Efficacy and safety of desloratadine in adults with chronic idiopathic urticaria: a randomized, double-blind, placebo-controlled, multicenter trial

The Effect of Placebo on Pruritus in Patients with Chronic Urticaria: A Systematic Review and Meta-Analysis of Randomized Placebo-Controlled Trials

BACKGROUND

The anti-pruritic effect of placebo in patients with chronic urticaria has gained increasing attention in clinical research. However, the extent of placebo effect and its influencing factors in the treatment of chronic urticaria are not well understood.

OBJECTIVE

The objective of this systematic review and meta-analysis was to investigate the effect of placebo on pruritus in patients with chronic urticaria and to explore relevant influencing factors.

METHODS

PubMed, Embase, Web of Science, Cochrane Library, and PsycINFO were searched from inception to 10 July, 2024. Primary outcome included pruritus scores. The secondary outcomes focused on global symptoms and quality of life. Subgroup analyses and meta-regression analyses were conducted based on drug types, sample size, participants' age, and other variables. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system and a trial sequential analysis were employed to establish the reliability of evidence.

RESULTS

A total of 65 eligible publications (including 67 randomized controlled trials) involving 10,704 patients with chronic urticaria were included. The pruritus scores decreased following placebo treatment (moderate evidence). In addition, favorable results were observed in global symptoms (moderate evidence) and quality of life (low evidence) after placebo treatment. Subgroup analyses indicated that the type of active medication in intervention groups was an influencing factor of placebo effect of pruritus. Meta-regression analyses demonstrated that the anti-pruritic effect of placebo was inversely correlated with sample size and positively correlated with participants' age. A trial sequential analysis provided further support for the anti-pruritic effect of placebo.

CONCLUSIONS

A substantial improvement of pruritus after placebo treatment was observed in patients with chronic urticaria. The anti-pruritic effect of placebo varied with sample size, participants' age, and type of active medication used. Future research should further investigate the effect size of placebo and clarify the potential mechanism.

PROSPERO REGISTRATION

The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) as CRD42023482608.

An update on the use of antihistamines in managing chronic urticaria

INTRODUCTION

Urticaria, a mast cell-mediated skin disease, manifests as acute or chronic, with the latter divided into spontaneous and inducible types and requires individualized management, including identifying triggers and comorbidities. Antihistamines, particularly the second generation group, form the mainstay of primary treatment plans consisting of dosage adjustments and/or in combination with other treatment modalities depending on underlying disease control.

AREAS COVERED

A literature search was conducted using 'antihistamines,' 'urticaria,' 'pharmacogenomics,' 'genomics,' 'biomarkers' and 'treatment response' as key words. In this review, we focus on the comprehensive understanding and application of antihistamines in managing adult and adolescent patients with chronic urticaria.

EXPERT OPINION

Using antihistamines to treat urticaria is set to change significantly, focusing more on personalized medicine and identifying key biomarkers to enhance treatment response prediction. These changes aim to make treatments more specific and cost-effective by avoiding unnecessary tests. Applying new approaches in everyday clinical care faces challenges like proving the biomarkers' reliability, updating current guidelines, and incorporating individualized treatments into standard procedures. Efforts should now concentrate on finding easy-to-use biomarkers, improving access to pharmacogenomics, understanding why some patients are resistant to treatment, and creating more specific treatment options based on patient needs.

The Efficacy and Safety of High Dose (10 mg) of Desloratadine (Dazit® 10) in the Treatment of Chronic Spontaneous Urticaria in India: A Phase III, Multicentric, Open-Label, Single-Arm Study

BACKGROUND

Chronic spontaneous urticaria (CSU) is a debilitating affliction that affects diverse quality of life (QoL) parameters such as sleep, self-esteem, and daily activities. Second-generation antihistamines, such as desloratadine, are more effective and safer in managing CSU. Desloratadine is a nonsedating, potent, and highly selective H1 receptor antagonist. At its daily dose of 5 mg, almost half of CSU patients do not show symptomatic improvement. European Academy of Allergy and Clinical Immunology (EAACI)/Global Allergy and Asthma European Network (GA2LEN)/European Dermatology Forum (EDF) (EuroGuiDerm)/Asia Pacific Association of Allergy, Asthma and Clinical Immunology (APAAACI) guidelines recommend increasing the dosage to up to four times in such nonresponsive patients. However, there is insufficient clinical evidence in Indian settings.

METHOD

We evaluated the efficacy and safety of 10 mg desloratadine (OD) in 256 nonresponsive patients with moderate to severe CSU. The primary outcome was the change in Urticaria Activity Score (UAS7) from baseline to four weeks. Additionally, change in Chronic Urticaria Quality of Life (CU-Q2oL) scores during the course of treatment was also evaluated.

RESULT

The mean UAS7 scores showed a significant reduction from 31.9 ± 4.8 at baseline to 18.2 ± 8.1 at the end of the study (p < 0.0001). The use of a higher dose of desloratadine also decreased the CU-Q2oL scores significantly from 59.8 ± 14.7 at baseline to 35.4 ± 10 at four weeks (p < 0.0001). The incidence of adverse events (AEs) possibly linked to the drug was low (1.6%), and no serious adverse events were reported.

CONCLUSION

Results indicated improvements in the disease severity as well as its positive impact on participants' QoL. This study confirms the efficacy and safety of daily use of a twofold dose of desloratadine in nonresponsive moderate to severe CSU patients.

Comparative effectiveness and safety of drug therapy for chronic urticaria: a network meta-analysis and risk-benefit assessment

BACKGROUND

Chronic urticaria (CU) is a prevalent chronic skin condition characterized by recurrent wheals. Clinical guidelines recommend multiple drugs for CU treatment. Our study aims to compare the effectiveness and safety of drug therapy for CU.

METHODS

We conducted a comprehensive search of randomized controlled trials (RCTs) and real-world studies (RWSs) in PubMed, EMBASE, and Cochrane. A network meta-analysis (NMA) was conducted to assess the response rate, decline in Urticaria Activity Score over 7 Days (UAS7), Dermatology Life Quality Index (DLQI), and adverse event rates of standard-dose and high-dose H1 antihistamine (H1AH), omalizumab (OMA) 75, 150, and 300 mg, cyclosporine and placebo. The risk-benefit assessment was conducted by probabilistic simulation and stochastic multicriteria acceptability analysis (SMAA).

RESULTS

A total of 39 studies were identified, including 37 RCTs and 2 RWSs. OMA 300 mg and 150 mg both had significantly higher response rate than standard-dose H1AH (p < 0.05, respectively). OMA 300 mg and 150 mg both consistently led to a huge drop in UAS7 and DLQI compared to standard-dose H1AH and high-dose H1AH (p < 0.05).

CONCLUSION

Regarding risk-benefit assessment, OMA 300 mg emerges as the optimal pharmacological intervention for CU, while OMA 150 mg stands as a secondary alternative compared to H1 antihistamines and cyclosporine.

Comparative Safety Profiles of Individual Second-Generation H1-Antihistamines for the Treatment of Chronic Urticaria: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

BACKGROUND

The comparative safety and/or dosing regimens of individual second-generation H1-antihistamines (sgAHs) in patients with chronic urticaria (CU) remain poorly elucidated.

OBJECTIVE

To compare the safety profiles of individual sgAHs and/or dosing regimens in adolescents or adult patients with CU using a systematic review and network meta-analysis of all available evidence.

METHODS

With limited English publications, electronic databases and gray literature were searched for randomized clinical trials from inception, with searches last updated on January 20, 2023. Relevant safety outcomes included treatment unacceptability (all-cause discontinuation), tolerability (discontinuation due to any adverse events), adverse events, serious adverse events, central nervous system (CNS) side effects, and anticholinergic side effects. Regarding the network estimates, the probability of being associated with the highest adverse outcome risk was estimated for each treatment comparison.

RESULTS

Fifty-one randomized clinical trials with 14 individual sgAHs and different dosing regimens, involving 7502 participants, were included. On the basis of the findings from network meta-analyses, variations in sgAH treatment comparisons were observed regarding the unacceptability of treatment, tolerability, adverse events, and CNS side effects. There were no statistically significant differences between the results of sgAH treatment for serious adverse events and those for anticholinergic side effects. On the basis of the ranking of safety profiles, emedastine 4 mg, mizolastine 10 mg, and cetirizine 10 mg were the top 3 ranked treatments with unfavorable safety profiles associated with CNS side effects and any adverse events.

CONCLUSIONS

These findings suggest evidence of variations in safety profiles among sgAHs for CU treatment, particularly in terms of adverse events and CNS side effects.

Comparative Efficacy and Acceptability of Licensed Dose Second-Generation Antihistamines in Chronic Spontaneous Urticaria: A Network Meta-Analysis

BACKGROUND

Licensed dose second-generation H1-antihistamines (sgAHs) are the first-line treatment in chronic spontaneous urticaria (CSU). However, the available evidence up to the present is insufficient to rank sgAHs in terms of their efficacy.

OBJECTIVES

To study the comparative efficacy and acceptability of all licensed dose sgAHs in CSU treatment.

METHODS

We searched PubMed, Scopus, the Cochrane Central Register of Controlled Trials, and Web of Science for randomized controlled trials (RCTs) that included licensed dose sgAHs in CSU treatment up until March 2020. A network meta-analysis was performed to estimate the standardized mean difference (SMD) and 95% confidence interval (CI) from both direct and indirect evidence for efficacy outcomes. The primary outcome was the total symptom score (TSS) changes from baseline. Secondary outcomes were changes in pruritus score and wheal score from baseline. The acceptability was estimated using odds ratios.

RESULTS

We identified and included 22 RCTs with 3943 patients for evidence synthesis. Olopatadine, fexofenadine, bilastine, rupatadine, and levocetirizine were more efficacious than placebo in TSS. Olopatadine was ranked first for all efficacy outcomes (TSS: SMD -1.26 [95% CI: -1.94 to -0.58], pruritus score: SMD -0.82 [95% CI: -1.30 to -0.35], and wheal score: SMD -0.65 [95% CI: -1.10 to -0.55]). The acceptability of all included sgAHs was not inferior to the placebo.

CONCLUSIONS

Olopatadine, fexofenadine, bilastine, rupatadine, and levocetirizine demonstrate superior therapeutic efficacy to placebo for the treatment of patients with CSU. Because of the low to very low quality of almost all studies included in this study, rigorous head-to-head trials are needed to confirm our findings.

Urticaria: A comprehensive review: Treatment of chronic urticaria, special populations, and disease outcomes

Second-generation antihistamines are considered first-line agents in the treatment of chronic urticaria because of their safety and efficacy profile. Some patients require higher doses of H₁ antihistamines alone or in combination with other classes of medications, including H₂ antihistamines, leukotriene receptor antagonists, or first-generation H₁ antihistamines. One major therapeutic advance has been omalizumab, a humanized monoclonal anti-immunoglobulin E that was recently approved by the US Food and Drug Administration for the treatment of chronic urticaria that is unresponsive to H₁ antagonists. In addition, the second article in this continuing medical education series outlines several evidence-based alternative treatments for urticaria and the differences in recommendations between 2 major consensus groups (the European Academy of Allergy and Clinical Immunology/World Allergy Organization and the American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force).

Antihistamines and itch

Histamine is one of the best-characterized pruritogens in humans. It is known to play a role in pruritus associated with urticaria as well as ocular and nasal allergic reactions. Histamine mediates its effect via four receptors. Antihistamines that block the activation of the histamine H₁receptor, H₁R, have been shown to be effective therapeutics for the treatment of pruritus associated with urticaria, allergic rhinitis, and allergic conjunctivitis. However, their efficacy in other pruritic diseases such as atopic dermatitis and psoriasis is limited. The other histamine receptors may also play a role in pruritus, with the exception of the histamine H₂receptor, H₂R. Preclinical evidence indicates that local antagonism of the histamine H₃receptor, H₃R, can induce scratching perhaps via blocking inhibitory neuronal signals. The histamine H₄receptor, H₄R, has received a significant amount of attention as to its role in mediating pruritic signals. Indeed, it has now been shown that a selective H₄R antagonist can inhibit histamine-induced itch in humans. This clinical result, in conjunction with efficacy in various preclinical pruritus models, points to the therapeutic potential of H₄R antagonists for the treatment of pruritus not controlled by antihistamines that target the H₁R.

H1-antihistamines for chronic spontaneous urticaria

Background Chronic spontaneous urticaria (CSU) is characterised by the development of crops of red, itchy, raised weals or hives with no identifiable external cause.Objectives To assess the effects of H1-antihistamines for CSU.Search methods We searched the following databases up to June 2014: Cochrane Skin Group Specialised Register, CENTRAL (2014, Issue 5), MEDLINE(from 1946), EMBASE (from 1974) and PsycINFO (from 1806). We searched five trials registers and checked articles for references to relevant randomised controlled trials.Selection criteria We included randomised controlled trials of H1-antihistamines for CSU. Interventions included single therapy or a combination of H1-antihistamines compared with no treatment (placebo) or another active pharmacological compound at any dose.Data collection and analysis We used standard methodological procedures as expected by The Cochrane Collaboration.Our primary outcome measures were proportion of participants with complete suppression of urticaria: 'good or excellent' response,50% or greater improvement in quality of life measures, and adverse events.We present risk ratios (RR) with 95% confidence intervals(CIs). Main results We identified 73 studies (9759 participants); 34 studies provided data for 23 comparisons. The duration of the intervention was up to two weeks (short-term) or longer than two weeks and up to three months (intermediate-term).Cetirizine 10mg once daily in the short term and in the intermediate term led to complete suppression of urticaria by more participants than was seen with placebo (RR 2.72, 95% CI 1.51 to 4.91). For this same outcome, comparison of desloratadine versus placebo in the intermediate term (5 mg) (RR 37.00, 95% CI 2.31 to 593.70) and in the short term (20 mg) (RR 15.97, 95% CI 1.04 to 245.04)favoured desloratadine, but no differences were seen between 5 mg and 10 mg for short-term treatment.Levocetirizine 20 mg per day (short-term) was more effective for complete suppression of urticaria compared with placebo (RR 20.87,95% CI 1.37 to 317.60), and at 5 mg was effective in the intermediate term (RR 52.88, 95% CI 3.31 to 843.81) but not in the shortterm, nor was 10 mg effective in the short term.Rupatadine at 10 mg and 20 mg in the intermediate term achieved a 'good or excellent response' compared with placebo (RR 1.35,95% CI 1.03 to 1.77).Loratadine (10 mg) versus placebo (RR 1.86, 95% CI 0.91 to 3.79) and loratadine (10 mg) versus cetirizine (10 mg) (RR 1.05, 95%CI 0.76 to 1.43) over short-term and intermediate-term treatment showed no significant difference for 'good or excellent response' or for complete suppression of urticaria, respectively.Loratadine (10 mg) versus desloratadine (5 mg) (intermediate-term) showed no statistically significant difference for complete suppression of urticaria (RR 0.91, 95% CI 0.78 to 1.06) or for 'good or excellent response' (RR 1.04, 95% CI 0.64 to 1.71). For loratadine(10 mg) versus mizolastine (10 mg) (intermediate-term), no statistically significant difference was seen for complete suppression of urticaria (RR 0.86, 95% CI 0.64 to 1.16) or for 'good or excellent response' (RR 0.88, 95% CI 0.55 to 1.42).Loratadine (10mg) versus emedastine (2mg) (intermediate-term) showed no statistically significant difference for complete suppression(RR 1.04, 95% CI 0.78 to 1.39) or for 'good or excellent response' (RR 1.09, 95% CI 0.96 to 1.24); the quality of the evidence was moderate for this comparison.No difference in short-term treatment was noted between loratadine (10mg) and hydroxyzine (25mg) in terms of complete suppression(RR 1.00, 95% CI 0.32 to 3.10).When desloratadine (5 to 20 mg) was compared with levocetirizine (5 to 20 mg), levocetirizine appeared to be the more effective (P value < 0.02).In a comparison of fexofenadine versus cetirizine, more participants in the cetirizine group showed complete suppression of urticaria(P value < 0.001).Adverse events leading to withdrawals were not significantly different in the following comparisons: cetirizine versus placebo at 10 mg and 20 mg (RR 3.00, 95% CI 0.68 to 13.22); desloratadine 5 mg versus placebo (RR 1.46, 95% CI 0.42 to 5.10); loratadine 10 mg versus mizolastine 10 mg (RR 0.38, 95% CI 0.04 to 3.60); loratadine 10mg versus emedastine 2mg (RR 1.09, 95%CI 0.07 to 17.14);cetirizine 10 mg versus hydroxyzine 25 mg (RR 0.78, 95% CI 0.25 to 2.45); and hydroxyzine 25 mg versus placebo (RR 3.64, 95%CI 0.77 to 17.23), all intermediate term.No difference was seen between loratadine 10 mg versus mizolastine 10 mg in the proportion of participants with at least 50%improvement in quality of life (RR 3.21, 95% CI 0.32 to 32.33).Authors' conclusions Although the results of our review indicate that at standard doses of treatment, several antihistamines are effective when compared with placebo, all results were gathered from a few studies or, in some cases, from single-study estimates. The quality of the evidence was affected by the small number of studies in each comparison and the small sample size for many of the outcomes, prompting us to downgrade the quality of evidence for imprecision (unless stated for each comparison, the quality of the evidence was low).No single H1-antihistamine stands out as most effective. Cetirizine at 10 mg once daily in the short term and in the intermediate term was found to be effective in completely suppressing urticaria. Evidence is limited for desloratadine given at 5 mg once daily in the intermediate term and at 20 mg in the short term. Levocetirizine at 5 mg in the intermediate but not short term was effective for complete suppression. Levocetirizine 20 mg was effective in the short term, but 10 mg was not. No difference in rates of withdrawal due to adverse events was noted between active and placebo groups. Evidence for improvement in quality of life was insufficient.

Urticaria and its subtypes: the role of second-generation antihistamines

Urticaria is a heterogeneous group of debilitating skin disorders characterized by wheals, pruritus, and frequently angioedema. The various forms of urticaria are often chronic and can exact a toll on quality of life. New diagnostic criteria and management guidelines are available to assist primary care physicians in the identification and proper treatment of different subtypes of urticaria. Second-generation antihistamines are recommended as first-line therapy because of their high degree of efficacy and safety. It is important to note, however, that European indications for most agents in this class are limited to specific forms of urticaria. The exception is desloratadine, the only second-generation antihistamine approved for the treatment of all urticaria subtypes in the European Union. Guidelines and best practice suggest that doses of antihistamines up to 4 times higher than those normally recommended for urticaria may benefit patients who do not respond to standard doses of antihistamines. Adjunctive therapy with leukotriene receptor antagonists may be advantageous in certain subgroups of patients who have suboptimal responses to antihistamine monotherapy. In all cases, physicians should work closely with patients to ensure proper adherence to prescribed regimens-a component that is often lacking but holds the key to successful outcomes.

Chronic urticaria: a comparison of management guidelines

INTRODUCTION

Chronic urticaria is characterized by recurring episodes of spontaneous transient dermal wheals and pruritus, with or without angioedema, which can persist for ≥ 6 weeks. Chronic urticaria impairs quality of life, emphasizing the need for effective treatments. Professional societies and clinical experts have issued evidence-based recommendations for the management of chronic urticaria, including recommending the use of second-generation antihistamines as a first-line therapy.

AREAS COVERED

A Medline search was conducted from 2000 to 2011 using the following terms, alone or in combination: 'chronic urticaria', 'management guidelines', 'consensus guidelines' and 'expert opinions'. Ten management guidelines/expert opinions met the inclusion criteria.

EXPERT OPINION

There was a universal agreement among the articles reviewed, that low-sedating, second-generation antihistamines should be prescribed as a first-line treatment of chronic urticaria. For refractory urticaria, however, recommendations varied and included dose escalation of second-generation antihistamines and adjunctive treatments with other agents of the same class, such as sedating antihistamines or leukotriene receptor antagonists. More research into effective second-line treatments and consistent implementation of current guidelines is needed, to ensure that treatment is based on clinical evidence.

Unmet clinical needs in chronic spontaneous urticaria. A GA²LEN task force report

Chronic spontaneous urticaria, formerly also known as chronic idiopathic urticaria and chronic urticaria (CU), is more common than previously thought. At any time, 0.5-1% of the population suffers from the disease (point prevalence). Although all age groups can be affected, the peak incidence is seen between 20 and 40 years of age. The duration of the disease is generally 1-5 years but is likely to be longer in more severe cases, cases with concurrent angioedema, in combination with physical urticaria or with a positive autologous serum skin test (autoreactivity). Chronic spontaneous urticaria has major detrimental effects on quality of life, with sleep deprivation and psychiatric comorbidity being frequent. It also has a large impact on society in terms of direct and indirect health care costs as well as reduced performance at work and in private life. In the majority of patients, an underlying cause cannot be identified making a causal and/or curative treatment difficult. Nonsedating H₁-antihistamines are the mainstay of symptomatic therapy, but treatment with licensed doses relieves symptoms effectively in < 50% of patients. Although guideline-recommended updosing up to fourfold increases symptom control in many patients, a substantial number of patients have only little benefit from H₁ -antihistamines. Consequently, there is a great need for new therapeutic strategies.

Antihistaminic, anti-inflammatory, and antiallergic properties of the nonsedating second-generation antihistamine desloratadine: a review of the evidence

The allergy cascade presents widespread inflammatory and proinflammatory activation, robust cytokine and chemokine signaling, and heterogeneous immune and endothelial responses that lead ultimately to the manifestations of allergic reaction. Histamine, a small peptide with inherent vasoactive properties, is released from granules contained within mast cells, basophils, lymphocytes, and other reservoirs and interacts with histamine receptors to regulate numerous cellular functions involved in allergic inflammation and immune modulation. Of the known histamine receptors, the H(1)-receptor is most clearly associated with potentiation of proinflammatory immune cell activity and enhanced effector function and is the prime focus of suppressive therapy. Second-generation oral H(1)-antihistamines, such as cetirizine, desloratadine, fexofenadine, levocetirizine, and loratadine, are mainstays of allergy treatment, acting as highly specific, long-acting H(1)-receptor agonists at its unique receptor. The ongoing identification of immune effector cells and mediators involved in the allergic cascade indicates that further research is necessary to define the role of antihistamines such as desloratadine in anti-inflammatory therapy.

Safety and efficacy of desloratadine in subjects with seasonal allergic rhinitis or chronic urticaria: results of four postmarketing surveillance studies

BACKGROUND AND OBJECTIVE

Allergic rhinitis (AR) and chronic urticaria (CU) are common diseases with symptoms that impair quality of life. Second-generation antihistamines (e.g. cetirizine, desloratadine, fexofenadine, loratadine and mizolastine) are recommended first-line treatment for both conditions; however, studies of clinically relevant differences among these agents are lacking. The aim of this investigation was to evaluate the safety, tolerability and efficacy of desloratadine 5 mg once daily in four postmarketing surveillance studies in subjects with seasonal AR (SAR) or chronic idiopathic urticaria (CIU) in real-world clinical practice settings.

METHODS

This programme of prospective surveillance studies was conducted in Germany between February 2001 and March 2002 in allergy; dermatology; ear, nose and throat; or general practice settings. Subjects (total number 77 880) were aged > or =12 years and met the requirements for treatment of SAR or CIU with desloratadine as outlined in the package insert. All subjects received oral desloratadine 5 mg once daily for a mean duration of up to 40.4 days. Adverse events (AEs) were reported throughout the studies; serious AEs were recorded for up to 30 days after treatment. Investigators and subjects both rated tolerability at the end of treatment. Symptom severity and sleep and daily activity impairment were evaluated at baseline and after treatment using 4-point scales (0 = none; 1 = mild; 2 = moderate; 3 = severe). A post hoc subanalysis assessed desloratadine efficacy and onset of symptom relief in subjects who had received monotherapy with another second-generation antihistamine.

RESULTS

A total of 386 AEs were reported by 287 subjects (0.37%) in the four studies. The most commonly reported treatment-related AEs were fatigue (0.07%), headache (0.07%), dry mouth (0.04%) and nausea (0.03%). Tolerability was rated as excellent/good by 99.1% of investigators and 98.5% of subjects. Desloratadine therapy significantly reduced nasal and ocular symptom severity, itching and wheals, and sleep and activity disruption (p < 0.0001), as indicated by a reduction in mean total and individual symptom scores, and reported impairment of sleep and daily activities. The efficacy of desloratadine was rated as significantly greater by 59.4-88.0% of subjects who had previously received monotherapy with cetirizine, fexofenadine, loratadine or mizolastine (p < 0.01 for all). The percentage of subjects who rated onset of symptom relief with desloratadine as faster than previous treatment ranged from 51.6% to 82.4%.

CONCLUSION

Desloratadine was safe, well tolerated and efficacious in this series of surveillance studies. A post hoc analysis of subjects who had received previous monotherapy with a second-generation antihistamine found that most subjects rated efficacy as higher than their previous treatment, with a faster onset of symptom relief.

Comparison of the efficacy and safety of bilastine 20 mg vs levocetirizine 5 mg for the treatment of chronic idiopathic urticaria: a multi-centre, double-blind, randomized, placebo-controlled study

BACKGROUND

Bilastine is a novel nonsedative H(1)-receptor antagonist, which may be used for the symptomatic treatment of chronic idiopathic urticaria (CU). The aim of this study was to compare the clinical efficacy and safety of bilastine 20 mg vs levocetirizine 5 mg and placebo in CU patients with moderate-to-severe symptoms.

METHODS

Overall 525 male and female subjects aged 18-70 years were randomized to receive bilastine 20 mg, levocetirizine 5 mg or placebo, once daily for 28 days, in double-blind manner, in 46 centres across Europe and Argentina. Patients rated symptoms of pruritus, number of wheals, and maximum size of wheals (on predefined scales) as reflective (over past 12 h) symptoms twice daily, for assessment of change from baseline in the total symptoms scores (TSS) over 28 days as the primary efficacy measure. Changes in reflective and instantaneous symptoms scores, Dermatology Life Quality Index (DLQI), and CU-associated discomfort and sleep disturbance were assessed as secondary outcomes. Safety was assessed according to adverse events, laboratory tests and electrocardiograms.

RESULTS

Bilastine reduced patients' mean reflective and instantaneous TSS from baseline to a significantly greater degree than placebo (P < 0.001); from day 2 onwards of treatment. The DLQI, general discomfort, and sleep disruption were also improved significantly in bilastine-treated patients as compared with placebo-treated patients (P < 0.001 for all parameters). Comparison with levocetirizine indicated both treatments to be equally efficacious as well as equally safe and well tolerated as compared with placebo.

CONCLUSIONS

Bilastine 20 mg is a novel effective and safe treatment option for the management of CU.

Parental attitudes toward new dosage forms of desloratadine in an online survey: results from four European countries

BACKGROUND

Allergic disease affects an estimated 50% of children worldwide and causes considerable impairment in academic performance and daily activities. Pediatric formulations for allergy treatment are often highly sugared or contain ingredients to improve palatability, appearance, and patient acceptance/adherence. These excipients, however, are associated with dental caries, gastrointestinal intolerance, and dermatologic reactions.

OBJECTIVE

To assess the appeal of new sugar-free/dye-free syrup and orodispersible formulations of the second-generation antihistamine desloratadine to parents of children with allergy in four European countries.

DESIGN

In an online survey of households with children aged < or =12 years with allergies in France, Italy, the Netherlands, and Spain, respondents were asked to consider one of two desloratadine product concepts: a sugar-free, dye-free oral solution or an orodispersible tablet.

PARTICIPANTS

Eligible households had to have at least one child aged < or =12 years with symptomatic seasonal, pet, or indoor allergies or hives for > or =1 week/year. Respondents had to be the decision makers regarding their child's allergy medication and to be likely to treat symptoms with prescription medication some of the time.

RESULTS

There were 627 eligible households. Most (88%) parents in Spain were likely to ask their physician about and to consider trying sugar-free, dye-free desloratadine syrup, followed by 76% of those in France, 68% in Italy, and 56% in the Netherlands. About three-quarters of parents in France, Spain, and Italy and more than half of those in the Netherlands were likely to ask their physician about and to consider trying the orodispersible formulation.

LIMITATIONS

There is no control group for comparisons between the study's online responses and those that would have resulted from another survey methodology. Further, response biases do exist across countries based on cultural norms.

CONCLUSION

Survey respondents were generally receptive to the new sugar-free, dye-free syrup and orodispersible tablet formulations of the second-generation antihistamine desloratadine. At least half of parents surveyed indicated their willingness to try the new products.

Desloratadine for the Relief of Nasal and Non-nasal Allergy Symptoms: An Observational Study

Introduction

The rates of allergic rhinitis, allergic asthma, and atopic eczema range from 6% to 16% globally. Second-generation antihistamines have been shown to be safe and effective for the treatment of symptoms of allergic disease. This study investigated the efficacy and safety of desloratadine, a nonsedating second-generation antihistamine, in the treatment of common allergy symptoms.

Methods

In this open-label, uncontrolled, non-randomized, observational study, subjects (N = 973) with allergy symptoms were given desloratadine 5 mg daily for 3 weeks. Nasal, ocular, and dermal symptom severity was rated as asymptomatic, mild, moderate, or severe; changes in the percentage of subjects in each severity category were assessed. Overall efficacy and tolerability of desloratadine treatment were evaluated separately by physicians and subjects.

Results

Allergic rhinitis was the most frequent diagnosis, occurring in 59.0% of subjects. Approximately 40% of subjects had received previous treatment with other antihistamines, systemic/topical glucocorticosteroids, or beta-sympathicomimetics. Slightly more than half of subjects received concomitant medication during the study; 263 (53.0%) of those used intranasal steroids. A significant reduction in severity scores was observed in all symptom subgroups (P < 0.001). Desloratadine efficacy was judged to be excellent or good by 90.2% of physicians and 88.6% of subjects; 82.5% of investigators and 80.9% of subjects considered it more effective than previous therapy. The tolerability of desloratadine was rated excellent or good by 97.0% of both groups. Thirty-one subjects (3.2%) experienced adverse events.

Conclusions

In an open-label, uncontrolled, non-randomized, observational study allergy symptoms improved significantly in subjects treated with desloratadine.

How to prescribe antihistamines for chronic idiopathic urticaria: desloratadine daily vs PRN and quality of life

BACKGROUND

Chronic idiopathic urticaria (CIU) impairs quality of life (QoL). Currently, no consensus exists regarding how second-generation H(1)-antihistamines (proven to control CIU symptoms) should be taken long-term: as daily treatment or only when symptoms return (PRN). We sought to determine which regimen improves or better maintains QoL in CIU: desloratadine (DL) daily or PRN.

METHODS

Subjects with CIU initially responding to DL 5 mg/day for 4 weeks were randomized for an additional 8 weeks, to DL 5 mg/day (arm 1: 'continuous', n = 46) or to DL only on days when urticarial wheals were present (arm 2: "PRN", n = 60). To ensure blinding, treatment was presented in both arms as a combination of daily treatment (arm 1: DL; arm 2: placebo), plus a "rescue" tablet (arm 1: placebo; arm 2: DL) to be taken only in case of symptoms. The main outcome measure was QoL assessed by the VQ-Dermato, a validated French QoL instrument, and the Dermatology Life Quality Index (DLQI).

RESULTS

At 4 and 8 weeks after randomization, subjects taking continuous DL showed statistically significant improvements in VQ-Dermato Global Index score (P = 0.001 and P = 0.016, respectively) and dimension scores for daily living activity, mood state, and social functioning vs subjects taking DL PRN. Improvement in DLQI score at Week 4 was also significantly greater with continuous DL (P = 0.001).

CONCLUSION

Continuous daily therapy with DL 5 mg is a better regimen than PRN treatment to maintain or improve QoL in subjects with CIU.

Comparison of the efficacy of levocetirizine 5 mg and desloratadine 5 mg in chronic idiopathic urticaria patients

BACKGROUND

Nonsedating H(1)-antihistamines are recommended for the treatment of urticaria by the recent EAACI/GA(2)LEN/EDF guidelines. The aim of this study was to compare the efficacy, after 4 weeks of treatment, with levocetirizine 5 mg and desloratadine 5 mg, both once daily in the morning, in symptomatic chronic idiopathic urticaria (CIU) patients.

METHODS

This multi-center, randomized, double-blind study involved 886 patients (438 on levocetirizine and 448 on desloratadine). The primary objective was to compare their efficacy on the mean pruritus severity score after 1 week of treatment. Mean pruritus severity score over 4 weeks and pruritus duration score, number and size of wheals, mean CIU composite score (sum of the scores for pruritus severity and numbers of wheals), quality of life, and the patient's and investigator's global satisfaction with treatment, were secondary efficacy measures.

RESULTS

Levocetirizine led to a significantly greater decrease in pruritus severity than desloratadine over the first treatment week; mean pruritus severity scores of 1.02 and 1.18 for levocetirizine and desloratadine, respectively (P < 0.001). The result was similar for the entire 4-week treatment period (P = 0.004). In addition, levocetirizine decreased pruritus duration and the mean CIU composite scores to a significantly greater extent than desloratadine during the first week (P = 0.002 and 0.005, respectively) and over the entire study (P = 0.009 and P < 0.05, respectively). Similarly, levocetirizine increased the patients' global satisfaction after one and 4 weeks (P = 0.012 and 0.021, respectively), compared with desloratadine. Safety and tolerability were similar in both groups.

CONCLUSIONS

Levocetirizine 5 mg was significantly more efficacious than desloratadine 5 mg in the treatment of CIU symptoms.

High-dose desloratadine decreases wheal volume and improves cold provocation thresholds compared with standard-dose treatment in patients with acquired cold urticaria: a randomized, placebo-controlled, crossover study

BACKGROUND

Increased dosing of nonsedating antihistamines is recommended by the current European Academy of Allergology and Clinical Immunology/Global Allergy and Asthma European Network/European Dermatology Forum guidelines on patients with acquired cold urticaria (ACU) who do not respond satisfactorily to the standard dose. Prospective data supporting this recommendation are scant.

OBJECTIVE

We sought to assess the effects of 5 and 20 mg of desloratadine and placebo on cold-induced urticarial reactions in patients with ACU.

METHODS

In this prospective, randomized, double-blind, 3-way crossover trial, patients with ACU (n = 30) received placebo, 5 mg of desloratadine, and 20 mg of desloratadine every day each for 7 days separated by 14-day washout periods. At the end of each treatment, patients underwent cold provocation with the TempTest 2.0/2.1 system, and urticarial reactions were assessed by using digital 3-dimensional time-lapse photography and thermography; the critical temperature threshold (CTT) and critical stimulation time threshold (CSTT) were measured. Adverse events (AEs) reported during the study were assessed.

RESULTS

Compared with placebo, 7 days of desloratadine at 5 and 20 mg/d significantly reduced the volume of cold-induced wheals and areas of hyperthermic skin and improved CTT and CSTT results. Desloratadine at 20 mg/d significantly reduced cold-induced wheal volume and CTT and CSTT values versus desloratadine at 5 mg/d. Desloratadine was well tolerated, with no increased rate of somnolence or other AEs with 20 mg of desloratadine.

CONCLUSIONS

Desloratadine at standard and high doses significantly improved objective signs of ACU provoked by cold exposure. Desloratadine at 4 times the standard dose significantly reduced ACU lesion severity versus 5 mg of desloratadine without an increase in AEs. This study supports current guidelines that increased desloratadine dosing might benefit patients with urticaria who do not respond to standard doses.

H1 antihistamines: current status and future directions

In this review, we compare and contrast the clinical pharmacology, efficacy, and safety of first-generation H1 antihistamines and second-generation H1 antihistamines. First-generation H1 antihistamines cross the blood-brain barrier, and in usual doses, they potentially cause sedation and impair cognitive function and psychomotor performance. These medications, some of which have been in use for more than 6 decades, have never been optimally investigated. Second-generation H1 antihistamines such as cetirizine, desloratadine, fexofenadine, levocetirizine, and loratadine cross the blood-brain barrier to a significantly smaller extent than their predecessors. The clinical pharmacology, efficacy, and safety of these medications have been extensively studied. They are therefore the H1 antihistamines of choice in the treatment of allergic rhinitis, allergic conjunctivitis, and urticaria. In the future, clinically advantageous H1 antihistamines developed with the aid of molecular techniques might be available.

Non-sedating antihistamines in the treatment of chronic idiopathic urticaria using patient-reported outcomes

BACKGROUND

Chronic idiopathic urticaria (CIU) greatly impairs quality of life (QoL). Thus, patient-reported outcome (PRO) measures, using validated scoring instruments, are probably the most accurate tools available for assessing the efficacy of medications that treat CIU, such as second-generation antihistamines.

RESEARCH METHODS

A structured search of the MEDLINE database was conducted to identify English-language papers published between 1 January 1991 and 30 September 2007 on the treatment of CIU with the second-generation antihistamines cetirizine, desloratadine, fexofenadine, and levocetirizine, and their effects on patient-reported QoL. We used the following search terms alone or in combination: 'chronic idiopathic urticaria'; 'pruritus'; 'wheals'; 'hives'; 'second-generation antihistamines'; 'cetirizine'; 'desloratadine'; 'fexofenadine'; 'levocetirizine'; and 'quality of life'.

SCOPE

We evaluated the effects of second-generation antihistamines on the QoL of subjects with CIU using desloratadine as a treatment model. Desloratadine was selected because it is the most frequently assessed non-sedating second-generation antihistamine in QoL studies in patients with CIU.

FINDINGS

Desloratadine 5 mg QD improved QoL in numerous PRO studies. Treatment with desloratadine significantly (p < 0.05) lowered (better) scores in three studies (n = 364) that used validated dermatology-specific scoring instruments. Three 6-week double-blind, placebo-controlled trials (n = 553) found that desloratadine significantly (p < 0.05) improved patient-reported pruritus, sleep disruption, and interference with daily activities. Desloratadine was associated with a low incidence of adverse events and an overall tolerability profile similar to placebo.

LIMITATIONS

Limitations in this review include divergence in search practices that may lead to omission of relevant research, unintentional error in data transfer, inconsistency in quality of selected papers, and potential publication bias against papers that report results from small studies.

CONCLUSIONS

The favorable impact of second-generation antihistamines on the QoL of patients with CIU was demonstrated using desloratadine, the most frequently investigated drug in this field, as a treatment model.

Desloratadine for chronic idiopathic urticaria: a review of clinical efficacy

Chronic idiopathic urticaria (CIU) is a disabling affliction that considerably limits patients' daily activities and interferes with sleep. Clinical studies have shown that histamine H1-receptor antagonists (antihistamines) are highly effective for inhibiting the hives/wheals and pruritus associated with CIU, as well as improving patients' quality of life. Desloratadine is a rapid-acting, once-daily, nonsedating selective H1-receptor antagonist/inverse receptor agonist with proven clinical efficacy in patients with CIU. It has 10-20 times the in vivo H1 receptor-binding affinity of loratadine, its parent compound, and 52-194 times the H1 receptor-binding affinity of cetirizine, ebastine, loratadine, and fexofenadine. Desloratadine displays linear pharmacokinetics after oral administration. Age and sex have no apparent effect on the drug's metabolism and elimination, and food does not affect its bioavailability or absorption. Desloratadine also exerts anti-inflammatory effects via mechanisms that are independent of H1-receptor antagonism. Results from randomized, double-blind, placebo-controlled studies of 6 weeks' duration in adults and adolescents with moderate-to-severe CIU indicate that desloratadine significantly minimizes the severity of pruritus, reduces the number and size of hives, and improves disease-impaired sleep and daily activities. Improvements were noted after a single dose of desloratadine and were maintained over 6 weeks of treatment. Desloratadine was safe and well tolerated in clinical trials of patients with CIU. The adverse effect profile of desloratadine in adults, as well as in children aged from 6 months to 11 years, is comparable to that of placebo. Evaluations of cognitive and psychomotor performance in adults indicate no impairment of function with dosages of desloratadine 5 mg/day. In conclusion, desloratadine is an important therapeutic option for prompt and enduring symptom relief in patients with moderate-to-severe CIU. In addition to efficacy and safety, desloratadine affords a convenient administration regimen, rapid onset of action, and an absence of drug-drug or drug-food interactions. Other important prescribing considerations are that, unlike all first-generation and some second-generation antihistamines, desloratadine is nonsedating at its clinically approved dosage and does not impair psychomotor function.