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Bilastine improves symptoms, quality of life in elderly patients with acute and chronic urticaria

Prof. Maria Teresita Gabriel
Research Institute for Tropical Medicine Philippines
Prof. Kanokvalai Kulthanan
05 Aug 2016

Case 1
Presentation

A 66-year-old Filipino female dressmaker sought consult due to pruritus with the appearance of about less than 20 wheals on both of her forearms and wrists. This condition appeared 2 weeks prior to consult. There was no rapid swelling or angioedema noted and symptoms did not have a pattern.

She complained that the pruritus made it difficult for her to perform her usual daily activities. The itch bothered her and affected her sleep, social relationship, and eating behaviour. The condition limited her options for food, personal care products, and clothes.

The patient had no known allergies and there were no coexisting psychosomatic or psychological conditions and gastrointestinal problems. Past medical history was negative for exposure to possible triggers such as certain drugs, exercise, food, menstruation, or smoking. Her previous medications were prednisone 10 mg thrice daily for 2 days and levocetirizine 5 mg once daily in the evening for 10 days which brought about some improvement.On physical examination, she had multiple plaques with smooth surface and polycyclic curved borders. There was no angioedema, no discharges from ears, eyes, nose and throat or lymphoid hyperplasia or hypertrophy as well as no palpable thyroid gland. The patient was diagnosed with acute spontaneous urticaria.

Management
She was prescribed with bilastine 20 mg once daily for 7 days and was advised to return after a week. On follow-up, it was noted that she no longer had pruritus, and the wheals had disappeared completely (Figure 1). After 2 weeks, Urticaria Quality of Life scores improved (Figure 2).

Bilastine Figure01
Bilastine Figure02

After the course of treatment with bilastine, the patient’s work as a dressmaker was no longer affected. She carried on with her normal physical activities, started to sleep well, and had improved focus and less anxiety. Her mood also improved and pruritus no longer bothered her.

She can now eat well, socialize, and resume her activities of daily living with no restrictions. She is no longer embarrassed to go to public places, and no longer bothered with her choice of cosmetics and clothes.

Case 2
Presentation
A 69-year-old male businessman from Thailand consulted for spontaneously occurring wheals of 12 months duration with associated pruritus and angioedema. The appearance of wheals usually occurred at night and was triggered by exercise. He reported that symptoms somewhat interfered with his work, physical activities and sleep.

Previous medication to control his symptoms include fexofenadine 180 mg once daily, levocetirizine 5 mg daily and chlorpheniramine 4 mg before bedtime. He stopped taking the medications 1 week prior to consult. The patient has known allergy to shrimps, but has no other comorbid conditions. Family history is unremarkable.

Physical examination revealed multiple erythematous wheals with smooth surfaces and polycyclic curved borders on the chest, back, left posterior arm and flexor surface of forearms. The patient tested positive for dermographism and was diagnosed with chronic spontaneous urticaria.

Management
Bilastine was initiated at a dose of 20 mg once daily. Wheal and pruritus were completely controlled after 2 days of the treatment and during 2 weeks of follow-up (Figure 3). The patient noted improved ability to do work and physical activities, but with some persistent difficulty in sleeping due to discontinuation of his long-term sedating antihistamine. Regular intake of bilastine was recommended in this patient for long-term control of symptoms.

Bilastine Figure03

Discussion

Urticaria is the appearance of wheals and/or angioedema. The wheals are characterized by swelling and erythema, itching or burning sensation, and transient nature with the skin returning to normal within 24 hours.1 Current data on the burden of urticaria in the Asia-Pacific region is yet to be reported but the lifetime prevalence may be as high as 23 percent.2

Acute urticaria refers to the occurrence of spontaneous wheals with or without angioedema for less than 6 weeks.1 It may be triggered by infections such as the common colds and certain medications, such as NSAIDs and aspirin. Other possible triggers include antibiotics (eg, penicillin, cephalosporins, sulphonamide) and antihypertensive drugs (eg, beta-blockers, ACE inhibitors, diuretics). These information are important in assessing urticaria in the elderly.3

Chronic urticaria is the occurrence of hives with or without angioedema for 6 weeks or more. It is characterized by pruritic wheals, which, when severe, can be highly debilitating and adversely impact patient quality of life. While some cases of chronic urticaria are idiopathic, evidence suggests that 30 to 50 percent  of cases are triggered by IgG autoantibody-mediated activation of high affinity IgE receptors on basophils and dermal mast cell.1,3

The goal of treatment in urticaria is complete symptom control. Joint guidelines by the Asian Academy of Dermatology and Venereology, European Academy of Allergy and Clinical Immunology, the Global Allergy and Asthma European Network, the European Dermatology Forum, and the World Allergy Organization recommend the use of modern second-generation antihistamines for the management of urticaria.2

Bilastine is a novel second-generation antihistamine indicated for the symptomatic treatment of urticaria in adults and children aged 12 years and older. Bilastine is rapidly absorbed with an onset of clinical effect within an hour of administration. It allows once-daily dosing due to its long duration of action of more than 24 hours.2

A randomized trial compared bilastine 20 mg with levocetirizine 5 mg and placebo in chronic urticaria patients with moderate-to-severe symptoms.3 After 28 days of once daily dosing, bilastine decreased mean reflective and instantaneous total symptom scores (TSS) from baseline better than placebo (p<0.001). Significant reduction of TSS was observed starting day 2 of treatment and maximal from days 6 to 7 onwards. Compared to placebo, bilastine therapy significantly improved Dermatology Life Quality Index scores and reduced general discomfort and disruption of sleep (p<0.001). The recommended therapeutic dose of bilastine (20 mg once daily) was also well-tolerated and safe in chronic urticarial patients.3

Improvements in health-related quality of life measures and mean visual analog scale scores also demonstrated that bilastine is as effective as cetirizine, levocetirizine, fexofenadine, or desloratadine in controlling symptoms of chronic urticaria.3,4

In the case of our patients, who experienced severe pruritus and wheals that interfere with their daily activities, bilastine was effective in reducing their symptoms and improving quality of life and was generally well-tolerated. Bilastine represents a safe and effective option for the treatment of elderly patients with acute and chronic urticaria. Bilastine has a favourable safety profile with low potential to cause CNS depression such as drowsiness, sedation and somnolence. It is unlikely to cause drug-drug interactions involving cytochrome P450.6 and dose adjustments may not be necessary for elderly patients.3,4                      

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Dr. Joseph Delano Fule Robles, 14 Nov 2017

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