Drugs & Aging

, Volume 32, Issue 4, pp 271–282 | Cite as

Management of Chronic Spontaneous Urticaria in the Elderly

  • Maria Teresa Ventura
  • Nicoletta Cassano
  • Paolo Romita
  • Michelangelo Vestita
  • Caterina Foti
  • Gino Antonio Vena
Therapy in Practice

Abstract

The guidelines for the management of urticaria in adults and children have been revised and updated recently. However, there are few data in the literature concerning several aspects of this disease in the elderly (e.g., epidemiology, etiopathogenesis, clinical aspects, association with co-morbidities, efficacy and safety profiles of treatments, and management strategies). This is an obvious deficiency in the data, as this disease causes a deterioration in quality of life, affecting the quality of sleep, everyday life habits and activities, and inducing severe disability. Chronic spontaneous urticaria (CSU) can also be associated with internal, infectious, autoimmune, or neoplastic diseases. It is therefore necessary to pay particular attention to these clinical issues through appropriate clinical examinations. At the same time, the specific features of medications used to treat CSU in the elderly should be carefully evaluated, as its pharmacological treatment raises a number of problems related both to the clinical condition of the patient and to concomitant diseases, as well as to the polypharmacotherapy, which is common in older subjects and may cause safety problems because of the drug interactions. Non-sedating new-generation antihistamines are the mainstay treatment of CSU for the elderly. The efficacy and safety of alternative treatment options have not been assessed in the geriatric population with CSU; corticosteroids and cyclosporine (ciclosporin) should be used by this population with extreme caution. Similarly, there are no data regarding the actual safety profile of the new-generation antihistamines at higher doses than those recommended in elderly patients.

References

  1. 1.
    Zuberbier T, Aberer W, Asero R, Bindslev-Jensen C, Brzoza Z, Canonica GW, et al. The EAACI/GA(2)LEN/EDF/WAO guideline for the definition, classification, diagnosis, and management of urticaria: the 2013 revision and update. Allergy. 2014;69(7):868–87.CrossRefPubMedGoogle Scholar
  2. 2.
    Zuberbier T, Aberer W, Asero R, Bindslev-Jensen C, Brzoza Z, Canonica GW, et al. Methods report on the development of the 2013 revision and update of the EAACI/GA2LEN/EDF/WAO guideline for the definition, classification, diagnosis, and management of urticaria. Allergy. 2014;69(7):e1–29.CrossRefPubMedGoogle Scholar
  3. 3.
    Zuberbier T, Asero R, Bindslev-Jensen C, Walter Canonica G, Church MK, Giménez-Arnau A, et al. EAACI/GA(2)LEN/EDF/WAO guideline: definition, classification and diagnosis of urticaria. Allergy. 2009;64(10):1417–26.CrossRefPubMedGoogle Scholar
  4. 4.
    Maurer M, Weller K, Bindslev-Jensen C, Giménez-Arnau A, Bousquet PJ, Bousquet J, et al. Unmet clinical needs in chronic spontaneous urticaria. A GA2LEN task force. Allergy. 2011;66(3):317–30.CrossRefPubMedGoogle Scholar
  5. 5.
    Zuberbier T, Balke M, Worm M, Edenharter G, Maurer M. Epidemiology of urticaria: a representative cross-sectional population survey. Clin Exp Dermatol. 2010;35(8):869–73.Google Scholar
  6. 6.
    Ramos-Romey C, López-Malpica F, Nazario S, Jiménez-Velázquez IZ. Urticaria in the elderly. Bol Asoc Med P R. 2008;100(3):32–5.PubMedGoogle Scholar
  7. 7.
    Chen YJ, Wu CY, Shen JL, Chen TT, Chang YT. Cancer risk in patients with chronicurticaria: a population-based cohort study. Arch Dermatol. 2012;148(1):103–8.CrossRefPubMedGoogle Scholar
  8. 8.
    Magen E, Mishal J. Schlesinger M. Clinical and laboratory features of chronic idiopathic urticaria in the elderly. Int J Dermatol. 2013;52(11):1387–91.CrossRefPubMedGoogle Scholar
  9. 9.
    Ventura MT, Napolitano S, Buquicchio R, Cecere R, Arsieni A. An approach to urticaria in the elderly patients. Immunopharmacol Immunotoxicol. 2012;34(3):530–3.Google Scholar
  10. 10.
    Seymour R, Routledge PA. Important drug–drug interactions in the elderly. Drugs Aging. 1998;12(6):485–94.CrossRefPubMedGoogle Scholar
  11. 11.
    Malde B, Regalado J, Greenberger PA. Investigation of angioedema associated with the use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. Ann Allergy Asthma Immunol. 2007;98:57–63.CrossRefPubMedGoogle Scholar
  12. 12.
    Ventura MT, Napolitano S, Menga R, Cecere R, Asero R. Anisakis simplex hypersensitivity is associated with chronic urticaria in endemic areas. Int Arch Allergy Immunol. 2013;160(3):297–300.CrossRefPubMedGoogle Scholar
  13. 13.
    Cardona V, Guilarte M, Luengo O, Labrador-Horrillo M, Sala-Cunill A, Garriga T. Allergic diseases in the elderly. Clin Transl Allergy. 2011;1(1):11–20.CrossRefPubMedCentralPubMedGoogle Scholar
  14. 14.
    Lindelöf B, Sigurgeirsson B, Wahlgren CF, Eklund G. Chronic urticaria and cancer: an epidemiological study of 1155 patients. Br J Dermatol. 1990;123(4):453–6.CrossRefPubMedGoogle Scholar
  15. 15.
    Karakelides M, Monson KL, Volcheck GW, Weiler CR. Monoclonal gammopathies and malignancies in patients with chronic urticaria. Int J Dermatol. 2006;45(9):1032–8.CrossRefPubMedGoogle Scholar
  16. 16.
    Manganoni AM, Tucci G, Venturini M, Farisoglio C, Baronchelli C, Calzavara Pinton PG. Chronic urticaria associated with thyroid carcinoma: report of 4 cases. J Investig Allergol Clin Immunol. 2007;17(3):192–5.Google Scholar
  17. 17.
    Sugiyama A, Nishie H, Takeuchi S, Yoshinari M, Furue M. Hashimoto’s disease is a frequent comorbidity and an exacerbating factor of chronic spontaneous urticaria. Allergol Immunopathol (Madr). 2014. doi:10.1016/j.aller.2014.02.007.
  18. 18.
    Confino-Cohen R, Chodick G, Shalev V, Leshno M, Kimhi O, Goldberg A. Chronic urticaria and autoimmunity: associations found in a large population study. J Allergy Clin Immunol. 2012;129(5):1307–13.CrossRefPubMedGoogle Scholar
  19. 19.
    Staubach P, Dechene M, Metz M, Magerl M, Siebenhaar F, Weller K, et al. High prevalence of mental disorders and emotional distress in patients with chronic spontaneous urticaria. Acta Derm Venereol. 2011;91(5):557–61.PubMedGoogle Scholar
  20. 20.
    Gupta MA, Gupta AK. Chronic idiopathic urticaria and post-traumatic stress disorder (PTSD): an under-recognized comorbidity. Clin Dermatol. 2012;30(3):351–4.Google Scholar
  21. 21.
    O’Donnell BF, Lawlor F, Simpson J, Morgan M, Greaves MW. The impact of chronic urticaria on the quality of life. Br J Dermatol. 1997;136(2):197–201.CrossRefPubMedGoogle Scholar
  22. 22.
    Baiardini I, Pasquali M, Braido F, Fumagalli F, Guerra L, Compalati E, et al. A new tool to evaluate the impact of chronic urticaria on quality of life: chronic urticaria quality of life questionnaire (CU-QoL). Allergy. 2005;60(8):1073–8.CrossRefPubMedGoogle Scholar
  23. 23.
    Baiardini I, Giardini A, Pasquali M, Dignetti P, Guerra L, Specchia C, et al. Quality of life and patients’ satisfaction in chronic urticaria and respiratory allergy. Allergy. 2003;58(7):621–3.CrossRefPubMedGoogle Scholar
  24. 24.
    Ban G-Y, Kim M-Y, Yoo H-S, Nahm D-H, Ye Y-M, Shin Y-S, et al. Clinical feature of elderly chronic urticaria. Korean J Intern Med. 2014;29(6):800–6.CrossRefPubMedCentralPubMedGoogle Scholar
  25. 25.
    Zuberbier T, Maurer M. Urticaria: current opinions about etiology, diagnosis and therapy. Acta Derm Venereol. 2007;87(3):196–205.PubMedGoogle Scholar
  26. 26.
    Saini SS. Chronic spontaneous urticaria: etiology and pathogenesis. Immunol Allergy Clin North Am. 2014;34(1):33–52.CrossRefPubMedGoogle Scholar
  27. 27.
    Zuberbier T, Asero R, Bindslev-Jensen C, Walter Canonica G, Church MK, Giménez-Arnau AM, et al. Dermatology Section of the European Academy of Allergology and Clinical Immunology; Global Allergy and Asthma European Network; European Dermatology Forum; World Allergy Organization. EAACI/GA(2)LEN/EDF/WAO guideline: management of urticaria. Allergy. 2009;64(10):1427–43.CrossRefPubMedGoogle Scholar
  28. 28.
    Simons FE, Simons KJ. H1 antihistamines: current status and future directions.World Allergy Organ J. 2008;1(9):145–55.Google Scholar
  29. 29.
    Vena GA, Cassano N, Buquicchio R, Ventura MT. Antiinflammatory effects of H1-antihistamines: clinical and immunological relevance. Curr Pharm Des. 2008;14(27):2902–11.CrossRefPubMedGoogle Scholar
  30. 30.
    Khan DA. Alternative agents in refractory chronic urticaria: evidence and considerations on their selection and use. J Allergy Clin Immunol Pract. 2013;1(5):433–440.Google Scholar
  31. 31.
    Asero R, Tedeschi A, Cugno M. Treatment of refractory chronic urticaria: current and future therapeutic options. Am J Clin Dermatol. 2013;14(6):481–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Grattan CE, O’Donnell BF, Francis DM, Niimi N, Barlow RJ, Seed PT, et al. Randomized double-blind study of cyclosporin in chronic ‘idiopathic’ urticaria. Br J Dermatol. 2000;143(2):365–72.CrossRefPubMedGoogle Scholar
  33. 33.
    Vena GA, Cassano N, Colombo D, Peruzzi E, Pigatto P, Neo-I-30 Study Group. Cyclosporine in chronic idiopathic urticaria: a double-blind, randomized, placebo-controlled trial. J Am Acad Dermatol. 2006;55(4):705–9.CrossRefPubMedGoogle Scholar
  34. 34.
    Maurer M, Rosén K, Hsieh HJ, Saini S, Grattan C, Gimenéz-Arnau A, et al. Omalizumab for the treatment of chronic idiopathic or spontaneous urticaria. N Engl J Med. 2013;368(10):924–35.CrossRefPubMedGoogle Scholar
  35. 35.
    Kaplan A, Ledford D, Ashby M, Canvin J, Zazzali JL, Conner E, et al. Omalizumab in patients with symptomatic chronic idiopathic/spontaneous urticaria despite standard combination therapy. J Allergy Clin Immunol. 2013;132(1):101–9.CrossRefPubMedGoogle Scholar
  36. 36.
    Saini SS, Bindslev-Jensen C, Maurer M, Grob JJ, Bülbül Baskan E, Bradley MS, et al. Efficacy and safety of omalizumab in patients with chronic idiopathic/spontaneous urticaria who remain symptomatic on H1 antihistamines: a randomized, placebo-controlled study. J Invest Dermatol. 2015;135(1):67–75.CrossRefPubMedCentralPubMedGoogle Scholar
  37. 37.
    Zuberbier T. Pharmacological rationale for the treatment of chronic urticaria with second-generation non-sedating antihistamines at higher-than-standard doses. J Eur Acad Dermatol Venereol. 2012;26(1):9–18.CrossRefPubMedGoogle Scholar
  38. 38.
    Sánchez-Borges M, Caballero-Fonseca F, Capriles-Hulett A. Treatment of recalcitrant chronic urticaria with nonsedating antihistamines: is there evidence for updosing? J Investig Allergol Clin Immunol. 2013;23(3):141–4.Google Scholar
  39. 39.
    Hansen J, Klimek L, Hörmann K. Pharmacological management of allergic rhinitis in the elderly: safety issues with oral antihistamines. Drugs Aging. 2005;22(4):289–96.CrossRefPubMedGoogle Scholar
  40. 40.
    Hall MRP. Drug interactions in the elderly. J Am Geriatr Soc. 1982;28(Suppl 1):18–24.Google Scholar
  41. 41.
    Dávila I, delCuvillo A, Mullol J, Jáuregui I, Bartra J, Ferrer M, et al. Use of second generation H1 antihistamines in special situations. J Investig Allergol Clin Immunol. 2013;23(Suppl 1):1–16.Google Scholar
  42. 42.
    Yanai K, Zhang D, Tashiro M, Yoshikawa T, Naganuma F, Harada R, et al. Positron emission tomography evaluation of sedative properties of antihistamines. Expert Opin Drug Saf. 2011;10(4):613–22.CrossRefPubMedGoogle Scholar
  43. 43.
    Church MK, Church DS. Pharmacology of antihistamines. Indian J Dermatol. 2013;58(3):219–24.CrossRefPubMedCentralPubMedGoogle Scholar
  44. 44.
    Tashiro M, Kato M, Miyake M, Watanuki S, Funaki Y, Ishikawa Y, et al. Dose dependency of brain histamine H(1) receptoroccupancy following oral administration of cetirizine hydrochloride measured using PET with [11C]doxepin. Hum Psychopharmacol. 2009;24(7):540–8.CrossRefPubMedGoogle Scholar
  45. 45.
    Gupta A, Gillard M, Christophe B, Chatelain P, Massingham R, Hammarlund-Udenaes M. Peripheral and central H1 histamine receptor occupancy by levocetirizine, a non-sedating antihistamine; a time course study in the guinea pig. Br J Pharmacol. 2007;151(7):1129–36.CrossRefPubMedCentralPubMedGoogle Scholar
  46. 46.
    Dubertret L, Zalupca L, Cristoroulo T, Benea V, Medina I, Fantin S, et al. Once-daily rupatadine improves the symptoms of chronic idiopathic urticaria: a randomized, double-blind, placebo-controlled study. Eur J Dermatol. 2007;17(3):223–8.PubMedGoogle Scholar
  47. 47.
    Barbanoj MJ, García-Gea C, Antonijoan R, Izquierdo I, Donado E, Pérez I, et al. Evaluation of the cognitive, psychomotor and pharmacokinetic profiles of rupatadine, hydroxyzine and cetirizine, in combination with alcohol, in healthy volunteers. Hum Psychopharmacol. 2006;21(1):13–26.CrossRefPubMedGoogle Scholar
  48. 48.
    Slavin RG. Treating rhinitis in the older population: special considerations. Allergy Asthma Clin Immunol. 2009;5(1):9.CrossRefPubMedCentralPubMedGoogle Scholar
  49. 49.
    Bom AT, Pinto AM. Allergic respiratory diseases in the elderly. Respir Med. 2009;103(11):1614–22.CrossRefPubMedGoogle Scholar
  50. 50.
    Scichilone N, Battaglia S, Benfante A, Bellia V. Safety and efficacy of montelukast as adjunctive therapy for treatment of asthma in elderly patients. Clin Interv Aging. 2013;8:1329–37.PubMedCentralPubMedGoogle Scholar
  51. 51.
    Ingelsson E, Yin L, Bäck M. Nationwide cohort study of the leukotriene receptor antagonist montelukast and incident or recurrent cardiovascular disease. J Allergy Clin Immunol. 2012;129(3):702–7.CrossRefPubMedGoogle Scholar
  52. 52.
    Riccioni G, Bäck M. Leukotrienes as modifiers of preclinical atherosclerosis? Sci World J. 2012;2012:490968.CrossRefGoogle Scholar
  53. 53.
    Altomare G, Ayala F, Bardazzi F, Bellia G, Chimenti S, Colombo D, et al. Consensus on the use of cyclosporine in dermatological practice. G Ital Dermatol Venereol. 2014;149(5):607–25.Google Scholar
  54. 54.
    Kovarik JM, Koelle EU. Cyclosporin pharmacokinetics in the elderly. Drugs Aging. 1999;15(3):197–205.CrossRefPubMedGoogle Scholar
  55. 55.
    Falck P, Asberg A, Byberg KT, Bremer S, Bergan S, Reubsaet JL, et al. Reduced elimination of cyclosporine A in elderly (>65 years) kidney transplant recipients. Transplantation. 2008;86(10):1379–83.CrossRefPubMedGoogle Scholar
  56. 56.
    Lill J, Bauer LA, Horn JR, Hansten PD. Cyclosporine-drug interactions and the influence of patient age. Am J Health Syst Pharm. 2000;57(17):1579–84.PubMedGoogle Scholar
  57. 57.
    Metz M, Ohanyan T, Church MK, Maurer M. Omalizumab is an effective and rapidly acting therapy in difficult-to-treat chronic urticaria: a retrospective clinical analysis. J Dermatol Sci. 2014;73(1):57–62.CrossRefPubMedGoogle Scholar
  58. 58.
    Korn S, Schumann C, Kropf C, Stoiber K, Thielen A, Taube C, et al. Effectiveness of omalizumab in patients 50 years and older with severe persistent allergic asthma. Ann Allergy Asthma Immunol. 2010;105(4):313–9.CrossRefPubMedGoogle Scholar
  59. 59.
    Omalizumab: a second look in severe persistent asthma: new adverse effects. Prescrire Int. 2011;20(115):90–2.Google Scholar
  60. 60.
    Ali AK, Hartzema AG. Assessing the association between omalizumab and arteriothrombotic events through spontaneous adverse event reporting. J Asthma Allergy. 2012;5:1–9.CrossRefPubMedCentralPubMedGoogle Scholar
  61. 61.
    Kaplan AP. Treatment of chronic spontaneous urticaria. Allergy Asthma Immunol Res. 2012;4(6):326–31.CrossRefPubMedCentralPubMedGoogle Scholar
  62. 62.
    Weller K, Viehmann K, Bräutigam M, Krause K, Siebenhaar F, Zuberbier T, et al. Management of chronic spontaneous urticaria in real life—in accordance with the guidelines? A cross-sectional physician-based survey study. J Eur Acad Dermatol Venereol. 2013;27(1):43–50.Google Scholar
  63. 63.
    Piper JM, Ray WA, Daugherty JR, Griffin MR. Corticosteroid use and peptic ulcer disease: role of nonsteroidal anti-inflammatory drugs. Ann Intern Med. 1991;114(9):735–40.CrossRefPubMedGoogle Scholar
  64. 64.
    Church MK, Maurer M, Simons FE, Bindslev-Jensen C, van Cauwenberge P, Bousquet J, et al. Global Allergy and Asthma European Network. Risk of first-generation H(1)-antihistamines: a GA(2)LEN position paper. Allergy. 2010;65(4):459–66.CrossRefPubMedGoogle Scholar
  65. 65.
    Kaliner MA. H1-antihistamines in the elderly. Clin Allergy Immunol. 2002;17:465–81.Google Scholar
  66. 66.
    Simons FE. Advances in H1-antihistamines. N Engl J Med. 2004;351(21):2203–17.CrossRefPubMedGoogle Scholar
  67. 67.
    Juniper EF, Stahl E, Doty RL, Simons FE, Allen DB, Howarth PH. Clinical outcomes and adverse effect monitoring in allergic rhinitis. J Allergy Clin Immunol. 2005;3(Suppl. 1):S390–413.CrossRefGoogle Scholar
  68. 68.
    Agostini JV, Leo-Summers LS, Inouye SK. Cognitive and other adverse effects of diphenhydramine use in hospitalized older patients. Arch Intern Med. 2001;161(17):2091–7.CrossRefPubMedGoogle Scholar
  69. 69.
    Rothberg MB, Herzig SJ, Pekow PS, Avrunin J, Lagu T, Lindenauer PK. Association between sedating medications and delirium in older inpatients. J Am Geriatr Soc. 2013;61(6):923–30.CrossRefPubMedGoogle Scholar
  70. 70.
    American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616–31.Google Scholar

Copyright information

© Springer International Publishing Switzerland 2015

Authors and Affiliations

  • Maria Teresa Ventura
    • 1
  • Nicoletta Cassano
    • 2
  • Paolo Romita
    • 3
  • Michelangelo Vestita
    • 3
  • Caterina Foti
    • 3
  • Gino Antonio Vena
    • 2
  1. 1.Department of Interdisciplinary Medicine (DIM)University of Bari, Medical School, PoliclinicoBariItaly
  2. 2.Dermatology and Venereology, Private PracticeBari and BarlettaItaly
  3. 3.Dermatological Clinic, Department of Biomedical Science and Human OncologyUniversity of Bari Medical SchoolBariItaly

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