Higher doses for heavy hives.

Sir,

Urticaria affects 15-20% of the population once or more during a lifetime. Chronic urticaria is a frequently recurrent eruption that occurs over a period of more than 6 weeks; the cause remains a mystery in 75% cases. Urticaria and angioedema may be produced by immunological and non-immunological means. Other medical conditions may also have wheals and these conditions need to be differentiated from urticaria.[1]

Classification of the urticarial diseases is based on duration and frequency. The timeline of 6 weeks of daily or nearly daily symptoms has been chosen as the arbitrary dividing point between acute and chronic urticaria (CU). This classification has been useful for appropriate differential diagnosis, as common causes of acute and chronic urticaria are different and the 2 conditions behave differently.

Non-sedating antihistamines are recommended as a first line treatment for patients with urticaria. The current European Academy of Allergology and Clinical Immunology/Global Allergy and Asthma European Network/European Dermatology Forum (EAACI/GA 2 LEN/EDF) guidelines call for up-dosing of non-sedating anti-histamines (up to 4 times the standard dose) in urticaria patients who do not respond satisfactorily to the standard doses.[2]

In our study, 30 patients with chronic urticaria for at least 6 weeks were enrolled after an informed written consent. Out of 30 patients 16 were females and 14 were males, in the age group of 16-55 years (average age 33 years).

After a 1-day washout without treatment, we graded symptoms using the urticaria activity score (UAS). The UAS measures 2 symptoms - number of wheals and intensity of itching - each on a 0-3 scale each day. The UAS was recorded by each patient daily and was obtained from the patients weekly. The number of wheals was scored from 0 to 3 where 0- no wheals; 1 - less than 20 wheals; 2 - 20-50 wheals; 3 - >50 wheals almost covered large confluent areas of wheals. Severity of itch was scored as 0 - none; 1 - mild; 2 - moderate; and 3 - severe. One has to add both of these scores, viz., for both the number of wheals and the severity of itch, on a given day for each of the days in a given week to get the weekly UAS. The average daily UAS thereby ranged from 0 to 6. To monitor urticaria, we recorded UAS at the beginning and at the end of 1, 2 and 4 weeks of treatment.

The exclusion criteria included physical urticaria, urticarial vasculitis, pregnant or lactating women, gastritis, a history of sensitivity to aspirin or NSAIDs and a history of aggravation of symptoms by pressure. Urticaria activity score of less than 3 at zero week were not included in our study. Routine investigations like complete blood count, blood sugar, thyroid stimulating hormone (TSH) and urine examinations were done to rule out infections before starting therapy. All 30 patients had chronic urticaria of duration ranging from 3 months to 5 years (mean duration 19.6 months).

Patients with urticaria activity score (UAS) of 3 or more, were started on tablet levocetirizine on a dose of 10 mg at bedtime at the onset of the treatment.

Out of 30 patients only 5 patients were symptomatic at the end of first week and were started on 20 mg of levocetirizine. Three out of 5 patients were asymptomatic after starting higher dose of 20 mg at the end of second week with reduction in UAS. Twenty eight out of 30 patients showed good response and a decrease in the UAS within 2 weeks, with a higher dose of levocetirizine. However 2 patients showed no response to treatment even with 20 mgs of levocetirizine.

Average UAS at 0 week was 4.767, which came down to 1.8 at the end of first 2 weeks UAS was 1.4. At the end of 4 weeks average UAS came down to 0.4, showing a marked downward trend with high doses of levocetirizine given at the very onset of the disease. Therefore patients with a higher UAS at the time of presentation should be started on a higher dose of levocetirizine at the onset of the treatment for better symptomatic relief and suppression of the disease within first week.

Investigations revealed microcytic anemia in 4 patients and raised TSH in 2 patients and a high blood sugar in 2 patients. Appropriate treatment was advised for these abnormalities.

One patient with 20 mg of levocetirizine complained of sedation, which was mild and another patient with 10 mg of levocetirizine also complained of sedation which was also mild in nature.

A study by Godse, showed that up-dosing of levocetirizine at weekly intervals significantly brought down the UAS in patients with chronic idiopathic urticaria.[3] In a recent study, levocetirizine 5 mg was significantly more efficacious than desloratadine 5 mg in the treatment of chronic idiopathic urticaria symptoms.[4]

Another study from Germany showed that desloratadine at standard and high doses significantly improved objective signs of acquired cold urticaria provoked by cold exposure. Desloratadine at 4 times the standard dose significantly reduced acquired cold urticaria lesion severity compared to 5 mg of desloratadine without an increase in adverse events.[5] According to the findings in our study use of a higher dose of non-sedating anti-histamine in patients with UAS of 3 or more at the very start of the therapy brings about a better control and rapid suppression of the symptoms, suggesting the need for “higher doses for heavy hives.”