P013 Referral pathways and diagnostic approaches in chronic spontaneous urticaria: results from the REVEAL UK survey

Abstract

Chronic spontaneous urticaria (CSU) is characterized by recurrent itchy weals and/or angio-oedema for > 6 weeks) (Kolkhir P, Muñoz M, Asero R et al. Autoimmune chronic spontaneous urticaria. J Allergy Clin Immunol 2022; 149: 1819–31). The objective of the REVEAL survey was to gain better understanding of the diagnosis, management and treatment of patients with CSU in the UK. UK consultants directly involved in the treatment and management of patients with CSU completed a 45-min online survey, exploring key areas of treatment, accompanied by Novartis Medical Science Liaisons. The sample comprised 33 dermatologists and 17 immunologists/allergists (I/As). The results were analysed descriptively. Overall, 70% of referrals are from primary care, 44% of which had an inaccurate or no diagnosis. Consultants’ top challenge in CSU management is referral times (dermatologists 45%, I/As 24%), with diagnosis in primary care in second place. Guidance is given to general practitioners for referral requests, uptitrating antihistamines for suspected CSU, and for diagnosis. In cases of uncertain diagnoses or unresponsiveness to antihistamines, referral is advised. I/As refer to dermatology after failure of omalizumab, whereas the rationale for referrals to immunology from dermatologists varies. Patients with severe angio-oedema are more likely referred from dermatologists to I/As. Common diagnostic tests include full blood count (72%), thyroid-stimulating hormone (64%) and thyroid antibodies (62%). Dermatologists are more likely to measure total IgE throughout. Testing for all healthcare professionals varies at treatment decisions (46%), response assessment (78%) and monitoring (60%). Primary reasons to omit testing include perceived limited impact on treatment decisions, and guidelines not recommending testing if appropriate investigations have already been completed at diagnosis. UK dermatologists and I/As report heterogeneous referral pathways in CSU, influenced by patient characteristics and consultant specialty. Key challenges include misdiagnosis in primary care, referral times, variable interspecialty referral rationales, and inconsistent use of laboratory testing after diagnosis.