguese Urticaria Center of Reference and Excellence (UCARE), treated with omalizumab for at least 6 months, between 2015 and 2022. At T0, all patients underwent quantification of specific immunoglobulin E (IgE) for total extract of most prevalent aeroallergens (ImmunoCAP Thermo Fisher Scientific®) and were divided in 2 groups, according to their response to omalizumab during the first 16 weeks of treatment: responders (R) (UAS7 <7) versus partial (PR) (UAS7 = 7-15) and nonresponders (UAS7 >15). R were further classified as fast (FR) (4-6 weeks) and slow responders (SR) (12-16 weeks). Total serum IgE, circulating eosinophil, and basophil counts were compared between groups at T0. p < 0.05 was considered statistically significant (SPSS® v25.0). RESULTS: Ninety-six patients (80% female) were studied, mean age 49 ± 14 years. Median CSU duration pre-omalizumab was 3 (0.6-20) years and mean omalizumab treatment duration was 3.7 ± 2.3 years. 38 (40%) had concomitant chronic inducible urticaria and 72 (75%) angioedema. Based on positive results of the specific IgE assay, 35 patients (36%) were considered atopic. Most patients (n = 30; 86%) were sensitized to house dust mites (HDM) (Dermatophagoides farinae = 28, Dermatophagoides pteronyssinus = 27, Blomia tropicalis = 19, Lepidoglyphus destructor = 17), followed by pollens (n = 12; 34%) (mixture of grasses = 10, Olea europaea = 7, Parietaria officinalis = 6), epithelia (n = 9; 26%) (dog = 8, cat = 7), and fungi (Alternaria alternata = 4; 11%). Eight patients (23%) were monosensitized to HDM and 4 (11%) to pollens. No significant association was found between aeroallergen sensitization and CSU duration, concomitant chronic inducible urticaria, or angioedema. Atopic patients featured significantly higher levels of baseline total serum IgE than nonatopic (469 vs. 94 U/mL, respectively; p = 0.0009). Mean baseline counts of eosinophils and basophils were not significantly different between atopic and non-atopic, respectively: eosinophils (128 vs. 121/mm3) and basophils (26 vs. 28/mm3). Regarding response to omalizumab, most patients (58; 60%) were responders: FR - 46 (79%); SR - 12 (21%). There was no significant association between aeroallergen sensitization and omalizumab response or speed of response. CONCLUSIONS: As far as we know, this is the first study exploring the influence of atopy sensitization pattern on omalizumab response in CSU. According to our results, presence of atopy/sensitization pattern does not influence omalizumab response in CSU patients.

Omalizumab is effective for a patient with pollen-food allergy syndrome who experienced intractable lip edema.

Pollen-food allergy syndrome (PFAS) is an immunoglobulin E (IgE)-mediated allergic reaction caused when patients with pollen allergy ingest food having cross-reactivity with pollen. To date, no effective treatment method for this has been established. Here we report the case of a patient with PFAS who experienced lip edema, causing difficulties in treatment. This report describes the case of a 12-year-old boy with perennial allergic rhinitis since the age of 8 years. After ingesting fresh fruits and raw vegetables at the age of 11 years, he started to experience lip edema repeatedly. Thus, the patient was referred to our department. Based on the results of serum antigen-specific IgE, prick-to-prick, and allergen component tests, he was diagnosed with PFAS. He has been instructed to avoid causative food. Furthermore, the treatment using an antihistamine and antileukotriene receptor antagonist was initiated for pollen allergy. Sublingual immunotherapy (SLIT) for Japanese cedar pollen was initiated because the patient experienced severe nasal allergy symptoms during the dispersal season of this pollen. These treatments alleviated the nasal symptoms; however, the lip edema persisted. Omalizumab administration improved the lip edema. The combination of SLIT and omalizumab may be an effective treatment option for patients with PFAS.

An Overview of Clinically Imperative and Pharmacodynamically Significant Drug Interactions of Renin-Angiotensin-Aldosterone System (RAAS) Blockers.

INTRODUCTION: Hypertension is a leading cause of cardiovascular disease and chronic kidney disease, resulting in premature death and disability. The Renin-Angiotensin-Aldosterone System (RAAS) blockers, including Angiotensin-Converting Enzyme (ACE) inhibitors or Angiotensin Receptor Blockers (ARBs), are used as first-line antihypertensive therapy to treat hypertensive patients with comorbidities, including diabetes, ischemic heart disease, heart failure, and chronic kidney disease. The use of RAS blockers is associated with the risks, such as hyperkalemia, angioedema, etc. The drugs potentiating them interact pharmacodynamically, resulting in adverse consequences. This review article focuses on the clinically important drug interactions of RAAS blockers. MATERIALS AND METHODS: The electronic databases, such as Medline/PubMed Central/PubMed, Google Scholar, ScienceDirect, Cochrane Library, Directory of Open Access Journals (DOAJ), Embase, and reference lists were searched to identify relevant articles. RESULTS: The risk of hyperkalemia may be enhanced potentially in patients receiving a RAS blocker and potassium-sparing diuretics, potassium supplements, trimethoprim, adrenergic betablockers, antifungal agents, calcineurin inhibitors, pentamidine, heparins or an NSAID, concomitantly. The patients taking ACE inhibitors and mTOR inhibitors, DPP4 inhibitors, alteplase, or sacubitril/valsartan concurrently may be at increased risk of developing angioedema. CONCLUSION: Clinicians, pharmacists, and other healthcare practitioners should be accountable for medication safety. To avoid adverse implications, prescribers and pharmacists must be aware of the drugs that interact with RAAS blockers.

What's New in the Treatment of Urticaria and Angioedema.

Chronic urticaria and angioedema are diseases often managed by Allergy and Immunology specialists. Recent international guidelines have outlined a stepwise approach to management of patients using dose escalation of second-generation antihistamines followed by use of omalizumab and finally cyclosporine in more refractory cases. In select patients (those with refractory chronic urticaria), nonbiologic alternative medications with anti-inflammatory or immunosuppressant activity may be considered. Angioedema without wheals may have several different pathophysiologic mechanisms. Optimal management of mast cell-mediated angioedema is less clear but is often managed similar to chronic spontaneous urticaria. Drug-induced angioedema due to angiotensin-converting enzyme inhibitors is a common cause of angioedema in the emergency department. Although bradykinin is thought to be a primary mediator for this type of angioedema, studies of targeted therapies have been generally disappointing. In contrast, several targeted therapies have been proven successful using acute and preventive approaches for management of hereditary angioedema. Further developments, including novel biologics, novel oral therapies, and gene therapy approaches, may hopefully continue to broaden therapeutic options to ensure optimal individual management of patients with hereditary angioedema.

Angioedema Due to Lamiaceae Allergy.

We present a 13-year-old male childallergic to three different plants (Salvia officinalis, Mentha piperita and Origanum onites L.) of Lamiaceae family. The patient developed angioedema 20-30 minutes after eating chicken meat with cheddar cheese. There was no history of allergy. Oral food challenge (OFC) with both cheddar cheese and chicken meat was negative. Skin tests for inhalant allergens were negative. 3 weeks later, the patient was admitted with angioedema after drinking sage tea. OFC with sage was applied and angioedema was observed. It was recognized that the first trigger, chicken meat with cheddar cheese, included oregano (Origanum onites L.). OFC for oregano was positive. Prick to prick test for Lamiaceae herbs (oregano, sage, mint) was performed. A positive reaction was observed only to mint. OFC was repeated with fresh mint and angioedema developed after 16 hours. Diagnose of Lamiaceae allergy is complicated and cross-sensitivity is common. Skin prick test (prick to prick)revealed a positive response only to mint but not to oregano and sage. Commercial radioallergosorbent (RAST) tests are available only for a few members of the family. Finally, thediagnose is based mainly on OFC. Spices from Lamiaceae group should be considered as potential triggers of allergic reactions.

The Expanding Field of Biologics in the Management of Chronic Urticaria.

Chronic urticaria (CU) is the occurrence of urticaria with or without angioedema for at least 6 weeks. Management has traditionally involved antihistamines as first-line therapy with various alternative therapies for refractory cases. Largely based on the success of biologics for various diseases, this class of drugs has come to the forefront of medical research. The first and only Food and Drug Administration-approved biologic for the management of CU is omalizumab (humanized anti-IgE mAb). In the past decade, a substantial amount of research has been centered on the mechanism of action, efficacy, dosing, and safety of omalizumab. This review will focus on the data surrounding the management of CU with omalizumab, off-label use of other biologics for CU, and biologics currently under investigation for use in CU. We will also discuss management considerations and areas of interest for future research.

Bariatric Surgery: A Novel Risk Factor for Food Allergy?

In this case report, we describe a birch pollen-allergic patient in whom a Fobi pouch gastric bypass was associated with the transition from a mild, localized, birch pollen-related oral allergy syndrome to more severe, generalized allergic reactions to peach.

Current and future therapies for the treatment of histamine-induced angioedema.

INTRODUCTION: Angioedema, a sudden, self-limited swelling of localized areas of any part of the body that may or may not be associated with urticaria, is thought to be the result of a mast-cell mediated process versus a bradykinin etiology. Understanding the mechanism is key in determining the proper treatment. Areas Covered: Clinical presentation of varying angioedema types may be similar; however, the appropriate treatment algorithm is dependent upon clinicians' knowledge of the underlying pathophysiology and classification of angioedema. Literature review of recent guidelines, available medications, and alternative therapies was completed to provide an overview of options. CONCLUSION: There are no formal guidelines for treatment of acute or chronic histamine-mediated angioedema, and therefore, algorithms for the treatment of acute and chronic urticaria should be followed until such information becomes available. Differentiating histamine-mediated versus bradykinin mediated angioedema is essential, as treatments and treatment responses are quite different. Further research is needed to better understand idiopathic angioedema that is unresponsive to H1/H2 antagonists, LTMAs, or medications designed to treat bradykinin-mediated angioedema.

Apis mellifica em tratamento de urticária crônica e angiodema: relato de caso

É relatado um caso de paciente com quadro de urticária crônica e angioedema com mais de 18 anos de evolução. Mal controle de sintomas com tratamento alopático e visitas frequentes ao pronto socorro deterioravam sua qualidade de vida e traziam insegurança devido ao potencial de gravidade do quadro. Em sua primeira consulta homeopática foi verificado alto grau de semelhança sintomática com a patogenesia de Apis mellifica, o qual foi introduzido e modificou a história de vida da paciente em questão, com excelente controle do quadro clínico. Realizada revisão da literatura sobre urticária e o policresto Apis mellifica, que vem sendo estudado in vitro na busca por evidências que possam explicar os efeitos da Homeopatia. (AU)

Reported case of a pacient with chronic urticaria and angioedema of more than 18 years of evolution. Poor control of symptoms with allopathic treatment and frequent visits to the emergency room deteriorated her quality of life and brought insecurity due to the potencial severity of the condition. In her first homeopathic appointment was verified high degree of symptomatic similarity to the pathogenesis of Apis mellifica, which was introduced and modified the patient’s life history, with excellent control of the condition. Performed literature review on urticaria and the policresto Apis mellifica that has been studied in vitro in search for evidence that might explain the effects of Homeopathy. (AU)

Apis mellificaem tratamento de urticária crônica e angioedema: relato de caso / Apis mellifica treatment of chronic urticaria and angioedema: case report

É relatado um caso de paciente com quadro de urticária crônica e angioedema com mais de 18 anos de evolução. Mal controle de sintomas com tratamento convencional e visitas cada vez mais frequentes ao pronto socorro deterioravam sua qualidade de vida e traziam insegurança devido ao potencial de gravidade do quadro. Em sua primeira consulta homeopática foi verificado alto grau de semelhança sintomática com a patogenesia de Apis mellifica, o qual foi introduzido e modificou a história de vida da paciente em questão, com excelente controle do quadro clínico. Foi realizada revisão da literatura sobre urticária e o policresto Apis mellifica.Este relato tem como objetivos chamar atenção para a existência e importância de recursos terapêuticos não convencionais, como é o caso da homeopatia, e também compartilhar com os colegas homeopatas a condução do caso, desde o diagnóstico e escolha do medicamento, ao seguimento da paciente. (AU)

We report the case of a patient with chronic urticaria and angioedema for more than 18 years. The symptoms were poorly checked with conventional treatment and increasingly frequentvisitsto the emergency department seriously affectedthe patient’s quality of life, in addition to makingher feel insecure about the severity of her condition. During the first homeopathic consultation we detected a high degree of similarity with the pathogenetic symptoms of Apis mellifica. The remedy was prescribed and changed the patient’s life history, achieving excellent control of her clinical condition. A literature review was performed on urticaria and polycrest medicine Apis mellifica. The aim of this case report is to call the attention to the availability and relevance of non-conventional therapeutic resources, such as homeopathy, and to share with colleagues aspects of the case management from diagnosis and medicine selection to follow up. (AU)

Apis mellificaem tratamento de urticária crônica e angioedema: relato de caso / Apis mellifica treatment of chronic urticaria and angioedema: case report

É relatado um caso de paciente com quadro de urticária crônica e angioedema com mais de 18 anos de evolução. Mal controle de sintomas com tratamento convencional e visitas cada vez mais frequentes ao pronto socorro deterioravam sua qualidade de vida e traziam insegurança devido ao potencial de gravidade do quadro. Em sua primeira consulta homeopática foi verificado alto grau de semelhança sintomática com a patogenesia de Apis mellifica, o qual foi introduzido e modificou a história de vida da paciente em questão, com excelente controle do quadro clínico. Foi realizada revisão da literatura sobre urticária e o policresto Apis mellifica. Este relato tem como objetivos chamar atenção para a existência e importância de recursos terapêuticos não convencionais, como é o caso da homeopatia, e também compartilhar com os colegas homeopatas a condução do caso, desde o diagnóstico e escolha do medicamento, ao seguimento da paciente.

We report the case of a patient with chronic urticaria and angioedema for more than 18 years. The symptoms were poorly checked with conventional treatment and increasingly frequent visits to the emergency department seriously affected the patient’s quality of life, in addition to making her feel insecure about the severity of her condition. During the first homeopathic consultation we detected a high degree of similarity with the pathogenetic symptoms of Apis mellifica. The remedy was prescribed and changed the patient’s life history, achieving excellent control of her clinical condition. A literature review was performed on urticaria and polycrest medicine Apis mellifica. The aim of this case report is to call the attention to the availability and relevance of non-conventional therapeutic resources, such as homeopathy, and to share with colleagues aspects of the case management from diagnosis and medicine selection to follow up.

Oscillococcinum leading to angioedema, a rare adverse event.

Oscillococcinum is an alternative medicine prepared by serial dilution of wild duck heart and liver extracts. This preparation has been labelled as a 'non drowsy, homoeopathic medicine' that 'reduces the duration and severity of flu and flu-like symptoms'. Clinical evidence exists to support this claim and the product has not previously been reported to cause any serious adverse drug reactions. We bring to light, however, a case of angioedema in our patient who was using oscillococcinum for flu-like symptoms. Consumers must therefore exercise caution at the outset of allergy symptoms.

Timing isn't everything: A case of recurrent angio-oedema

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