What is the initial medical work-up for an 81-year-old patient presenting with new onset urticaria at night?

From the Guidelines

The initial medical work-up for an 81-year-old patient with new onset urticaria at night should include a comprehensive history, physical examination, and targeted laboratory tests to rule out underlying conditions that may be contributing to the urticaria, with a focus on minimizing morbidity, mortality, and improving quality of life. Begin by documenting the timing, duration, and characteristics of the hives, along with potential triggers such as new medications, foods, or environmental exposures, as suggested by guidelines for evaluation and management of urticaria in adults and children 1. A thorough medication review is essential as many drugs can cause urticaria, particularly in older adults. Physical examination should assess the extent and appearance of the urticarial lesions and look for signs of systemic involvement. Basic laboratory tests should include complete blood count with differential, comprehensive metabolic panel, thyroid function tests, and erythrocyte sedimentation rate or C-reactive protein to screen for underlying inflammatory conditions. Consider specific IgE testing or skin prick tests if the history suggests allergic triggers. In elderly patients, particular attention should be paid to ruling out underlying malignancies, autoimmune conditions, or infections that may present with urticaria, as outlined in consultation and referral guidelines citing the evidence: how the allergist-immunologist can help 1. Initial symptomatic treatment typically includes non-sedating H1 antihistamines such as cetirizine 10mg daily or loratadine 10mg daily, with potential dose adjustments based on renal function in this age group, as recommended by guidelines for evaluation and management of urticaria in adults and children 1. For nighttime symptoms, adding hydroxyzine 25mg at bedtime may help, though use caution due to anticholinergic effects in elderly patients. Document response to treatment as this information helps guide further diagnostic workup and management.

Some key points to consider in the work-up and management of urticaria in elderly patients include:

• The importance of a thorough medication review to identify potential causative agents
• The need to rule out underlying conditions such as malignancies, autoimmune conditions, or infections
• The use of non-sedating H1 antihistamines as first-line treatment, with potential dose adjustments based on renal function
• The consideration of adding sedating antihistamines at night for symptom control, with caution due to anticholinergic effects
• The importance of documenting response to treatment to guide further diagnostic workup and management, as suggested by guidelines for evaluation and management of urticaria in adults and children 1 and consultation and referral guidelines citing the evidence: how the allergist-immunologist can help 1.

It is also important to note that the use of antihistamines in urticaria is supported by evidence, with guidelines suggesting that all patients should be offered the choice of at least two nonsedating H1 antihistamines because responses and tolerance vary between individuals 1. Additionally, the use of sedating antihistamines as monotherapy is now less common due to concerns about reduced concentration and performance, but they can be effective and well tolerated by some individuals 1.

Overall, the management of urticaria in elderly patients requires a comprehensive approach that takes into account the potential underlying causes of the condition, as well as the need to minimize morbidity, mortality, and improve quality of life. By following a thorough work-up and treatment plan, healthcare providers can help to improve outcomes for these patients, as suggested by guidelines for evaluation and management of urticaria in adults and children 1 and consultation and referral guidelines citing the evidence: how the allergist-immunologist can help 1.

From the Research

Initial Medical Work-up for New Onset Urticaria

The initial medical work-up for an 81-year-old patient presenting with new onset urticaria at night involves a thorough clinical evaluation to determine the underlying cause of the condition.

• The diagnosis of urticaria is made clinically, and anaphylaxis must be ruled out 2.
• A limited nonspecific laboratory workup should be considered unless elements of the history or physical examination suggest specific underlying conditions 2.
• The most common causes of new onset urticaria in older children and adults are post-infection or acute idiopathic urticaria, which are not helped by systemic steroids and are almost never caused by an IgE-mediated allergy 3.

Treatment Options

Treatment options for urticaria include:

• High-dose nonsedating antihistamines for acute idiopathic urticaria 3.
• Avoidance of triggers, if identified, as the mainstay of treatment 2.
• Second-generation H1 antihistamines as first-line pharmacotherapy, which can be titrated to greater than standard doses 2.
• First-generation H1 antihistamines, H2 antihistamines, leukotriene receptor antagonists, high-potency antihistamines, and brief corticosteroid bursts may be used as adjunctive treatment 2.

Specific Considerations

• An epinephrine prescription is not indicated for onset acute urticaria or angioedema, unless there is a strong suspicion of anaphylaxis, and they have been acutely treated with epinephrine 3.
• Antihistamines, epinephrine, and systemic corticosteroids are completely ineffective in treating idiopathic or bradykinin-mediated angioedema 3.
• Suspect hereditary or acquired angioedema if there is recurrent non-itchy swelling with abdominal pain triggered by mechanical trauma 3.