What are the treatment options for chronic urticaria?

From the Guidelines

Chronic urticaria treatment options include antihistamines, omalizumab, and cyclosporine.

First-line Treatment

• Antihistamines are the mainstay of therapy, with options including cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine, and mizolastine 1
• Doses can be increased up to 4-fold higher than the standard dose if necessary, with the goal of achieving complete disease control 1

Second-line Treatment

• Omalizumab is recommended for patients who do not respond to antihistamines, with a starting dose of 300 mg every 4 weeks 1
• Updosing of omalizumab can be considered in patients with insufficient response, with a maximum recommended dose of 600 mg every 14 days 1

Third-line Treatment

• Cyclosporine can be considered for patients who do not respond to omalizumab, with a recommended dose of 4 mg/kg/day 1
• However, cyclosporine carries potential risks, including hypertension, epilepsy, hirsutism, gum hypertrophy, and renal failure, and requires regular monitoring of blood pressure and renal function 1

General Measures

• Avoidable physical or dietary triggers should be identified and avoided whenever possible 1
• Immunomodulating therapies should be restricted to patients with disabling disease who have not responded to optimal conventional treatments 1

From the Research

Treatment Options for Chronic Urticaria

• First-line treatment: Second-generation H1 antihistamines are considered the first-line treatment for chronic urticaria, with a partial or complete response observed in approximately 40% of patients 2.
• Second-line treatment: The monoclonal anti-IgE antibody omalizumab is recommended as second-line treatment for antihistamine-refractory chronic spontaneous urticaria 2, 3.
• Third-line treatment: Cyclosporine, used off-label, can improve symptoms in approximately 54% to 73% of patients, especially those with autoimmune chronic spontaneous urticaria and nonresponse to omalizumab 2.
• Alternative treatments: Other treatment options include:
  • H2 antihistamines
  • Leukotriene receptor antagonists
  • First-generation H1 antihistamines
  • Corticosteroids
  • Immunosuppressives like methotrexate, cyclosporine, and omalizumab 4, 5, 3, 6
• Special considerations: Treatment should address both physical symptom relief and improvements in quality of life, and may involve a step-wise approach to optimize and individualize treatment for patients with chronic urticaria 4, 5.