Letter to the Editor
I was excited to read about this (new to me) option in “Antidepressants an Ace in the Hole for Urticaria” by Richard Pescatore, DO. (EMN. 2019;41:8; http://bit.ly/2YGBcAc.) I also read the article he cited as “detailing [the] efficacy and suitability” of doxepin. Unfortunately, the article actually only uses the word doxepin twice:
“Old first-generation H1-antihistamines are a particular concern in the elderly in whom they increase the risk of impaired cognition, inattention, disorganized speech, altered consciousness, and falls. The doses of drugs such as diphenhydramine, hydroxyzine, and doxepin used in urticaria, are massive compared with the doses actually proven to be effective for the treatment of insomnia (i.e., to produce sedation), for example, doxepin 3 mg.” (Allergy 2014;69:868; http://bit.ly/2LOrp9v.)
This is hardly a “guideline outlining efficacy and suitability.” The same article goes on to make other useful recommendations. First-line treatment would be modern second-generation antihistamines and then an increased dose up to fourfold if symptoms persist after two weeks. If symptoms still persist after another one to four weeks, the article says to add omalizumab, ciclosporin A, or montelukast, and it also notes that a short course (maximum of 10 days) of corticosteroids may also be used at all times if exacerbations demand it.
I am relieved and happy when egregious claims are called into question by your publication (like the article, “New tPA Study Just a Statistical Parlor Trick;” EMN. 2019;41:1; http://bit.ly/2FM63UB), and this egregious claim should be questioned just the same.
Michael Bouska, MD, MPH
Dr. Pescatore responds: Apologies for the poor citation. I agree that sedating the elderly into oblivion is not an ideal approach. Consider instead the 2014 Joint Task Force on Practice Parameters update representing the American Academy of Allergy, Asthma and Immunology, the American College of Allergy, Asthma and Immunology, and the Joint Council of Allergy, Asthma & Immunology, which reads:
“Treatment with hydroxyzine or doxepin can be considered in patients whose symptoms remain poorly controlled with dose advancement of second-generation antihistamines and/or addition of 1 or more of the following: H2 antihistamines, first-generation H1 antihistamines at bedtime, and/or antileukotrienes.” (J Allergy Clin Immunol. 2014one;133:1270.)
I imagine such a recommendation comes from trials that reflect similar outcomes to Greene (J Am Acad Dermatol. 1985;12:669), Ozkaya (Dermatol Ther. 2019;32:e12993), Adhya (Clin Exp Allergy. 2015;45:1370), Neitaanmaki (J Am Acad Dermatol. 1984;11:483), or somewhere among the other 3000 papers that result when doxepin's role in chronic urticaria is queried. Certainly, adoption of new practices should only come with your own research and synthesis of the collated literature.