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Urticaria, a condition characterized by wheals and/or angioedema, is usually short-lived, lasting less than 6 weeks for most patients. In the chronic form of the disease, the course lasts greater than 6 weeks and may be either spontaneous or physically induced by factors such as pressure or extreme cold.¹

For chronic spontaneous urticaria (CSU) sufferers, an increased dose of a first-line, second-generation H1-antihistamine may be tried.¹ Another option for treatment in these cases is a short course of a systemic corticosteroid鈥攕uch as prednisone or dexamethasone. However, according to the investigators of a newly published systematic review and meta-analysis of the efficacy and safety of systemic corticosteroids for urticaria, the evidence hasn鈥檛 been adequately characterized.²

The benefits (and risks) of adding corticosteroids

To help fill this knowledge gap, an international team led bv Xiajing Chu, MPH, McMaster University, Hamilton, Ontario, Canada, reviewed the benefits and harms of treatment with or without systemic corticosteroids for both acute and chronic urticaria flares by looking at 12 randomized trials that included 944 patients.² The investigators conducted random-effects meta-analyses of urticaria activity, itch severity, and adverse events as part of a guideline update to the American Academy of Allergy, Asthma & Immunology (AAAAI)/American College of Allergy, Asthma and Immunology (ACAAI) Joint Task Force on Practice Parameters for Chronic Urticaria. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluations (GRADE) approach.

After reviewing the evidence, the investigators found that the use of add-on systemic corticosteroids was likely to improve urticaria activity by a 14% to 15% absolute difference among patients with low or moderate probability (17.5% to 64.0%) to improve with antihistamines alone (odds ratio [OR] 2.17, 95% confidence interval [CI] 1.43 to 3.31; number needed to treat [NNT] 7; moderate certainty). The use of add-on systemic corticosteroids was likely to improve urticaria activity by a 2.2% absolute difference (NNT 45; moderate certainty) among those with a high chance (95.8%) to improve with antihistamines alone. While itch severity may be improved with the use of short-course corticosteroids (OR 2.44, 95% CI 0.87 to 6.83; risk difference 9%; NNT 11; low certainty), there鈥檚 also a good chance that adverse events will increase with these agents (OR 2.76, 95% CI 1.00 to 7.62; risk difference 15%; number needed to harm 9; moderate certainty). The most common adverse events reported were gastrointestinal discomfort and neuropsychiatric changes.

Large randomized trials are needed

鈥淎mong patients who are antihistamine responsive, systemic corticosteroids, such as prednisone or dexamethasone, likely provide little benefit,鈥� says senior investigator Derek K. Chu, MD, PhD, The Research Institute of St. Joe鈥檚 Hamilton, Hamilton, Ontario, Canada. 鈥淎mong those who are antihistamine refractory, benefits are modest. These are balanced, however, by systemic steroids increasing overall adverse effects. Thus, systemic corticosteroids for acute urticaria or chronic urticaria exacerbations likely improve urticaria, depending on antihistamine responsiveness, but also likely increase adverse effects by approximately 15%.鈥�

Dr. Chu believes that there鈥檚 much that remains to be learned about the use of systemic corticosteroids in patients with urticaria, and that their future use may be muted by other treatment advances, such as those detailed in a new systematic review and meta-analysis.³

鈥淲e need large randomized trials addressing the role of systemic steroids for acute urticaria and flares of chronic urticaria to increase the certainty and precision of estimates, and inform about potential disease-modifying effects,鈥� he says. 鈥淲e also need better prediction tools for who will derive the greatest net benefit from a short course of systemic steroids. These may, however, be replaced by a growing number of new, rapidly acting medications for urticaria.鈥�

Published: August 06, 2024