Proposition

Information

• Explain that the episodes of angioedema described by the patient, resolving within 48 hours and associated with superficial urticaria, do not require corticosteroid therapy. They are not life-threatening, unlike acute allergic urticaria. They are part of the CSU “picture”.
• Explain that there is a possible adverse impact of corticosteroids on the severity of CSU (they may promote anti-H1 antihistamine resistance), and on the more frequent occurrence of angioedema episodes.
• Explain that the patient’s metabolic syndrome (hypertension and diabetes) may be aggravated by corticosteroids.
• Explain the need for more regular monitoring of her high blood pressure and diabetes; there may be an association between being overweight and CSU.
• The episodes of angioedema described here are in principle related to CSU and not to ACE inhibitors (association with skin lesions, rapid resolution). It is preferable to seek the advice of a reference centre for angioedema to determine whether the ACE inhibitors should be discontinued.

Assessment

• It is necessary to assess the impact of CSU on her quality of life before proposing a third-line treatment (after anti-H1 antihistamines at conventional dose and then quadruple dose). The assessment can be made using the /home/clients/2d968a8758d292fa1ac968882da338c1/vhost/sfdermato.org/reco/dev/APP/view/content/uaf/cas/vignette-02.php on line 57
  ">DLQI or CU-QoL scores. It is also preferable to assess CSU activity at this stage, using the UCT and UAS7 scores.

Treatment

• The preferred treatment option is the addition of omalizumab to anti-H1 antihistamines, as the patient is overweight and has high blood pressure (advising against the use of cyclosporine). Omalizumab is often effective in treating episodes of angioedema. The patient should be referred to a hospital for initiation of treatment. Omalizumab is prescribed at a dose of 300 mg/4 weeks subcutaneously. ^*Some experts do not start omalizumab until after corticosteroid cessation has been achieved; other experts recommend introducing omalizumab earlier to help with weaning.
• L’option thérapeutique à proposer prioritairement est l’adjonction d’omalizumab aux anti-H1, la patiente étant en surpoids et ayant une hypertension artérielle (faisant déconseiller la cyclosporine). L’omalizumab est souvent efficace sur les épisodes d’angio-œdème. Il faut adresser la patiente en milieu hospitalier pour l’initiation du traitement. L’omalizumab se prescrit à la dose de 300 mg/4 semaines par voie sous-cutanée. ^*Certains experts ne débutent l’omalizumab qu’une fois le sevrage en corticoïdes établi ; d’autres experts recommandent au contraire d’introduire l’omalizumab rapidement, pour aider à ce sevrage.

References

• Omalizumab treatment
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  " title="Download PDF">Scores (appendix 7)
• Corticosteroids treatment