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Chronic idiopathic urticaria/chronic spontaneous urticaria

Acute urticaria (hives) is often caused by viruses or allergy. Chronic urticaria (hives) lasts longer than  6 weeks and is thought to be autoimmune. Urticaria is itchy, comes and goes, and can move around. The eruptions are spontaneous or inducible by exercise (exercise-induced anaphylaxis and cholinergic urticaria), water (aquagenic urticaria), coldness (cold urticaria), or sunlight (solar urticaria). One-third to two-thirds of cases are associated with angioedema (swelling beneath the skin). If a patient is on an ACEI drug, this must be stopped. Urticaria usually resolves in 24 hours and angioedema in 72 hours. Severity is measured by the weekly urticaria activity score (UAS7). If individual lesions last over 24 hours, a skin biopsy may be required.

The treatment algorithm starts with a second generation antihistamine like cetirizine (10-40mg/day), desloratadine (5-20mg/day), fexofenadine (120-480mg/day), or loratadine (10-40mg/day). These drugs can be increased up to four times the standard dose. Montelukast can be added and exacerbations may be treated with an oral steroid.

Omalizumab and cyclosporine are third-line therapies initiated at the specialist level.

Resources:

www.itchingforanswers.ca

www.skintolivein.com

www.optionsinciu.ca

CIU Tracker App on App store and Google play

Over-The-Counter

A recent survey among physicians and pharmacists have identified the top over-the-counter brands recommended by Canadian professionals.

Adult allergies: Reactine

Children’s allergies: Benadryl

Nausea: Gravol

Children’s painkiller: Tylenol

Painkilling cream: Voltaren

Scar/stretch mark therapy: Bio-Oil

Sunscreen: Ombrelle

Wart treatment: Compound W

Cold sore cream: Abreva

Vaginal lubrication: Replens

Antibiotic cream: Polysporin

Antibiotic eye and ear drops: Polysporin eye and ear drops

Dry eye drops: Systane

Vaginal yeast infection cream: Canestan

Vaginal yeast infection pill: CanesOral

Iron supplement: Feramax

Laxative: Lax-A-Day

Lice treatment: Nix

Natural cold remedy: Cold-FX

Pregnancy test kit: First Response

Blood Glucose Monitor: OneTouch

Blood Pressure Monitor: Omron

Hand Dermatitis (eczema)

Hand dermatitis (eczema) is associated with irritants or allergies and can be triggered or aggravated at work (occupational dermatitis). Many patients are employed as healthcare workers/nurses, hair stylists, restaurant servers/staff, bakers, or printers.

There are 3 types of hand dermatitis: irritant, allergic, and atopic.

Chronic hand dermatitis lasts at least three months or incurs two relapses in a calendar year. Alitretinoin, cyclosporine, high potency topical corticosteroids, and phototherapy are indicated in Canada for the treatment of chronic hand dermatitis. (Acitretin, azathioprine, methotrexate even soriatane are sometimes used.)

Itchiness is a symptom of both allergic and atopic hand dermatitis. Irritant hand dermatitis often has little or no itchiness.

Common irritants include friction, dryness, moisture, and chemicals (e.g., hand disinfectants, germicides, detergents, ink, dyes, solvents, etc.). When these offending exposures are in the working environment, symptoms develop gradually, show little improvement on weekends, but marked recovery with extended periods away from work.

Allergens like latex, animal fur/dander, perfumes, and food are also be implicated. This is often characterized by redness, blistering, and severe itchiness. Work exposure usually improves on weekends, symptoms disappear on vacation, but recur soon after returning to work. A patch test can confirm the diagnosis.

Atopic dermatitis is frequently unrelated to occupation and a family history of allergy is common. It can involve the flexor surfaces of the wrists, the nails, and the “snuff box”. Blisters are often seen and the skin can turn thick and leathery (lichenification).

The mainstay of hand dermatitis treatment is topical corticosteroids.

Moderate potency corticosteroids are sometimes used for 4-8 weeks (2 weeks if dorsal location) to manage mild-to-moderate chronic hand dermatitis. Severe chronic hand dermatitis uses a potent topical corticosteroid for 4 to 8 weeks (2 weeks if dorsal location) or super-potent topical corticosteroid for 2 weeks.

When moderate chronic hand dermatitis is not improved by prevention strategies, emollient therapy, and a high potency topical corticosteroid of 2-week duration, it is treated as severe and phototherapy/oral treatment is considered. An oral treatment is alitretinoin but pregnancy must be avoided (pregnancy prevention program).

Treatment should be combined with moisturizing therapy and hand protection (eg, gloves), which should continue after discontinuation of corticosteroids.

In hyperkeratotic dermatitis, salicylic acid 20% or urea 5–10% is sometimes prescribed to smooth the skin and help with treatment penetration.

Topical steroids— Potency

Low

  • Desonide 0.05%
  • Hydrocortisone 0.5%, 1%, 2.5%
  • Hydrocortisone acetate 0.5%, 1%, 2%

Medium

  • Betamethasone valerate 0.05%, 0.1%
  • Clobetasone butyrate 0.05%
  • Diflucortolone valerate 0.1%
  • Fluocinolone acetonide 0.01%, 0.025%
  • Hydrocortisone valerate 0.2%
  • Mometasone furoate 0.1%
  • Triamcinolone acetonide 0.025%, 0.1%, 0.5%
  • Prednicarbate 0.1%

High

  • Amcinonide 0.1%
  • Betamethasone dipropionate 0.05%
  • Fluocinonide 0.05%
  • Halcinonide 0.1%
  • Desoximetasone 0.05%, 0.25% •

Ultra-high

  • Beclomethasone dipropionate 0.05% in base containing propylene glycol
  • Clobetasol propionate 0.05%
  • Halobetasol propionate 0.05%

RESOURCES

Diabetes

Patient task list:

  • Have HbA1C tested every 3 months
  • Annual eye examination
  • Annual foot examination
  • Intermittent cholesterol levels, ECG, kidney function
  • DASH diet if no kidney disease
  • Quit smoking
  • Exercise at least 150 minutes per week (moderate-intensity exercise) and resistance training (three times per week)
  • Prioritize at least 7 hours of sleep per night

Intervention Targets

  • The traditional HbA1C target is <7%
  • An HbA1C target ≤6.5% will decrease the risk of eye disease (retinopathy), kidney disease (nephropathy), and nervous system disease (neuropathy).
  • The blood pressure target is <130/80 mmHg
  • LDL-Cholesterol target is <2 mmol/L
  • Patients with a BMI ≥25 should aim for reduction of body weight by 5 to 10%

Patient resources: http://www.diabetes.ca


Doctors secrets …

Pre-diabetes is associated with a 5-fold increased risk for future type 2 diabetes. Metformin reduces the risk of future diabetes in pre-diabetic patients by 25 to 30%

Step 1 Rx = start metformin (if GFR >45 and monitor B12 in chronic use), stop if GFR <30

If the A1C is >7.5%, the patient will likely need dual treatment. If HBA1C >9%, start dual treatment. If the A1C is >8% despite dual treatment, the patient likely needs basal insulin. Consider insulin when HBA1C >10% and symptomatic.

Add additional agent if not in target >3/12 e.g SU, TZD, (edema, HF, bone fracture, weight gain risks), DPP-4-i (avoid if Hx of pancreatitis), SGLT-2-i, thiazolidinedione, GLP-1-RA( avoid if FH of medullary thyroid carcinoma, MEN2, pancreatitis, gastroparesis), basal insulin. CVS outcomes reduced with Liraglutide (GLP-1), empagliflozin (SGLT-2). Watch for euglycemic DKA in SGLT-2 inhibitors. Watch for CCF with saxagliptin, alogliptin (DPP-4); (if pre-existing CCF or CKD). Avoid dpp4-i + GLP-1-RA.

 

– Insulin

Start 10U (or 0.1 to 0.2U/kg) of basal and increase dose by 10-15% (or 2-4U) once or twice weekly until FBG in target. NPH is cheapest. If HBA1C <8% or hypoglycaemia- decrease dose by 4U (or 10-20%). If insulin does >0.5U/kg and not at target, need to start adding basal

– Rapid insulin

Start 4U per meal (0.1U/kg, or 10% of basal dose)- consider decreasing basal dose by same amount of starting mealtime dose. Increase 1-2U (10-15%) once or twice weekly. Hypoglycemia- decrease 2-4U (10-20%)

– Premixed insulin

divide basal dose into 2/3am and 1/3 pm. Increase 1-2U (10-15%) once or twice weekly to target. Hypoglycemia- decrease 2-4U or 10-20%. Can increase to TID dosing if failure to control.

Intrauterine contraception (IUC)

Are you interested in intrauterine contraception? There are a few questions you need to ask yourself.

Are you currently sexually active and do you need birth control? Do you have any plans to get pregnant and, if yes, how soon? How important is it for you not to be pregnant right now? How would your relationship/job/education be affected by becoming pregnant? What do you want to achieve before you fall pregnant?What contraception have you used in the past and what are you using now? What is the most important factor in your choice of birth control?

IUC is highly effective.

No contraception method is foolproof, but for women who are serious about not falling pregnant anytime soon, IUC is their best bet. Contraceptive failure rates (i.e. pregnancy rates per 1000 women during the first year of use) are as follows:

1) Condoms: 180/1000 women
2) Pill/patch/ring: 90/1000 women
3) Injection: 60/1000 women
4) Copper IUD: 8/1000 women
5) Levonorgestrel-releasing intrauterine system (e.g. Mirena, Jaydess, Kyleena): 2/1000 women

IUC can be left in place for 3, 5, or 10 years depending on the device. When removed, fertility rapidly returns to normal.

To view an excellent resource for patients, go to http://www.sexandu.ca

Dispelling a few intrauterine contraception myths …

Women and adolescents can use IUC whether they have given birth in the past or not. When discontinuing IUC use, women can rapidly conceive and fertility rates are the same as those of women who have never used an IUC. Women using IUC have less than half the risk of ectopic pregnancy compared to women who are not using contraception (remember IUC is highly effective in preventing pregnancy). IUC can be placed at any time during the menstrual cycle provided there is certainty that the woman is not pregnant. IUC does not cause infections (e.g. pelvic inflammatory disease or PID). PID is caused by sexually transmitted infections. However, there is a small risk of PID related to the insertion procedure in the first 20 days after IUC placement. Some women may stop menstruating while the IUC is in place. This is not unhealthy. Placement may cause a little pain in some women but every woman experiences pain differently.

Primary Headache Treatment

Behavioural management

•Keep a headache diary

•Reduce caffeine intake

•Regular exercise

•Adequate sleep

• Stress reduction

Medications

Medications can be used as acute treatment (when needed) or prevention treatment (daily prophylaxis). In chronic migraines (occurring on more than 15 days a month, for over 3 months), prevention medications are used daily for at least 3 months. If effective (50% improvement), the drug may be continued for 6 to 12 months.

Chronic tension-type headache 

Acute treatment: non-steroidal anti-inflammatory drugs (NSAIDS)

Prophylaxis: amitriptyline or topiramate.

Menstrual migraines

Perimenstrual prophylaxis (starting 2 days before the period and continuing during the period), e.g. frovatriptan 2.5 mg twice daily, zolmitriptan 2.5mg three times a day, naproxen 500 mg twice daily or mefenamic acid 500 mg three times a day. Continuous use of the combined contraceptive pill or estrogen patch can also help.

Cluster headache

Acute treatment: subcutaneous sumatriptan 6 mg (maximum two per day) or intranasal zolmitriptan 5 mg or 20mg intranasal sumatriptan (or 10mg zolmitriptan orally); 100% oxygen 12 L/min for 15 min through non-rebreathing mask.

Prophylaxis: verapamil 240-480 mg/day in three divided doses (bridge with 60 mg of prednisone for 5 days, then reduced by 10 mg every 2 days until discontinued)

Acute migraine

Combination therapy: triptan+non-steroidal anti-inflammatory drug (NSAID) or actaminophen+antiemetic

  • Acetaminophen 1000 mg
  • Domperidone 10 mg or metoclopramide 10 mg for nausea

NSAID options:

  • Ibuprofen 400 mg
  • Aspirin 600–900 mg (ideally effervescent)
  • naproxen sodium 500-550 mg
  • Diclofenac 50mg

Triptan options:

  • Oral: eletriptan 40 mg (Relpax), rizatriptan 10 mg (Maxalt), zolmitriptan 2.5 mg, oral sumatriptan 100 mg, , almotriptan 12.5 mg (Axert),  , frovatriptan 2.5 mg, naratriptan 2.5 mg
  • Oral wafer (if fluid ingestion worsens nausea): rizatriptan 10 mg or zolmitriptan 2.5 mg
  • Nasal spray (if nausea): zolmitriptan 5 mg or sumatriptan 20 mg
  • Subcutaneous sumatriptan 6 mg

Triptans should be used, on average, on no more than 2 days per week (10 days per month) to reduce the risk of a triptan-overuse headache. Nasal preparations have a faster onset of action than oral preparations and the subcutaneous injection has the fastest onset.

Medication overuse headaches happen when patients use combination analgesics, opioids, or triptans on ≥ 10 days per month or acetaminophen or NSAIDs on ≥15 days per month.

Migraine prophylaxis

Over the counter options

• butterbur 75 mg twice daily

• riboflavin 400 mg/d

• melatonin 3mg daily

• magnesium citrate 300 mg twice daily

• coenzyme Q10 100 mg 3 times daily

Prescription options

Usually topiramate or a beta blocker.

• topiramate 25mg to 50mg twice daily (useful if the patient is overweight, avoid in depression, can reduce the efficacy of the contraceptive pill)

• propranolol 20-80mg twice daily (avoid in asthma, diabetes, depression, smokers and >60 years of age)

• metoprolol 25-100mg twice daily (avoid in asthma, diabetes, depression, smokers and >60 years of age)

• amitriptyline 10-50mg at bedtime (useful if depression, anxiety, insomnia, or tension-type headache)

• venlafaxine 37.5-150mg/d (consider for migraine in patients with depression)

• gabapentin 300-1800 mg/d

• divalproex 250-500mg twice daily (avoid in pregnancy or when pregnancy is possible)

• candesartan 8-16mg/d

• onabotulinumtoxinA 155-195 units every 3 months for chronic migraines only (headaches on ≥15 days per month)


 

Resource: https://actt.albertadoctors.org/CPGs/Pages/Headache.aspx

Doctors secrets …

Headache Impact Test (HIT 6)

Migraine Disabilities Assessment Test (MIDAS)

Hospital Anxiety and Depression Scale (HADS)

Strictly unilateral headache: consider hemicrania continua and conduct a 9-day indomethacin challenge. Headaches should respond to indomethacin 75 mg to 100 mg daily (given in three divided doses) for three days; the dose can then be increased if necessary to a total daily dose of 150 mg for three days, followed if necessary by a total daily dose of 200 mg to 225 mg daily (given in at least three divided doses per day) for three days. Arrange for neuroimaging.

Guideline: http://www.cfp.ca/content/cfp/61/8/670.full.pdf

Intensive Blood Pressure Management

Intensive management targets a systolic blood pressure ≤120 mmHg and may be considered in high-risk patients who are ≥50 years old, have systolic blood pressure ≥130 mmHg and have any of the following:

  • Clinical or subclinical cardiovascular disease
  • Chronic kidney disease (nondiabetic nephropathy, proteinuria <1 g/d, eGFR 20-59 mL/min/1.73 m2)
  • Framingham risk score ≥15%
  • Age ≥75 years

This approach is based on The Systolic Blood Pressure Intervention Trial (SPRINT).

During SPRINT, patients treated intensively (<120 mmHg), instead of routinely (<140 mmHg), had a 25% lower relative risk of major cardiovascular events and death and a 27% lower relative risk of death from any cause.

Patients who may not be suitable for intensive management include those with:

  • Secondary hypertension
  • Diabetes
  • Recent heart attack (within 3 months)
  • History of stroke
  • Heart failure (reduced left ventricular ejection fraction <35%)
  • Kidney disease (eGFR <20)
  • Standing SBP <110 mmHg following one minute of standing
  • Frail or institutionalized elderly

 

Hypertension

High blood pressure is the main risk factor for death in Canada. One in five Canadian adults have high blood pressure and nine out of 10 Canadians will develop high blood pressure during their lifetime.

High blood pressure increases the risk of heart attack, heart failure, stroke, kidney disease, eye disease, dementia and erectile dysfunction.

Systolic blood pressure (SBP) measures the pressure when your heart beats and pumps blood. It is the top number of the blood pressure reading. Diastolic blood pressure (DBP) is the pressure when your heart relaxes and fills with blood. It is the bottom number of the blood pressure reading.

A decrease of 10 in SBP or 5 in DBP decreases the risk of heart failure by 50%, stroke by 38%, heart attack by 15% and death by 10%.

High blood pressure can be diagnosed at home or in the clinic. AOBP (automated office blood pressure) is preferred but this is not always available. In most clinics, 3 measurements are taken. The first reading is discarded and the average of the other two readings is recorded. The diagnosis of hypertension can be made over 3 to 5 visits. [hypertension diagnostic algorithm]

When blood pressure (BP) is measured at home, 2 readings are done each morning and evening for 7 days (28 readings). We then review the data, discard the first day and average out the last 6 days.

Hypertension is diagnosed when the average clinic BP is  ≥140/90 mmHg or the average home BP is  ≥135/85 mmHg.

Targets

The target for most patients will be <140/90 mmHg. Diabetics should strive for <130/80mmHg. Certain high-risk patients may qualify for intensive management*.

It is best to discuss your target blood pressure with your doctor. Blood pressure targets are highly individualized and will differ depending on various factors. Adults aged 60 years and older tend to have several coexisting problems and more permissive targets are sometimes used. http://bit.ly/2jYp3WB

Risk reduction

Patients with hypertension should consider reducing their risk of cardiovascular disease even further by using a statin if they have ≥3 of the following risk factors:

• Male sex
• Age ≥55 years
• Diabetes
• Tobacco use
• Previous stroke or transient ischemic attack
• Peripheral arterial disease
• Albuminuria or chronic kidney disease
• Family history of premature cardiovascular disease
• Total cholesterol to high-density lipoprotein ratio ≥6
• Left ventricular hypertrophy
• Electrocardiogram abnormalities

In addition, hypertensive patients who are 50 years or older should consider low-dose aspirin.

It is common to be on several different blood pressure medications at the same time. The use of multiple medications is preferred over maximizing monotherapy because complementary drugs work together, allowing one to take lower doses with fewer side-effects. Medications are often added over time to achieve targets but two medications are sometimes introduced at the onset (e.g. if the systolic blood pressure is >20 mmHg or the diastolic blood pressure >10 mmHg above target). Triple therapy (3 medications) will usually include a diuretic.

Patients with high blood pressure should discuss increasing their dietary potassium (fresh fruit, vegetables, legumes) with a doctor or dietician. Caution is advised in those at risk of developing hyperkalaemia (eGFR <60mL/min/1.73 m2, on ACE inhibitor drugs or potassium-sparing medications, or baseline potassium level >4.5).

Changing an unhealthy deathstyle into a healthy lifestyle

  • Quit smoking
  • Strive for maintaining a healthy weight (BMI 18.5 to 24.9kg/m2)
  • Ask about the DASH diet and limit sodium intake
  • Lead an active lifestyle (150 minutes per week of moderate-intensity exercise)
  • Alcohol consumption must be in moderation
  • Focus on stress reduction

Intensive blood pressure management must be discussed with your doctor.


Doctor’s secrets …

Screen every 2 years (≥ 18 years) or annually if pre-hypertensive (120-139/80-89)

Hypertensive Urgencies and Emergencies:

Hypertensive urgency: BP ≥180/120 without target organ damage

Hypertensive emergency: BP ≥180/120 with target organ damage:

  • Hypertensive encephalopathy
  • Acute aortic dissection
  • Acute left ventricular failure
  • Acute coronary syndrome
  • Acute kidney injury
  • Intracranial hemorrhage
  • Acute ischemic stroke
  • Eclampsia of pregnancy

Diagnostic tests:

  • Urinalysis
  • Blood chemistry
  • Fasting blood glucose
  • Fasting cholesterol panel
  • Standard 12-lead ECG
  • Urinary albumin in diabetics

Examples of Target Organ Damage:

  • Cerebrovascular disease
  • Stroke
  • Dementia
  • Hypertensive retinopathy
  • Left ventricular dysfunction
  • Coronary artery disease
  • Renal disease
  • Peripheral artery disease

Trigger Warning: Designer Babies

Lay media has let another bioethics bogeyman out of the closet.

This week, headlines griped about the imminent threat of CRISPR (http://tinyurl.com/z4ohams) and the moral malady of the 3-parent baby ( http://tinyurl.com/j5ycr47).

[For those who wish to brush up on CRISPR: http://tinyurl.com/kpqdwsu]

So it struck me as somewhat ironic when this week also saw The London Sperm Bank release its new mobile app, which allows clients to search sperm donors by specific traits, including eye colour, hair colour, ethnicity, race, and personality profile. http://tinyurl.com/habamnu

My instinct is that designer babies are inevitable.

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