新荨麻疹指南强调简单实用

纽约——印度新孟买帕蒂尔医学院/医院的Kiran Godse医生在美国皮肤病学会夏季会议上指出，新的荨麻疹诊断和治疗指南已获得15个专业组织认可，目前正准备发表。

该指南由欧洲变态反应与临床免疫学会(EAACI)皮肤病组、全球过敏和哮喘欧洲网络(GA2LEN)、欧洲皮肤病论坛(EDF)、美国过敏、哮喘和免疫学会(AAAAI)及世界过敏组织(WAO)共同制订。Godse医生表示，新的胆碱能性荨麻疹治疗指南直截了当，相对简单，并且是真正为了全球应用而制订。



在该指南中，荨麻疹的定义包括3个特征：“风团、血管性水肿或两者兼有”。虽然定义中仍然指出这些疾病应与自身炎症综合征、遗传血管性水肿和其他产生荨麻疹或肿胀的疾病进行鉴别，但新指南放弃了“特发性”这一术语。Godse医生表示，目前对病因和发病机制的认识已使我们能够识别大部分病例的病因，而且目前的目标是要发现并回避触发因素，将病例归类为“特发性”而不进行进一步检查的话，一点用也没有。

指南对自发荨麻疹、诱导型荨麻疹、急性荨麻疹和慢性荨麻疹等多个子分类进行了定义，并使用这些子分类指导临床管理。对于急性荨麻疹患者，不建议在获得详细病史后还进行诊断性检查，除了回避策略失败且复发常见的时候之外。甚至对于慢性荨麻疹(定义为症状持续至少6个月)，指南也只建议进行“有限的”初始诊断性检查。该指南依赖于详细的患者病史而非临床检查来鉴别该病的主要形式，如寒冷性荨麻疹、热性荨麻疹、迟发压力性荨麻疹、日光性荨麻疹和有症状的皮肤划痕症，这实际上表明通常不需进行广泛检查来查明潜在病因。然而，指南建议使用慢性荨麻疹生活质量(CU-QoL)和血管性水肿生活质量(Ae-QoL)量表对持续存在显著疾病的患者进行较广泛的检查。强烈建议在基线时使用这两个量表评估症状负担。分步骤管理的治疗目标明确，即症状完全消失。

如果单纯通过回避病因和加重因素而无法消除症状的话，指南建议使用第二代非镇静H1抗组胺药作为一线药物治疗。指南特别建议在最低有效剂量水平连续给药而非按需给药治疗。然而，如果治疗1~4周后症状仍持续存在，应增加给药频率，然后再变更至辅用额外治疗。指南列举的辅助治疗包括奥马珠单抗、环孢素A和孟鲁司特。前两种药物的证据等级高，获得强烈建议，但第三种药物的证据等级低，获得弱建议。对于经这些药物治疗失败的患者，替代药物较多，包括短期糖皮质激素、免疫调节疗法，如甲氨蝶呤和静脉注射免疫球蛋白。虽然这些药物中的任何一种均可能对患者有益，但获益的总体证据质量较低。

最后，指南试图定义一种可在不同人群、所有可能病因范围内和不同医疗系统内统一应用的方法。

Godse医生声明没有与其演讲相关的经济利益冲突。

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By: TED BOSWORTH, Internal Medicine News Digital Network

NEW YORK – New guidelines for the diagnosis and treatment of urticaria have been endorsed by 15 professional organizations so far and are now being prepared for publication, according to a consensus meeting participant who summarized key points at the American Academy of Dermatology summer meeting.

The guidelines, developed at an earlier conference held in Berlin attended by experts from 39 countries, are straightforward, relatively simple, "and truly developed for global application," according to Dr. Kiran Godse of Patil Medical College and Hospital, Navi Mumbai, India. The guidelines represent a joint initiative of the Dermatology Section of the European Academy of Allergology and Clinical Immunology (EAACI), the Global Allergy and Asthma European Network (GA2LEN), the European Dermatology Forum (EDF), the American Academy of Allergy, Asthma and Immunology (AAAAI), and the World Allergy Organization (WAO).

New guidelines for treating cholinergic urticaria are straightforward, relatively simple, "and truly developed for global application," said Dr. Kiran Godse.
 
The simplicity of the guidelines starts with the definition of urticaria. It consists of three characteristics: "wheals, angioedema, or both." While the definition goes on to specify that these conditions should be differentiated from autoinflammatory syndromes, hereditary angioedema, and other diseases that produce hives or swelling, the new guidelines abandon the term "idiopathic."

"Our understanding of the etiology and pathogenesis has advanced to the point that we can identify the causes in most cases," said Dr. Godse, indicating that classifying cases as "idiopathic" without further investigation is unhelpful when the goal is to find and avoid triggers.

A number of subclassifications, such as spontaneous urticaria, inducible urticaria, acute urticaria, and chronic urticaria, are defined and employed to guide clinical management. In patients with acute urticaria, diagnostic testing beyond a careful history is not recommended, except when avoidance strategies fail and recurrences are common.

Even in chronic urticaria, which is defined as symptoms persisting for at least 6 months, Dr. Godse said that the guidelines recommend "limited" initial diagnostic studies.

By relying on careful patient history rather than clinical tests to differentiate the major forms of this disease, such as cold urticaria, heat urticaria, delayed pressure urticaria, solar urticaria, and symptomatic dermographism, the guidelines in effect propose that underlying etiologies do not usually require an extensive workup. However, the guidelines do advise more extensive tests in individuals with persistent and significant disease, which can be measured with the Chronic Urticaria Quality of Life (CU-QoL) and the Angioedema Quality of Life (Ae-QoL) instruments. Both are strongly recommended for baseline assessment of symptom burden.

The treatment goal of the stepwise management is clear: complete absence of symptoms. "Treat the disease until it is gone," said Dr. Godse, summarizing this recommendation.

If symptoms cannot be eliminated simply by avoiding causes and aggravating factors, the guidelines identify second-generation, nonsedating H1 antihistamines as the first-line pharmacotherapy. Dr. Godse said that the guidelines specifically recommend continuous rather than on-demand regimens at the lowest effective dose. However, if symptoms persist after 1-4 weeks of therapy, the dosing frequency should be increased before moving to adjunctive use of additional therapies. Adjunctive therapies listed in the guidelines include omalizumab, cyclosporine A, and montelukast. The first two of these options received strong recommendations on the basis of a high level of evidence, but the third was given a weak recommendation on the basis of a low level of evidence.

In those who fail these therapies, the list of alternatives is lengthy and includes a short course of corticosteroids, immunomodulating therapies such as methotrexate, and intravenous immunoglobulins. While any one of these may be useful in an individual patient, the overall evidence of benefit was considered to be of relatively low quality.

Ultimately, the guidelines attempt to define an approach that is uniformly applicable across diverse populations, a full range of possible etiologies, and within different systems of medical care, according to Dr. Godse.

Asked for their opinion after hearing the guidelines explained at the meeting, Dr. Paul Schneiderman and Dr. Aaron Warshawsky said they were favorably impressed. Both thought the guidelines were clear, reasonable, and potentially helpful in clinical practice. Dr. Schneiderman, an associate clinical professor of dermatology at Yale University, New Haven, Conn., who maintains a private practice in Syosset, N.Y., reported that he will be able to better judge the clinical applicability of the new guidelines when he sees the full publication, but both he and Dr. Warshawsky, a dermatologist in private practice in Poughkeepsie, N.Y., agreed that advances in urticaria justify updated guidelines.

Dr. Godse reported no financial disclosures relevant to his presentation.