Rupatadine for the treatment of urticaria.

INTRODUCTION: Rupatadine fumarate is a second-generation antihistamine provided with a potent, long-lasting and balanced in vivo dual platelet-activating factor (PAF) and histamine antagonist activity and it uniquely combines both activities at a high level of potency. Rupatadine has a rapid onset of action and a long-lasting effect, so a once-daily dosing is permitted, moreover is well tolerated by young adults and the elders. Rupatadine does not present the side effects of first-generation H1-antihistamines, such as somnolence, fatigue, headache, impaired memory and learning, sedation, increased appetite, dry mouth, dry eyes, visual disturbances, constipation, urinary retention and erectile dysfunction. AREAS COVERED: This study evaluates the effectiveness and safety of rupatadine in chronic urticaria (CU) and acquired cold urticaria (ACU), through a systematic review of the literature. EXPERT OPINION: Patients affected by urticaria are often discouraged because frequently their disease does not recognize a cause and it is unresponsive to treatments. Patients can control their symptoms assuming second-generation H1-antihistamines, such as rupatadine. Several randomized, double-blind, placebo-controlled trials testify effectiveness and safety of rupatadine in CU and ACU. However, further clinical trials to evaluate the efficacy of rupatadine in different urticaria subtypes and to test the safety of doses higher than 20 mg are encouraged.

A mysterious case of gastroparesis: could the secret be found in a drink?

BACKGROUND: Gastroparesis is a disorder characterized by delayed gastric emptying of a meal in the absence of a mechanical gastric outlet obstruction. Idiopathic gastroparesis is at least as common as diabetic gastroparesis in most case series, and the true prevalence of gastroparesis is unknown. RESULTS: We report here an interesting case of idiopathic gastroparesis characterized by sudden onset in a female patient. The diagnosis was confirmed by ultrasonographic study of gastric emptying and electrogastrography, by gastric endoscopy/histology, and finally by allergy tests. The disorder was found to be due to a rare cause, namely an allergic predisposition. In fact, our patient, who demonstrated an allergy to gold salts, had drunk a glass of a liqueur containing gold flakes and developed an eosinophilic aggregation in the gastric mucosa observed at gastric endoscopy/histology. The symptoms disappeared after steroid administration. CONCLUSION: Our experience suggests that gastric histology and close enquiry into any history of allergy may be useful diagnostic tools in cases of idiopathic gastroparesis.

Allopurinol hypersensitivity reactions: desensitization strategies and new therapeutic alternative molecules.

Allopurinol, an analog of hypoxanthine has been worldwide used for the treatment of hyperuricemia and gout for over 40 years. Unfortunately some patients assuming this medication have developed hypersensitivity reactions ranging from mild cutaneous eruption to more severe clinical manifestations such as allopurinol hypersensitivity syndrome or Steven-Johnson syndrome and lethal toxic epidermal necrolysis. Various strategies of slow desensitization have been elaborated to reintroduce allopurinol in a part of these patients, mainly patients affected by mild skin reactions as fixed drug eruption or exanthema. However, several new uricosuric therapies have been recently introduced. Actually drugs as recombinant urate oxidase and febuxostat are under post-marketing surveillance to control potential adverse effects related to their immunogenicity even.

Latex immunotherapy: state of the art.

OBJECTIVE: Latex allergy remains a significant problem, especially among certain professional categories, and specific immunotherapy has been suggested as a suitable therapeutic option. The objective of the this article is to review the available literature on clinical trials of specific immunotherapy in latex allergy. DATA SOURCES: Literature databases (PubMed, Embase, Google Scholar) were searched for latex immunotherapy clinical trials. STUDY SELECTIONS: Clinical trials (either open or randomized controlled) using subcutaneous or sublingual immunotherapy with latex extracts were selected. Only articles published in English in peer-reviewed journals were considered. Case reports quoted in the clinical trials were also described, when pertinent. RESULTS: Eleven clinical trials (3 with subcutaneous and 8 with sublingual immunotherapy) were identified. Two of the 3 randomized trials of subcutaneous immunotherapy reported some benefit in adults but a remarkable occurrence of side effects. Concerning sublingual immunotherapy (SLIT), there were 6 randomized placebo-controlled (1 in children), 1 randomized open, and 1 open trials. All but 1 trial reported positive results, and the safety profile was overall superior to injection immunotherapy. The overall quality of the study was moderate, and the number of subjects studied was low. CONCLUSION: Although guidelines do not consider allergy to latex as an accepted indication to desensitization, SLIT can be offered, in addition to symptomatic treatment, to selected patients, when avoidance measures are not feasible or effective.

Vicia faba Hypersensitivity and ASA Intolerance in a Farmer: A Case Report.

The IgE-mediated allergic reactions to food are caused, generally, by ingestion. However, they can be rarely induced by exposure to airborne food particles through the handling or the cooking. Vicia faba is a vegetable which belongs to Legumes or Fabaceae family, Fabales order. Allergic reactions after ingestion of legumes and cases of asthma after exposure to the cooking vapors have been reported in the literature. A paper assessed the volatile substances (insect repellents) released by V. faba. The authors demonstrated that this plant produces several chemical substances, such as small quantities of methyl salicylate. We describe a case of occupational allergy, induced by handling during picking up of fresh broad beans, in a farmer with history of adverse reaction after eating the cooked and raw vegetable.

The employment of leukotriene antagonists in cutaneous diseases belonging to allergological field.

Leukotrienes (LTs) are potent biological proinflammatory mediators. LTC4, LTD4, and LTE4 are more frequently involved in chronic inflammatory responses and exert their actions binding to a cysteinyl-LT 1 (CysLT1) receptor and a cysteinyl-LT 2 (CysLT2) receptor. LTs receptor antagonists available for clinical use demonstrate high-affinity binding to the CysLT1 receptor. In this paper the employment of anti-LTs in allergic cutaneous diseases is analyzed showing that several studies have recently reported a beneficial effects of these agents (montelukast and zafirlukast as well as zileuton) for the treatment of some allergic cutaneous related diseases-like chronic urticaria and atopic eczema although their proper application remains to be established.

The safety of a novel sublingual rush induction phase for latex desensitization.

OBJECTIVES: In latex allergic individuals the avoidance of all exposure to natural rubber latex products is recommended. Sublingual immunotherapy against latex has recently been proposed. The aim of the study is to evaluate the tolerability of sublingual immunotherapy with latex extract, by a double-blind, placebo-controlled study, according to a three-day build-up phase rush protocol in a population of patients with latex-induced contact urticaria without a professional exposure to latex. METHODS: Twenty-one patients with latex-induced urticaria were randomized to receive sublingual immunotherapy (SLIT) with latex extract or placebo. Rush (3-day) induction protocol of latex sublingual immunotherapy was performed with increasing doses of ALK-Abelló latex extract at three concentrations of latex proteins (5, 50 and 500 microgmL(-1)). Any side-effects that might be related to immunotherapy, the corresponding dose and treatment were registered. RESULTS: Among the 21 patients, 12 were treated with latex sublingual immunotherapy (9 women and 3 men) and 9 with placebo (8 women and one man). All patients ended the rush protocol. Four patients (19.0%) [one in the SLIT group (8.3%) and three in the placebo group (33.3%)] developed adverse reactions. One SLIT patient reported mouth itching and burning of the tongue. In the placebo group, one patient presented gastrointestinal complaints while two patients reported unspecific symptoms. All these side-effects regressed spontaneously. No statistically significant differences were found between the proportions of adverse events in the two examined groups. CONCLUSION: This study supports the safety of SLIT against latex conducted in adult patients with latex-induced contact urticaria according to a 3-day build-up phase rush protocol. The proposed 3-day induction phase for latex sublingual immunotherapy should be conducted under medical supervision, although in patients with only latex-induced contact urticaria the registered adverse reactions were so slight that it could be argued that patients could start safely our tested rush protocol at home.

Safety of parecoxib in patients with nonsteroidal anti-inflammatory drug-induced urticaria or angioedema.

BACKGROUND: Parecoxib is the first injectable cyclooxygenase 2 selective inhibitor indicated for the treatment of acute postoperative pain. OBJECTIVE: To describe the results of a challenge with parecoxib in patients with a history of urticaria or angioedema to 1 or more nonsteroidal anti-inflammatory drugs (NSAIDs). METHODS: The study was performed from October 1, 2006, through March 31, 2007, with 79 patients who historically had experienced urticaria or angioedema after use of NSAIDs. The patients underwent a single-blind challenge with parecoxib, 40 mg. RESULTS: No reaction to placebo was observed in any patient. Similarly, no reaction to parecoxib was observed in any patients in the single-class or multiple-class intolerance group. CONCLUSION: Our report demonstrates that parecoxib does not induce cross-reactivity in patients with a history of urticaria or angioedema. Hence, this finding suggests that this drug could be safely proposed as an alternative (but only after a prior challenge) in patients with previous hypersensitive reactions to NSAIDs, even if there are added risk factors such as atopy and antimicrobial allergy, who require an analgesic drug perioperatively.

Tolerance to etoricoxib in 37 patients with urticaria and angioedema induced by nonsteroidal anti-inflammatory drugs.

BACKGROUND: The use of cyclooxygenase-2 inhibitors, a new class of analgesic drugs, is suggested in patients with hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs). OBJECTIVE: To evaluate tolerance to etoricoxib, a new cyclooxygenase-2 inhibitor, in NSAID-sensitive patients with urticaria-type adverse reactions. PATIENTS: Thirty-seven patients with adverse reactions to NSAIDs. METHODS: Single-blind, placebo-controlled oral challenge with increasing doses of etoricoxib. RESULTS: Thirty-four patients tolerated etoricoxib treatment without adverse reactions, but a generalized urticarial rash developed in 3 patients (8%). CONCLUSIONS: Etoricoxib, like other cyclooxygenase-2 inhibitors, is a well-tolerated drug in most NSAID-sensitive patients. However, according to our experience, a previous challenge test in a safe environment may be necessary before prescribing the drug to such patients.

Short-term tolerability of etoricoxib in patients with cutaneous hypersensitivity reactions to nonsteroidal anti-inflammatory drugs.

BACKGROUND: Etoricoxib is a novel cyclooxygenase 2 selective inhibitor. Until now, there has not been information in the literature about its tolerability in patients with a history of hypersensitivity reactions to nonsteroidal anti-inflammatory drugs (NSAIDs). OBJECTIVE: To determine the short-term tolerability of etoricoxib in patients with a history of cutaneous adverse reactions to NSAIDs. METHODS: Single-blind challenge testing was performed on 2 different days using placebo (talc) and etoricoxib. On the first day, 2 placebo capsules were administered 1 hour apart; 7 days later, each patient received divided doses of the total therapeutic dose of 90 mg of etoricoxib: 22.5 mg initially and 67.5 mg 1 hour later if no reactive symptoms were noted. RESULTS: Of 141 patients who underwent challenge testing with etoricoxib, only 2 (1.4%) had positive test results; both developed wheals on the extremities. These 2 patients were treated with chlorpheniramine maleate (10 mg intravenously), and the symptoms completely resolved within 2 hours. None of the patients experienced adverse reactions to the placebo challenge. CONCLUSION: The low rate of adverse reactions to etoricoxib, tested by oral challenge, suggests that patients with previous cutaneous hypersensitivity reactions to NSAIDs (primarily urticaria and angioedema) may tolerate this drug.

Short-term and long-term tolerability of rofecoxib in patients with prior reactions to nonsteroidal anti-inflammatory drugs.

BACKGROUND: Rofecoxib is a selective cyclooxygenase 2 (COX-2) inhibitor and is well tolerated as an alternative to nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with a previous adverse reaction to other classes of NSAIDs. Until now, there has not been information in the literature about its long-term tolerability. OBJECTIVE: To provide follow-up data on patients with a history of adverse cutaneous reactions to NSAIDs who underwent and tolerated a challenge test with rofecoxib. METHODS: Study patients had historically experienced cutaneous adverse reactions to aspirin and NSAIDs and had undergone single-blind challenges with rofecoxib, 25 mg. A questionnaire was distributed to all participants. In particular, they were asked to clarify any reactive symptoms they had developed after ingestion of the drug. All patients were reexamined 1 to 3 years after testing. At reexamination, they were carefully and personally interviewed using the previously distributed questionnaire. RESULTS: Of the 182 patients who participated in the study, none reacted to rofecoxib during single-blind challenges. Fifty-one (28%) never received rofecoxib again, whereas 131 (72%) were exposed to rofecoxib, often on multiple occasions. Only 7 (5%) of the 131 patients reported cutaneous reactions to rofecoxib during the 3 years of follow-up. CONCLUSIONS: Rofecoxib appears to be a safe alternative drug among atopic individuals, antibiotic-hypersensitive individuals, and individuals who experienced adverse cutaneous reactions to more than 1 class of NSAIDs, but it is less safe among chronic urticaria patients. Further investigations that include a larger sample are required to confirm our results especially among chronic urticaria patients.

Atopy and risk factors for latex sensitization in a selected population.

The value of recommending latex allergy screening in allergy departments of the Army's Hospital was studied. The purpose of the study was to evaluate whether atopy was a risk factor for latex sensitization in a specific population such as the young male soldiers of the Italian Army. The study was also aimed to assess the role of other risk factors. One thousand five hundred male subjects (1000 subjects who were atopic and 500 subjects who were nonatopic), visiting the Department of Allergology and Respiratory Physiopathology of the Army's Hospital in Bari, Italy, were enrolled into the study. The protocol included a questionnaire (symptoms of atopy, use of latex gloves and condoms and possible reactions previous surgical procedures), a clinical examination, a skin-prick test to latex and common allergens to evaluate atopy, and in part a latex challenge. Among the 1000 subjects who were atopic, 2.8% had evidence for sensitization to latex compared with 1.2% in the 500 subjects in the nonatopic group. The risk of latex sensitization was 19 times higher for subjects with a history of reactions to latex exposure and had a twofold increase for each surgical procedure and for each skin test positivity for inhalant allergens. Another risk factor was positivity to skin-prick tests for Artemisia vulgaris, cypress, and molds. Atopy significantly relates to an increased risk of latex sensitization. Screening is recommended in the Army's Hospital to identify latex-sensitized subjects and inform them about the risks connected with this condition.