https://www.sciencedirect.com/science/article/pii/S2213219824004008
The Journal of Allergy and Clinical Immunology: In Practice, Available online 18 April 2024
Xiajing Chu, Jason Wang, Leonardo Ologundudu, Romina Brignardello-Petersen, Gordon H. Guyatt, Paul Oykhman, Jonathan A. Bernstein, Sarbjit S. Saini, Lisa A. Beck, Susan Waserman, Joseph Moellman, Dave A. Khan, Moshe Ben-Shoshan, Diane R. Baker, Eric T. Oliver, Javed Sheikh, David Lang, Sameer K. Mathur, Tonya Winders, Sanaz Eftekhari, Donna D. Gardner, Lauren Runyon, Rachel N. Asiniwasis, Emily F. Cole, Jeffrey Chan, Kathryn E. Wheeler, Kathryn P. Trayes, Paul Tran, Derek K. Chu
HIGHLIGHTS
What is already known about this topic?
For patients with urticaria, systemic corticosteroids are commonly prescribed to address acute urticaria or chronic urticaria flares. However, the benefits and harms of systemic corticosteroids for urticaria are unclear.
What does this article add to our knowledge?
Systemic corticosteroids likely importantly improve urticaria control, depending on antihistamine-responsiveness (non-responsive NNT 7; responsive NNT 45), but also likely increase adverse effects (NNH 9). These findings suggest that any possible benefits of systemic corticosteroids for urticaria must be weighed against their harms.
How does this study impact current management guidelines?
These findings should inform revised guidelines addressing optimal use of systemic corticosteroids for urticaria by considering the treatment’s benefits and harms, patient values and preferences, and contextual factors.
ABSTRACT
Background
Short courses of adjunctive systemic corticosteroids are commonly used to treat acute urticaria and chronic urticaria flares (both with or without mast cell-mediated angioedema), but their benefits and harms are unclear.
Objective
To evaluate the efficacy and safety of treating acute urticaria or chronic urticaria flares with versus without systemic corticosteroids.
Methods
We searched MEDLINE, EMBASE, CENTRAL, CNKI, VIP, Wanfang, and CBM databases from inception to July 8, 2023 for randomized controlled trials of treating urticaria with versus without systemic corticosteroids. Paired reviewers independently screened records, extracted data, and appraised risk of bias with the Cochrane 2.0 tool. We did random effects meta-analyses of urticaria activity, itch severity and adverse events. We assessed certainty of the evidence using the GRADE approach.
Results
We identified 12 randomized trials enrolling 944 patients. For patients with low or moderate probability (17.5% to 64%) to improve with antihistamines alone, add-on systemic corticosteroids likely improve urticaria activity by a 14% to 15% absolute difference (odds ratio [OR] 2.17, 95%CI 1.43-3.31; Number needed to treat [NNT] 7; Moderate certainty). Among patients with a high chance (95.8%) for urticaria to improve with antihistamines alone, add-on systemic corticosteroids likely improved urticaria activity by a 2.2% absolute difference (NNT, 45; Moderate certainty). Corticosteroids may improve itch severity (OR, 2.44; 95%CI 0.87-6.83; Risk difference, 9%; NNT, 11; Low certainty). Systemic corticosteroids also likely increase adverse events (OR, 2.76; 95%CI 1.00-7.62; Risk difference, 15%; number needed to harm [NNH], 9; Moderate certainty).
Conclusion
Systemic corticosteroids for acute urticaria or chronic urticaria exacerbations likely improve urticaria, depending on antihistamine-responsiveness, but also likely increase adverse effects in approximately 15% more.
KEYWORDS: Systemic corticosteroids (prednisone, methylprednisolone, prednisolone, dexamethasone) Acute urticarial Chronic urticaria flares/exacerbations flare ups exacerbation Patient-important outcomes Urticaria activity Hives Wheals (welts) Angioedema Itch severity Adverse events (harms) Systematic review Meta-analysis
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