Antimalaria drug hydroxychloroquine use for chronic urticaria is based on only one published study

What is it?

Hydroxychloroquine is an antiinflammatory drug and antimalarial agent. The relative safety of the low doses, and the low cost of hydroxychloroquine makes it a reasonable agent in the treatment of refractory chronic urticaria (CU). One of the disadvantages is the relatively slow onset of action.

How the works?

The mechanism of action includes suppression of T lymphocyte activation and antigen processing.

Paucity of research data

Apparently, there is only one published study in PubMed, from 10 years ago, which included only 18 patients with chronic urticaria (http://www.ncbi.nlm.nih.gov/pubmed/15086698). The patients were treated with a combination of therapies for CU (H1 antihistamines, H2 antihistamines, glucocorticoids, and doxepin) and randomized to receive either:

- hydroxychloroquine (5 mg/kg daily)
- or no additional drug

After 3 months of treatment, patients in the hydroxychloroquine arm had improved quality of life. Hydroxychloroquine was well tolerated for 12 weeks (200 mg of hydroxychloroquine twice daily). However, because of small size and 3 dropouts (from 21 to 18), the study was underpowered to detect significant differences.

Expert recommendations

The 2014 edition of UpToDate includes the expert recommendation to start hydroxychloroquine with a dose of 200 mg twice a day. A 3-month trial is usually required to determine effectiveness. Hydroxychloroquine rarely causes serious side effects. The most common adverse reactions are related to the gastrointestinal tract (nausea), skin (various macular lesions), and central nervous system (headache).

Ophthalmologic problems, including corneal deposits (reversible) and retinopathy (potentially vision threatening) are possible, but rare with the low daily doses of hydroxychloroquine used in CU.

No studies have evaluated the ideal length of treatment.

Eye screening

 The risk of retinopathy is low in the first 5 years of use, but after 5 years of use it increases to approximately 1%.

Recent recommendations from the American Academy of Ophthalmology (http://www.ncbi.nlm.nih.gov/pubmed/21292109) are:

- baseline ophthalmologic examination within the first year of starting hydroxychloroquine
- annual examinations after 5 years of therapy



Chronic Urticaria Treatment Options in 6 Steps (click to enlarge the image).

References:

Impact of hydroxychloroquine therapy on chronic urticaria: chronic autoimmune urticaria study and evaluation. Intern Med J. 2004 Apr;34(4):182-6.
http://www.ncbi.nlm.nih.gov/pubmed/15086698

PubMed search for "hydroxychloroquine chronic urticaria" shows the lack of research on the topic, most results are from review articles http://buff.ly/1zEUBxo

Chronic urticaria: Treatment of refractory symptoms. UpToDate, 2014.

Alternative agents in refractory chronic urticaria: evidence and considerations on their selection and use. J Allergy Clin Immunol Pract. 2013 Sep-Oct;1(5):433-440.e1. doi: 10.1016/j.jaip.2013.06.003. Epub 2013 Aug 2.

http://www.jaci-inpractice.org/article/S2213-2198(13)00281-X/fulltext

Image source: Urticaria, Wikipedia, public domain.

Allergic rhinitis - top articles for August 2014

Here are my suggestions for some of the top articles about allergic rhinitis for August 2014:

Allergic airway disease in a tropical urban environment is driven by dominant mono sensitization: dust mite http://buff.ly/1iCXf14

Rhinitis as a risk factor for depression in pre-adolescents: risk increased from 11 to 17.7% http://buff.ly/1gSq1GO

Is There a Need to Repeat Skin Test in Childhood Allergic Diseases? Yes, 40% had different results 4 yrs later http://buff.ly/1mw3abw

Impermeable dust mite covers were not helpful in primary and tertiary prevention of allergic disease (meta-analysis) http://buff.ly/1jSJuKz

Allergic rhinitis impairs asthma control by enhancing lower airway inflammation - a striking impact found in study http://buff.ly/1lwo3mQ

Is chronic rhinosinusitis related to allergic rhinitis? Evaluate for underlying allergies any patient with CRS http://buff.ly/1uU3Nyk

Asthma and Allergen Sensitization start earlier in life than previolsy reported (age 2 for asthma, age 1 for allergy), dust mite is the culprit in 80% http://buff.ly/1uU6P5u

Can Allergy Medicines Suddenly Stop Working? 20% of patients think so http://bit.ly/1k5ZZY1

Nonallergic rhinitis - 2014 review by Phil Lieberman http://buff.ly/1i5bcFi

Allergens on desktop surfaces in schools: Mouse allergen found in 97% of samples, cat in 80%, dog in 77% http://buff.ly/1ntrhoU

Aquarium fish food arthropods are potent allergens http://buff.ly/1fIkRTV

"There's no shortcut. Everybody thinks that there ought to be a technology, but reading pollen grains takes a human eye to do it" http://buff.ly/1s5E7dN

The articles were selected from Twitter @Allergy and RSS subscriptions. Some of the top allergy accounts on Twitter contributed links. I appreciate the curation provided by @Aller_MD @AllergyNet @IgECPD @DrAnneEllis @mrathkopf.

Please feel free to send suggestions for articles to AllergyGoAway AT gmail DOT com and you will receive an acknowledgement in the next edition of this publication.

Image source: Wikipedia, Creative Commons license.

Hay fever - 1953 documentary film about allergic rhinitis by Wellcome Library

From Wellcome Library history of medicine collection: Short documentary film (15 minutes) describing the causes and symptoms of hay fever and showing how pollen is collected and made into desensitising sets for sufferers.



Please note: Allergy shots are no longer administered at home by patients.

Here is the current approach to therapy of allergic rhinitis:



Treatment Options for 
Allergic Rhinitis (AR) and 
Non-Allergic Rhinitis (NAR) in 6 Steps (click to enlarge the image).

Pulmonary findings in common variable immunodeficiency (CVID)

It is not clear if interstitial lung disease (ILD) in common variable immunodeficiency (CVID) is a consequence of chronic infection or a manifestation of dysregulated lymphoid proliferation.

This retrospective review of electronic medical records of 61 patients with CVID evaluated clinical and laboratory correlates of bronchiectasis, ground glass opacity, and pulmonary nodules on CT scan.

Here are the correlations:

- Bronchiectasis was strongly correlated with a CD4+ T-cell count lower than 700 cells/μL and was associated with a history of pneumonia and older age.

- Pulmonary nodular disease was correlated with increased CD4+:CD8+ T-cell ratios, a history of autoimmune hemolytic anemia or immune thrombocytopenic purpura, elevated IgM, and younger age.

- Ground glass opacity had similar clinical and laboratory characteristics as those for nodular lung disease but was associated with elevated monocyte counts and the presence of liver disease.

Bronchiectasis were more strongly associated with infection and T-cell lymphopenia. ILD was more strongly linked with autoimmunity and lymphoproliferation.

References:

Pulmonary radiologic findings in common variable immunodeficiency: clinical and immunological correlations. Maglione PJ1, Overbey JR2, Radigan L1, Bagiella E2, Cunningham-Rundles C3. Ann Allergy Asthma Immunol. 2014 May 28. pii: S1081-1206(14)00297-X. doi: 10.1016/j.anai.2014.04.024. [Epub ahead of print]
http://www.ncbi.nlm.nih.gov/pubmed/24880814

A series of "How to Use Inhalers" videos by National Jewish Health



Using a Metered-Dose Inhaler: Open-Mouth Technique.



Using a Metered-Dose Inhaler: Closed-Mouth Technique.



How to Use a Nebulizer.



How to Use a Diskus.



How to Use a Flexhaler.



How to Use a Twisthaler.



How to Use a HandiHaler.



How to Use a Respimat.



How to Use an Aerolizer.



How to Use an Aerochamber® with Mask.



How to Use an Autohaler.



How to Use a Peak Flow Meter.
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