Efficacy and Safety of Systemic Corticosteroids for Urticaria: A systematic review and meta-analysis of randomized clinical trials

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

doi:10.1016/j.jaip.2024.04.016

Efficacy and Safety of Systemic Corticosteroids for Urticaria: A systematic review and meta-analysis of randomized clinical trials

J Allergy Clin Immunol Pract. 2024 Apr 18:S2213-2198(24)00400-8. doi: 10.1016/j.jaip.2024.04.016. Online ahead of print.

Authors

Xiajing Chu¹, Jason Wang², Leonardo Ologundudu², Romina Brignardello-Petersen¹, Gordon H Guyatt¹, Paul Oykhman³, Jonathan A Bernstein⁴, Sarbjit S Saini⁵, Lisa A Beck⁶, Susan Waserman⁷, Joseph Moellman⁸, Dave A Khan⁹, Moshe Ben-Shoshan¹⁰, Diane R Baker¹¹, Eric T Oliver⁵, Javed Sheikh¹², David Lang¹³, Sameer K Mathur¹⁴, Tonya Winders¹⁵, Sanaz Eftekhari¹⁶, Donna D Gardner¹⁷, Lauren Runyon⁹, Rachel N Asiniwasis¹⁸, Emily F Cole¹⁹, Jeffrey Chan²⁰, Kathryn E Wheeler²¹, Kathryn P Trayes²², Paul Tran⁷, Derek K Chu²³

Affiliations

¹ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Evidence in Allergy Group, McMaster University, Hamilton, ON, Canada.
² Evidence in Allergy Group, McMaster University, Hamilton, ON, Canada.
³ Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
⁴ Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA.
⁵ Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁶ Department of Dermatology, University of Rochester Medical Center, Rochester, NY, USA.
⁷ University of Arizona College of Medicine, Phoenix Children's Hospital, Phoenix, AZ, USA.
⁸ Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
⁹ Department of Internal Medicine, Division of Allergy and Immunology, The University of Texas Southwestern Medical Center, Dallas, TX, USA.
¹⁰ Department of Pediatrics, Division of Allergy, Immunology and Dermatology, McGill University, Montreal, QC, Canada.
¹¹ Department of Dermatology, Oregon Health & Sciences University, Portland, OR, USA.
¹² Department of Clinical Immunology and Allergy, Southern California Permanente Medical Group, Los Angeles, CA, USA.
¹³ Allergy/Immunology, Cleveland Clinic, Cleveland, OH, USA.
¹⁴ Division of Allergy, Pulmonary and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
¹⁵ Global Allergy & Airways Patient Platform, Vienna, Austria.
¹⁶ Asthma and Allergy Foundation of America, Arlington, VA, USA.
¹⁷ Allergy & Asthma Network, Fairfax, VA, USA.
¹⁸ Division of Dermatology, University of Saskatchewan, Regina, SK, Canada.
¹⁹ Department of Dermatology, Duke University, Durham, NC, USA.
²⁰ Emergency Medicine, Southlake Regional Health Centre, Newmarket, ON, Canada.
²¹ Department of Pediatrics, University of Florida, Gainesville, FL, USA.
²² Department of Family and Community Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
²³ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Evidence in Allergy Group, McMaster University, Hamilton, ON, Canada; Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, Ontario, Canada; The Research Institute of St. Joe's Hamilton, Hamilton, Ontario, Canada. Electronic address: chudk@mcmaster.ca.

PMID: 38642709
DOI: 10.1016/j.jaip.2024.04.016

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: Acute urticaria; Adverse events (harms); Angioedema; Chronic urticaria flares/exacerbations; GRADE; Hives; Itch severity; Meta-analysis; Patient-important outcomes; Systematic review; Systemic corticosteroids (prednisone, methylprednisolone, prednisolone, dexamethasone); Urticaria activity; Wheals (welts); exacerbation; flare ups.