Chronic Urticaria: Meeting Patients’ Needs On Their Journey to Diagnosis, Management and Treatment (Recording)
This webinar was recorded on October 16, 2024
Chronic urticaria are hives that occur most days of the week for six weeks or more. It affects more than 500,000 people in the United States. In this webinar, learn how chronic urticaria is diagnosed, treated and managed long-term.
Speaker:
- William Berger, MD
Board Certified in both pediatrics and allergy and immunology, Dr. Berger founded the Allergy and Asthma Associates of Southern California Medical Group in 1981 in Mission Viejo, Calif., where he practices both adult and pediatric allergy. Dr. Berger entered the field of medicine because he wanted to make a positive difference in the lives of others. His commitment to improving patient care has extended beyond his practice to clinical research, publications, leadership in professional organizations and his work with Allergy & Asthma Network.
This Advances webinar is in partnership with the American College of Allergy, Asthma & Immunology. ACAAI offers CMEs for physicians for this webinar. If you are a member of ACAAI, you can obtain CME through the member portal for Advances webinars.
All attendees will be offered a certificate of attendance. No other continuing education credit is provided.
Sponsored by the American College of Allergy, Asthma and Immunology
Transcript: While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.
Catherine: OK, we are going to get started. Hello, again, everyone. Thank you so much for joining us today. My name is Catherine Blackwell, chief health equity officer for the allergy and asthma network. Welcome, welcome, welcome to the webinar. We are in for a real treat, as we have Dr. William Be rger as today’s presenter. All participants will be on mute for the webinar. We are going to record the webinar into posted on her website within a few days. You will be able to find all of our recorded webinars on our website. All you have to do is scroll to the bottom of the page to find our recorded webinars and any upcoming webinars that you might be interested in. This webinar is going to be one hour. That includes time for questions. We are going to take the questions at the end of the webinar. You can put your questions in the Q&A at any time. The Q and a fox is right at the bottom of your screen, there. We are going to have someone monitoring the chat if you have questions or need help during the presentation. We are going to get to as many questions as we possibly can before the webinar. This webinar is in partnership with the American College of allergy, asthma, and immunology. AC AAI can give CME or attendance credits for the member portal. All attendees will be offered a certificate of attendance in no other continuing education credit will be provided. A few days after the webinar you will get an email supplemental information and a link to download the certificate of attendance. We will also try to add it to the chat. So, let’s get started. Today’s topic is Chronic Urticaria: Meeting the Needs on the Patient Journey to Diagnosis, Management and Treatment. Chronic Urticaria, hives that occur most days of the week for six days or more, affecting more than 500,000 people in the United States. Today you will learn more about the difference between acute and chronic Urticaria and how it is diagnosed, treated, and managed long-term. It is my esteemed pleasure to introduce our speaker of the afternoon, Dr. William Berger, board in pediatrics and immunology, he founded the allergy asthma Associates of Southern California medical group in 1981 in Mission Viejo, California, where he practices adult and pediatric allergies. He entered the field of medicine because he wanted to make a positive difference in the lives of others. His commitment to improving patient care has extended beyond his practice to clinical research, publications, leadership, and his work with the allergy and asthma network. Dr. Berger, thank you for being here today and I’m going to turn it over to you now.
Dr. Berger: Thank you, everybody, for taking time out of your schedules to learn about Chronic Urticaria. The mission of our sponsor, the allergy and asthma network, is to end the needless suffering due to asthma, including needless death and related conditions through outreach, education, advocacy, and research. As mentioned, I was the medical director for the allergy and asthma network and founder of allergy asthma solutions, a group in terms of helping organizations to develop programs for allergy and asthma. I’ve worked with inter-immune therapeutics. No other relationships concerned. But we are talking about today are comparing and contrasting the presentation and evaluation of acute and Chronic Urticaria, stepping up treatment, and the new guidelines around management of this problem. So, what is question — what is Urticaria? It can vary in size and shape from small to large areas with surrounding areas of erythema. Chronic signs are scratchy itchy feelings all the time. Individual lesions will usually fade within a day or two. Comparatively, and she edema, which — angioedema can be more painful, causing erythema and non-terrific edema. It can take longer to resolve, up to 72 hours. When you see a patient with Urticaria, one of the most important aspects is getting a complete history, which should include time of onset of the disease, the shape, size, frequency, duration, and distribution of the urticaria. Other associated systems, like angioedema, possible causes, bone, joint pain, fever, cramps, and one of the most important things is to evaluate whether there is any physical agent or exercise involved. Often you might hear in a history that there is a relationship to menstrual cycles. You want to find out if it is related to food or drugs the patient is taking. And whether the patient has had any previous or present infections. Or is under a lot of stress. Of course, if they have received previous therapy and if they have, what has been the response and if any previous diagnostic tests or procedures have been done. It’s also important to get a personal medical history of the infections, autoimmune disorders , or atopic conditions like asthma like line-itis. Family history can give you clues to what’s going on. Of course, you need to get a social history to see if there are possible exposures that the patient may not realize have an important aspect to their disease. And of course, any occupational history — where are they working, what type of hours do they do, what things are they coming in contact with?
As many of you know, thyroid dysfunction has been associated with urticaria. Connective tissue disorders, autoimmune diseases and immune to sump — dysfunction. As was mentioned by Catherine, previously, we want to differentiate between acute and chronic urticaria. Acute is defined by the new guidelines as occurring less than six weeks, recurring episodes exposing the same trigger. Look for possible IGA mediated triggers, like foods they might have an immediate response to, medications — classic medications are the nonsteroidal anti-inflammatory is like ibuprofen and other related Motrin, Advil, over-the-counter medications. Taking something over-the-counter doesn’t mean that it doesn’t have a pharmacological effect that needs to be evaluated. Also, you might want to do some immunoassay and do some scratch tests, allergy tests to see if there are possible allergens involved. In addition, there are non-IG triggers, like by roles, common in the pediatric group, physical triggers, and toxins. Strom Boyd is usually from bad fish, can cause hives and redness on the skin. You want to determine if it is chronic or spontaneous. The treatment usually involves using antihistamines, small amounts, and avoid any presumed triggers. Chronic is over six weeks, recurring, usually periodic, and can be associated with angioedema, but in many cases not, can occur with autoimmune disorders and infections and disorders that affect the mass cells, causing aggravation. For example, activation syndromes that can cause the release of histamine and other inflammatory mediators. Mass cell disorders are a very high concern for patients with hives. Immunoassays and pricked tests don’t usually give you any additional information. Usually these patients are found to have auto antibodies against the receptor on the mass cell and five percent to 10% antibody against IgE. When you look at acute urticaria , these are some of the things you would think about.
Whether there is any contact, whether there has been anything physical in those areas, food allergy, adverse reactions — those of you in allergy clinics know that you get hives from allergy shots if the dose is too high. As I mentioned, adverse drug reactions with opiates, very often causing hives. Base inhibitors. And as I mentioned before, NSAIDs. Capillary, because my bites, this could be scabies, fleas, or bedbugs. Infections, especially EB virus, Epstein-Barr, or any food or contaminated foods where toxins or poisons have occurred. Acute urticaria angioedema, you have to be concerned about a sign of anaphylaxis. If there is an episode with angioedema and other symptoms like wheezing, coughing, gastrointestinal, often patients will have a form of stomach disorder with stomach pains. Nervousness, a feeling of impending doom. And any cardiac changes like an increase in heart rate and a drop in blood pressure. Treated with epinephrine, you know that those are injectables and there is a newly approved intranasal form. Nasal spray should be surprised if — prescribed if there is concern over possible anaphylaxis. Chronic urticaria occurs in at least 100,000 adults. Now the numbers are much higher. Global prevalence is somewhere up to 3%. Women, unfortunately, are affected much, much greater than men. The usual age group is in their 40’s. In other areas of the world we see it, the 50’s, the 70’s. It is not unusual for it to last several years, two years to five years. Half coexist with angioedema and 35% resolved within a year. Chronic urticaria may or may not occur with systemic illnesses such as autoimmunity, infection, and as I mentioned before, immunoassays and skin pricked tests are not normally recommended. Very often, we really cannot determine a clear pathological mechanism, but we want to look for any inflammatory infiltrates or autoantibody introduction to assess whether there is a mass cell dysfunction or disorder. Also, we want to include other diseases in the differential diagnosis and understand — there is a much greater concern now — about really being evaluated for disease activity. These patients with chronic urticaria really have an important impact on quality of life and in some cases, it has been compared to the same affected quality of life as coronary artery disease. And we want to make every effort to identify any triggers of exacerbation. In terms of angioedema and isolation, the first question of course is family history. We want to know if there are any comorbid diseases.
Autoimmune diseases, malignancies, they can sometimes present with angioedema. Whether the patient uses an ACE inhibitor as treatment for high blood pressure. Are there physical triggers? What is important is to be able to see whether there is anything you can identify. We will go into that in a couple of minutes. There is inducible and spontaneous. Is there a particular site that it seems to be involved in? Around the joints or the eyes, any particular area, you need further investigation. Of course, if there are any systemic systems. The Senate philia — eosinophil lia can lead you to certain disorders. One of the other known, vasculitis, these types of urticaria lesions are painful, burning, palpable and non-blanching, as opposed to traditional urticaria. It can persist for several days and when result, there is residual pigmentation that you don’t see in classical urticaria . One of the things that you need to do is to consider getting serum complement. You should work with a dermatologist, or if you have the training, do a skin biopsy to see if, under examination, there is a sign of glucose idle plastic vasculitis. Uveitis, all of these autoimmune types of disorders, and looking for obstructive lung disease that — for those not of complement levels. OK, let’s talk about the pathophysiology of chronic urticaria. It is basically a mast cell and basil filled mediated disease. Precise mechanism is not clear but it is being investigated on a regular basis. The key thing is the D granulation of the mast cells. When you have that, you have histamine, metabolites, leukotrienes, and platelet activating factors with vasodilation and sensory nerve activation. The wheels are due to the edema of the upper dermis, dilation, and in first — increased permeability in the lymph vessels, operation of the endothelial growth factors. You can often see a mixed inflammatory infiltrates. What you do not see is any vessel wall necrosis. That’s a differential. In terms of non-regional skin, you want to see if there are any upregulated adhesion molecules, eosinophil infiltration or altered side a keen expression. In angioedema, you will see changes in lower dermis subcu Titus — subcu this. There’s a lot of research going on in the area of autoantibody, present and about 10% of patients in recent investigations. That number may be higher, 20%, 25%. Type one autoimmune, IgE auto antibodies to auto antigens, like thyroid peroxidase, the differentiation, why it is important, these patients respond very well to Melissa Mab — Omalizumab. The drug binds the antibodies for reduced activation. Type two autoimmunity is more of an IgE autoantibody to the FC receptor site and as a result, Omalizumab does not work as well, you get a slow response to a slow loss of memory in IgE because of the antibodies on the mast cell. Now, here is how we divide chronic urticaria.
There is what we call inducible, that’s about 20% of cases. It’s a result of environmental stimuli and physicals triggers on inflammatory cells. Several physical triggers may even coexist. A practice in 2017 looked at less than 250 patients and 75% had the physical trigger, 30% had the positive challenge test, and 25% had the symptomatic skin stroking. When patients describe physical urticaria, these triggers should be possible to verify it in your office and we will talk about some of these tests and what they are. The response can range from mild to severe. Believe it or not, you can have life-threatening, especially cold urticaria who develop hives with exposure to cold, if they are immersed in cold water, it can cause severe release of mediators throughout the body and could be a life-threatening condition. If a severe episode occurs, obviously you want to consider giving the patient a prescription for epinephrine. The problem is that these types of physical urticarias are less responded — responsive to standard treatments, that’s why it is so important to avoid the trigger and have antihistamines available. The spontaneous represents 80%, the majority of the chronic urticarias. However, they are not exclusive. You can have chronic urticaria, but may have some inducible symptoms. Let’s talk about what some of them are. First, there is Opera genic, meaning water, and it can be any water source, usually occurring after 30 minutes. The temperature is usually not an issue, whereas holder can make a difference. There’s a different response to ionic concentration, and there is no difficulty drinking the water. It is basically dermatological contact. Females seem to be more affected, tends to occur after puberty. It’s not real clear with the pathologic mechanism is. There are some theories that the water acts as a vehicle for the transport of antigens into the dermis. Releasing mass — mast cell granulation. Enough studies have shown that if you remove strata 4:00 a.m., you get enhanced response, and the degree is determined by the degree of water penetration. It’s possible that NS the Teal Cohen lien, which causes sweating and open pores, could be involved. This is to be distinguished from Aqua genic pruritus, where there is an increase in the cells. : Aaron Sherrick — cholinergic urticaria represents about 5% of all cases of chronic urticaria, which is significant, and of the physical urticarias, it’s about a third, and results in poor body temperatures. The classic presentation with — is with exercise, hot showers, stress, sweating. It is thought that it might be an exaggerated response to cholinergic substances. There is a difference in some patients. Some have greater sensitivity and a lack of — they may also be affected by a lack of sweating, hypo Hydro’s is. It’s important that you distinguish this from exercise-induced anaphylaxis, which will have other symptoms like breathing difficulties and possibly a fall in blood pressure. All of the signs of anaphylaxis.
Here in cholinergic, its skin, and with anaphylaxis it could be a possible life-threatening situation. It’s important to differentiate the history. Cold urticaria is interesting and I do see a lot of patients presenting with cold urticaria chronically. They have swelling with exposure to cold. There is a primary cold induced urticaria. There are some familial auto inflammatory symptoms. And there are hereditary symptoms, like the C JAMA two enzyme. This is one of the things I warn patients of who have cold urticaria, don’t jump into a cold body of water, because the mast cell releases throughout the body and they could go into shock. It can be a life-threatening situation. Producing more of it in the — we are seeing more of it in the colder areas of the country. Places like California, not so much where there’s a lack of cold water, but more so where there is snow, ice, cold water, you will see more of these kinds of problems. Delayed pressure urticaria angioedema is with — is angioedema associated with four to six hours after exposure, up to 24 areas in some cases. It affects the areas with pressure, palms of the hands and the soles of your feet. Or your buttocks, if you are sitting right now. The swelling is deep, unfortunately, and painful. There could be burning dissidents Asia — distant esthesia — dysesthesia. Very often, these patients have painful joints, arthralgia. The skin biopsy shows a difference from other physical urticarias, in which there is no infiltrate scene. What you do see is the predominant infiltrate, resembling what you would see in a late phase of allergic reaction. What are the triggers? Things that put pressure on the skin. Working with tools. Sitting a lot. Sitting on a bench. Believe it or not, clap your hands, because it causes pressure. Prolonged standing, of course, affects the bottom of the feet. And garments that are very restrictive, such as pants or undergarments that might be very tight on the skin. Unfortunately, these patients don’t really do well with antihistamines in usually require much higher doses. They may even require steroids for a few days. There are alternative agents as modifiers and others that we will talk about beyond antihistamines. This has substantial impairment on the quality of life. They have to modify their activities, lifestyle, if they are sitting or walking a lot, they may have to modify. Also hobbies that involved pressure on their feet, for example — jogging. Employment, are they going to be sitting all the time? Dramatic graph is him — derm atographism, the way that we can diagnose this is by writing on the skin. In dermatology textbooks, you can see the word Donna, their name, written in the skin on their back. It is the most common of all of them and it affects up to 5% of the general population and can occur with other physical urticarias and chronic spontaneous urticaria. Scratch the skin, the wheel in flare occurs within five minutes , occurring from scratching or stroking the skin. Emoluments in this case can sometimes help with the problems associated with dermatographism. Solo — solar urticaria is related to sunlight. What’s interesting is the skin that is more frequently exposed to sunlight is less sensitive and reactive. The skin that is covered is the one that rack — reacts the most . One of the ways to help resolve this is to remove the affected skin from exposure. It occurs in about half of 1% of the chronic patients. The key is to use sunscreen and limit your exposure to the sun. There are other types of photo dermatitis. Those other types should also be evaluated. There is actually something called vibratory urticaria, angioedema and pruritus within one to three minutes of exposure , persisting for an hour, often resulting within 24 hours.
Triggers are working with things that vibrate. Jackhammers, mowing the lawn, riding motorcycle, running, massage, even bowling has been associated with vibratory urticaria. The ones most at risk of the people who work with jackhammers, lawnmowers, like machinists, carpenters, metal renders. One thing that we do mention is possibly gradually building up to a level of activity where we can reach the level of understanding tolerable before the symptoms get out of control. Kind of like working out with weights. Starting with five pounds since 10 pounds, working your way up. Just briefly, these are the challenges we received from the physical urticarias. Water, apply to the skin for about 30 minutes. Cholinergic, immersion in hot water. Dermatographism, easy, stroking the skin. Delayed pressure, 15 pounds on the shoulder, waiting to enter 15 minutes. With vibratory, you might finally find another use for your vortex mixer. I applied it to the forearm for about four minutes. Cold urticaria is the ice cube test. You can see the positive. You put it on the forearm for about five minutes. As you take it away and it warms backup, the hive appears. Similar exposure to soup specific wavelengths of light and exercises in a treadmill challenge to see if it results in release. Workup. Obviously, political suspicion, that is why the history and exam are so important. Complete blood count. Look for inflammatory markers. And for many of these patients, you want to look for thyroid stimulating hormones. You don’t always, although we do that with a lot of patients, the yield is not always very high. Obviously, we want to look for any exogenous causes. In chronic urticaria, we usually say that chronic — extensive workups are not warranted, but I do suggest you do that history. Testing antibodies to the IgE , and also the receptor sites is interesting, but the utility of what you do about it, it’s basically just a predictor of whether the Xolair will be effective on the patients. In terms of assessment, what’s important is disease burden, therapeutic response, body surface area of involvement, severity of the itch. We now have all of these scoring systems in terms of urticaria connectivity scores. Urticaria control tests and quality of life. As you can see here, the urticaria activity score, seven days, daily score, zero to six, from zero to three, maximum being 42. Treatment. Well, obviously try to avoid the triggers. Especially when it comes to physical urticarias. Patients should be advised that if they are having urticaria, they may not want to use NSAIDs, instead they should use other alternative medications. Heat and extreme temperature will certainly aggravate. Type clothing, opiates. Alcohol is a vasodilator, causing problems, so limit the intake of alcohol. Topical core to may be helpful, but really not that effective for chronic urticaria. We don’t recommend topical antihistamines very often, they can cause contact dermatitis. The pharmacological treatment follows an approach after the treatment at the bottom on the right. Initially second generation antihistamines, going to higher doses of specific antihistamines , two times to four times the dose. So, that may be taking two antihistamines in terms of taking two in the morning and two in the evening. However, we don’t recommend at this point using first generation antihistamines. Step three is considering other additional antihistamine medications, like hydroxyzine, and advancing antihistamines to even higher doses. Step four involves cyclosporine. As I mentioned, there are guidelines, American guidelines, which start by using second generation antihistamines. Guidelines from the college in the Academy, there is a step two of using second generation antihistamines.
Adding inhibitors. Step three, using other antihistamine compounds. The European guidelines are much clearer, second generation antihistamines. They don’t go into using these other preparations. They go directly to Omalizumab and if you don’t respond to a combination of antihistamines and Omalizumab, you go to cyclosporine, a suppressant. OK, obviously you want to follow them up on a regular basis to assess their progress and modify the treatment. It is felt that these patients should be kept on two months to three months of treatment before making them step up or step down. Six weeks is an arbitrary distinction between acute and chronic care intervention. H1 antagonists are the mainstay. Daily dosing is more effective than using the as needed, because those histamine antagonists are much more effective if they fire at the receptor site and to give after the patient has had symptoms. Putting patients on antihistamines on a regular basis. Some people use first generation. The majority of allergies are only second generation. First generation antihistamines, you can see the negative aspects, sedation, cognitive performance impairment, anti-cholinergic effect. There are a few risks of dementia, believe it or not. Males are particularly concerned about urinary retention. In older patients, the criteria is to use only medicines that are safe and effective in the geriatric population.
Obviously, you have to be careful about using antihistamines. Even some of those patients can be machine operators. So, first generations are lipophilic, as opposed to the later generations that don’t cross the blood brain barrier. Here are examples of first generation. Second generation is that savanna Dean — those of the ones we tend to use more often, the second generations. Oral glucocorticoids, many of you are aware of them, the side effects for short-term use are really important, it can affect the dose. Be aware of all of the side effects. Patients should be monitored. Especially those patients with, for example, diabetes. Phase two antihistamines are well tolerated and can often be combined with H1. The majority have been done with accommodations. The key thing is that cimetidine would inhibit cytochrome P 400 and 50. Some people will use leukotriene modifiers. There is a possible role of them in chronic urticaria. One of the predictors that we ask about is whether the patient is sensitive to NSAIDs and aspirin, they may be overproducing in a gland. It seemed to work with various physical pressure urticarias. Next step, if they don’t do well on antihistamine therapy, which might be 50% of your patients, the guideline recommendation is to use Omalizumab, cyclosporine, and alternative agents. Omalizumab has been around since 2002, 2003. It was initially a medicine for asthma and was found to also be valuable in urticaria and just got approved for food allergies, as you know. The mechanism of action is not completely clear, but the key thing is that it inhibits the binding of IGE to the receptor site. When you reduce that site on the mast cell basal surfaces, you have less release on mediators. There have been reports that it works on some of the physical urticarias and also on the spontaneous urticarias. There is no bio marker right now to predict response to Omalizumab, other than it is more effective on type one auto allergens. There have been studies, multicenter studies, looking at this. The majority , patients must stay on it as long as they have urticaria. As you can see, this is the itch score, compared to the placebo, the bottom line is+ given — the bottom line is Omalizumab , and in terms of hives, again, the yellow line at the bottom shows a decrease in the hives compared to the lower doses. Unfortunately, at the end of 12 weeks it was discontinued. You can see the line going back up. Once Omalizumab is discontinued, the response changes and then you start having symptoms once again. In terms of adverse events, basically primary outcome is that the instance of adverse events were similar between Omalizumab and placebo. Here again, at the 300 milligrams dose, you can see that the severity was significantly decreased at 12 weeks. This basically shows that the improvement in those receiving Omalizumab as a post of the placebo. Cyclosporine, as I mentioned, dominates Th1 antibody generation.
The main thing with cyclosporine’s is to monitor them for side effects like blood pressure issues and kidney impairment. They should be monitored on a regular basis, and because it is immunosuppression, you have to be careful about infection. So, this is the dose. It has not been clearly defined. Be aware of the fact that different preparations have different liabilities. Going real quickly, pregnancy. Wanted to let you know that with first generation antihistamines, it is sometimes secreted in low concentrations in breast milk. We recommend a lower dose with second generation antihistamines under chronic urticaria. Studies with Omalizumab showed there was no pregnancy fetal complications, so that’’s good news. Safe in a pregnant patient. There is, I’m told, a pregnancy registry. Essentially, they are looking at it with no problems, no major issues. Here you can see that Omalizumab and pregnancy in terms of risk, it’s what you would expect. General population, risk was no higher from the general population. Lastly, be careful about using oral glucocorticoids. The key thing, rarely used, the benefits should clearly outweigh the risk for use. Escalation of care should be on a case-by-case basis. In the elderly, same treatment approach. Monitor the antihistamines. Be aware of the fact that the overpopulation has medical problems like cognitive impairment, they are on many other drugs in many cases. They have decreased kidney function. Therefore, you might have to cut back on the dose. Areas for further research, being able to monitor the epidemiology, consequences of those issues and being able to further identify the factors in those markers. To be able to identify better biomarkers and further identify in the articles that are coming out all the time about chronic urticaria, the valuation of co-impact on morbid quality of life. Why certain patients are resistant to antihistamines. Further, long-term safety evaluation available for treatments. There is a trial going on right now for additional treatment options. One of them who is looking the best at this is, with the autoimmune diseases that continue to have an excellent profile in the path of urticaria . There are agents on the market right now. Some of these new Biologics to provide treatment. I have tried to get through this as quickly as possible and let you answer, have answered any questions. With that, I will complete the lecture. Thank you for your time.
Catherine: Thank you, Dr. Berger, that was a lot of information there. We are going to the question and answer session, now. We have a couple of questions. First question for you is — can you review cimetidine versus famotidine to treat chronic urticaria?
Catherine: They are —
Dr. Berger: They are both H2 receptors. The one taken off the market over concerns of cancer, using either, they are both H receptor antagonists. Using either one is fine. The key is to use it in combination with an H1 receptor antagonist. It’s found that the combination together gives you a better clinical response.
Catherine: OK. One question has to do with self-management of hives, if you will. The question, the comment was basically — when you have a case of hives, if you break out in hives, the first thing that they do is they will call, research Dr. Google. They will say OK, self-management for hives, they don’t call with chronic urticaria. I guess that’s the first thing. They wanted to know if I antihistamines or Benadryl are there go to. I talked to you and other allergists who kind of shied away from Benadryl, but a lot of the people who break out in hives or have chronic urticaria who haven’t been diagnosed yet, there go to his Benadryl. In any of the search engines that you go to, it comes out. Can you comment on that?
Dr. Berger: OK, Benadryl is a very old antihistamines developed in the late 1940’s, early 1950’s. It has become synonymous with the word antihistamine. The problem is Benadryl has significant side effects and one of the major side effects is the drowsiness, the sleepiness. As a matter of fact, if you are an airline pilot flying the plane and you have Benadryl, it’s like a DUI. Same thing, I think many states in the U.S., if you are pulled over and they do a blood test on you and they find diphenhydramine in your system, that’s DUI. The reason it is used is because it is so common. It’s used as a sleep medicine for insomniacs. If you want to pay more for it, buy it as a sleep medicine. That is really short acting, that’s the other problem, only lasting four hours to six hours. That medicine is antiquated. We use the ones, like the ones I favor, Beck’s affinity, completely non-sedating. If you increase the dose, as I mentioned, the recommended dosage on the guidelines is up to two tablets twice a day. If you do that with diphenhydramine, typical dosage is 25 milligrams and he won’t be able to stay awake. You will be able to do that. Someone gave me a cup, one of my patients, and I loved it. On the cup of the coffee mug and said, “please don’t confuse your Google search with my medical degree.” Doing a Google search does not replace good medical care. Hives now and then, if you were to take a Benadryl, fine, but chronic urticaria, you have to be able to still live your life. Be active, drive your car, work, go to school. You are not going to be able to do that with Benadryl.
Catherine: Let’s see if there are any other questions in the Q&A. This is terminology that I don’t understand, Dr. Berger, but I’m sure you will. It just says “immuno modulating as H CQ.”
Dr. Berger: Immuno modulating meaning I’m not sure what they mean by H CQ.
Catherine: I’m not sure, either. They just typed in immuno modulating as H CQ. I’m not familiar with that acronym.
Dr. Berger: I’m not sure what they mean, HCQ. Yes, there are immunomodulators. We talked about the second score as an immuno lot — immuno modulator. Any of the Biologics are immunomodulators. If they are talking about the monochrome of antibodies, they are all modulated in terms of having an effect, for example. There is research being done and these are inhibitors, showed real promise in the treatment of urticaria. There are studies being done and we might see new medications in the next year or two.
Catherine: OK, thank you. All right, I don’t see any other questions in the chat. So, Dr. Berger, this has been very, very informative. I wanted to let you all know that we have several webinars coming up. October 31, noon Eastern standard, we will welcome Dr. merchant to discuss biologic treatments, how they work, and who might benefit from them. November 12 at noon, Eastern standard Time, another advanced webinar with Dr. Michael Bly’s, discussion — discussing consensus statement. You will get an email from Zoom in a few days with a link to the recording and sublimation resources. Please fill it out, it will help us to make things better for you, making sure it resonates and has meaning for you. Thank you again from all of us at Allergy & Asthma Network. Enjoy us as we work every day to work — breathe better together. Have a great afternoon.
