by Prof Richard J Powell and Dr Susan Leech (April 2015)
This updates the BSACI Guideline published in 2007 and the significant additions are highlighted here.
The format includes separate sections on the management of urticaria in both Adults and Children with sections on the management of urticaria in pregnancy and in women that are breastfeeding, focussing on safe prescribing.
The guideline has adopted the new nomenclature substituting spontaneous urticaria (CsU) for the older term idiopathic urticaria. In addition the term inducible urticaria replaces the term physical when describing responses to cold, water etc.
Antihistamines - Higher doses of antihistamines are recommended for urticaria with the addition of Tranexamic acid for angioedema.
Possible Food Allergy - allergic reactions to allergens, such as omega-5 gliadin in wheat and lipid transfer proteins in plant-derived foods, which may occasionally present as intermittent spontaneous urticaria/exercise-induced anaphylaxis. In this context, reactions to Crustacea and GAL in red meat must also be considered although the latter is rare in the UK.
Anti IgE therapy - Omalizumab is effective in randomised double blind placebo controlled trials in patients with spontaneous and autoimmune chronic urticaria who have persistent symptoms despite high dose antihistamines . An EAACI position paper recommends omalizumab when higher dose antihistamines have failed . It requires monthly injections and appears well tolerated. It is effective in approximately 80% of individuals with persistent/resistant symptoms leading to a rapid improvement. 6 months but typically relapses occur when treatment is discontinued.
Psychological stress - individuals with CsU experience high rates of anxiety, depression and somatoform disorders such as fibromyalgia, with half of subjects with CsU being affected by at least one of these conditions [33;34]. A recent meta-analysis confirmed the high prevalence of an association between psychological factors and CU . Even if psychological symptoms develop subsequent to CU and play little part in its pathogenesis, the positive correlation between CU and markers of poor psychological wellness indicates that psychotherapeutic treatments and behavioural interventions may prove beneficial.
Type 111 Hereditary angioedema (HAE) - This is a rare condition and is associated with mutations of Factor XII where the levels of C1 inhibitor remain normal or only slightly reduced. Type III affects women more frequently and more severely, probably related to oestrogen . The benefit of progestin contraception rather than an oestrogen-progestin contraception in Type III is reported [49).
Treatment in children
Tranexamic acid has been added as second line treatment for isolated angioedema. A dose of 15-25 mg/kg (maximum 1.5g) 2-3 times per day is recommended.
Anti-IgE therapyis also effective in severe chronic urticaria in children over 7 years old, resistant to first line treatment. Three to six injections of 150 – 300 mg can be administered monthly. The treatment is well tolerated, but should be restricted to specialist centres.
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