What is the treatment for urticaria?

From the Guidelines

The treatment for urticaria should start with non-sedating antihistamines, such as cetirizine (10mg daily), loratadine (10mg daily), or fexofenadine (180mg daily), with the option to increase dosing up to four times the standard dose for persistent symptoms, as recommended by the most recent guidelines 1. The goal of treatment is to relieve symptoms and identify triggers.

• First-line treatment includes non-sedating antihistamines like cetirizine, loratadine, or fexofenadine.
• For severe or unresponsive cases, adding H2 blockers like ranitidine or famotidine may help.
• Short courses of oral corticosteroids like prednisone can be used for acute severe flares, as supported by earlier guidelines 1.
• For chronic urticaria resistant to antihistamines, omalizumab injections may be prescribed by specialists, with a recommended starting dose of 300 mg every 4 weeks and the option to updose if necessary, as outlined in the latest guidelines 1. It is essential to avoid identified triggers and keep skin cool and wear loose clothing to prevent worsening symptoms. Antihistamines work by blocking histamine receptors, reducing itching and swelling, while corticosteroids reduce inflammation. Patients should seek emergency care if experiencing difficulty breathing, throat tightness, or other signs of anaphylaxis with their hives. The treatment approach should follow an "as much as needed and as little as possible" principle, stepping up or down treatment based on disease control, as recommended by the latest guidelines 1.

From the FDA Drug Label

XOLAIR is indicated for the treatment of adults and adolescents 12 years of age and older with chronic spontaneous urticaria (CSU) who remain symptomatic despite H1 antihistamine treatment. The safety and efficacy of XOLAIR for the treatment of chronic spontaneous urticaria (CSU), previously referred to as chronic idiopathic urticaria (CIU) was assessed in two placebo-controlled, multiple-dose clinical trials of 24 weeks' duration (CSU Trial 1; n= 319, [NCT01287117]) and 12 weeks' duration (CSU Trial 2; n=322, [NCT01292473]). Patients received XOLAIR 75 mg, 150 mg, or 300 mg or placebo by SC injection every 4 weeks in addition to their baseline level of H1 antihistamine therapy for 24 or 12 weeks, followed by a 16-week washout observation period.

The treatment for chronic spontaneous urticaria (CSU) is XOLAIR (omalizumab), which can be administered via subcutaneous injection every 4 weeks. The recommended dosage is 150 mg or 300 mg, in addition to the patient's baseline level of H1 antihistamine therapy. Key points to consider:

• XOLAIR is indicated for adults and adolescents 12 years of age and older with CSU who remain symptomatic despite H1 antihistamine treatment.
• The safety and efficacy of XOLAIR for the treatment of CSU was assessed in two placebo-controlled clinical trials.
• Patients received XOLAIR 75 mg, 150 mg, or 300 mg or placebo by SC injection every 4 weeks.
• The treatment is not indicated for the emergency treatment of allergic reactions, including anaphylaxis 2.

From the Research

Urticaria Treatment Overview

• Urticaria, also known as hives, is a common disease characterized by erythematous, edematous, itchy, and transient plaques that involve skin and mucous membranes 3.
• The mainstay of treatment for urticaria is avoidance of triggers, if identified, and pharmacotherapy 4.

First-Line Treatment

• Second-generation antihistamines are considered first-line agents in the treatment of chronic urticaria due to their safety and efficacy profile 5, 4, 6.
• Examples of second-generation antihistamines include loratadine, cetirizine, and mizolastine 6.

Adjunctive Treatment

• First-generation antihistamines, H2 antihistamines, leukotriene receptor antagonists, and brief corticosteroid bursts may be used as adjunctive treatment for urticaria 5, 3, 4.
• Omalizumab, a humanized monoclonal anti-immunoglobulin E, may be used for the treatment of chronic urticaria that is unresponsive to H1 antagonists 5, 4.

Treatment of Acute Urticaria

• The addition of corticosteroids to an antihistamine for the treatment of acute urticaria is unclear and needs to be further investigated 7.
• The combination of diphenhydramine and ranitidine or cimetidine may be effective for relief of urticaria in some cases 7.

Special Considerations

• Urticarial vasculitis, drug eruptions, viral eruptions, and urticaria pigmentosa must be considered in the diagnosis of urticaria 3.
• Angioedema, which can involve the respiratory tract, is a life-threatening condition that requires urgent treatment 3.