A survey of the treatment and management of patients with severe chronic spontaneous urticaria

Chronic spontaneous urticaria (CSU) is characterized by the recurrent appearance of weals, angio-oedema or both, occurring at least twice weekly for longer than 6 weeks. It is often managed with antihistamines, but occasionally requires other systemic agents in recalcitrant cases. A cross-sectional survey was conducted by means of an internet-based survey tool (Typeform; https://www. typeform.com). Participating consultants with a specialist interest in urticaria were identified through the specialist registers of the British Society of Allergy and Clinical Immunology (BSACI), the Improving Quality in Allergy Services (IQAS) Group and the British Association of Dermatologists (BAD), and invited to take part. The survey content was based on current CSU treatment guidelines from EAACI/GA2LEN/EDF/WAO and the British Society for Allergy and Clinical Immunology (BSACI). The EAACI/GA2LEN/EDF/WAO guidelines are a joint initiative of the Dermatology Section of the European Academy of Allergy and Clinical Immunology (EAACI), the Global Allergy and Asthma European Network (GA2LEN) (a European Union-funded network of excellence), the European Dermatology Forum (EDF), and the World Allergy Organization (WAO). To standardize responses, all participants were presented with a case of recalcitrant CSU (failed on maximum dose of nonsedating antihistamines and montelukast), requiring alternative systemic treatment. Questions covered usage of systemic treatments, routine disease severity assessments, adherence to treatment guidelines and perceived barriers to prescribing. Responses (Table 1) were received from 19 UK consultants (26 surveys sent; completion rate 73%), 15 of whom had > 10 years’ experience in the treatment of CSU. The majority were allergy (58%) and dermatology consultants (37%). Of the 19 consultants, 56% provide a dedicated urticaria service, 37% treat both adult and paediatric patients, and the majority (79%) use systemic medications other than antihistamines and montelukast. Omalizumab and ciclosporin were the most commonly used first-line agents (47% and 27% respectively) (Fig. 1). The majority (84%) of consultants use validated measures to assess disease severity, including the weekly Urticaria Table 1 Summary of survey results.

A survey of the treatment and management of patients with severe chronic spontaneous urticaria doi: 10.1111/ced.13778 Chronic spontaneous urticaria (CSU) is characterized by the recurrent appearance of weals, angio-oedema or both, occurring at least twice weekly for longer than 6 weeks. 1 It is often managed with antihistamines, but occasionally requires other systemic agents in recalcitrant cases.
A cross-sectional survey was conducted by means of an internet-based survey tool (Typeform; https://www. typeform.com). Participating consultants with a specialist interest in urticaria were identified through the specialist registers of the British Society of Allergy and Clinical Immunology (BSACI), the Improving Quality in Allergy Services (IQAS) Group and the British Association of Dermatologists (BAD), and invited to take part.
The survey content was based on current CSU treatment guidelines from EAACI/GA2LEN/EDF/WAO 1 and the British Society for Allergy and Clinical Immunology (BSACI). 2 The EAACI/GA2LEN/EDF/WAO guidelines are a joint initiative of the Dermatology Section of the European Academy of Allergy and Clinical Immunology (EAACI), the Global Allergy and Asthma European Network (GA2LEN) (a European Union-funded network of excellence), the European Dermatology Forum (EDF), and the World Allergy Organization (WAO). To standardize responses, all participants were presented with a case of recalcitrant CSU (failed on maximum dose of nonsedating antihistamines and montelukast), requiring alternative systemic treatment. Questions covered usage of systemic treatments, routine disease severity assessments, adherence to treatment guidelines and perceived barriers to prescribing.
Responses (Table 1) were received from 19 UK consultants (26 surveys sent; completion rate 73%), 15 of whom had > 10 years' experience in the treatment of CSU. The majority were allergy (58%) and dermatology consultants (37%). Of the 19 consultants, 56% provide a dedicated urticaria service, 37% treat both adult and paediatric patients, and the majority (79%) use systemic medications other than antihistamines and montelukast. Omalizumab and ciclosporin were the most commonly used first-line agents (47% and 27% respectively) (Fig. 1). The majority (84%) of consultants use validated measures to assess disease severity, including the weekly Urticaria Activity Score (UAS-7, 63%), the Physician Global Assessment (63%), the Patient Global Assessment (44%) and the Dermatology Quality of Life Index (DLQI) (38%). Guidelines are used by 89% to direct their management of CSU, with 50% using the EAACI/GA2LEN/EDF/WAO guideline, 1 compared with 31% primarily using the BSACI guideline. 2 The main perceived barriers to prescribing systemic medications were potential adverse effects (AEs) (32% strongly agreed), potential long-term toxicity (26% strongly agreed), cost of treatment (42% strongly agreed), and views expressed by the patient and their family (37% agreed). Our findings show variance between dermatology, allergy and immunology consultants with regard to the prescribing of systemic agents in CSU (Fig. 2). Our findings suggest that allergists are more likely to prescribe omalizumab as first-line treatment, whereas dermatologists more commonly prescribe ciclosporin, which is not in keeping with National Institute for Care Excellence guidance. 3 Drug-related AEs are the main perceived barrier for clinicians to prescribe systemic medications. Other barriers to prescribing are the cost of medications. The list price for omalizumab 300 mg monthly for 12 months is £6150, 4 excluding the cost of post-injection observations required in a secondary care setting, whereas ciclosporin (in generic formulation) costs £2660 for 12 months (300 mg/day; 4 mg/kg/day for a patient weighing 75 kg), 4 excluding the cost of renal function and blood-pressure monitoring. The main limitation to our survey was the number of respondents, as we chose to focus on consultant physicians with a specialist interest in urticaria.
In summary, our UK survey highlights the differences in management of CSU between dermatologists and other specialists, resulting in variation in the care provided for patients with CSU. Although national and international treatment guidelines now recommend omalizumab as a