11/5/2012
I am seeing an 82 year old woman with chronic renal failure (about 70% function), diabetes, cardiac arrhythmias, and depression who has had chronic urticaria for the last 18 months. The severity of the hives have progressed and have substantially affected the patients quality of life especially with regard to sleep (the hives are worse from 4PM-6AM).

Laboratory studies are as follows: thymoglobulin Ab 97.5 U/ml, hemoglobin of 11.2 g/dL, hematocrit 34.6% , 24% eosinophils of diff (AEC 1046), potassium of 5.3 mmol/L, glucose of 136 mg/dL, BUN of 60 mg/dL, negative ANA, TSH 1.8 uIU/ml, ESR of 44 mm/hr, normal liver function studies, negative hepatitis panel, trace protein on urinalysis, negative histamine release study through Quest laboratories and a total IgE of 132 kU/L . She had ImmunoCAP drawn and showed class II levels of IgE to dust mites of 2.23 and 2.78.

Skin biopsy is consistent with chronic urticaria.

She has been treated with prednisone and Medrol tapers which controls the hives but she was never able to reduce the dose to less than 15-20 mg without the hives recurring. Zyrtec 30 mg daily with Pepcid 40 mg daily and Singulair 10 mg daily did not offer any benefit. A 6 week trial of dapsone did not help. Benadryl and hydroxyzine were not helpful.

She was having uncontrolled sugars, experiencing worsening of neuropathies and developed some retinal bleeds on prednisone and she discontinued this medication.

The nephrologists recommended against cyclosporine or tacrolimus. The endocrinologist recommended against levothyroxin. We have discussed a trial of sulfasalazine and hydroxycholoroquine. We have also talked Xolair and immunotherapy.

Do have any suggestions as to best approach to this patient? Thank you.

Thank you for your inquiry.

I believe that you have done due diligence in searching out alternative therapies for your patient, and have in essence covered “most of the bases” in this regard.

Of the drugs that you have mentioned, my first choice would be omalizumab if you can get over the payment issue. My second choice would be hydroxychloroquine. However, there is another reasonably good alternative that I would favor over hydroxychloroquine. This is mycophenolate mofetil. This is one of the drugs that are mentioned in two excellent reviews, both entitled “Therapeutic Alternatives for Chronic Urticaria, an Evidence-Based Review.” The publications appeared in successive issues of the Annals of Allergy, Asthma, and Immunology. The references are:

1. Morgan and Kahn. Therapeutic alternatives for chronic urticaria, an evidence-based review, Part 1. Annals of Allergy, Asthma and Immunology, Volume 100 (Number 5), pages 403-412, May 2008.

2. Morgan and Kahn. Therapeutic alternatives for chronic urticaria, an evidence-based review, Part 2. Annals of Allergy, Asthma and Immunology ,Volume 100 (Number 6), pages 517-526, 2008.

I might mention parenthetically that there may be some significance of her eosinophilia. You did not mention the drugs that she was taking, but I assume that all drugs that can be substituted have been substituted, and all that can be discontinued have been discontinued. It is of course possible that her urticaria is related to a drug and, as you know, one of the etiologies of eosinophilia is a drug reaction.

With this observation in mind, if drugs have not been discontinued or substitutions for each drug where possible, this is something that I would consider as well.

Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.