From the Guidelines
Autoimmune urticaria should be treated with a stepped approach, starting with second-generation antihistamines, followed by omalizumab, and finally cyclosporine for refractory cases, as recommended by the latest international urticaria guideline. The treatment algorithm has been streamlined to feature three steps, with guidance on updosing and duration for each treatment option 1.
Treatment Options
- Second-generation antihistamines, such as cetirizine, loratadine, or fexofenadine, can be increased up to four times the standard dose if needed, with the goal of achieving complete disease control 1.
- Omalizumab, a second-line treatment, is recommended to be started at a dose of 300mg every 4 weeks, with the option to updose to 600mg every 14 days if needed, based on well-designed robust double-blind placebo-controlled studies 1.
- Cyclosporine, a third-line treatment, can be considered for patients who do not respond to higher than standard doses of omalizumab, but requires monitoring for potential side effects, such as hypertension, epilepsy, and renal failure 1.
Treatment Approach
- The "as much as needed and as little as possible" approach should be used, with treatment stepped up or down based on levels of disease control assessed with the Urticaria Control Test (UCT) 1.
- Step-down protocols should be implemented with prudence and patience, with patients not stepping down a higher than standard-dosed antihistamine before completing at least 3 consecutive months of complete control 1.
From the Research
Definition and Prevalence of Autoimmune Urticaria
- Autoimmune urticaria is a type of chronic urticaria characterized by the presence of autoantibodies against IgE or the IgE receptor 2.
- The prevalence of autoimmune urticaria is not well-established, but it is estimated to be a significant proportion of chronic urticaria cases 2.
- Chronic urticaria has a lifetime prevalence of approximately 20 percent in the general population 3.
Diagnosis of Autoimmune Urticaria
- The diagnosis of autoimmune urticaria is based on the presence of autoantibodies against IgE or the IgE receptor, which can be detected by the autologous serum skin test (ASST) 2.
- The ASST is considered positive if the patient's serum induces a wheal-and-flare reaction when injected into their own skin 2.
- Routine laboratory investigation is not cost-effective in chronic spontaneous urticaria, unless patients have clinical suggestions of autoimmune diseases 4.
Treatment of Autoimmune Urticaria
- The treatment of autoimmune urticaria typically involves the use of antihistamines, such as levocetirizine, and other medications like montelukast 5.
- Low-dose prednisolone therapy administered for a few months has been shown to be effective in treating autoimmune urticaria, with a complete long-lasting response achieved in 83.3% of patients 2.
- The use of omalizumab, an anti-IgE antibody, has also been shown to be effective in treating chronic spontaneous urticaria, including autoimmune urticaria 4, 6.
Clinical Response to Treatment
- The clinical response to treatment can be measured using the urticaria activity score (UAS) and visual analogue scale (VAS) questionnaires 5.
- Treatment with levocetirizine and montelukast has been shown to decrease COX-1 and COX-2 serum levels and tissue expression, which may contribute to their effectiveness in treating autoimmune urticaria 5.
- The effectiveness of treatment can vary depending on the individual patient and the specific treatment used, and further studies are needed to determine the optimal treatment approach for autoimmune urticaria 6, 5.