Prioritising patient-centred care in the management of chronic urticaria in Asia-Pacific countries

Abstract

Background: Chronic urticaria (CU), in both inducible and spontaneous forms, is associated with a substantial burden in the Asia-Pacific region (APAC). Patient-centred care recognises patients desire to be involved in decisions regarding their health. Although patient-centred approaches have previously not been studied in the context of CU management, they have demonstrated benefits in the management of other chronic conditions.

Methods: Information and opinions regarding the barriers and solutions to the implementation of patient-centred approaches to the management of CU were gathered from a group of 13 expert dermatologists and allergist/immunologists from APAC through surveys and a face-to-face meeting.

Results: Barriers identified there included a lack of awareness of CU amongst patients, delays in consulting healthcare providers, financial constraints, and low adherence. Particular issues raised included a lack of suitable online information for patients (83% of experts), and patients accessing oral corticosteroids without a prescription. Compliance issues were also identified as key reasons for inadequate responses to treatments (67% of experts). Solutions proposed by the authors were improving patients' knowledge about their condition (92% strongly agree, 8% agree), physicians' consideration of patient characteristics when choosing treatments (92% strongly agree, 8% agree), implementing shared decision-making (85% strongly agree, 15% agree), and using patient-reported outcome measures (70% strongly agree, 23% agree).

Conclusion: Expert opinion within APAC supports the use of patient-centred approaches to improve the management of CU. We provide several recommendations focusing on patient education and involvement in disease management as well as disease monitoring methods that can be implemented by physicians in APAC.

Keywords: Allergy and immunology; Asia; Chronic urticaria; Decision making; Dermatology; Patient-centred care; Shared; Urticaria.

Fig. 1

Patient Journey for patients with chronic urticaria. Abbreviations: AH, antihistamine; CSU, chronic spontaneous urticaria; IgE, immunoglobulin E; LTRA, leukotriene receptor antagonist; OTC, over the counter; PCP, primary care provider; QoL, quality of life; Rx, prescription.

Fig. 2

Visual guide to the choices of antihistamines for different age groups. Abbreviation: ODT, orodispersible tablet. This heatmap was drafted using the prescribing information for each included antihistamine, , , , , , , in addition to input from both the allergic rhinitis and urticaria STAR-Network expert groups. ^aCare should be taken in dose selection due to the potential for renal impairment. ^bCaution in elderly patients with renal/hepatic impairment.^cWith adjustment for renal function.^dUse with caution.

Fig. 3

Visual guide to antihistamine choices from patient-centred criteria Abbreviations: ARIA, Allergic Rhinitis and its Impact on Asthma; CV, cardiovascular. This heatmap was drafted using the prescribing information for each included antihistamine, , , , , , , in addition to input from both the allergic rhinitis and urticaria STAR-Network expert groups. ^aColours based on the classification of these antihistamines by H1 receptor occupancy in Kawauchi et al., with green being non-brain penetrating, pale green being non-sedating, and yellow being less sedating. ^bH1 receptor occupancy data are not available for rupatadine. However, it is classified as non-sedating based on patient-reported scales and driving tests.^cAs reported for histamine skin wheal studies in prescribing information/package inserts. Coloured according to time values. ^dPatients with CV disease or a history of CV disease receiving fexofenadine should be alerted to the fact that antihistamines as a therapeutic group have been associated with the undesirable effects of tachycardia and palpitations.^eShould be used with caution in patients with known prolongation of the QT interval, uncorrected hypokalaemia, or ongoing proarrhythmic conditions.^fShould be used with caution in patients with prolonged QT interval, hypokalaemia, or with concomitant use of QT-prolonging agents.^gDose adjustments required and contraindicated with severe renal impairment.^hDose adjustments required. Contraindicated in severe renal impairment.ⁱThe use of rupatadine is not presently recommended in patients with impaired kidney or liver functions due to a lack of clinical experience in these patients. ^jDose adjustments are recommended for some forms of cetirizine in patients with hepatic impairment. ^kContraindicated with severe liver failure. Caution with severe hepatic impairment. ^lAs a precautionary measure, it is preferable to avoid the use of bilastine during pregnancy. ^mFexofenadine should only be used during pregnancy when the potential benefits justify the possible risks to the foetus. ⁿPreferable to avoid use during pregnancy, contraindicated/caution for lactation. ^oPreferable to avoid in pregnancy, not recommended in lactation. ^pThe use of levocetirizine may be considered during pregnancy, if necessary. Caution should be exercised when prescribing levocetirizine to lactating women. ^qShould only be used if benefits outweigh potential risks. ^rAs a precautionary measure it is preferable to avoid the use of rupatadine during pregnancy. ^sNot recommended in pregnant or lactating women. ^tGreen indicates updosing of these antihistamines by up to fourfold is reported as supported by evidence in international guidelines. ^uAs reported in Wang et al. Coloured according to score with 10 as green, 7–10 as pale green, and <7 as yellow. ^vA score for rupatadine was not available in Wang et al.^wAs reported in package inserts and prescribing information. ^xPlasma concentration may be decreased by OATP1A2 substrates or inhibitors. Avoid coadministration of bilastine and P-glycoprotein inhibitors in patients with moderate or severe renal impairment. ^yCaution with sedative use. ^zErythromycin/ketoconazole may increase plasma levels. Aluminium/magnesium-containing antacids decrease AUC and Cmax if administered at a similar time. ^aaConcomitant use with central nervous system suppressants should be avoided. Decreased clearance of cetirizine with theophylline. Increased exposure of levocetirizine with ritonavir. ^abAvoid use with strong CYP3A4 inhibitors. Caution when co-administering with statins. Concomitant administration with ketoconazole or erythromycin increases systemic exposure to rupatadine. ^acCaution with QT-prolonging agents, hepatic enzyme inhibitors (CYP450 2J2, 4F12, 3A4) such as imidazole antifungals or macrolide antibiotics. Care should be taken with imidazole antifungals, macrolide antibiotics, and antituberculosis drugs. ^adCaution in epileptic patients and patients with predisposition to urinary retention. ^aeCaution should be used in patients with history of seizures and patients with predisposition to urinary retention. ^afCaution should be used in patients with a history of seizures. ^agCaution in epileptic patients and patients with predisposition to urinary retention. ^ahNot for use in patients with rare genetic disorders of galactose intolerance, Lapp lactase deficiency, or glucose-galactose absorption disorders.