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Clinical Practice Guideline 2557 กก (Urticaria/Angioedema) กกก

Clinical Practice Guideline 2557 ก ˇˆ˙ ˝ˇ˛˘˚ ˜ˇ ˝!#˚ ... · 238 Clinical Practice Guideline Urticaria/Angioedema ?5 - ,˛ˆ - Clinical Practice Guideline ˜ˇ ˝!"#˚

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Clinical Practice Guideline 2557

������ก��������ก���� �!"#�

(Urticaria/Angioedema)

,���-���.

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Clinical Practice Guideline Urticaria/Angioedema 238

?5�-����,���-� Clinical Practice Guideline

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ก��!ก����56�E��<ก��:

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Clinical Practice Guideline Urticaria/Angioedema 239

��!�-� +��� �ก ��+-�ก2 !��-�#�2/+����!��((� '�8��� �'�6��"��ก����ก-$"�+#� /�()�9�3,�ก ��+-

�ก2 ����1� !��-�#�2/+����!��((� '�&)��� ก!��-�#�2/+����!��((� � �'ก��:4���'����&��(!���&)���'�8�� '�,$�"���� ��4� +��� �ก ��+-�ก2 !��-�#�2/+����!��((� 533�(4 '�8�+��� ��� ��3!��-�#�2/+����!��((� �()'ก��:4���'��(spontaneous urticaria) '�" �4� +��� ��()� �����(4'#&)����'�8�+��� ��� ��3+#� /�)���+-�+#� /'5# �� ��()�+-����1� !��-�#�2��ก ��+-�ก2 ����1� ����"ก�, ,��(),����9�3,�ก ��ก2 , ��()'�( �����$ก���ก � �4��(4'#� �����1� +,"-�� �(�H*� �()+,ก," �ก� ก �� �+��� �ก ��ก2 �(4'�8�ก ���� �� ,�I �+-�#%� ก ��+-�ก2 !��-�#�2/+����!��((� '#&)�������� ���()� #3+#� /���3�� ��)����" �����3ก ��+-�ก2 �()( +��� �ก ��+-�ก2 !��-�#�2533�(4 '�8�ก ���3��$�+��� �ก ��ก2 �()����� �:4�533+�ก '�&)��J #$��.ก� � 2552 '#&)����'�&4�� �(�� �����

�#.�! !��-�#�2 �&� !����&�ก-$"����!���()�(� ก �� ��������()�(-ก2��'�8��&)����+-�+� (wheal and

flare) +-�/��&��(ก �3���,��4������� (angioedema) T:)�'ก���� ก�- �H�� � �'ก�� ก� '�,$�()�" �ก �(�9�ก��� ,"� � � � ก �,�'�&4� ��)�ก��,$��� �ก 0 # (physical) ��&�!������33�&)�V ����" �ก +,"! �"����*"�ก,�����"#3� '�,$

F�ก����5F�ก���/��

1;A��!"#� (urticaria) �(-ก2���� '# � �&� �&)�3����� +� (wheal and flare) �(�� ��"+�"��� � ��-� ,$"� $���&��ก ��&�� ��(-ก2���-� +���() 'ก��:4��()3��'�������" �ก ก6�� 3 �� � ��(� ก �3���,��4��������()'�( ก�" +����!��((� (angioedema) �"���� T:)���3'ก�3��'��'�&4��"�� '�"� ���, ���WJ� ก '�8�,�� � ก ��ก'ก��:4����(��� �(� ก ���'"� +,"-��&)��ก��� �� ��0 �� 24 �)�!��! ��"'�-&��"���� 0 �-��&)� $3 +-��&)��ก��'�8�V� V +-� � ,� +��"���'�&)� V ก��(� ก�(0 ��+����!��((� �"���� �� !���ก3��� �"� �'ก��ก�" 24 �)�!�� +-��(� ก �'�63�"����

� " ���ก6, ��&)�-�#�2������1� 3 �� � �'�8�� ก �+����:)����0 �� anaphylaxis T:)�� ��(� ก �+���()�� ���&)��� '�"� � ก �+�"���� �ก � ����"���ก '�( �+�3 ��3�& ��������&�����'�� +�"����ก �� 3 �� � �'ก�� ก �'�8�-���&����,�� ก�� ��!-��,,)� ��&��(0 ���6���'�� (anaphylactic shock) !��-�#�2+3"�, ��� �'�- �()'ก���'�8� 2 ��� �&�

1. �!"#�[email protected]"��� (acute urticaria) �&� �(� ก ��&)�-�#�2 ,"�'�&)��ก���"'ก�� 6 �� �/ 2. �!"#�6�;KF��� (chronic urticaria) �&� �(� ก ��&)�-�#�2� " ���� 2 ��4�,"��� �/ ,"�'�&)��ก�� กก�" 6 �� �/

Clinical Practice Guideline Urticaria/Angioedema 240

M�����@A 1 ก ��� +�ก������!��-�#�2 (+�-�� ก'�ก� ��� ������ '-� (1) +-� (2))

ก�<3! ก�<3!.3F. ��!2!�.

�&)�-�#�2�()'ก��:4�'�� (Spontaneous urticaria)

• �&)�-�#�2'5( 3#-� (Acute spontaneous urticaria)

�&)�-�#�2 +-�/��&� +����!��((� 'ก�,"�'�&)��ก� ��"'ก�� 6 �� �/

• �&)�-�#�2'�&4��� (Chronic spontaneous urticaria)

�&)�-�#�2 +-�/��&� +����!��((� 'ก�,"�'�&)��ก�� กก�" 6 �� �/

4N,,�.ก�5M<:� �&)�-�#�2�()'ก�� กก �ก��,$��! �H�� � �� �ก 0 # (Inducible urticaria or physical urticaria)

• Cold urticaria �,b$' 6� � ก .' 6� �4� ' 6� -�' 6� • Delayed pressure urticaria

+��ก��+���)� ���� ���'ก��&)�3�����0 ��'�- ���� � 3-12 �)�!�� �-�b�กก��,$��

• Heat urticaria

�� �����

• Solar urticaria

+���-,�� ��!�'-, +-�/��&� +���()���'�6���

• Symptomatic dermographism

+���(�"�� (mechanical shearing forces) ���� ���'ก�-�#�20 �� 1-5 � �(�-�b�กก��,$��

• Vibratory angioedema

+���)���'�&�� '�"� '��&)���$'� �b�� (pneumatic hammer) ���� ���'ก��� !��0 �� 1-2 �)�!��

• Aquagenic urticaria

�4�

• Cholinergic urticaria

�$��0������" �ก �()'#�)�����:4�

• Contact urticaria ����ก3� ��()ก"����'ก�-�#�2

ก���#�#,I�.�� � . ก �Tก����,�+-�,����" �ก '#&)�ก ������5 !�� � � '�,$ �H�� ก��,$�� �+����+��0��� 1

��ก� ก�(43 �� � �,��������5 + ก!��� ก!���()��#��/ก3!��-�#�2��&� syndromes �()�(� ก ���&�� ก �+������&)�-�#�2 +-�/��&�+����!��((� �, � ��() 2

Clinical Practice Guideline Urticaria/Angioedema 241

�1�9�!# 1 ก ������5 + ก!�� ('�ก� ��� ������ '-� (2) +-� (3)) �� '�,$ ACEI, angiotensin converting enzyme inhibitors; HAE, hereditary angioedema; AAE, acquired angioedema

Histamine and other mast cell mediators

Urticaria Angioedema

+ -

�3���� � ก-$"� ACEI ?

+ -

+ - + - + - - +

+ - +

+ - Chronic inducible urticaria

HAE I-III AAE

Chronic spontaneous

urticaria

Urticarial vasculitis

Auto-inflammatory

disease

History Diagnostic tests Mediators

ACEI- induced

angioedema

Interleukin-1 Bradykinin

�����"�� 3� '�,$, �"��'#-( , ����� ?

�&)�-�#�2� �"� �

> 24 �)�!�� ?

��� hereditary (HAE) ��&� acquired angioedema (AAE) ?

� ก �(�:4�0 �-�

� ก� $ ?

Provocation test

Inducible symptoms ?

-

��� Autoinflammatory

disorder ?

Histology: vasculitis ?

Clinical Practice Guideline Urticaria/Angioedema 242

M�����@A 2 !���()�(�� ���#��/ก3!��-�#�2��&� syndromes �()�(� ก ���&�� ก �+������&)�-�#�2 +-�/��&� +����!��((� (+�-�� ก'�ก� ��� ������ '-� (2)) �� �@A!@ ��!/�!"��D0ก�J�� �!"#�

Maculopapular cutaneous mastocytosis (urticaria pigmentosa) Urticarial vasculitis Bradykinin-mediated angioedema ('�"� hereditary angioedema) Exercise-induced anaphylaxis Cryopyrin-associated periodic syndromes: recurrent fever attacks, arthralgia or arthritis, eye inflammation, fatigue and headaches -Muckle-Wells syndrome -Neonatal onset multisystem inflammatory disease -Familial cold autoinflammatory syndrome Schnitzlerxs syndrome: monoclonal gammopathy, recurrent fever attacks,

bone and muscle pain, arthralgia or arthritis, lymphadenopathy

Gleichxs syndrome (episodic angioedema with eosinophilia): IgM gammopathy, eosinophilia Wellxs syndrome (eosinophilic cellulitis): granulomatous dermatitis with eosinophilia ��ก� กก ������5 !�� +-����'����� ��$�+�� 3 �� � ��"�,���� ������9�3,�ก � , ����3"��(4� ก����,�+-�ก �,����" �ก '#&)�� � '�,$�&)�-�#�2 �, � ��() 3

Clinical Practice Guideline Urticaria/Angioedema 243

M�����@A 3 ก ��&3���+-�ก �,���� ������9�3,�ก �'#&)�ก ������5 !��-�#�2 ! '5# �� " � �)���ก��(�(���3"��(4 ��&���",�3����,"�ก ��ก2 (+�-�� ก'�ก� ��� ������ '-� (2) +-� (4))

ก��/;J :�

1;A��!"#��@A6ก#�EBK�6F�

(Spontaneous urticaria)

�� �!"#�[email protected]"���

��"�( routine diagnostic tests ( ก'��� b� ����,���� � " �� ก)

�� �!"#�6�;KF��� (CSU) Differential blood count**, ESR** � $ �()��� '�"� NSAID � ��� ก �,���'#�)�',�� '�"� autologous serum skin test*, test �� ��3

Helicobacter**, gastroscopy**, ANA**, D-Dimer*,†, ,����$�� ��� # ��**, ก ����3������**, specific IgE**, ���� /|��/!�� +-� autoantibodies** (������1� '6ก� $��� ก�" 15 �J ก �,��� antibodies ������� / ��"�� '�8�,����� �$ก� )

1;A��!"#�,�ก4N,,�.����:��ก�.9�" 1. Cold urticaria Cold provocation test (ice cube, cold water) *, differential blood count**,

ESR**, cryoglobulins** 2. Delayed pressure urticaria Pressure test* ! ���+�"��4� ��ก� �3�,��� ��&��-� ����4� ��ก 0.2- 1.5

กก./,�.T�. '�8�'�- 10 +-� 20 � �( ��&����b$��� ��ก�� �-� 6.8 ก�!-ก�� (15 ���/) '�&)��,"�ก�! ���'�&�ก��&���$+b3ก�� � +-��� �# 3���-"�������1� ���" �)�'�8�'�- 15 � �(

3. Heat urticaria Warm arm bath* 4. Solar urticaria +���-,�� ��!�'-, +-� visible light ���"���-&)�," � V* 5. Symptomatic

dermographism ,���� dermographism*, differential blood count** +-� ESR**

6. Vibratory angioedema ���'��&)�� vortex � �3�����+����&���4��&�'�8�'�- 1-5 � �(* 7. Aquagenic urticaria ����� �$3�4� �()�$��0������� � �3�����+��� � 20 � �( 8. Cholinergic urticaria Exercise ��'��&)���ก��&�'��)�'��&)� ��&� hot bath '�8�'�- 15-20 � �(* 9. Contact urticaria �(� '�,$���4�� ก immunologic +-� nonimmunologic ก ������5 �

� '�,$ � �,����� ก ����3'�"� patch test, skin prick testing +���� ����"���:ก2 +#� /���'�() �� *

�� '�,$ * ก ��&3���'#&)�ก ������5 ** ก ��&3���'#&)�ก �� � '�,$ † ����1� CSU 3 �� � ��(ก �ก��,$�� coagulation pathway �� ����(��3 plasma D-Dimer ����:4��� CSU, chronic spontaneous urticaria; NSAID, non-steroidal anti-inflammatory drug;

ANA, antinuclear antibodies; ESR, erythrocyte sedimentation rate

Clinical Practice Guideline Urticaria/Angioedema 244

� " ���ก6, � �&)�-�#�2�4����'5( 3#-�+-����'�&4����"����*" b:�+����Tก����,� ,����" �ก !

-�'�( +-��"�,���� ������9�3,�ก ��ก-" �+-�� ก6�ก,�����"#3� '�,$ �� ��3 chronic spontaneous urticaria (CSU) T:)���"�(� '�,$� ก0 ��ก�4� spontaneous wheals � �'ก�

� กก-�ก," �V 0 ���" �ก '�"�

- ����1� �( autoantibodies (IgG) ,"� high-affinity IgE receptor (FcεRI) ��&� ,"� IgE T:)�#3���� ���� -� 30-50 �������1� ��ก-$"� CSU '�( ก����1� ก-$"��(4�" autoimmune urticaria

- ����1� CSU 3 �� � ��(ก �ก��,$�� coagulation pathway �� ����(��3 plasma D-Dimer ����:4���

Clinical Practice Guideline Urticaria/Angioedema 245

������E�K�MF�U�ก��/;J :�1�:4V�.�� �!"#� �1�9�!# 2 �4�,����ก ��+-����1� !��-�#�2'5( 3#-�������1� '6ก+-������*"

2!�.62M<

• ��ก��(�()�&)�'�8�� ก � �#�� �� ��� �3���� ��',��� / '�"� prednisolone 20-30 �ก. ,"��� ! �)����ก��"'ก�� 10 ��

• ����-(ก'-() � ��&�� ��()� �ก��,$�����'ก�-�#�2 ��&��� ����&)�-�#�2ก� '��3 '�"� aspirin, NSAIDs, codeine, morphine, ACEI '�8�,��

�� '�,$ NSAIDs, non-steroidal anti-inflammatory drugs; ACEI, angiotensin converting enzyme inhibitors

Clinical Practice Guideline Urticaria/Angioedema 246

M�����@A 4 'ก��/ก ������5 0 �� anaphylaxis*

9��5 anaphylaxis ,5Z�ก�#�#,I�.6!;AF!@F�ก�� 1 U� 3 E:F ���M3F84�@K 1. � ก ��()'ก��:4�'5( 3#-� (0 ��'�- '�8�� �( ��&��- �)�!��) � ก �� �'ก��:4�� ���33��������&�' &)�3$

��&��4����� " � '�"��(-�#�2�:4��)�,� �� �&)�+� ��&��(���WJ� ก -�4� '# ��"�� ��&����, 3�� '�8�,�� �3�!ก�J F�ก��F.3���:F.2�BA�F.3�����M3F84�@K

1.1. � ก �� ���33� �'��� �� '�"� ��3'��&)� � ���('�( ���(� ก�-�-��(),(3,� '�( �|&4,��� ��'�� (stridor) '�( �+�3 ����ก �4� ��ก��- �(ก �--����ก ��� � ������ '�"� �(�" peak expiratory flow (PEF) --� ��3��กT�'����'���'-&�--� '�8�,��

1.2. �� ��!-��,--���&��(ก �-��'�-������33," �V '�"� hypotonia (collapse) '�8�-� �$�� �� �H�� ��� '�8�,��

2. �(� ก �� กก�" ��&�'�" ก3 2 ��� �,"����(4 ������1� �()����ก3/���@A�3�,564[�/��ก3F9�!#�": (0 ��'�- '�8�� �( ��&��- �)�!��) 2.1. �(� ก �� ���33��������&�' &)�3$ '�"� �&)�-�#�2�)�,� �� �&)�+� � ก-�4�+-�'# ��"��3�� '�8�,�� 2.2. �(� ก �� ���33� �'��� �� '�"� ��3'��&)� � ���('�( ���(� ก�-�-��(),(3,� '�( �|&4,��

� ��'�� (stridor) '�( �+�3 ����ก �4� ��ก��- �(ก �--���� PEF ��3��กT�'����'-&�--� '�8�,��

2.3. �� ��!-��,--���&��(ก �-��'�-������33," �V '�"� '�8�-� �$�� �� �H�� ��� '�8�,�� 2.4. �(� ก �� ���33� �'��� � � '�"� ������ �-&)���� � '�( � ����'�( '�8�,��

3. �� ��!-��,--��-�� ก����ก3/���@A1�:4V�.���J�3��":!�ก3F� (0 ��'�- '�8�� �( ��&��- �)�!��) 3.1. ��'6ก���b&�'� �� �� systolic �(),)� ก�" �� ���ก,�, �� $ ��&��� �� systolic �()--�� กก�"

��� -� 30 ����� �� systolic '��* 3.2. �������*"���b&�'� �� �� systolic �()��� ก�" 90 mmHg ��&��� �� systolic �()--�� กก�" ��� -�

30 ����� �� systolic '��

* 'ก��/ก� ���" �� �� systolic �(),)� ��'6ก �&� < 70 mmHg ��'6ก� $ 1 '&��-1 �J < 70 mmHg + (2 x � $) ��'6ก� $ 1 � 10 �J < 90 mmHg ��'6ก� $ 11-17 �J

*������6�=4]#J�M#/-�2��Jก������1�:4V�.�@A!@ก���":=�#��<���� (Clinical Practice Guidelines for

Management Anaphylaxis) 533�J #...2551 ��� ! �� ��!��0���+#� !���& +-���� 0����$��ก�+�"����'�.�� �"��ก3 �� ��'��3� 3��ก�,+�"����'�.�� � ���� - � $�+#� /+�"����'�.�� � ���� - ก$� �+#� /+�"����'�.�� � ���� - !�, .� � ��ก+#� /+�"����'�.�� �� ��'��. �,�/5$ก'5��+�"����'�.�� +-��� ��'��. �,�/���3���+�"����'�.��

Clinical Practice Guideline Urticaria/Angioedema 247

�1�9�!# 3 �4�,����ก ��&3�������1� !��-�#�2'�&4��� (+�-�� ก'�ก� ��� ������ '-� (5) +-� (6))

�� '�,$ NSAIDs, non-steroidal anti-inflammatory drugs; SLE, systemic lupus erythematosus; SPT, skin prick testing; ESR, erythrocyte sedimentation rate; ANA, antinuclear antibodies; ASST, autologous serum skin testing

* ���Tก����,���)�ก��,$��� �ก 0 # '�"� ก ����,� �3���4� +-�������

Clinical Practice Guideline Urticaria/Angioedema 248

������U�ก������1�:4V�.

1. ��ก��M�!/�62M< ก� �� '�,$ b� � � '�,$#3+-�� � �bก� ��� '�"� �&)�-�#�2�()'ก�� ก ก �� $ ,��'�,$���� ����&)� $3

-� ����-(ก'-() ���&�-ก ������H�� ,��'�,$��&��H�� ก��,$�����'ก�!��-�#�2 '�"� '��&)��&)��()�(+�-ก�|�-/

�1�9�!# 4 +��� �ก ��ก2 -�#�2'�&4���

�� '�,$ Response rate ��� H1-antihistamines = 45-50%, low-dose corticosteroids = 70-80%, ciclosporin = 70-80%, +-� omalizumab = 70-80% * NSAIDs, non-steroidal anti-inflammatory drugs 1 �()�(ก �.:ก2 �" '�&)��(ก �'#�)��� �()�3���� � (��b:� 4 '�" ) ��'#�)���������0 #��ก ��ก2 +,"��"'#�)�

�$3,�ก ��/���� ก ���"#:�������/� ก ��+ก" fexofenadine, rupatadine, desloratadine +-� levocetirizine ,� �|��, �(�3 ���� ก �'#�)��� �()�3���� �� ���"���- (2)

2 �-กI �� ����������-� �"��'ก��/,)� +,"��3 �� � ����- � ก��"���-�-���� ��+-�� 2-4 �� �/���#�� �� � $

3 ����"�,"�+#� /���'�() �� *

Clinical Practice Guideline Urticaria/Angioedema 249

ก��������A�846";AF�� ��!8�EF�1#�2��� (Non-pharmacotherapy to minimize skin hyper-responsiveness) 1.1 ก������8!3U2:1#��2:� +���� ��)�� ��(���&�!-�)��()����4� ���'#&)��������$"��&4�+-�-�� ������

������ 1.2 2�@ก6�@A.�ก��ก�5M<:�1#�2��� ��+ก" +���� ����-(ก'-() �ก �'ก ก ��(�"�� ก ���"'�&4�� ก ���#

��&���4������ก ก ����,� �3���4� +-������� ก �#�ก���� ก �����4� ��� ก �!�+� ก �� �"���()������&��� �� ก'ก����

2. ก����ก���:�..�

2.1 .�M:��`#/M�!@� (Antihistamines) .�M:��`#/M�!@�=�#��@A 1 (H1-antihistamines) �ก������3� ก ��&)�-�#�2��( �(4�( 2 �$"� ��(4

ก. .�M:��`#/M�!@�=�#��@A 1 �<3��@A 1 (First-generation or sedating antihistamines) ,� �|��, �(�����(4�(�-�� �'�( �'�&)��T:�, �"����� +-�� ก��+��� ����-(ก'-() ���������� $ ��&�ก��(�()�(����� ���� ��+ก" ,"��-�ก�� ก!, (benign prostate hypertrophy) ,����� (glaucoma) !���& '�&)��� ก�-�� �'�( ���� ก-$"��(4 �� ��� EAACI/GA2LEN/DEF/WAO Guideline 2013 +���� ����-(ก'-() �ก ���� ��ก-$"��(4 ก'�����ก��(�()��"�( non-sedating antihistamines ���'-&�ก��� (2) ��ก� ก�(4�(ก �.:ก2 #3�" ก ���� sedating antihistamines ก"����� �"��ก3 non-sedating antihistamines ��ก� ก����"'#�)���������0 #��ก ��ก2 !��-�#�2'�&4���+-�� ��� ���'ก��-�� �'�( ��&�� ก ��"�������,��ก- ����(ก�� (7) sedating antihistamines �(�- ����, � ��() 5

E. .�M:��`#/M�!@�=�#��@A 1 �<3��@A 2 (Second-generation or non-sedating antihistamines) (, � ��()

6) '�8� �()�(����� � �-�� �'�( �'�&)���"�����+-�� ก��+������ ���#�� �� ��� ��ก-$"��(4'�8���3+�ก ! '5# �� " � �)�������1� �(),����� � ��$�'��&)���ก� �3�b �,/ �:4��()��� � '�( � +-�������� $

Clinical Practice Guideline Urticaria/Angioedema 250

M�����@A 5 ,� �|��, �(�����() 1 �$"��() 1 (First-generation or sedating antihistamines)

Drug Pediatric dosage

(mg/Kg/day)

Age

approved Adult dosage

Pregnancy

category Dose adjustment

Grades of

evidence

Strength of

recommendation

Chlorpheniramine* 0.35-2 1 �J 4 �ก. �$ก 4-6 ��. B -

4 C*

Cyproheptadine 0.25 2 �J 4 �ก. �$ก 6-8 ��. B ก��(ก ��� � ����

,33ก#�"��

Diphenhydramine 5 2 �J 25-50 �ก. �$ก 4-6 ��. B ก��(ก ��� � ����

,33ก#�"��

Hydroxyzine* 1-2 6 '&�� 10 �ก. �$ก 6 ��. C ก��(ก ��� � ����

,33ก#�"��

* �4��������(4 �( grades of evidence +-� strength of recommendation ,)� '�&)��� ก'�8� 'ก" �()���ก�� � � �:��(ก �.:ก2 '��( 3'�( 3��� � " ���ก6, �� �#�� �� �����ก ��ก2 0 ��-�#�2'5( 3#-���'6ก

250 Clinical Practice Guideline Urticaria/Angioedema

Clinical Practice Guideline Urticaria/Angioedema 251

M�����@A 6 ,� �|��, �(�����() 1 �$"��() 2 (Second-generation or non-sedating antihistamines) (+�-�� ก'�ก� ��� ������ '-� (2) +-� (8))

Drug Pediatric dosage Age

approved Adult dosage Dose adjustment

Pregnancy

category Grades of

evidence*

Strength of

recommendation* Age Dose

Cetirizine 2-6 �J

2.5 �ก. ��-� 2 ��4� ��&� 5 �ก.��-���4� >2 �J 10 �ก. ��-���4�

ก ��� � ����,3 ��&��, 3ก#�"�� (Ccr<30 �-/� �(/1.73m2)

B 1a A >6 �J 10 �ก. ��-���4�

Desloratadine

6-11 '&�� 1 �ก.��-���4�

>6 '&�� 5 �ก. ��-���4� ก ��� � �����, 3ก#�"���$�+��

(Ccr<30 �-/� �(/1.73m2) C 1a A

1-5 �J 1.25 �ก.��-���4� 6-11 �J 2.5 �ก.��-���4� >12 �J 5 �ก.��-���4�

Fexofenadine

6 '&��- < 2 �J 15 �ก. ��-� 2 ��4�

>6 '&�� 180 �ก. ��-���4�

��&� 60 �ก. �$ก 12 ��

ก ��� � �����, 3ก#�"�� (Ccr< 80 �-/� �(/1.73m2)

C 1a A 2-11 �J 30 �ก.��-� 2 ��4�

>12 �J 60 �ก. ��-� 2 ��4� ��&�

180 �ก.��-���4�

Levocetirizine > 6 �J 5 �ก.��-���4� >6 �J 5 �ก. ��-���4�

��"�� '�8�,�����3�� ������1� �()�(,3���ก,�'#( �� " �'( � +,"�����3��

������1� �()�(�4�,3+-��,�� � ����ก,� (Ccr<50 �-/� �(/1.73m2)

B 1a A

Loratadine

2-12 �J 5 �ก.��-���4� >2 �J 10 �ก. ��-���4� ก ��� � ����,33ก#�"�� B 1a A

>12 �J, >30 กก. 10 �ก.��-���4�

Rupatadine 6-11 �J

( ≥ 25 กก.) 5 �ก.��-���4�

>12 �J (��,�'�6) >6 �J (��,��4� )

10 �ก. ��-���4� ก ��� � ����,3��&��,3ก#�"��

(Ccr<30 �-/� �(/1.73m2) B 1a A

�� '�,$ *+�-�� ก'�ก� ��� ������ '-� (8)

Clinical Practice Guideline Urticaria/Angioedema 251

Clinical Practice Guideline Urticaria/Angioedema 252

2.2 ก����ก���:�..�F;A�f

• F�0M#� /6MF�F.�0 (Corticosteroids) ���#�� �� ��� ���/,�!��',��� /����3���� � '�"� prednisolone ��ก��('�8�-�#�2'5( 3#-��()

'�8��$�+�� (acute severe urticaria), serum sickness �()'�8��$�+��, urticarial vasculitis +-� delayed pressure urticaria �()��",�3����,"�ก ��ก2 +," ���/,�!��',��� /����3���� ���"�"� ���-�� physical urticaria �&)� V

E:F��5�-� ��"������ prednisolone '�8������ ��&����� " �,"�'�&)��'�8�'�- � ���!��-�#�2'�&4��� +,"� ����'�8��� �'�- �4�V ��ก ��ก2 ก �'�"�����&)� (acute exacerbation) ��!��-�#�2'�&4��� ��&����'�8��� �'�- �4� V '#&)�����&)�-�#�2'�&4����()&4�,"�ก ��ก2 ��3-�

• ก��U=:.�M:��`#/M�!@�=�#��@A 1 ��5 2 �3�!ก�� (H1- and H2-antihistamines) #3�" quality of evidence ��� ,� �|��, �(�����() 2 (H2-antihistamines) �"��ก3 ,� �|��, �(����

�() 1 (H1-antihistamines) ��(��� ��������0 #��� ��ก ��ก2 ����1� -�#�2 ���"�'�� � " ���ก6, ����'�() �� *3 �� ���+���� ������ ��ก-$"��(4�"��ก3 ,� �|��, �(�����() 1 '�&)��� ก�(�� ��-�0 ���, � � b�ก +-� � ��"� ���� ก ��������1� (�:4�3 �� '�&)�'�( 3ก3ก ���� H1-antihistamine '() � V ��4��:�+���� ���� �-����� 2 ก-$"��(4�"��ก�������1� �()��"�"� ,�3����,"�ก ���� H1-antihistamines �4��(4� ก��"���-���� �'�- ���� � 2-4 �� �/ ���� $

• Leukotriene receptor antagonist �(ก ��� montelukast � -�����������1� !��-�#�2'�&4���(chronic urticaria) �()��"�"� ,�3����,"�ก ��ก2 �� ,� �|��, �(� #3�" montelukast � ��(�-�"� ��ก ��ก2 ����1� !��-�#�2�()�(0 �� aspirin-sensitive �(4� ��(���! ��/������1� chronic urticaria 3 �� '�&)�����"��ก3 ,� �|��, �(� +," quality of evidence � �"����3,)� ��4�� ก��� montelukast � �ก�" 2-4 �� �/+-����"���- ���� $

• Ciclosporin �� �()���-��ก ��ก2 �&)�-�#�2� กก �.:ก2 �"����*" � �"������" � 2.5-5 �ก./กก./�� '�&)��� ก ciclosporin '�8� �()�(� � �'�&)���-�� �'�( ���3"� ��"������ � �'ก�� 3-6 '&�� +-� ���"�(�����-'#( �#�'ก() �ก3ก ���� �(4��'6ก� $��� ก�" 18 �J

• Omalizumab �(ก �.:ก2 'ก() �ก3��������0 #��� �(4�" ���-��ก ��ก2 (������1� -�#�2 �(4���3ก ���$�,�� ก�� �ก� ����ก���ก �� � �+-� ก������� � ���$� �������ก2 ����1� !��-�#�2'�&4����()�(� $ 12 �J�:4����()��",�3����,"�ก ��ก2 � ,�I � � " ���ก6, � �(4 ��(� � �"���� ���� '�&)�'��( 3'�( 3ก3ก ��ก2 �� ���(�&)� ��ก��(�()���" �(���3"��(4 ����"�+#� /���'�() �� * (appendix II; +��� �ก ��ก2 �� omalizumab)

Clinical Practice Guideline Urticaria/Angioedema 253

M�����@A 7 �()'�8�ก ��ก2 � �'-&�ก��ก ��ก2 !��-�#�2(+�-�� ก'�ก� ��� ������ '-� (2) +-� (8))

.� !@ก��7Bก���JJ RCT

��.U=: .�=�#�6�@.�

!@ก��7Bก���JJ RCT��.U=:

�3�!ก�J non-sedating

H1-antihistamines

!@ก��7Bก���JJ RCT "J�3�8!3

8�:1�2�;F1�.��E���.:�ก��

8!3!@ RCT (uncontrolled studies ,

case reports) Grades of evidence*

Strength of

recommendation*

Doxepin X 3b B Ketotifen X 3b B

Montelukast X 4 C Nifedipine X 4 C

PUVA X 4 C Warfarin X 4 C

Ciclosporin X 1a A Hydroxychloroquine X 4 C

Montelukast X 3b B Narrow band UVB X 4 C

Omalizumab X 1a A Stanozolol X 3b B Cromolyn X 4 C

Sedating H1-antihistamines + H2-antihistamines (cimetidine)

X 4 C

Sedating H1-antihistamines + terbutaline X 4 C Tranexamic acid X 4 C

Dapsone X 4 C Corticosteroids X 3b B

Interferon X 4 C Intravenous immunoglobulins X 4 C

Methotrexate X 4 C Plasmapheresis X 4 D Sulfasalazine X 4 C

�� '�,$ *+�-�� ก'�ก� ��� ������ '-� (8) ; RCT, randomized controlled trial

Clinical Practice Guideline Urticaria/Angioedema 253

Clinical Practice Guideline Urticaria/Angioedema 254

3. ก����ก��F;A�f

3.1 ก��U=:.� calamine lotion T:)�'�8�+����4� ��� menthol '#&)����' 6� ���� 3��'���()'�8��&)�-�#�2�"� -� ก ��� �� �������1� ��"+ก�'ก ��'ก��������ก'�3� กก �'ก � ����+���' 6���&��� ' 6�����33��'���&)�-�#�2�()��ก6��

3.2 ก��U2: -�FD#J�.ZB�/�62M< ก�5J��ก��6ก#� ก���-�6�#��� ก��".�ก�?0EF��� ก������,#MU,��5

F��!?0EF�1�:4V�. ����1� !��-�#�2'�&4���3 �� ���������,��" �� �'��( �(�-�� ����&)�'�"�+-�'�8��$�+���:4� '�&)��" � ���/� ��(�-�� ����(ก �'�"�����&)�-�#�2 +,"��� �ก-3ก� !��-�#�2ก6� ��3ก����,��+-�� ���/�������1� ��� ก'�"�ก� T:)���ก ��+-�ก2 ����1� ก6������� �:�b:��H�� �(4�� (holistic approach) ������3 �������1� �� 3�" �"����*"!���ก����"�$�+�� ���"� �������1� +-�* ,���"��,กก��- ����������1� �� ����3 ��3�$���,����"���'�" �������"� ���� ก ����-�#�2��3-�'�6��:4�

ก��/3�M3F1�:4V�.U2:1�:6=@A.�=�p

��ก��(+#� /�)����()���ก ��ก2 , ��4�,���()+���� , � guidelines +-�� ���"� � �b��3�$�� ก ��������1� �� +���� ����"���:ก2 ���'�() �� *

ก��".�ก�?0��

1. �� �!"#�[email protected]"��� �"����*"�ก��� '�� ��'�- '�8��� �/ �"����*"�ก��"'ก�� 3 �� �/ �� ��3����1� � ��� �('#( �ก �.:ก2 '( �� ก!��'�( �+#� / #3�" ���� � 1 �� 5 ��&� ��� -� 21 '�&)�,�, �,"�����ก- '�8�!��-�#�2'�&4��� (9)

2. �� �!"#�6�;KF��� U�1�:U2p3 ���� ���� -� 50 �������1� �()�(�&)�-�#�2! ��"�(�&)�+����!��((� !��� 0 ��'�- 1 �J ���� ���� -� 20 �������1� �()� ��(�&)�'�8� V � V ,"���� กก�" 20 �J ��ก-$"�����1� �()�(�&)�-�#�2�"��ก3+����!��((� ��&��(+,"�&)�+����!��((� � " �'( � #3�" ��� -� 75 �������1� !����� �"� �ก�" 1 �J +-���� -� 20 �������1� !��'�8�� �ก�" 20 �J ! 0 #������-�#�2'�&4��������� �4� ���� �'�- 1 �J ���� � 1 �� 3 ��&� ��� -� 34 �(!����3 (remission) ! �� �'�- '5-() ���!���&� 390 �� U�6�>ก ���� ���� -� 50 �(� ก �-�#�2� �"� �'ก�� 1 �J ('5-() 16 '&��) +-�#3�" ��� -� 19 !����30 �� 1 �J

Clinical Practice Guideline Urticaria/Angioedema 255

9� 1��ก

• ก��M��,���2:F�4]#J�M#ก�� ���� '�&)��(���3"��(4� ก����,�+-�ก �,����" �ก '#&)�� � '�,$�&)�-�#�2

��&���� �&)�-�#�2'�&4����()��",�3����,"�ก ��ก2 �ก,� (first-line treatment �� ,� �|��, �(�) '�"�

1. ก��M��,���2:F�4]#J�M#ก�� - Complete blood count (CBC) - Erythrocyte sedimentation rate (ESR) - Stool examination - Chest X-ray - Sinus X-ray - Antinuclear antibodies (ANA) - D-dimer - ก ����3�� ��3 Helicobacter - Gastroscopy - Thyroid antibodies +-�/��&� thyroid function test: � ��� ��ก��(�()��� �" ���(!�����,"������ /�"���� ! '5# �� " � �)� '�&)���� 0 �� autoimmune urticaria 2. ก����/FJ9�!#�":���1#�2�����.�#D@/5ก#� (skin prick testing, SPT): '�8�ก �,���� ก �+#���� IgE-mediated �-3�ก� กก ����3�(4 '�8�ก �3"��" �(����1� �( allergen-specific IgE +,"��"��'�8�ก ������5 �" � ก �� ��-���ก�4�,���'ก�� กก �+#�� �ก"�0���+#�'����� �� ��3� � � ก ����3�()����--3�(�� �'�&)�b&� (negative predictive accuracy) �� � กก�" ��� -� 95 �&��ก,0 �� IgE-mediated reactions ��ก���� +,"b� ����-3�ก���( positive predictive accuracy ��� ก�" ��� -� 50 '�&)�'�( 3ก3ก ����3! double-blind, placebo-controlled food challenge ��4�ก �+�-�-3�ก��� SPT �:������ �� �� ��������

SPT �(3�3 ���� ��0 ���&)�-�#�2'�&4��� �ก���� ��ก��(�()��� ��&�'#&)� &� �ก �+#�� � ���&�+#� �()ก-�ก�" �� � IgE ��0 �� acute allergic urticaria � กก�"

3. ก���#�#,I�.ก���":F�2��

Gold standard ��ก ������5 ก �+#�� � � �&�ก ��� double-blinded, placebo-controlled food challenge '�&)��� ก�9�ก��� ,"�� � � � �'ก����4�� ก IgE-mediated +-� non-IgE-mediated reaction

ก ������5 ก �+#�� � ��()'�8� IgE-mediated reaction �� ��! skin prick testing ��&� '� �'-&�,��� serum specific IgE T:)�ก6��,������������ก �+�-�- /-�2��Jก��M��, specific serum IgG M3FF�2����K� 8!3!@

4�5�.=�0 ��5�-�U2:ก���4�1�1#�"���8�:

Clinical Practice Guideline Urticaria/Angioedema 256

4. ก��M��,2� Autoantibodies U�6�;F� 6";AFก���#�#,I�.U�1�:4V�.�� chronic autoimmune urticaria �(�- ���( ��+ก"

4.1 In vivo test

• Autologous serum skin testing (ASST) '�8� screening test �()�(���! ��/��ก �,��������5 � � '�,$������1� chronic autoimmune urticaria ก �,����(4�(�� ������� ���� -� 70 +-��(�� ��� '# ���� -� 80 ก ����3����-3�ก����� -� 30-60 �������1� CSU +,"� " ���ก6, � � ���"�(�-,"�ก �'�-() �+�-�ก ��ก2

4.2 In vitro test ��+ก"

• Basophil histamine release assay* '�8�ก �,���� functional autoantibodies ��T(�)��������1� ก �,�����,������ fresh basophils � ก���ก,�

• Direct immunoassays* ���(�(4'�8�ก �,���� �4� non-functional +-� functional anti- FcεRI autoantibodies ก �,���'�-" �(4��+ก" Western blotting, immunoprecipitation, enzyme-linked

immunosorbent assay, flow cytometry ! ��� chimeric cell lines �() express human FcεRI α

* ก �,���'�-" �(4 ����(4 ��� ��'5# ���3 ����'�.'�" �4� +-� �����" ����" ���

Clinical Practice Guideline Urticaria/Angioedema 257

Appendix I. , � �+�� grades of evidence +-� strength of recommendation �()����� ������ clinical practice guideline 533�(4 Grades of evidence (+�-�� ก'�ก� ��� ������ '-� (8)) 1a Metaanalysis of RCT 1b Single RCTs 2a Systemic review of cohort studies 2b Single cohort studies and RCTs of limited quality 3a Systematic review of case control studies 3b Single case control study 4 Case series, case cohort series or cohort studies of limited quality, expert committee opinion RCT, randomized controlled trial Classification of strength of recommendation (+�-�� ก'�ก� ��� ������ '-� (8))

Recommendation strength Evidence grade A 1a, 1b B 2a, 2b, 3a, 3b C 4 D Expert opinion

Clinical Practice Guideline Urticaria/Angioedema 258

Appendix II +��� �ก ��ก2 �� Omalizumab

Omalizumab omalizumab ����� ��3�ก2 !��-�#�2'�&4����()'ก��:4�'���()��",�3����,"�ก ��ก2 #&4�I ��������*"+-�

� �$"� (� $ 12 �J �:4���) ก ��ก2 �� omalizumab ��,������'����ก3ก ��ก2 �� H1-antihistamines ��-ก2�� add on therapy /-�2��Jก����ก���:�..� omalizumab (anti-IgE treatment) 1�:4V�.M:F�!@��ก�?5M�!6ก?t0���M3F84�@K

1. ����1� ,���� �"��ก ��+-���+#� /���'�() �� *� �!��������+-�/��&�!��0���+#�

2. �(� $ 12 �J�:4���

3. ���3ก �,��������5 '#�)�',���" ��"�(� '�,$��&��H�� ก��,$���&)��()�� ���'ก�!��-�#�2

- ก �,���� ������9�3,�ก ��()�� '�8� �&� complete blood count (CBC), ANA, +-� urine analysis

4. ���3ก ������5 � ก+#� /���'�() �� *�" '�8�!��-�#�2'�&4����()'ก��:4�'�� (chronic spontaneous urticaria) +-���"

,�3����,"�ก ��ก2 #&4�I � �(�� ��$�+�����!����3� �ก- �b:��$�+��

5. ����1� �(� ก ����!��� � " ���� 3 '&�� +," ���",�3����,"�ก ��ก2 b:�+�������3ก ��ก2 , ��4�,��ก ��ก2

� ,�I � (�� ����+��� �ก ��ก2 !��-�#�2+�"����'�.�� 2557 ! �� ��+#� /������+�"����'�.�� �� ��

0���+#� !���&+-���� 0����$��ก�+�"����'�.�� +-�����+#� /������'6ก+�"����'�.�� ) �:����(ก �#�� �� ���

omalizumab

'��)�ก ��ก2 �� nonsedating H1-antihistamines ���� � ,�I � � " ���� 4 �� �/

#�� �� '#�)� nonsedating H1-antihistamines � กก�" 1 ��� ��&� modern second-generation H1-antihistamines �� ���1 (� กb:� 4 '�" ����� �()���3ก ��3���) � �� " ���� 4 �� �/

����1� ���3ก ������5 �" '�8�!��-�#�2'�&4����()'ก��:4�'�� (chronic spontaneous urticaria)

��",�3����,"�ก ��ก2

��",�3����,"�ก ��ก2

Clinical Practice Guideline Urticaria/Angioedema 259

U=:6ก?t0

Urticaria Activity Score 7 (UAS7) >16

������1� �()�" �ก ��ก2 , ��� �,��� +-����",�3����,"�ก ��ก2 +-�����1� �(-ก2���,"����(4 1. !@ absolute contraindications M3F.� ciclosporin2

* ��ก��(����1� '6ก '�&)��� ก��"�(�����-��������0 #��� ciclosporin ��'6ก� $,)� ก�" 18 �J ก ���� ����:4�� �"ก3$-#�������+#� /

2. !@ absolute contraindications M3F.� systemic

corticosteroids3

������'����� ��$�+�����!��� ก+33���'���� ก ��&)�

-�#�2,-��� �'�- 7 �� (Urticaria Activity Score 7; UAS7) ! �����#�� �� ก ��ก2 �� omalizumab ��� �()�(

��+�� UAS7 � กก�" ��&�'�" ก3 16 ��+�� (� ก��+��',6� 42 ��+��)

�� '�,$: ก�$� �� ����'#�)�',�����"����� Relative contraindications ,"� ciclosporin2 +-� systemic corticosteroids3

8!3M:F�U=:6ก?t0

Urticaria Activity Score 7 (UAS7) >16

������1� �()�" �ก ��ก2 , ��� �,��� +-�� +-�����1� �(-ก2���,"����(4 ���#�� �� ก ��ก2 �� omalizumab ! ��",������'ก��/ UAS7 >16 1. Ciclosporin

- �(0 �� ciclosporin dependence ��"� � �b� $ ciclosporin ���-���� � '�8�'�- 3 '&�� ��&�

- ��",�3����,"�ก ��ก2 �� ciclosporin (�(��+�����'��� UAS7 --���"b:� 30% � ก�" '��)�,���-�� ก���3 ���� ��"'ก�� 3 �ก./กก./�� � �� " ���� 4 �� �/) ��&�

- �(0 �� ciclosporin treatment intolerance '�"� �(�� ����ก,�����,+-�/��&��� ��!-��,����-����3 ! �( blood pressure >140 mmHg systolic ��&� >90 mmHg diastolic ,�,"�ก�� � 2 �� �/

2. Corticosteroids - ���3 oral prednisolone �� � กก�" ��&�'�" ก3 10

��--�ก��,"���,�,"�ก�� �'ก�� 30 �� - �(0 �� corticosteroid dependence ��"� � �b-���� �

��&�� $ ��

#�� �� ��� ก-$"� H2-antihistamines ��&� leukotriene receptor antagonists (LTRAs) �"��ก3 H1-antihistamines � �� " ���� 4 �� �/

���#�� �� ��� ciclosporin ���� ��"'ก�� 3 �ก./กก./�� � �� " ���� 4 �� �/ +,"��"���'ก�� 3-6 '&��

��",�3����,"�ก ��ก2 �( absolute

contraindications ,"� ciclosporin2

���#�� �� ��� omalizumab

��",�3����,"�ก ��ก2 ��&� �(���3"��(4��ก ���� omalizumab

Clinical Practice Guideline Urticaria/Angioedema 260

ก��U2:ก����ก����5ก��4�56!#�1�:4V�.2���8�:��J.� omalizumab �� �+�ก ���'��)�ก ��ก2 �� �� 150 ��--�ก�� �$ก 4 �� �/ �� ก ����'���ก �,�3����,"�ก �

�ก2 �() 4 �� �/ 0 �-����3ก ��ก2 ! ���+33���'���� ก ��&)�-�#�2,-��� �'�- 7 �� (UAS7) � ก#3�" ����1� �( complete response (�(��+�� UAS7 --�� " ���� 90% � กก"��'��)�ก ��ก2 ) ��&��( significant improvement (�(��+�� UAS7 --�� �"���"�� 30 � 90% � กก"��'��)�ก ��ก2 ) ���#�� �� ��� ,"��� �� '�" '���&� 150 ��--�ก�� �$ก 4 �� �/��'�8��� �'�- 3-6 '&��

+,"b� ���'�������1� �-����3 '�8�'�- 4 �� �/+-�� #3�" ��"�( significant improvement (�(��+�� UAS7 --���� ก�" 30% � กก"��'��)�ก ��ก2 ) ���'#�)��� '�8� 300 ��--�ก�� +-����'�������1� ���(ก 2 �� �/b�� � ก����1� �����"�( significant improvement ,"�ก ��ก2 ��b&��" ����1� ��",�3����,"�ก ��ก2 (�(��+�� UAS7 --���� ก�" 30%) ���#�� �� � $

b� ����1� ,�3����,"� omalizumab ( +-�� � �b- �&)�V �� � �#�� �� -�� omalizumab ��&�'#�)��� ��" ����ก �3��� � ��� $ omalizumab +���� ���#�� �� �$ก 3-6 '&��

ก ���� T4� �-�� ก� $ ����1� ��,������3ก ����'���T4� , �'ก��/�� �,�� �#D@ก��J�#2��.� omalizumab

�� omalizumab �()�����!���&)�-�#�2'�&4����()'ก��:4�'���&� 150-300 ��--�ก�� �$ก 4 �� �/ �� ��35('�� �,�������'�" �4� ,� +��"��()+���� �&� ,��+�� (deltoid) ��&�,��� (thigh) �-(ก'-() �3��'���� !��-�#�2 ก ��ก2 �� omalizumab ��,������'����ก3ก ��ก2 �H��$3��������1� ��-ก2�� add on therapy

�(� � �0 �� anaphylaxis +-� anaphylactoid reactions �-����3 ���� � 0.1% ��ก �.:ก2 ��� � ��-���ก +-����� � 0.2% � ก����3ก ��/ก ���� �-���ก��",- ��4�+���� ����� 3 ��4�+�ก���ก �5( ����(ก �'W� ����0 �� anaphylaxis ������1� '�8�'�- 2 �)�!���-�5( +-���ก �5(��4�b������(ก �'W� ����'�8�'�- 30 � �(�-�5( E:F2:�!U=:

- ����()+#�,"�,� omalizumab ��&��"�����ก�3�&)�V��� �(4 E:F ���5���

- ����*���(),4����0/+-������3$,� (Pregnancy Category B) - �9�ก��� 0���+#� ���b:� anaphylaxis - ก �,�'�&4�����, (����1� �()�(�� �'�() ����,"�ก �,�'�&4�����# ��) - ก �5(��T(���� live attenuated vaccines ���5(��T(�0 �-�� ก� $ omalizumab � " ���� 1-3

'&��

Clinical Practice Guideline Urticaria/Angioedema 261

2!�.62M< 1 modern second-generation non-sedating H1-antihistamines �()�(ก �.:ก2 �" '�&)��(ก �'#�)��� �()

�3���� � b:� 4 '�" ���"� '#�)���������0 #��ก ��ก2 +,"��"'#�)��$3,�ก ��/���� ก ���"#:�������/� ก ��+ก" fexofenadine, rupatadine, desloratadine, +-� levocetirizine

2 Absolute contraindications ,"� ciclosporin ��+ก" - �(����,�5( Live attenuated vaccines 0 ���� �'�- 1-3 '&��ก"��'��)� - Uncontrolled or severe hypertension - Serious infection - Immune compromise

Relative contraindication ,"� ciclosporin ��+ก" - �()� ����3ก��'�, 3�-�T:���� ciclosporin ��&��� �������b0 #���,3+ "-� - ก ���� ciclosporin �"��ก3 methotrexate, phototherapy ��&� immunosuppressive �&)�V

3 Absolute contraindications ,"� systemic corticosteroids ��+ก"

- Systemic fungal infections - Herpes simplex keratitis - Hypersensitivity

Relative contraindications ,"� systemic corticosteroids ��+ก" - Active tuberculosis or a positive tuberculin test (purified protein derivative [PPD]) - Active peptic ulcer disease (PUD) - Recent anastomotic surgery - Hypertension - Depression or psychosis - Diabetes mellitus (DM) - Osteoporosis - Cataracts and glaucoma

Clinical Practice Guideline Urticaria/Angioedema 262

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Urticaria Activity Score 7 Diary �9����3��:ก� ก ��&)�-�#�2ก"��ก ��ก2 �� ��33��:ก� ก �����" �ก"����ก ��ก2 +-�'#&)����'���ก ���3�$�� ก ����!���&)�-�#�2'�&4��� ก�$� �� 3��:ก�����-���9�����(4 ����5 1 ��K�M3F6�;AF�ก�� 7 ��� ! ,�3�� b �������� �,"����(4

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References

��+�� 0 ��"�(� ก ��� ��+�� 1 � ก ������ (�(� ก ���� '�&���()������'-6ก��� ��"ก"����'ก��� ��� � *+-���"�"��-ก���3,"�ก �� '����(��,) ��+�� 2 � ก ���� �ก- � (� ก ���ก"����'ก��� ��� � * +-��"��-ก���3,"�ก �� '����(��,����� ����&�ก �����-33 �'�- ) ��+�� 3 � ก ���� ก (� ก ���ก"����'ก��� ��� � *� ก +-��"��-ก���3,"�ก �� '����(��,����� ����&�ก �����-3,-�'�- )

Clinical Practice Guideline Urticaria/Angioedema 263

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