From the Guidelines
The first-line medication for hives (urticaria) is a non-sedating, second-generation antihistamine such as cetirizine (Zyrtec) 10mg daily, loratadine (Claritin) 10mg daily, or fexofenadine (Allegra) 180mg daily. These medications block histamine receptors, reducing itching, redness, and swelling associated with hives. They are preferred because they cause minimal drowsiness compared to older antihistamines, as noted in the guidelines for chronic spontaneous urticaria 1. For severe or persistent hives, the dose can be increased up to four times the standard dose (under medical supervision), as recommended in the latest update of the international urticaria guideline 1.
Taking the medication daily rather than as-needed provides better control of symptoms. If hives persist despite treatment, adding an H2 blocker like famotidine (Pepcid) 20mg twice daily may help, as suggested in the guidelines for evaluation and management of urticaria in adults and children 1. For immediate relief of itching, cool compresses can be applied to affected areas. It is essential to note that the treatment approach should be individualized, and the dose should be adjusted based on the patient's response, as recommended in the guidelines for chronic spontaneous urticaria 1.
The use of antihistamines, particularly non-sedating second-generation antihistamines, is supported by the guidelines for the diagnosis and management of food allergy in the United States, which recommend the use of H1 antihistamines, such as diphenhydramine, as adjunctive treatment for urticaria 1. However, the most recent and highest quality study, the chronic spontaneous urticaria guidelines, recommends the use of non-sedating second-generation antihistamines as first-line treatment 1.
In terms of specific medications, cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine, and mizolastine are all options, but cetirizine and loratadine are commonly used due to their efficacy and safety profile, as noted in the guidelines for evaluation and management of urticaria in adults and children 1. Ultimately, the choice of medication should be based on the individual patient's needs and response to treatment, as recommended in the guidelines for chronic spontaneous urticaria 1.
If hives are accompanied by difficulty breathing, throat tightness, or facial swelling, seek emergency medical attention immediately, as this could indicate a severe allergic reaction. The guidelines for the diagnosis and management of food allergy in the United States recommend the use of epinephrine auto-injectors as first-line treatment for anaphylaxis, which can be a life-threatening allergic reaction 1.
In summary, the treatment of hives should prioritize the use of non-sedating second-generation antihistamines, with individualized dosing and adjustment based on patient response, as recommended in the guidelines for chronic spontaneous urticaria 1.
From the Research
First-Line Medication for Hives
The first-line treatment for hives, also known as urticaria, typically involves the use of antihistamines.
- Second-generation antihistamines are preferred over first-generation antihistamines due to their reduced sedative and anticholinergic effects 2, 3, 4.
- Examples of second-generation antihistamines include cetirizine, desloratadine, fexofenadine, levocetirizine, and loratadine 2, 3, 5, 6, 4.
Efficacy and Safety of Second-Generation Antihistamines
- Studies have shown that second-generation antihistamines are effective in reducing the severity of pruritus, minimizing the number and size of hives, and improving disease-impaired sleep and daily activities 2, 3, 5.
- These medications are generally well-tolerated, with rare reports of adverse effects 3, 5, 6.
- Up-dosing of second-generation antihistamines may be recommended for patients who do not respond to standard doses, with bilastine, fexofenadine, levocetirizine, and cetirizine being recommended for up-dosing in non-responsive patients with chronic spontaneous urticaria 6.
Specific Second-Generation Antihistamines
- Desloratadine has been shown to have a rapid onset of action and a high in vivo H1 receptor-binding affinity, making it an effective option for patients with chronic idiopathic urticaria 5.
- Levocetirizine has been found to have a greater in vivo H1 receptor occupancy compared to other second-generation antihistamines, which may confer an advantageous efficacy/safety profile 2.
- Fexofenadine has been shown to have a low occupancy of H1 antihistamine receptors in the brain, reducing the likelihood of sedation 2.