Risk of first-generation H(1)-antihistamines: a GA(2)LEN position paper

ARIA 2019, Allerjik Rinite Tedavi Yaklaşımı-Türkiye

Gerçek yaşamda, çevresel maruziyetlerin de etkilediği rinit ve astım mültimorbidite durumlarında, dijitalleşmiş ve kişiye odaklanan tedaviler için bütünleştirilmiş tedavi yollarının değerlendirilmesi önerilmektedir. Gerçek yaşamdaki bu durum mültisipliner bir yaklaşımla basamaklandırılıp, rehberilerinde ülkelerdeki gereksinimlere göre değiştilmesini gerektirebilir. Allerjik rinitte hem farmakoterapi hem immünoterapi açısından acil yeni yaklaşımlara ihtiyaç olduğu görülmüştür. 3. Aralık 2018'de Paris'te bir toplantı yapılmış ve iki ayrı belge hazırlanmıştır. Bu yayında bunlara ait bir özet sunulup, ülkeye ve sağlık sistemine uygun kullanımın çerçevesi oluşturulmak istenmiştir.

[Recommendations on the management of urticaria in Primary Care]

Urticaria is a common cause for patient consultations in Primary Care (PC). However, the optimal approach to managing urticaria in PC is controversial and not well-established. For this reason, there is a clear need to clarify the causes of urticaria and to develop treatment protocols to improve urticaria management in the PC setting. The present work has been developed with this objective. A group of experts in PC and dermatology, with specific expertise in treating urticaria, have reviewed the main clinical guidelines and publications on urticaria in order to develop clear, interdisciplinary recommendations on managing urticaria. In this article, consensus-based recommendations are presented that include simple, practical diagnostic, and treatment algorithms. These guidelines will help to optimise the management of patients with urticaria, increasing their quality of life and reducing the socioeconomic costs associated with this illness.

Antihistamines: ABC for the pediatricians

Antihistamines are currently one of the most commonly administered drugs in children. They are used to treat symptoms that depend on histamine release, namely allergic diseases, such as rhinitis, asthma, urticaria, and anaphylaxis. It is possible to distinguish first- and second-generation antihistamines. Pharmacological effects and therapeutic indications are similar, but second-generation antihistamines have fewer adverse effects because they are more selective for peripheral H1 receptors. Although they have been on the market for several years, there are still many adverse effects linked to the antihistamine safety profile, especially in the first years of life. Thus, many antihistamines are prescribed off-label, especially in children younger than 2 years of age, which is the age-group where most of the data on drug safety are lacking and many antihistamines are not recommended. This article aims to provide a practical update on the use of antihistamines in children.

Does Over-the-Counter Purchase of Antihistamines by Residents of Dhaka City, Bangladesh Align with the Prescribing Choices of the Physicians Practicing in That City?

Most current guidelines recommend prescribing second-generation antihistamines (SGAs) over first-generation antihistamines because SGAs are less likely to cause sedation and impairment of heavy work performance. However, common residents who use these antihistamines as over-the-counter (OTC) medicines are less likely to know that. So, this study was designed to compare the over-the-counter use of antihistamines by common residents with the prescribing preferences of physicians residing at Dhaka City, Bangladesh. Between June and August of 2017, a total of 100 Physicians from some of the top medical institutions of the city and 350 randomly selected common residents were directly interviewed with two separate semistructured questionnaires specifically designed for each population. Data was statistically analyzed using Fischer’s exact test, Spearman’s rank correlation test and Kendall’s tau rank correlation test. The data shows that physicians prefer second-generation antihistamines with fexofenadine (48.09% of the total responses), desloratadine (16.03%), and rupatadine (13.74%) taking the top spots. Cetirizine (29.46% of total responses), desloratadine (14.73%), and chlorpheniramine (14.52%) were the most used OTC antihistamines by the common residents. Statistical analysis with Fischer’s exact test revealed that the difference in preference of first-generation antihistamines between physicians and common residents were extremely significant (p<0.0001). Furthermore, cetirizine (which is known to have some degree of sedating activity) and chlorpheniramine are more preferred among common residents than among physicians (extremely significant difference, p<0.0001 in both cases). The study concludes that physicians of Dhaka City are complying with practice guidelines, but sedating antihistamines still retain some popularity among the common residents. Hence, a more engaging community pharmacy is needed to minimize adverse effects that can arise from OTC use of sedating antihistamines.

Updated guidelines for intravenous contrast use for CT and MRI

Intravenous (IV) contrast material is used extensively for CT and MRI scans done in emergency departments (ED). Its use is essential to make many critical diagnoses in ED patients. While adverse reactions can occur, newer research has added to our knowledge of IV contrast media tolerance and safety leading to improved and more liberal guidelines for intravenous contrast use. The updated information described in this review article indicates how intravenous contrast can be used safely in more patients, more expeditiously and with fewer precautions than with prior guidelines. This review article explains the basis for the new recommendations for intravenous contrast material use and describes indicated precautions and preparations to avoid adverse reactions for iodinated agents used for CT and gadolinium agents for MRI.

The therapeutic versatility of antihistamines: A comprehensive review

Antihistamines are common and readily available medications for primary care patients and those seeking over-the-counter treatments. This article provides an overview of available antihistamines, their mechanisms of action, safety concerns in specific populations, and their therapeutic uses in several common conditions.

ARIA guideline 2019: treatment of allergic rhinitis in the German health system

Background: The number of patients affected by allergies is increasing worldwide. The resulting allergic diseases are leading to significant costs for health care and social systems. Integrated care pathways are needed to enable comprehensive care within the national health systems. The ARIA (Allergic Rhinitis and its Impact on Asthma) initiative develops internationally applicable guidelines for allergic respiratory diseases. Methods: ARIA serves to improve the care of patients with allergies and chronic respiratory diseases. In collaboration with other international initiatives, national associations and patient organizations in the field of allergies and respiratory diseases, real-life integrated care pathways have been developed for a digitally assisted, integrative, individualized treatment of allergic rhinitis (AR) with comorbid asthma. In the present work, these integrated care pathways have been adapted to the German situation and health system. Results: The present ICP (integrated care pathway) guideline covers key areas of the care of AR patients with and without asthma. It includes the views of patients and other healthcare providers. Discussion: A comprehensive ICP guideline can reflect real-life care better than traditional guideline models.

Doxepin cream is not effective in reducing itch in burn scar patients: A multicenter triple-blind randomized clinical crossover trial

OBJECTIVE

To evaluate the effect of doxepin hydrochloride 5% cream on reducing pruritus in burn scar patients compared to a placebo cream.

METHOD

We conducted a multicenter triple-blind randomized clinical placebo-controlled crossover trial in which burn patients ≥18 years with an itch intensity ≥3 on a Visual Analogue Scale (VAS) were randomized between a doxepin-placebo or placebo-doxepin treatment protocol. Patients used each cream during two weeks with a wash-out period of one week in between. Primary outcome was change in itch intensity in two weeks' time using the VAS. Secondary outcome included the impact of itch (Burn Itch Questionnaire). Other parameters were the use of hydrating cream, silicon treatment, pressure garments, and other antipruritic medication.

RESULTS

Twenty-seven patients were included. The change in itch intensity (VAS) was not different during the doxepin and placebo period (p=0.994); neither the doxepin cream nor placebo cream reduced itch intensity. However, based on the Burn Itch Questionnaire, we observed a statistically significant decrease in itch intensity and improvement in impact scores in both treatment groups, but no difference in the degree of reduction between the groups.

CONCLUSION

Doxepin cream was not effective in reducing pruritus in our burn patient study population.

Real-life treatment of patients with cholinergic urticaria in German-speaking countries

BACKGROUND

Cholinergic urticaria (CholU) is a frequent type of chronic inducible urticaria. Symptomatic treatment with second-generation antihistamines (sgAH) is recommended by current guidelines as first-line therapy, but little is known about how patients with CholU are treated in real life and how they respond to treatment.

AIM

To assess real-life treatment of CholU in German-speaking countries.

METHODS

Patients with CholU (n = 111) took part in an online survey study that assessed their treatments and their treatment responses.

RESULTS

Virtually all patients (97 %) had used antihistamines, 87 % of them sgAH; 23 % had also taken first-generation antihistamines (fgAH). The proportion of patients who benefited from standard-dosed antihistamine treatment was low (sgAH: 32 % vs. fgAH: 16 %), and side effects of sgAH and fgAH were comparable. Updosing of antihistamines had been tried by 66 patients (59 %) (most commonly [98 %, n = 65] with sgAH) and resulted in marginally better responses (sgAH: 38 % vs. fgAH: 32 %). Only very few patients had used other treatments, mostly corticosteroids (30 %) and omalizumab (5 %).

CONCLUSIONS

SgAH were commonly used, but insufficient in about two thirds of CholU patients. Accordingly, improved use of third-line and fourth-line treatment options and development of better therapies for patients with CholU are needed.

2019 ARIA Care pathways for allergen immunotherapy

Allergen immunotherapy (AIT) is a proven therapeutic option for the treatment of allergic rhinitis and/or asthma. Many guidelines or national practice guidelines have been produced but the evidence-based method varies, many are complex and none propose care pathways. This paper reviews care pathways for AIT using strict criteria and provides simple recommendations that can be used by all stakeholders including healthcare professionals. The decision to prescribe AIT for the patient should be individualized and based on the relevance of the allergens, the persistence of symptoms despite appropriate medications according to guidelines as well as the availability of good-quality and efficacious extracts. Allergen extracts cannot be regarded as generics. Immunotherapy is selected by specialists for stratified patients. There are no currently available validated biomarkers that can predict AIT success. In adolescents and adults, AIT should be reserved for patients with moderate/severe rhinitis or for those with moderate asthma who, despite appropriate pharmacotherapy and adherence, continue to exhibit exacerbations that appear to be related to allergen exposure, except in some specific cases. Immunotherapy may be even more advantageous in patients with multimorbidity. In children, AIT may prevent asthma onset in patients with rhinitis. mHealth tools are promising for the stratification and follow-up of patients.

Using Patient Profiles To Guide The Choice Of Antihistamines In The Primary Care Setting In Malaysia: Expert Consensus And Recommendations

H1-antihistamines are recognized to be effective for conditions such as allergic rhinitis and chronic spontaneous urticaria. However, management of such conditions in the real-world primary care setting may be challenging due to diverse patient-specific considerations, the wide range of antihistamines available, choice of other treatment modalities, and the complexity of interpreting specialist treatment algorithms. Despite regular updates to international guidelines, regional/national surveys of healthcare professionals show a clear gap between guidelines and real-world practice, particularly at the primary care level. This article thus presents the consensus opinion of experts from relevant specialties in Malaysia - allergology, pediatrics, otorhinolaryngology, and dermtology - on harmonizing the use and choice of antihistamines in primary care. Patient profiling is recommended as a tool to guide primary care practitioners in prescribing the appropriate antihistamine for each patient. Patient profiling is a three-step approach that involves 1) identifying the individual's needs; 2) reviewing patient-specific considerations; and 3) monitoring treatment response and referral to specialists in more severe or difficult-to-treat cases. Concurrently, guidelct 3ines should be reviewed and updated periodically to include recommendations that are easily actionable for primary care practitioners.

Structural and clinical impact of anti-allergy agents: An overview

Allergic disorders are markedly rising in industrialized countries. The identification of compounds that trigger the immunoglobulin E (IgE)-dependent allergic reaction remain the means to improve the quality of life by limiting patient's exposure to critical allergens. Information concerning the treatment and onset of allergic disorders including atopic dermatitis, allergic rhinitis, and bronchial asthma has been provided by the research over the past decade. Recent studies also indicated that allergic inflammation is associated closely with their exacerbation and progression and indeed is the basic pathophysiology of allergic diseases. As a result of immunological and molecular biological studies our understanding of the mechanism of allergic inflammation with regard to therapeutic agents has improved. While much effort has been paid to developing a new anti-allergic agent, the allergic disease has yet to be completely conquered. The more extensive research will allow the development of new therapeutics to combat allergic diseases. Currently, with respect to mechanism of action anti-allergy drugs are classified into five types including histamine H₁ antagonists, leukotriene antagonists, Th₂ cytokine inhibitors, thromboxane A₂ inhibitors and mediator-release inhibitors. The use of two or more anti-allergy agents together is not acknowledged at present, but this will be the subject of research in the future because with different mechanisms of action anti-allergy agents used at the same time will theoretically increase their effects. This review article focuses on anti-allergy agents highlighting their applications, clinical trials and recent advancement on drugs.

Allergic Rhinitis in Children and Adolescents

Allergic rhinitis is a common disorder that regularly occurs in children and adolescents. The disease is associated with other allergic diseases, such as asthma, and it carries a heavy burden, with effects on sleep, school performance, and quality of life. Classic symptoms include sneezing, rhinorrhea, nasal obstruction, and nasal itching. When the eyes are involved, the term allergic rhinoconjunctivitis is used. Triggers may include airborne pollens, molds, dust mites, and animals. Skin or blood allergy testing can be a useful diagnostic modality that may guide therapy. Immunotherapy can prevent the development of further allergic sensitizations as well as subsequent asthma.

CSACI position statement: Newer generation H1-antihistamines are safer than first-generation H1-antihistamines and should be the first-line antihistamines for the treatment of allergic rhinitis and urticaria

Oral H₁-antihistamines (AHs) are the most commonly used therapy to treat allergic rhinitis and chronic urticaria. Older, first-generation AHs (e.g. diphenhydramine, hydroxyzine) have significant and common side effects including sedation, impairment with decreased cognitive function, poor sleep quality, dry mouth, dizziness, and orthostatic hypotension. These drugs have also been found to result in death from accidents, intentional or unintentional overdoses, and sudden cardiac death. The unfavourable risk–benefit profile of first-generation AHs led to the development of newer, less-sedating second- and third-generation AHs, which first became available in Canada in the 1980s. High-quality trials have proven that newer generation AHs are superior in safety compared to older first-generation AHs. On average, they have improved potency and efficacy. Second- and third-generation AHs are the recommended first-line treatment for mild allergic rhinitis and acute and chronic urticaria. Despite this evidence, older first-generation AHs continue to be over-utilized because of their over-the-counter (OTC) status and long history of use. The Canadian Society of Allergy Clinical Immunology (CSACI) recommends that newer generation AHs should be preferred over first-generation AHs for the treatment of allergic rhino-conjunctivitis and urticaria. To promote this recommendation, education of health professionals and the public is necessary. Further, given the dangers of older first-generation AHs, we believe they should be used only as a last resort with eventual consideration given to having them only available behind the counter in pharmacies.

Management of chronic urticaria in children: a clinical guideline

The aim of this guidance is to provide recommendations to clinicians and other interested parties on chronic urticaria in children. The Italian Society for Pediatrics (SIP), the Italian Society for Allergy and Immunology (SIAIP), the Italian Society for Pediatric dermatology (SIDerP) convened a multidisciplinary panel that prepared clinical guidelines for diagnosis and management of chronic urticaria in childhood. Key questions on epidemiology, natural history, diagnosis, and management were developed. The literature was systematically searched and evaluated, recommendations were rated and algorithms for diagnosis and treatment were developed. The recommendations focus on identification of diseases and comorbidities, strategies to recognize triggering factors, improvement of treatment by individualized care.

A multicenter study on the efficacy and safety of So-Cheong-Ryong-Tang for perennial allergic rhinitis

BACKGROUND

So-Cheong-Ryong-Tang (SCRT), also known as Xiao-Qing-Long-Tang or Sho-seiryo-to, is a mixed herbal formula that is used to treat allergic rhinitis, bronchitis, allergic asthma, and common cold in traditional Korean medicine.

OBJECTIVE

To assess the efficacy and safety of the SCRT for the treatment of allergic rhinitis.

METHODS

We conducted a double-blind, randomized, placebo-controlled, parallel-group, multicenter study of Korean adults with perennial allergic rhinitis. The trial consisted of a 4-week oral administration of SCRT or placebo, with two visits at 2-week intervals, and an 8-week follow-up period, with two visits at 4-week intervals. The primary outcome was a change in the total nasal symptoms score. The secondary outcomes included changes in the Rhinoconjunctivitis Quality of Life Questionnaire score, total serum immunoglobulin E (IgE), cytokines levels, and nasal endoscopy index.

RESULTS

SCRT improved nasal symptoms and quality of life in patients with PAR after 4 weeks medication, and these effects did not last 8 weeks after the end of medication. The level of serum IgE, eosinophil counts, and cytokines did not alter after medication. Nasal endoscopy index did not show significant difference. No serious AEs and safety assessment changes were observed in this trial.

CONCLUSION

SCRT is an effective and safe medication for patients with chronic, perennial, and moderate to severe AR. A clinical study with a >4-week period of medication use, and more participants for immune material test is needed to investigate the long-term efficacy of SCRT in relieving the symptoms of nasal obstruction and identifying the underlying mechanisms of action and indications for traditional Korean medicine.

Brain histamine H1 receptor occupancy after oral administration of desloratadine and loratadine

Some histamine H1 receptor (H1R) antagonists induce adverse sedative reactions caused by blockade of histamine transmission in the brain. Desloratadine is a second-generation antihistamine for treatment of allergic disorders. Its binding to brain H1Rs, which is the basis of sedative property of antihistamines, has not been examined previously in the human brain by positron emission tomography (PET). We examined brain H1R binding potential ratio (BPR), H1R occupancy (H1RO), and subjective sleepiness after oral desloratadine administration in comparison to loratadine. Eight healthy male volunteers underwent PET imaging with [11C]-doxepin, a PET tracer for H1Rs, after a single oral administration of desloratadine (5 mg), loratadine (10 mg), or placebo in a double-blind crossover study. BPR and H1RO in the cerebral cortex were calculated, and plasma concentrations of loratadine and desloratadine were measured. Subjective sleepiness was quantified by the Line Analogue Rating Scale (LARS) and the Stanford Sleepiness Scale (SSS). BPR was significantly lower after loratadine administration than after placebo (0.504 ± 0.074 vs 0.584 ± 0.059 [mean ± SD], P < 0.05), but BPR after desloratadine administration was not significantly different from BPR after placebo (0.546 ± 0.084 vs 0.584 ± 0.059, P = 0.250). The plasma concentration of loratadine was negatively correlated with BPR in subjects receiving loratadine, but that of desloratadine was not correlated with BPR. Brain H1ROs after desloratadine and loratadine administration were 6.47 ± 10.5% and 13.8 ± 7.00%, respectively (P = 0.103). Subjective sleepiness did not significantly differ among subjects receiving the two antihistamines and placebo. At therapeutic doses, desloratadine did not bind significantly to brain H1Rs and did not induce any significant sedation.

Histamine, histamine receptors, and anti-histamines in the context of allergic responses

Histamine is a bioactive amine which is considered a key player in the allergic response. Thus, histamine receptor blockers (antihistamines) play an important role in the treatment of a number atopic diseases such as allergic rhinitis, conjunctivitis, and acute and chronic forms of urticaria. Histamine is produced by immune cells but also by bacteria in the gut. Beyond its role in the acute allergic response, histamine exerts numerous effects by binding to its 4 pleiotropic G-protein coupled histamine receptors. Here, we describe the roles of these histamine receptors and antihistamines in the human system, clinical applications, side effects, and novel concepts for the usage of antihistamines with different specificity based on guidelines and recommendations.

Statement of novelty: This review provides an overview of histamine receptors and links it to clinical relevance of antagonizing their action in clinical routine.

Chronic cough in the elderly

Chronic cough is a multi-factorial syndrome commonly presenting as cough hypersensitivity in adult patients. It is a common medical condition in the communities but is more prevalent in older adults. Elderly patients (≥65 years) frequently suffer from multiple comorbidities, which may lead to more clinical heterogeneity in chronic cough and pose diagnostic and therapeutic challenges. Hyposensitivity in cough reflex, probably resulting from central nervous system illnesses, is another potential concern. Despite these complexities and challenges, elderly-specific issues have rarely been addressed in current clinical practice guidelines for chronic cough. Considering recent trends in global population aging, the burden of elderly chronic cough is expected to increase into the near future. This review aimed to respond to following clinical questions: (1) is chronic cough a more heterogeneous condition in the elderly compared to younger adults; and (2) are there additional considerations when choosing the diagnostic and therapeutic approaches to this condition in the elderly?

Do pharmacists counsel customers about the effects of sedating antihistamines on driving skills? A survey of community pharmacies in Saudi Arabia

Objective

To investigate the level of counselling regarding the effects of sedating antihistamines on driving skills provided by private community pharmacies in Madinah, Saudi Arabia.

Methods

This study randomly selected private community pharmacies. Mystery shoppers following a similar scenario individually visited these pharmacies. These clients asked for a commonly used brand of sedating antihistamine and noted the counselling offered by the pharmacist. If spontaneous counselling was not offered, necessary information regarding the medication’s use was requested. Finally, the content of counselling was documented.

Results

Of the 100 pharmacies selected, 12 were excluded for various reasons and 88 pharmacies were included in the study. Only 23 pharmacies offered spontaneous counselling. Although 73.9% of pharmacists (65 of 88), spontaneously or upon request, mentioned sedation as a side-effect, only one pharmacist warned the client against driving after taking the medication, and three other pharmacists warned against dealing with hazardous machinery. Other side-effects were almost ignored.

Conclusion

A life-threatening insufficiency in the quality of counselling at Saudi Arabian private community pharmacies exists. Traffic accidents, secondary to the side-effects of sedating antihistamines, may be avoided if proper counselling is offered. Saudi Arabian authorities should take appropriate actions to ensure optimal practice in community pharmacies.

[Age-specific aspects in the treatment of angioedema patients]

Manifestation of angioedema can occur at any age. We distinguish between two main subtypes: mast cell mediator-associated angioedema (often with hives) and the non-mast cell mediator-associated angioedema. The patient's history is very important due to the fact that one subtype can be hereditary, but we also have to consider new mutations and even not yet diagnosed patients. Acquired non-mast cell mediator-associated angioedema is rare in children, but very common in adults due to the intake of angiotensin-converting enzyme inhibitors. From a detailed anamneses, classification is very often possible. But especially in childhood, symptoms are often projected onto the gastrointestinal tract, which have to be seen differently. The burden of disease defined as disease activity and quality of life may change in the course of life, but is not always predictable. Therapies are available for all angioedema subtypes in any age. If treatment is necessary, the attacks should be treated early to positively influence duration and severity of the attacks. The management of the patients includes besides information, education of the patient and family members regarding therapy options and prevention of triggers and the repetition of education, especially in case of any change of life circumstances.

Antihistamines for Allergic Rhinitis Treatment from the Viewpoint of Nonsedative Properties

Antihistamines targeting the histamine H₁ receptor play an important role in improving and maintaining the quality of life of patients with allergic rhinitis. For more effective and safer use of second-generation drugs, which are recommended by various guidelines, a classification based on their detailed characteristics is necessary. Antihistamines for first-line therapy should not have central depressant/sedative activities. Sedative properties (drowsiness and impaired performance) are associated with the inhibition of central histamine neurons. Brain H₁ receptor occupancy (H₁RO) is a useful index shown to be correlated with indices based on clinical findings. Antihistamines are classified into non-sedating (<20%), less-sedating (20–50%), and sedating (≥50%) groups based on H₁RO. Among the non-sedating group, fexofenadine and bilastine are classified into “non-brain-penetrating antihistamines” based on the H₁RO. These two drugs have many common chemical properties. However, bilastine has more potent binding affinity to the H₁ receptor, and its action tends to last longer. In well-controlled studies using objective indices, bilastine does not affect psychomotor or driving performance even at twice the usual dose (20 mg). Upon selecting antihistamines for allergic rhinitis, various situations should be taken into our consideration. This review summarizes that the non-brain-penetrating antihistamines should be chosen for the first-line therapy of mild allergic rhinitis.

Atopic dermatitis

Atopic dermatitis (AD) is a common, chronic skin disorder that can significantly impact the quality of life of affected individuals as well as their families. Although the pathogenesis of the disorder is not completely understood, it appears to result from the complex interplay between defects in skin barrier function, environmental and infectious agents, and immune dysregulation. There are no diagnostic tests for AD; therefore, the diagnosis is based on specific clinical criteria that take into account the patient's history and clinical manifestations. Successful management of the disorder requires a multifaceted approach that involves education, optimal skin care practices, anti-inflammatory treatment with topical corticosteroids and/or topical calcineurin inhibitors, the management of pruritus, and the treatment of skin infections. Systemic immunosuppressive agents may also be used, but are generally reserved for severe flare-ups or more difficult-to-control disease. Topical corticosteroids are the first-line pharmacologic treatments for AD, and evidence suggests that these agents may also be beneficial for the prophylaxis of disease flare-ups. Although the prognosis for patients with AD is generally favourable, those patients with severe, widespread disease and concomitant atopic conditions, such as asthma and allergic rhinitis, are likely to experience poorer outcomes.

Surveillance of First-Generation H1-Antihistamine Use for Older Patients with Dementia in Japan: A Retrospective Cohort Study

BACKGROUND

This study aimed to investigate the rate of first-generation H1-antihistamines use for older adults with dementia in Japan.

METHODS

The study design was retrospective cohort using claims data between fiscal years 2010 and 2013. Subjects were 75 years or older, diagnosed with dementia, and given H1-antihistamines orally during the study period after being diagnosed with dementia. We investigated the cumulative number of oral H1-antihistamines administered and the relationship between first-generation H1-antihistamine use and each explanatory variable using crude and adjusted odds ratio.

RESULTS

The cumulative total for use of first-generation H1-antihistamine for older adults with dementia accounted for 32.1% of all antihistamine medication. The majority of first-generation H1-antihistamine prescriptions were indicated for cold treatment. Those with upper respiratory infection or asthma had a significantly positive relationship with first-generation H1-antihistamine use.

CONCLUSION

The study showed that first-generation H1-antihistamine drugs were highly prescribed in older adults with dementia in Japan.

The EAACI/GA²LEN/EDF/WAO guideline for the definition, classification, diagnosis and management of urticaria

This evidence- and consensus-based guideline was developed following the methods recommended by Cochrane and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group. The conference was held on 1 December 2016. It is a joint initiative of the Dermatology Section of the European Academy of Allergology and Clinical Immunology (EAACI), the EU-founded network of excellence, the Global Allergy and Asthma European Network (GA²LEN), the European Dermatology Forum (EDF) and the World Allergy Organization (WAO) with the participation of 48 delegates of 42 national and international societies. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS). Urticaria is a frequent, mast cell-driven disease, presenting with wheals, angioedema, or both. The lifetime prevalence for acute urticaria is approximately 20%. Chronic spontaneous urticaria and other chronic forms of urticaria are disabling, impair quality of life and affect performance at work and school. This guideline covers the definition and classification of urticaria, taking into account the recent progress in identifying its causes, eliciting factors and pathomechanisms. In addition, it outlines evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria.

Effects of levocetirizine and diphenhydramine on regional glucose metabolic changes and hemodynamic responses in the human prefrontal cortex during cognitive tasks

OBJECTIVE

Antihistamines often have sedative side effects. This was the first study to measure regional cerebral glucose (energy) consumption and hemodynamic responses in young adults during cognitive tests after antihistamine administration.

METHODS

In this double-blind, placebo-controlled, three-way crossover study, 18 healthy young Japanese men received single doses of levocetirizine 5 mg and diphenhydramine 50 mg at intervals of at least six days. Subjective feeling, task performances, and brain activity were evaluated during three cognitive tests (word fluency, two-back, and Stroop). Regional cerebral glucose consumption changes were measured using positron emission tomography with [¹⁸ F]fluorodeoxyglucose. Regional hemodynamic responses were measured using near-infrared spectroscopy.

RESULTS

Energy consumption in prefrontal regions was significantly increased after antihistamine administration, especially diphenhydramine, whereas prefrontal hemodynamic responses, evaluated with oxygenated hemoglobin levels, were significantly lower with diphenhydramine treatment. Stroop test accuracy was significantly impaired by diphenhydramine, but not by levocetirizine. There was no significant difference in subjective sleepiness.

CONCLUSIONS

Physiological "coupling" between metabolism and perfusion in the healthy human brain may not be maintained under pharmacological influence due to antihistamines. This uncoupling may be caused by a combination of increased energy demands in the prefrontal regions and suppression of vascular permeability in brain capillaries after antihistamine treatment. Further research is needed to validate this hypothesis.

Pretreatment Prediction of the Outcomes of Intranasal Steroid Sprays in Cases with Inferior Turbinate Hypertrophy

Objective

Intranasal steroid sprays (INSS) are frequently prescribed for treating inferior turbinate hypertrophy (ITH). Complications due to the long-term application of INSS such as crusting, epistaxis, nasal mucosa dryness, and septal perforation may occur. Predicting patients who would benefit from INSS early might lower treatment costs and complication rates. We examined the predictive value of nasal decongestant response rates for the outcomes of INSS in ITH.

Methods

Fifty patients with bilateral ITH were included in two groups: patients benefiting from INSS and those not benefiting. Nasal airflow was assessed by peak nasal inspiratory flow (PNIF) measurement in all cases. Measurements were taken three times: before and after the application of nasal decongestant sprays and after the application of INSS.

Results

In both groups, the nasal air flow rates significantly increased after the application of nasal decongestant sprays; however, the nasal decongestant response rates were higher in the group with patients benefiting from INSS. There was a strong correlation between the nasal air flow rates measured after the application of nasal decongestant sprays and after the application of INSS. The cut-off value for the relationship between increased nasal air flow rates after the application of nasal decongestant sprays and outcomes of INSS was 23%.

Conclusion

Measurement of nasal airflow increase rate after the application of nasal decongestant sprays is a simple and easy method for the early prediction of the outcomes of INSS in ITH. A higher than 23% increase in nasal air flow rates after the application of nasal decongestant sprays indicates much better outcomes of INSS for patients.

A systematic review of regulatory and educational interventions to reduce the burden associated with the prescriptions of sedative-hypnotics in adults treated for sleep disorders

BACKGROUND

The burden of Sedative-Hypnotics (SHs) has been known since the 1980s. Yet, their consumption remains high. A systematic review of the literature should help to assess efficient interventions to improve the appropriate use of SHs in sleep disorders.

OBJECTIVES

To identify and assess regulatory and educational interventions designed to improve the appropriate use of SHs for insomnia treatment.

METHODS

We conducted a systematic review of the literature according to PRISMA guidelines. A systematic search covering the period 1980-2015 was carried out in Medline, Web of Science, Embase and PsycInfo. We included studies reporting the implementation of regulatory or educational strategies directed towards patients and/or healthcare professionals to improve the appropriate use of SHs to treat insomnia in the community, hospitals and nursing homes.

RESULTS

Thirty-one studies were included: 23 assessed educational interventions (recommendations by mail/email, computer alerts, meetings, mass media campaigns, prescription profile), 8 assessed regulatory interventions (prescription rule restriction, end of reimbursement). The most recent was implemented in 2009. Restrictive prescription rules were effective to reduce the consumption of targeted SHs but led to a switch to other non-recommended SHs. Among educational interventions, only 3 studies out of 7 reported positive results of mono-faceted interventions; whereas, 13 out of the 16 multi-faceted interventions were reported as efficient: particularly, the active involvement of healthcare professionals and patients and the spread of information through mass media were successful. The risk of bias was high for 24 studies (mainly due to the design), moderate for 3 studies and weak for 4 studies.

CONCLUSION

Educational multifaceted studies are presented as the most efficient. But further better designed studies are needed to make evidence-based results more generalizable.

An assessment of the use of antihistamines in the management of atopic dermatitis

BACKGROUND

Antihistamines are often used to treat pruritus associated with atopic dermatitis (AD) despite lack of evidence for their efficacy. The American Academy of Dermatology does not recommend the general use of antihistamines in the management of AD, although the value of short-term sedating antihistamine use for insomnia secondary to itch is recognized.

OBJECTIVE

To assess the use of sedating and nonsedating antihistamines for AD in 2003-2012.

METHODS

The National Ambulatory Medical Care Survey provided data on physician visits in 2003-2012. Sedating and nonsedating antihistamine use was identified at visits for AD.

RESULTS

There were 990,000 annual visits for AD. Antihistamines were prescribed for AD in a significant proportion of visits across physician specialties (16%-44%). Dermatologists and pediatricians primarily used sedating antihistamines (58%-70%), whereas the majority of family/general practitioners, internists, and other specialists prescribed nonsedating antihistamines for AD (55%-100%) LIMITATIONS: We were limited by the accuracy of AD diagnosis and medication recording.

CONCLUSIONS

Antihistamines are widely used for the treatment of AD. There is no high-level evidence to suggest that nonsedating antihistamines reduce itch in patients with AD or that sedating antihistamines provide benefit in controlling AD symptoms (except perhaps sleep and AD comorbidities, such as allergic rhinitis).

Consensus Statement for the Diagnosis and Treatment of Urticaria: A 2017 Update

This article is developed by the Skin Allergy Research Society of India for an updated evidence-based consensus statement for the management of urticaria, with a special reference to the Indian context. This guideline includes updated definition, causes, classification, and management of urticaria. Urticaria has a profound impact on the quality of life and causes immense distress to patients, necessitating effective treatment. One approach to manage urticaria is by identification and elimination of the underlying cause(s) and/or eliciting trigger(s) while the second one is by treatment for providing symptomatic relief. This guideline recommends the use of second-generation nonsedating H1-antihistamines as the first-line treatment. The dose can be increased up to four times to meet the expected results. In case patients still do not respond, appropriate treatment options can be selected depending on the associated medical condition, severity of the symptoms, affordability of the drugs, and accessibility of modern biologics such as omalizumab.

Economic Burden of the Inadequate Management of Allergic Rhinitis and Urticaria in Asian Countries Based on the GA²LEN Model

Purpose

Across Hong Kong, Malaysia, the Philippines, Singapore, Thailand and Vietnam, (referred to as Asia) approximately 30–53 million individuals of the 151 million employed suffer from allergic rhinitis (AR) and urticaria. It is estimated that approximately 90% of patients with these allergic conditions are insufficiently treated, impacting the socioeconomic burden in terms of absence from work and decreased productivity. This study aims to estimate the socioeconomic burden of allergies in Asia and the cost savings that their adequate management can provide. Due to the limited availability of regional data, this study focused AR and urticaria in selected countries.

Methods

Published literature, information from statistical bureaus, clinician surveys and extrapolation of selected data from the European Union were used to determine the socioeconomic costs of AR and urticaria.

Results

Many patients in Asia suffer from perennial allergies and experience symptoms of AR and urticaria for up to 298 days per year. An estimate of the indirect costs of patients insufficiently treated for AR and urticaria amounts to USD 105.4 billion a year, which equates to USD 1,137–2,195 per patient due to absenteeism and presenteeism. Adherence to guideline-approved treatment can lead to estimated savings of up to USD 104 billion.

Conclusions

The current study suggests that within Asia, the socioeconomic impact of AR and urticaria is similar to that seen in the European Union in spite of the lower wages in Asia. This is due to the mainly perennial allergens prevailing in Asia, whereas the sensitization patterns observed in the European Union are dominated by seasonal exposure to pollen. These results underline the need for governmental initiatives to increase public awareness on the prevention and treatment of these and other allergic diseases as well as greater research funding and large-scale studies to reduce their growing socioeconomic burden in coming years.

Chronic urticaria in a health maintenance organization of Buenos Aires, Argentina - new data that increase global knowledge of this disease

BACKGROUND

In spite of the frequency of chronic urticaria, there are no epidemiological studies on its prevalence in Argentina.

OBJECTIVE

The objective of this study was to define the prevalence and epidemiological characteristics of chronic urticaria patients in Buenos Aires.

METHODS

The population studied were the members of the Italian Hospital Medical Care Program, a prepaid health maintenance organization located in the urban areas around the Autonomous City of Buenos Aires, Argentina. All patients with diagnosis of chronic urticaria members of the Italian Hospital Medical Care Program, and with at least 12 months of follow up were included in the study. All medical records obtained between January 1st, 2012 and December 31, 2014 were analyzed. The prevalence ratio for chronic urticaria per 100,000 population with 95% CI for December 31, 2014 was calculated. The prevalence rate for the entire population and then discriminated for adults and pediatric patients (less than 18 years old at diagnosis) was assessed.

RESULTS

158,926 members were analyzed. A total of 463 cases of chronic urticaria were identified on prevalence date (68 in pediatrics, 395 in adults), yielding a crude point prevalence ratio of 0.29% (CI 95% 0.26-0.31%). The observed prevalence of chronic urticaria in the adult population was 0.34 % (95% CI 0.31-0.38%), while in pediatrics it was 0.15 % (95% CI 0.11-0.20%).

STUDY LIMITATIONS

the main weakness is that the results were obtained from an HMO and therefore the possibility of selection bias.

CONCLUSIONS

chronic urticaria is a global condition. Its prevalence in Buenos Aires is comparable with other countries.