RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

SYNOPSIS OF DISSERTATION

“TO EVALUATE THE EFFICACY OF AUTOLOGOUS SERUM THERAPY IN CHRONIC URTICARIA”

Submitted by

DR.ANKITA GUPTA MBBS

POST GRADUATE STUDENT IN DVL (M.D)

DEPARTMENT OF

DERMATOLOGY, VENEROLOGY & LEPROSY

ADICHUNCHANAGIRI INSTITUTE OF MEDICAL SCIENCES,

B. G. NAGARA - 571448

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKAANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 NAME OF THE CANDIDATEAND ADDRESS(in block letters)

DR. ANKITA GUPTAP.G IN DVL,ADICHUNCHANAGIRI INSTITUTE OF MEDICAL SCIENCES, B.G. NAGARA,MANDYA -571448

2. NAME OF THE INSTITUTIONADICHUNCHANAGIRI INSTITUTE OF

MEDICAL SCIENCES, B.G.NAGARA.

3. COURSE OF STUDY AND SUBJECT M.D. IN DVL

4. DATE OF ADMISSION TO COURSE 24.06.2013

5. TITLE OF THE TOPIC “TO EVALUATE THE EFFICACY OF AUTOLOGOUS SERUM THERAPY IN CHRONIC URTICARIA”

6.BRIEF RESUME OF INTENDED WORK6.1 NEED FOR THE STUDY6.2 REVIEW OF LITERATURE6.3 OBJECTIVES OF THE STUDY

APPENDIX-IAPPENDIX-IAAPPENDIX-IBAPPENDIX-IC

7 MATERIALS AND METHODS

7.1 SOURCE OF DATA

7.2 METHOD OF COLLECTION OF DATA : (INCLUDING SAMPLING PROCEDURE IF ANY)

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER ANIMALS, IF SO PLEASE DESCRIBE BRIEFLY.

7.4 HAS ETHICAL CLEARENCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASE OF 7.3

APPENDIX-II

APPENDIX-IIA

APPENDIX-IIB

YESAPPENDIX-IIC

YES

8. LIST OF REFERENCES APPENDIX – IIl

9. SIGNATURE OF THE CANDIDATE

10. REMARKS OF THE GUIDEChronic urticaria is a common distressing dermatosis affecting the quality of life of the patients and poses a therapeutic challenge to the treating dermatologist. Numerous treatment options are currently available but have several limitations like long term treatment and potentially side effects. Hence, there is a need for novel therapeutic modality which is safe, efficaceous and economical option for the patients. In this regard Autologous serum therapy is a promising therapy for treatment of chronic urticaria. In view of very few indian studies and to improve the overall quality of life of the patients, this study has been taken up.

11. NAME AND DESIGNATION (in Block Letters)

11.1 GUIDE DR. H. B. BASAVARAJ MBBS, MDPROFESSOR DEPARTMENT OF DERMATOLOGY,AIMS, B.G. NAGARA-571448

11.2 SIGNATURE OF THE GUIDE

11.3 CO-GUIDE (IF ANY) -

11.4 SIGNATURE -

11.5 HEAD OF DEPARTMENT Dr. B. D. SATHYANARAYANA MD, DVDPROFESSOR AND HEAD,DEPARTMENT OF DERMATOLOGY,AIMS, B.G. NAGARA-571448

11.6 SIGNATURE

12 12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL

12.2 SIGNATURE

APPENDIX-I

6. BRIEF RESUME OF THE INTENDED WORK

APPENDIX - IA

6.1 NEED FOR THE STUDY:

The name “Urticaria” is derived from the Latin word urtica, meaning to burn or

hives.1 Urticaria is a heterogenous group of diseases defined in common as presence of

short lived, erythematous, edematous, cutaneous swellings secondary to transient dermal

edema and vasodilatation.2 Angioedema (synonym: angioneurotic edema, Quincke’s

edema) is a rapid swelling of the deeper dermis, subcutaneous tissue, mucosa and

submucosal tissue.3 Chronic urticaria is a common distressing dermatosis characterized

by spontaneous occurrence of wheals lasting for less than 24 hours, with or without

angioedema occurring daily or almost daily for more than 6 weeks.4,5

In majority of the patients with chronic urticaria, the exact etiology remains unknown,

hence they have been categorized under the term chronic idiopathic urticaria (50%).3

However in a significant number of patients with chronic urticaria (30-50%), circulating

histamine releasing functional autoantibodies directed either against high affinity IgE

receptor (anti FcɛRIa) on basophils and mast cells or less commonly against the

immunoglobulin E (IgE) have been identified. Thereby the term chronic autoimmune

urticaria has been assigned to these subgroup of patients.1

In rare cases, pseudoallergy (to salicylates, food colour, preservatives, antioxidants),

infections (bowel parasites, H.pylori, intercurrent viral infections, candidiasis of bowel

and chronic sepsis e.g. dental abscess), drugs (NSAIDS and aspirin, opioids, ACE

inhibitors), psychological factors (anxiety, depression, impaired quality of life, significant

discomfort in interpersonal relationships), and implants (metal pin in the femur, metal

dental prosthesis, dental amalgams and nickel allergy), are implicated in chronic

urticaria.3 Overheating and local pressure of belts and clothing aggravates chronic

urticaria and alcohol worsens urticaria by the mechanism of vasodilatation.6

Autologous serum skin test (ASST) is a simple in-vivo intradermal clinical test for the

detection of basophil histamine releasing activity.7 A positive result in the form of an

immediate hypersensitivity reaction (read against a control) signifies the presence of

circulating histamine releasing factors (autoantibodies).8 Hence, ASST is an useful

diagnostic aid in identifying chronic autoimmune urticaria. ASST as an investigative

technique has been found to have a sensitivity of approximately 70 % and a specificity of

80%.9 Though, basophil histamine release assay is the gold standard for detecting

functional autoantibodies, the procedure is lengthy, requires fresh basophils from healthy

donors and skilled expertise is desired. For this reason, the test is generally limited to

research laboratory centers.7,8

Treatments of chronic urticaria possess a therapeutic challenge for the physician and a

protracted, unsatisfactory ordeal for the patient. Chronic urticaria requires long term

treatment with medications having potentially hazardous side effects, without a definite

treatment period and hence, patient compliance and satisfaction is decreased. Moreover,

patients experience restrictions in daily life activities and social life due to unrelenting

symptoms, exhibit psychiatric co-morbidities, sexual difficulties, and reduced

dermatology life quality index.10

Antihistamines form the first line of treatment. They require long term therapy with no

definite treatment time. Doxepin and monteleukast have been tried with variable results.

Prednisolone in tapering dose is used occasionally in severe urticaria and angioedema.

Immunosuppressive drugs like methotrexate and cyclosporine form the third line of

treatment. They cannot be administered safely for a long period as they encompass

serious side effects like bone marrow suppression, hepatotoxicity, hypertension,

nephrotoxicity etc.6

As a result, there is a need for a novel therapeutic modality which is safe, efficacious and

an economical option for patients. Autologous hemotherapy is one such promising

treatment which has been found helpful in chronic urticaria patients. Patients whole blood

or extracted serum is autologously injected (weekly session) to induce tolerance to the

pro-inflammatory signals released in circulation.11 There is no risk of rejection or disease

transmission as it is produced from patient’s own blood. A study by Staubach et al

concluded that autologous whole blood injections were effective in ASST (+ve) patients

in 70% of cases. Conversely, it was not found efficacious in ASST (-ve) patients.12

Autologous serum therapy on the other hand, involves separation of serum from whole

blood, thereby doing away with the cellular components of blood since the autoreactive

histamine releasing factor is present in serum itself. It can be administered with a fine

gauge needle thereby making treatment less painful for the patients without reducing its

efficacy and thereby increasing the compliance. It was found effective in significant

proportion of autologous serum skin test positive patients in chronic urticaria though

some of the autologous serum skin test negative patients also benefited from this

treatment. Urticaria activity score and and patients requirement of antihistamines also

decreased remarkably. Thus, autologous serum therapy is a potentially curative modality

in patients with chronic urticaria.13

Hence the present study is undertaken to evaluate the efficacy of autologous serum

therapy in chronic urticaria patients.

APPENDIX – IB

6.2 REVIEW OF LITERATURE

The following related studies have been conducted by various authors.

Kulthanan K et al carried out a retrospective study of 450 chronic urticaria patients who

attended the department of dermatology, Siriraj hospital, Mahidol University, Bangkok

during the period 2000-2004. 337 (75%) were diagnosed with chronic idiopathic

urticaria. In 61 patients, ASST was done of which 15 patients (24.5%) had positive

results (i.e.) autoimmune urticaria. Antithyroid and antimicrosomal antibodies were

positive in 16% and 12% of chronic idiopathic urticaria patients respectively.14

Kiran V Godse undertook a prospective study in Navi Mumbai in the year 2004 and

reported that out of 45 patients with chronic idiopathic urticaria, 12 patients (26.67%)

showed a positive autologous serum skin test in the form of wheal and flare response of

more than 1.5 mm than the saline control. It was noted that all the 12 ASST (+ve)

patients had clinical features of severe urticaria.8

P. Staubach et al carried out a prospective study involving autologous whole blood

injections to patients with chronic urticaria with a positive autologous serum skin test in

department of dermatology, university of Mainz, Germany in the year 2005 demonstrated

that after repeated injections of autologous whole blood (AWB) in 9 of 13 ASST +ve

chronic urticaria patients, urticaria activity score had a significantly improvement by > 30

% and among all the ASST +ve chronic urticaria patients 70 % showed relevant

improvement, in contrast ASST –ve chronic urticaria patients did not show any

improvement. So it was concluded that ASST +ve chronic urticaria patients are

specifically benefited by the use of autohemotherapy which is a simple, inexpensive,

potentially curative and safe therapy.12

A.K Bajaj et al in a prospective study of autologous serum therapy in chronic urticaria

in Bajaj skin clinic in Allahabad in the year 2007 demonstrated that there was a

significant decrease in total severity score in both ASST (+ve) and ASST (-ve) patients

which continued even after cessation of therapy when assessed at final 21- 25 weeks

follow-up visit. The difference in reduction of total severity score in ASST (+ve) patients

(65%) and ASST (-ve) patients (43%) were not statistically significant at final follow-up.

Antihistamines use declined from 100 % at baseline in both ASST (+ve) and ASST (-ve)

groups to 38.7% of ASST (+ve) patients and 23.1% of ASST (-ve) patients. It was hence

concluded that autologous serum therapy is an effective therapeutic modality to reduce

diseases severity as well as antihistamine requirement. This therapy also prevented

relapse of symptoms for duration as long as 2 years in some patients.13

Surbhi Vohra et al in a prospective clinical study of autologous serum skin test in

dermatology outpatient department in Indira Gandhi medical college, Shimla in the year

2008 and demonstrated that a positive ASST result has a serum induced wheal with

redness score = 2 and diameter of ≥ 1.5mm as evaluated against a saline induced wheal at

30 minutes. Using this criteria, sensitivity and specificity of the autologous serum skin

test for detecting antibodies was found to be 70 % and 80 % respectively. Therefore, it

was concluded that ASST can be used as a predictive clinical test to diagnose

autoimmune urticaria.7

Sharmila Patil, et al in a prospective study of autologous serum therapy in chronic

urticaria in department of dermatology, Dr D.Y Patil medical college and hospital, Navi

Mumbai in the year 2013 noted that of the 20 ASST (+ve) chronic urticaria patients who

were administered autologous serum therapy, 45% of the patients showed excellent

improvement and improved dermatology life quality index (DLQI), 30 % of the patients

did not show satisfactory response and 25 % of the patients showed no response. UAS

(urticaria activity score) also came down within few weeks and patients requirement of

antihistamines also reduced remarkably. 11

APPENDIX – IC

6.3 AIMS AND OBJECTIVES OF THE STUDY

1. To assess autologous serum skin test in patients with chronic urticaria

2. To evaluate the efficacy of autologous serum therapy in patients with chronic

urticaria

APPENDIX-II

7.0 MATERIALS AND METHODS

APPENDIX-II A

7.1 SOURCE OF DATA

This study is being conducted in Department of Dermatology, Venereology

and Leprosy, Sri Adichunchanagiri Hospital and Research Centre, B.G. Nagara, on

out-patient basis, meeting the mentioned inclusion and exclusion criteria.

Study Design : Prospective, non-randomized uncontrolled study

Study Period : 18 months

Sample size : 50 cases

Total number of patients with chronic urticaria who presented to dermatology

outpatient department (OPD) in the past 3 years was retrospectively calculated and the

expected sample size for subsequent years was estimated.

APPENDIX-II B

7.2 METHOD OF COLLECTION OF DATA

INCLUSION CRITERIA

1. Spontaneous appearance of wheals occurring daily or almost daily for more than 6

weeks

2. Patients willing for the study and for weekly follow- up and injections

3. Patients aged above 18 years

EXCLUSION CRITERIA

1. Patients not willing for the study

2. Pregnant and lactating mother

3. Patients on systemic corticosteroids or immunosuppressive medications in the

past 6 weeks

4. Patients on chemotherapy in the past 1 year

PROCEDURE OF THE STUDY:

All patients attending the Dermatology outpatient department and satisfying the

aforementioned inclusion and exclusion criteria will be recruited in the study after

informed consent and ethical committee approval.

A detailed history will be taken as per the prepared questionnaire. Elaborate general and

systemic examination will be done and recorded in standard performa. A total of 50

patients with chronic urticaria will be screened and ASST will be performed in all the

patients followed by 8 weekly intramuscular injections of autologous serum

AUTOLOGOUS SERUM SKIN TEST:

Following are the pre-requisites for doing autologous serum skin test; short acting

antihistamines (chlorpheniramine maleate, brompheniramine maleate, promethazine

hydrochloride) are withdrawn at least 2 to 3 days prior to the test and long acting

antihistamines (cetrizine hydrochloride, loratidine, fexofenadine hydrochloride) ,doxepin

are withdrawn 2 to 6 weeks beforehand. Ethical approval is taken from the appropriate

body. Under aseptic precautions, two milliliters of patients venous blood is taken from

antecubital vein, collected in a sterile glass tube and allowed to clot for 30 minutes at

room temperature.15 The serum is then separated by centrifugation at 2000 rpm for 15

minutes. A site free of lesions is selected as the test area usually the volar aspect of

forearm. Approximately 0.05 ml (equivalent to 2 units on insulin syringe that has 1 ml

marked as 40 units) of autologous serum is injected intradermally over flexor aspect of

the left forearm. Equal amount of normal saline (negative control) is injected

intradermally over flexor aspect of the right forearm. Every time a separate syringe is

used for each solution. The results are read after 30 minutes. The test is considered

positive if the wheal and flare response occurs over the left forearm (serum injection site)

with a diameter of atleast 1.5 mm or more than that of saline induced response.7

AUTOLOGOUS SERUM THERAPY:

After 1 week run in period, baseline disease parameter and urticaria activity score will be

recorded, in intervening period if patients develops wheals then they will be advised to

take long acting antihistamine (levocetrizine 5 mg) orally. Autologous serum therapy is

instituted in all the enrolled patients. Every week for eight consecutive weeks, 5 ml blood

will be drawn, serum separated and 0.05 ml/kg body weight of patients serum is injected

deep intramuscularly in alternate buttocks (upper outer quadrant of the gluteus region) or

upper arms .11 Proper care is taken, so as not to injure nerves and blood vessels (by

withdrawing the plunger and checking for blood). During the treatment period, patient

will be advised to take oral antihistamines (Tab levocetrizine 5 mg) only when they

develop wheals, however if the severity is more (Urticaria Activity Score > 20) patient

will be immediately attended to, managed appropriately and will be withdrawn from the

study.

CLINICAL ASSESSMENT:-

Urticaria total severity score is calculated based on eleven separate parameters on 0-3

scale (Table 1) at week 0 (baseline), week 4, week 8 ( after the end of treatment) and at

the end of 12th week.12 Based on these, 0-33 total severity score (TSS) is generated and

overall disease severity classified as clear (TSS=0), mild (TSS=1-10), moderate

(TSS=11-20) and severe (TSS=21-33). A follow up score of 0 at 12th week will be

considered as complete remission, score of 1-10 marked improvement, a score of 11-20

moderate improvement and score of 21-30 poor or no improvement.13

Table 1: Urticaria activity score12

SYMPTOMS 0 1 2 3

Wheal number (daily average)

None <10 10-50 >50

Wheal size (average diameter)

None <1cm 1-3cm >3cm

Wheal duration (average, h)

None <1 h 1-24 h >24 h

Pruritus intensity (daily average)

None Mild Moderate Severe

Pruritus duration (average, h)

None <1 h 1-24 h >24 h

Erythema number(daily average)

None <10 10-30 >30

Erythema size(average diameter)

None <1 cm 1-3 cm >3 cm

Erythema duration (average, h)

None <1 h 1-24 h >24 h

Angioedema number (daily average)

None 1 2 3

Angioedema size (average diameter)

None <1 cm 1-3 cm >3 cm

Angioedema duration (average, h)

None <1 h 1-24 h >24 h

Outcome measures include:-

1) Decrease in severity of Urticaria activity score at week 12 (week 4 after

termination of treatment)

2) Requirement of antihistamine as rescue medication during the treatment period

and week 12 ( 4 weeks after termination of treatment )

Collected clinic-epidemiological data will then be analyzed using appropriate

stastical method, namely proportion, percentage and chi-square test.

APPENDIX-II C

7.3 Does the study require any investigation or intervention to be conducted on the

patients or animals, if so please describe briefly:

YES

The information elicited from the history and physical examination is used to direct the

selection of laboratory tests.

1) Complete Haemogram

2) Absolute eosinophil count (AEC)

APPENDIX-IID

PROFORMA APPLICATION FOR ETHICS COMMITTEE APPROVAL

SECTION A

a Title of the study“TO EVALUATE THE EFFICACY OF AUTOLOGOUS SERUM THERAPY IN

CHRONIC URTICARIA”

b Principle investigator(Name and Designation)

DR. ANKITA GUPTAPOST GRADUATE IN DERMATOLOGY,ADICHUNCHUNAGIRI INSTITUTE OF MEDICAL SCIENCES, B.G. NAGARA,MANDYA DISTRICT -571448

c Co-investigator(Name and Designation)

Dr. H. B. BASAVARAJ MBBS, MD

PROFESSOR DEPARTMENT OF DERMATOLOGYAIMS, B.G. NAGARA-571448

d Name of the CollaboratingDepartment/Institutions NIL

eWhether permission has been obtained from the heads of the collaborating departments & Institution

NA

Section – B Summary of the Project

APPENDIX ISection – C Objectives of the study

Section – DMethodology

APPENDIX IIB

A Where the proposed study will be undertakenDEPARTMENT OF DERMATOLOGY,

VENEREOLOGY & LEPROSYS.A.H. & R.C., B.G.NAGARA

B Duration of the Project 18 MONTHS

C Nature of the subjects:

Does the study involve Adult patients?

Does the study involve Children?

Does the study involve normal volunteers?

Does the study involve Psychiatric patients?

Does the study involve pregnant women?

YES

NO

NO

NO

NO

D If the study involves health volunteers

I. Will they be institute students?

II. Will they be institute employees?

III. Will they be paid?

IV. If they are to be paid, how much per

session?

NA

E Is the study a part of multi central trial? NO

F If yes, who is the coordinator?

(Name and Designation)

Has the trail been approved by the ethics

Committee of the other centers?

If the study involves the use of drugs please

indicate whether.

I. The drug is marketed in India for the

indication in which it will be used in the study.

II. The drug is marketed in India but not for the

indication in which it will be used in the study

III. The drug is only used for experimental use in

humans.

IV. Clearance of the drugs controller of India

has been obtained for:

Use of the drug in healthy volunteers

Use of the drug in-patients for a new

indication.

NA

-

NA

NA

NA

NA

NA

Phase one and two clinical trials

Experimental use in-patients and healthy

volunteers.

NA

G How do you propose to obtain the drug to be

used in the study?

- Gift from a drug company

- Hospital supplies

- Patients will be asked to purchase

- Other sources (Explain)

NA

H Funding (If any) for the project please state

- None

- Amount

- Source

- To whom payable

NIL

IDoes any agency have a vested interest in the out

come of the Project? NO

JWill data relating to subjects /controls be stored

in a computer?YES

K

Will the data analysis be done by

- The researcher?

- The funding agent

YES

NO

L Will technical / nursing help be required from

the staff of hospital.

If yes, will it interfere with their duties?

Will you recruit other staff for the duration of

the study?

If Yes give details of

I. Designation

YES

NO

NO

II. Qualification

III. Number

IV. Duration of Employment

NA

M Will informed consent be taken? If yes

Will it be written informed consent:

Will it be oral consent?

Will it be taken from the subject themselves?

Will it be from the legal guardian? If no, give

reason:

YES

YES

NO

YES

NA

N Describe design, Methodology and techniques APPENDIX II

Ethical clearance has been accorded.

Chairman,P.G Training Cum-Research Institute,

A.I.M.S., B.G.Nagara.Date:

PS: NA – Not Applicable

APPENDIX-III

8. LIST OF REFERENCES:

1. Sachdeva S, Gupta V, Amin SS, Tahseen M. Chronic urticaria. Indian J Dermatol

2011;56:622-8.

2. Clive EH, Ruth A, Malcom W. Chronic urticaria. J Am Acad Dermatol

2002;46:645-57.

3. Grattan CEH, Black AK. Urticaria and mastocytosis messenger. In: Burns T,

Breathnach S, Cox N, Griffiths C, editors. Rook’s textbook of dermatology, 8 th

ed. UK: Wiley-Blackwell; 2010. p. 22.1-26.

4. Godse KV. Urticaria meter. Indian J Dermatol 2012;57:410-1.

5. Tseng JTP, Lee WR, Lin SS, Hsu CH, Yang HH, Wang KH et al. Autologous

serum skin test and autologous whole blood injections to patients with chronic

urticaria: A retrospective analysis. Dermatol Sinica 2009;27:27-36.

6. Godse KV. Chronic urticaria and treatment options. Indian J Dermatol

2009;54:310-2.

7. Vohra S, Sharma NL, Mahajan VK. Autologous serum skin test: Methodology,

interpretation and clinical applications. Indian J Dermatol Venereol Leprol

2009;75:545-8.

8. Godse KV. Autologous serum skin test in chronic idiopathic urticaria. Indian J

Dermatol Venereol Leprol 2004;70:283-4.

9. Sabroe RA, Grattan CE, Francis DM, Barr RM, Kobza BA, Greaves MW. The

autologous serum skin test: A screening test for autoantibodies in chronic

idiopathic urticaria. Br J Dermatol 1999;140:446-52.

10. O’Donnell BF, Lawlor F, Simpson J, Morgan M, Greaves MW. The impact of

chronic urticaria on the quality of life. Br J Dermatol 1997;136:197-201.

11. Patil S, Sharma N, Godse K. Autologous serum therapy in chronic urticaria.

Indian J Dermatol 2013;58:225-6.

12. Staubach P, Onnen K, Vonend A, Metz M, Siebenhaar F, Tschentscher I et al.

Autologous whole blood injections to patients with chronic urticaria and a

positive autologous serum skin test: a placebo-controlled trial. Dermatology

2006;212:150-9.

13. Bajaj AK, Saraswat A, Upadhyay A, Damisetty R, Dhar S. Autologous serum

therapy in chronic urticaria: Old wine in a new bottle. Indian J Dermatol Venereol

Leprol 2008;74:109-13.

14. Kulthanan K, Jiamton S, Thumpimukvatana N, Pinkaew S. Chronic idiopathic

urticaria prevalence and clinical course. J Dermatol 2007;34:294-301.

15. Ghosh SK, Ghosh S. Autologous serum skin test. Indian J Dermatol 2009;54:86-

7.