Termeer Christian, Staubach Petra, Kurzen Hjalmar, Strömer Klaus, Ostendorf Rolf, Maurer Marcus
Private Practice Stuttgart, Department of Dermatology, University of Freiburg.
J Dtsch Dermatol Ges. 2015 May;13(5):419-28. doi: 10.1111/ddg.12633.
Chronic spontaneous urticaria (CSU) is a common and challenging disease, especially with respect to healthcare provision in the context of the German statutory health insurance system. If treatment with second-generation antihistamines is unsuccessful, current guidelines recommend further therapeutic options. However, most of these are off-label. This discrepancy between treatment according to guidelines and the ability to prescribe drugs at the expense of the statutory health insurance (reimbursability) often leads to uncertainties in everyday clinical practice. In addition, physicians prescribing certain drugs are faced with the difficulty of measuring and documenting therapeutic success/outcome. Respective outcome measurement methods have not yet been established in daily practice. Using a consensus process, a working group composed of dermatologists in private practice and specialized urticaria centers has defined a practical pathway for the implementation of current treatment recommendations based on the 2013 S3 guidelines for urticaria. Here, we present a diagnostic and therapeutic management pathway for CSU. Further, we discuss prescription issues in daily practice, including updosing of antihistamines, with regard to cost-effectiveness and drug approval on the basis of published studies and current legislation. Constituting the highest treatment level, the use of cyclosporine A, montelukast, and omalizumab, which has recently become available as therapeutic option, is reviewed. The urticaria control test (UCT) is presented as a valid outcome measure in routine practice. Our objective was to provide physicians in private practice with a practical guideline-based therapeutic decision tool, taking into account the requirements imposed by the statutory health insurance system. It is not meant to replace individualized history taking or treatment of this heterogeneous disease. Rather, we would like to suggest reference points for clinical diagnosis and treatment of CSU.
慢性自发性荨麻疹（CSU）是一种常见且具有挑战性的疾病，尤其是在德国法定医疗保险体系的医疗服务提供方面。如果第二代抗组胺药治疗无效，当前指南推荐了进一步的治疗选择。然而，其中大多数属于超说明书用药。根据指南进行治疗与法定医疗保险支付药物费用（可报销性）之间的这种差异，常常导致日常临床实践中的不确定性。此外，开具某些药物的医生面临着衡量和记录治疗成功/结果的困难。在日常实践中尚未建立相应的结果测量方法。一个由私人执业皮肤科医生和专业荨麻疹中心组成的工作组通过共识过程，根据2013年荨麻疹S3指南定义了一条实施当前治疗建议的实用路径。在此，我们展示了一条CSU的诊断和治疗管理路径。此外，我们根据已发表的研究和现行法规，讨论日常实践中的处方问题，包括抗组胺药的加量，涉及成本效益和药物批准情况。作为最高治疗水平，对环孢素A、孟鲁司特以及最近可用作治疗选择的奥马珠单抗的使用进行了综述。荨麻疹控制试验（UCT）被作为常规实践中的有效结果测量方法进行展示。我们的目标是为私人执业医生提供一个基于实用指南的治疗决策工具，同时考虑到法定医疗保险体系的要求。它并非旨在取代对这种异质性疾病的个体化病史采集或治疗。相反，我们希望为CSU的临床诊断和治疗提供参考要点。
