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Bilastina

The challenges of chronic urticaria part 2: Pharmacological treatment, chronic inducible urticaria, urticaria in special situations

By | New, Selected articles

Mario Sanchez-Borges, Ignacio J. Ansotegui, Ilaria Baiardini, Jonathan Bernstein, Giorgio Walter Canonica, Motohiro Ebisawa, Maximiliano Gomez, Sandra Nora Gonzalez-Diaz, Bryan Martin, Mario Morais-Almeida and Jose Antonio Ortega Martell

World Allergy Organ J . 2021 Jun 3;14(6):100546. doi: 10.1016/j.waojou.2021.100546. eCollection 2021 Jun.

Chronic spontaneous urticaria consists in the occurrence of wheals, angioedema, or both more than 6 weeks, and 1-2% of the population is affected. It is more prevalent in women and frequently compromises quality of life and the costs for national health systems can be considerable.

The World Allergy Organization (WAO) has reviewed a position paper published in 2012 regarding diagnosis and treatment of urticaria and angioedema. Since then, there have been advances in the knowledge of urticaria mechanism of action, and new treatments (biologics) have been released for severe refractory disease.

This is the second part of an update from the WAO, which intention is to provide an updated guidance for urticaria, especially in special situations such as childhood and pregnancy.

Second generation H1 antihistamines are recommended in major guidelines as the first line treatment for urticaria, as they are effective and safe. Some guidelines include first generation antihistamines for non responders. The dose can also be increased up to 4 times to improve efficacy (and without compromising safety). Combination of antihistamines does not seem to induce better effects, and patients who are refractory to antihistamines are candidates to omalizumab or cyclosporin-A. Omalizumab is the only biological approved for the treatment of antihistamine-refractory patients with moderate to severe urticaria. Cyclosporin-A is an immunosuppressing drug that inhibits T helper cells by blocking the production of inflammatory cytokines.

Special conditions associated with urticaria include autoinflammatory syndromes and various forms of urticarial vasculitis, which are treated with second generation antihistamines and systemic glucocorticoids, and alternatively immunomodulators and immunosuppressors.

 

Specialists are recommended to follow the guidelines, use validated PRO instruments and use effective and safe medications.

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The challenges of chronic urticaria part 1: Epidemiology, immunopathogenesis, comorbidities, quality of life, and management

By | New, Selected articles

Mario Sanchez-Borges, Ignacio J. Ansotegui, Ilaria Baiardini, Jonathan Bernstein, Giorgio Walter Canonica, Motohiro Ebisawa, Maximiliano Gomez, Sandra Nora Gonzalez-Diaz, Bryan Martin, Mario Morais-Almeida and Jose Antonio Ortega Martell World Allergy Organ J. 2021 Jun 1;14(6):100533. doi: 10.1016/j.waojou.2021.100533. eCollection 2021 Jun.

Chronic spontaneous urticaria consists in the occurrence of wheals, angioedema, or both more than 6 weeks, and 1-2% of the population is affected. It is more prevalent in women and frequently compromises quality of life and the costs for national health systems can be considerable.

The World Allergy Organization (WAO) has reviewed a position paper published in 2012 regarding diagnosis and treatment of urticaria and angioedema. Since then, there have been advances in the knowledge of urticaria mechanism of action, and new treatments (biologics) have been released for severe refractory disease. Urticaria pathological mechanisms include different cell types, mainly mast cells, basophils, eosinophils, T and B lymphocytes and epithelial and endothelial cells. The dysregulation of intracellular signaling pathways and autoimmune mechanisms have an important role in the activation of mast cells/basophils, which leads to the release of inflammatory mediators resulting in wheals and angioedema.

This is the first part of an update from the WAO, which intention is to provide an updated guidance for urticaria.

Biomarkers have been identified for the prognosis of chronic urticaria (total IgE, CRP, ASST, Anti-TPO, IL-17, IL-31, IL-33) and the assessment of the response of different therapies. Specialists are recommended to follow the guidelines, use validated PRO instruments and use effective and safe medications.

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Real-Life Experience of Efficacy and Safety of Bilastine in the Refractory Cases of Chronic Spontaneous Urticaria and its Effect on the Quality of Life of Patients

By | Articles about Bilastine, New

Abhishek De, Kiran Godse, Dhiraj Dhoot, and Aarti Sarda

Indian J Dermatol . Mar-Apr 2021;66(2):159-164. doi: 10.4103/ijd.IJD_771_20.

Chronic spontaneous urticaria is a skin condition with wheals and angioedema, for more than six weeks. Second-generation H1-antihistamines are the first line treatment for these allergic conditions, namely bilastine. The aim of this study was to assess long-term efficacy and tolerability of bilastine in patients with chronic spontaneous urticaria in India.

This was a retrospective analysis that identified patients with urticaria who were prescribe bilastine between May, 1, 2019 to March, 20, 2020 from analysis of electronic medical records. Patients with unsatisfactory response to previous treatment were also included. Unsatisfactory treatment was assessed as per Urticaria Activity Score 7 (UAS7). The efficacy of the treatment was evaluated by revising their UAS7 score ate weeks 4, 8, 12, 16, 20. DLQI was also evaluated and compared at baseline and week 24.

The study included 49 patients. At 24 weeks, 51% of them had achieved treatment response (UAS = 0) and the remaining 49% had a well-controlled urticaria (UAS <6). At 24 weeks, mean UAS7 was statistically significant compared to baseline values (1,35 ± 1,61 vs. 20,2 ± 5,73), and mean DLQI score also decreased to 1,63 ± 1,18, compared to 8,39 ± 2,49 at baseline.

In conclusion, this study demonstrated that patients who usually had an inadequate response with commonly used antihistamines, when switched to bilastine had their quality of life and symptoms improved.

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Pharmacokinetics and Safety of a Bilastine Once-Daily, Preservative-Free, Ophthalmic Formulation

By | Articles about Bilastine, New

Dolores Ochoa, Manuel Roman, Carmen Belmonte, Samuel Martin-Vilchez, Gina Mejia-Abril, Francisco Abad-Santos, Gonzalo Hernandez, Paula Arranz, Lorena Elgezabal, Nieves Fernandez

Adv Ther . 2021 Jun 12. doi: 10.1007/s12325-021-01801-y. Online ahead of print.

Bilastine is a second-generation H1 antihistamine for allergic conditions. A new ophthalmic formulation was developed based on the efficacy and safety profiles of the oral formulation. The aim of this study was to assess the safety and pharmacokinetics of ophthalmic bilastine (6 mg/ml) in adults after one and various doses.

This was an open-label, single-centre, phase 1, bioavailability study that included 12 healthy participants (aged 18-55 years old). Participants were administered one drop of the bilastine eye formulation in each eye for five days. Serum levels of bilastine were assessed by HPLC-MS/MS and adverse drug reactions registered during administration and follow-up.

After various admininistrations, bilastine blood levels were 2682,26 ± 1615,88 pg/mL at 2,5 hours. The half-life of bilastine was 7,88 ± 6,72 h. Area under the curve was 19512,51 ± 9248,76 h/pg/mL. Dysgeusia was the main adverse event, which was mild and transient.

The ophthalmic formulation has proved to be absorbed in low amounts to the bloodstream, showing a good safety profile after administration of various doses.

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Application of a dual mechanistic approach to support bilastine dose selection for older adults

By | Articles about Bilastine, New

Chaejin Kim, Valentina Lo Re, Monica Rodriguez, John C Lukas, Nerea Leal, Cristina Campo, Aintzane Garcia-Bea, Elena Suarez, Stephan Schmidt, Valvanera Vozmediano

CPT Pharmacometrics Syst Pharmacol . 2021 Jun 22. doi: 10.1002/psp4.12671. Online ahead of print.

Bilastine is a second-generation H1-selective antihistamine for the treatment of allergic conditions in adults and children. It has a rapid onset and a long duration of action. Its pharmacokinetic and pharmacodynamic properties are favorable for all ages, although there’s a lack of studies in older adults, who are heterogenous in different aspects, namely age, comorbidities and comedication.

The aim of this study was to assess the recommendation of the dose of bilastine in older adults.

This was done by integration of bilastine in vitro and in vivo physicochemical data from young adults and studying the effect of aging with two different approaches: a physiologically based pharmacokinetic (PBPK) model and a semi-mechanistic population pharmacokinetic model (Senescence). The PBPK model used intestinal apical efflux and basolateral influx transporters to capture the results from young adults after single IV (10 mg) and 20 mg oral doses, which supports the hypothesis of gut transporters involvement on secretion. The Senescence model was developed from a published PopPK model adding up declining functions on different physiological systems and body composition changes with age.

Both models were then qualified using data from 16 older adults, mean age 68,7 years. The PBPK model was also used to assess the dose in older people (80 years old).

Both models showed that a daily dose of 20 mg is safe and effective in older people, supporting the existing information in this age group.

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Cold Agglutinins and Cryoglobulins Associate with Clinical and Laboratory Parameters of Cold Urticaria

By | Selected articles

Mojca Bizjak, Mitja Kosnik, Dorothea Terhorst-Molawi, Dejan Dinevski, Marcus Maurer

Front Immunol. 2021 Apr 29;12:665491. doi: 10.3389/fimmu.2021.665491. eCollection 2021

Cold urticaria is a condition characterized by wheals and/or angioedema in response to cold. It is usually diagnosed after provocation testing, and trigger thresholds measure its activity. Just as “common” urticaria, cold urticaria is also a mast-cell driven condition, where cold is an activating signal which causes a release of histamine from dermal mast cells. Cold agglutinins and cryoglobulins were designated as elements related to cold urticaria. The objective of this study was to understand the impact of cold agglutinins and cryoglobulins on the molecular level and evaluate strategies for cold urticaria.

This was a single-center prospective cohort study that included 35 participants with cold urticaria. They were analyzed for cold agglutinins and cryoglobulin, demographics, history data, cold stimulation test results, complete blood count values, C-reactive protein, total immunoglobulin E levels, and basal serum tryptase levels.

Sixteen (46%) of the 35 participants tested positive for cold agglutinin, and 9 (27%) of 33 tested participants had a positive cryoglobulin test. There was no gender association for cryoglobulin. However, a positive cold agglutinin was mainly in female participants. Also, a positive cold agglutinin test showed a higher rate of reactions triggered by cold ambient air, immersion in cold water, and aggravated by summer humidity. These participants also had more angioedema triggered by cold foods or drinks.

Cold agglutinin serum levels correlated with erythrocyte and monocyte counts. Cryoglobulin concentrations associated with basal serum tryptase levels and cold urticaria duration.

In conclusion, this study suggests that cold agglutinins and cryoglobulins are related to the course and pathogenesis of cold urticaria. More studies are encouraged to explore mechanisms of action, treatment, and use as biomarkers.

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Effects of Serum Vitamin D Levels and Vitamin D Supplementation on Urticaria: A Systematic Review and Meta-Analysis

By | Selected articles

Yajia Li, Ziqin Cao, Jia Guo, Qiangxiang Li, Juan Su

Int J Environ Res Public Health. 2021 May 5;18(9):4911. doi: 10.3390/ijerph18094911.

Urticaria is characterized by itchy wheals and/or angioedema. It is a common condition with an impact on the quality of life driven by mast cells. Numerous studies have demonstrated that serum levels of 25-hydroxyvitamin D can impact urticaria. However, the relation between vitamin D and urticaria is not well recognized. The objective of this study was to systematically synthesize the associations of vitamin D and urticaria published until March 2021.

A systematic search was done in PubMed, EMBASE, Web of Science, and Cochrane. Observational studies with the comparisons of vitamin D and people with urticaria and clinical studies were included.

A meta-analysis of 17 studies of urticaria patients compared to controls demonstrated a mean difference of -9.35 ng/mL in vitamin D, which complied with the association of urticaria with a deficiency in vitamin D. Studies with supplementation of vitamin D also demonstrated a significant reduction in clinical urticarial score in people supplemented with vitamin D.

In conclusion, people with urticaria may have a lower level of serum vitamin D, and vitamin D supplementation may reduce urticaria symptoms and exacerbations and improve quality of life due to vitamin D immunomodulatory and anti-inflammatory properties. However, more studies are needed to assess the clinical benefits and mechanisms of action of vitamin D in urticaria.

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Could Histamine H1 Receptor Antagonists Be Used for Treating COVID-19?

By | Selected articles

Changbo Qu, Gwenny M. Fuhler, Yihang Pan

Int J Mol Sci . 2021 May 26;22(11):5672. doi: 10.3390/ijms22115672.

The pandemic of COVID-19, caused by SARS-CoV-2, has led to extensive and long-term health issues in those affected by the disease. It is essential to identify new treatments for COVID-19 infection with a better outcome too. The objective of this review is to summarize the use of H1 receptor antagonists in SARS-CoV-2 infection.

One of the common characteristics of severe COVID-19 is unbalanced lung inflammation. Reducing lung inflammation can help improve COVID-19 clinical manifestations. H1 receptor antagonists may inhibit SARS-CoV-2 either via the H1 receptor or via the ACE2 receptor. The virus spike proteins interact with both cellular heparan sulfate and ACE2 through its receptor-binding domain, and H1-antihistamines may disrupt the interaction between heparan sulfate and spike protein, inhibiting the virus entry in the cell.

New-generation H1 receptor antagonists, such as loratadine and desloratadine, may help inhibit SARS-CoV-2 infection by reducing lung inflammation induced by histamine, as well as other inflammatory activities. These antihistamines have also been shown to exert antiviral effects when blocking H1 receptors and, therefore, to affect SARS-CoV-2 replication via the mediation of metabolism and immune responses.

In conclusion, H1 receptor antagonists are relatively inexpensive drugs, ready to use and with the capacity to improve patient outcomes due to their role in reducing inflammation and antiviral effects. They may also be attractive prophylactic candidates for lowering the risk of SARS-CoV-2 infection in the general population.

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Triggers of Exacerbation in Chronic Urticaria and Recurrent Angioedema-Prevalence and Relevance

By | Selected articles

Anete Sevciovic Grumach, Petra Staubach-Renz, Ricardo Cardona Villa, Susana Diez-Zuluaga, Imke Reese, William R. Lumry

J Allergy Clin Immunol Pract . 2021 Jun;9(6):2160-2168. doi: 10.1016/j.jaip.2021.04.023

 

The causes of urticaria vary with patients, with hives mainly characterizing most of them. Urticaria can be classified as acute or chronic according to its duration. Most patients have triggers that cause exacerbations, which should be avoided to help control the disease. This review aims to describe the factors that may trigger chronic urticaria and angioedema, highlighting its mechanisms.

The major drug groups that may trigger urticaria include nonsteroidal anti-inflammatory drugs, antibiotics (especially beta-lactams), vaccines, bupropion, antidepressants, antihypertensives, H2 antihistamines, antifungals, and H1 antihistamines. Other drugs that decrease the degradation of bradykinin (from the mast cell degranulation cascade) lead to angioedema and include angiotensin-converting enzyme inhibitors, neutral endopeptidase, and dipeptidyl peptidase-4 inhibitors, resulting in the accumulation of bradykinin, followed by localized vasodilation and then angioedema.

Food and food components may also trigger urticaria or angioedema, such as food additives and naturally occurring substances (biogenic amines and aromatic compounds).

Other triggers of angioedema without urticaria include emotional distress, physical exertion, mechanical trauma, infection, menstruation, pregnancy, medical procedures, weather changes, alcohol ingestion, and some medicinal products.

In conclusion, patients with urticaria or angioedema must know trigger factors to introduce changes in their lifestyle and an individualized approach to treatment.

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Effects of pregnancy on chronic urticaria: Results of the PREG-CU UCARE study

By | Selected articles

Emek Kocatürk, et al.

Allergy. 2021 May 22. doi: 10.1111/all.14950. Online ahead of print.

Chronic urticaria is an inflammatory condition characterized by wheals, angioedema, or both for more than six weeks. Women are more affected, and it is thought that sex hormones have a modulation capacity in women with urticaria. The objective of this study was to assess the evolution and characteristics of chronic urticaria during pregnancy.

PREG-CU was an international, multicenter study of the Urticaria Centers of Reference and Excellence (UCARE) network that included 288 women with chronic urticaria who became pregnant within the last three years and completed a 47-item questionnaire.

A total of 288 pregnancies of 288 women with chronic urticaria from 13 countries were analyzed. Half of the women reported their chronic urticaria had improved, 29% reported worsening, and 20% didn’t notice changes. Urticaria exacerbations happened mainly in the first or third trimester (22,8% and 27,6%, respectively). The risk factors were: mild disease and no angioedema before pregnancy, no treatment before pregnancy, exacerbation in a previous pregnancy, treatment during pregnancy, and stress. After giving birth, 44% of the women reported no changes in the disease, 37% reported worsening, and 18% improved.

In conclusion, pregnancy impacts the course of urticaria, and counsel and management should be done on a one-to-one basis. More prospective studies are needed to assess the importance and reliability of urticaria risk factors during pregnancy.

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Future of Allergic Rhinitis Management

By | Selected articles

Sophia Linton, Alyssa G. Burrows, Lubnaa Hossenbaccus, Anne K. Ellis

Ann Allergy Asthma Immunol . 2021 May 7;S1081-1206(21)00337-9. doi: 10.1016/j.anai.2021.04.029. Online ahead of print.

Allergic rhinitis is a chronic inflammatory condition that affects up to 30% of people in America. Immunoglobulin E-mediated hypersensitivity responses to allergens cause it. This review aimed to provide a complete, clinical assessment of therapeutic agents and practices to manage allergic rhinitis.

A systematic review of the literature was completed using PubMed, published abstracts and virtual presentations, and results published on clinicaltrials.gov. Manuscripts with trial results, case reports, case series, and clinical trial data were selected.

Social media, telemedicine, and mHealth demonstrated useful tools for integrated care for allergic rhinitis management, as they can connect allergologists and their patients. A multidisciplinary approach is positive for optimal control of allergic rhinitis. Pharmacotherapy is the standard of care for the management of allergic rhinitis (azelastine hydrochloride and fluticasone propionate, or a combination of both) and represents the future of allergic rhinitis care. Intralymphatic immunotherapy (ILIT) and peptide immunotherapy (PIT) are the most promising new allergen immunotherapy options, with better time and cost-effectiveness than subcutaneous immunotherapy and sublingual immunotherapy, with studies demonstrating positive results. Studies of targeted biologics for allergic rhinitis are ongoing.

Probiotics, in particular, Bifidobacterium spp may be beneficial for allergic rhinitis management and as an add-on to allergen immunotherapy (AIT).

In conclusion, being a chronic and often comorbid condition, allergic rhinitis requires integrated care for optimal management. New formulations and combinations of existing treatments are the most promising and deserve future research.

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covid and rinitis

How does allergic rhinitis impact the severity of COVID-19?: a case-control study

By | Selected articles

Ali Guvey

Eur Arch Otorhinolaryngol . 2021 May 1;1-5. doi: 10.1007/s00405-021-06836-z. Online ahead of print.

 

SARS-CoV-2, which leads to coronavirus disease (COVID-19), is an exceptionally infectious disease which symptoms include fever, cough, fatigue, and dyspnea, and sometimes can be fatal in people with risk factors. Initially, some allergic diseases, including asthma, were defined as risk factors and poor outcomes. The objective of this study was to evaluate how allergic rhinitis affects the severity of COVID-19.

This was a case-control study conducted at Sakarya Educational and Research Hospital, Toyota Hospital, and Yenikent State Hospital between March 18, 2020, and August 30, 2020. It included 125 randomly selected patients previously diagnosed with allergic rhinitis before being diagnosed with COVID-19; and a control group of 125 patients without allergic rhinitis and diagnosed with COVID-19.

Patients were assessed regarding symptoms, lifestyle (smoke), comorbidities, and length of hospitalization.

The two groups did not have statistical differences in asymptomatic patients, smokers, hospitalization status, and length.

Two patients from each group went to an intensive care unit, and three patients died: one patient with allergic rhinitis and two from the control group.

In conclusion, allergic rhinitis did not impact the severity of COVID-19. However, more studies are needed with patients with allergic rhinitis and COVID-19.

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Advanced Biomarkers: Therapeutic and Diagnostic Targets in Urticaria

By | Selected articles

Yue Zhang, Hanyi Zhang, Shengyi Du, Siyu Yan, Jinrong Zeng

Int Arch Allergy Immunol . 2021 Apr 29;1-15. doi: 10.1159/000515753. Online ahead of print.

Urticaria is a skin disease characterized by rapid onset of hives (superficial dermis edema, erythema, pruritus, or burning sensation), which can be worsened by angioedema (edema of the deep dermis, fat tissue, and gastrointestinal tract). It reduces the quality of life of people and can consist of recurrent attacks. It can be considered acute urticaria or chronic urticaria if it takes longer than six weeks.

Chronic spontaneous urticaria is the most common and can be induced by autoreactivity or other causes. The diagnosis of chronic urticaria is usually complex and requires the exclusion of recurrent angioedema or hereditary angioedema, so biomarkers are essential to diagnose urticaria patients.

Currently, the assessment of chronic urticaria activity depends on the Urticaria Activity Score (UAS), with few evaluation indicators. Consistent biomarkers are needed to assess urticaria.

This article summarizes advanced biomarkers and related pathogenic pathways recently discovered, such as the cell adhesion/chemotaxis pathway, interleukin (IL)-6/Janus tyrosine kinase/STAT pathway, IL-17/IL-23 pathway, basophil- and mast cell-related pathway, coagulation/fibrinolysis-related pathways, single-nucleotide polymorphism, and some other pathways.

This review aims to discover adequate biomarkers to assess disease activity, find novel therapeutic targets, and predict the patients’ response to therapeutic agents (table 1).

 

Table 1. Biomarkers uses in urticaria

 

IL-18BP

IL-6 IL-33

Dimeric TCTP

IL-17

CRP

Siglec-8 IL-23

D-dimer

BDNF

CD203c

5-HT transporter protein

Syk

Vitamin D3/VDBP SSA

CCL17

Substance P

PAF

Keratin86; desmocollin 1; lectin, galactoside-binding, soluble, 7; lactotransferrin; keratin, type II cytoskeletal 4; keratin 31; keratin 80; premature ovarian failure, 1B; plakophilin 1; defensin, alpha 3, and neutrophil-specific

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The Diagnostic Workup in Chronic Spontaneous Urticaria-What to Test and Why

By | Selected articles

Martin Metz

J Allergy Clin Immunol Pract . 2021 Apr 20;S2213-2198(21)00435-9. doi: 10.1016/j.jaip.2021.03.049. Online ahead of print.

Chronic spontaneous urticaria (CSU) consists of wheals, angioedema, or both for longer than six weeks. Guidelines have limited procedures during the routine workup; however, some patients might need additional investigations. The objective of this article is to propose recommendations for the diagnostic and evaluation of some urticaria patients.

An extensive literature search was performed to identify important questions that should define diagnostic procedures based on expert consensus and published evidence.

The authors proposed seven questions for all chronic spontaneous urticaria patients: Confirm (rule out a differential diagnosis); Cause (look for indications of CSU); Cofactors (identify potential triggers, aggravators); Comorbidities (check for chronic inducible urticaria, autoimmunity, and mental health); Consequences (identify problems with sleep, distress, sexual health, work, and social performance); Components (assess potential biomarkers or predictors of treatment response); Course (monitor CSU activity, impact, and control).

Also, a complete medical history should be conducted in the assessment of the patient. CSU should be confirmed in all patients through a differential diagnosis, including blood testing for CRP and/or erythrocyte sedimentation rate and complete blood count with differential.

In conclusion, based on the answers, a decision for or against more diagnostic tests should be conducted by the specialist to prevent unnecessary and expensive testing and increase treatment effectiveness.

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Heterogeneity of the pharmacologic treatment of allergic rhinitis in Europe based on MIDAS and OTCims platforms

By | Selected articles

Jean Bousquet

Clin Exp Allergy . 2021 Apr 20. doi: 10.1111/cea.13884. Online ahead of print.

Allergic rhinitis is a prevalent chronic condition. There are different treatments across countries in Europe that depend on the cost and sales too. The objective of this study was to evaluate practices in Europe to implement the Good Practice of DG Santé (MASK-air). A secondary purpose included understanding the differences and propose improvement strategies.

This study consisted of analyzing a pharmaco-epidemiological database to evaluate prescribed allergic rhinitis treatment from 2016 to 2018 in the five principal markets in the EU (France, Germany, Italy, Poland, and Spain). To gather this information, the IQVIA platforms for prescribed medicines (MIDAS®—Meaningful Integration of Data, Analytics, and Services) and for OTC medicines (OTC International Market Tracking—OTCims) were used.

The analyses excluded intranasal decongestants as they are seldom prescribed for allergic rhinitis. France leads concerning the other countries in costs and Standard Units (SU). All other countries are similar in respect to SU. However, Poland’s costs are lower than the remaining. The use of medication is very different, though: in 2018, intranasal corticosteroid was the first treatment in Poland (70,0%), France (51,3%), Spain (51,1%), and Germany (50,3%). Systemic antihistamines were more sold in Italy (41,4%), followed by 30,1% of intranasal corticosteroids. In 2016 and 2017, the results were similar.

This study represents an excellent interest in assessing the differences in allergic rhinitis treatment in Europe and can be a start for future studies of treatment trends.

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