What is the evaluation and treatment approach for a 67-year-old woman presenting with hives?

From the Guidelines

For a 67-year-old woman presenting with hives, the initial approach should include a thorough history and physical examination to identify potential triggers, followed by symptomatic treatment with antihistamines, and consideration of an epinephrine auto-injector if signs of anaphylaxis are present, as outlined in the 2020 practice parameter update on anaphylaxis 1. The evaluation and treatment approach for this patient should prioritize identifying and avoiding potential triggers, as well as managing symptoms to prevent progression to anaphylaxis.

• Key considerations in the history and physical examination include:
  • Identifying potential allergens or triggers
  • Assessing for signs of anaphylaxis, such as sudden respiratory symptoms, reduced blood pressure, or gastrointestinal symptoms
  • Evaluating for underlying conditions that may be contributing to the hives, such as thyroid disorders or malignancies
• First-line treatment for hives includes second-generation H1 antihistamines, such as cetirizine 10mg, loratadine 10mg, or fexofenadine 180mg daily, which can be increased up to four times the standard dose if symptoms persist 1.
• For acute severe symptoms, a short course of oral corticosteroids like prednisone 40mg daily for 3-5 days may be considered, and an epinephrine auto-injector should be prescribed if there are signs of anaphylaxis, as recommended by the 2017 guidelines on epinephrine for first-aid management of anaphylaxis 1.
• Laboratory testing may include complete blood count, thyroid function tests, and consideration of autoimmune markers if chronic urticaria is suspected, and referral to an allergist or dermatologist is recommended for chronic cases unresponsive to antihistamines, as outlined in the 2006 consultation and referral guidelines citing the evidence 1.
• It is essential to prioritize the patient's safety and well-being, and to err on the side of caution when evaluating and treating hives, particularly in older adults who may be more susceptible to medication side effects and underlying conditions.

From the FDA Drug Label

8.5 Geriatric Use

Clinical studies for the treatment of anaphylaxis have not been performed in subjects aged 65 and over to determine whether they respond differently from younger subjects. However, other reported clinical experience with use of epinephrine for the treatment of anaphylaxis has identified that geriatric patients may be particularly sensitive to the effects of epinephrine Therefore, for the treatment of anaphylaxis, consider starting with a lower dose to take into account potential concomitant disease or other drug therapy.

The evaluation and treatment approach for a 67-year-old woman presenting with hives (possible anaphylaxis) should consider her age and potential sensitivity to epinephrine.

• Key considerations:
  • Potential concomitant disease
  • Other drug therapy
• Treatment approach:
  • Consider starting with a lower dose of epinephrine
  • Take into account potential concomitant disease or other drug therapy 2

From the Research

Evaluation Approach

• A thorough medical history and physical examination are essential to identify potential causes of hives in a 67-year-old woman 3, 4, 5.
• The evaluation should consider various factors, including the duration and severity of symptoms, presence of any underlying medical conditions, and current medications 3, 4, 5.

Treatment Approach

• The first-line treatment for chronic urticaria is antihistamines, which should be used on a regular basis and not only after hives occur 3, 4, 5.
• Second-generation antihistamines, such as levocetirizine and desloratadine, are preferred for day-time use due to their less sedating properties 4, 6.
• If antihistamines fail to control symptoms, addition of glucocorticosteroids can be tried for short periods, with most patients responding to doses equivalent to 40 mg of prednisone daily 3, 5.
• In cases of antihistamine-resistant patients, immunosuppressive drugs such as ciclosporin or omalizumab may be considered, although their use is limited by potential side effects and high cost 4, 5.

Special Considerations

• Hypersensitivity to H(1)-antihistamines is a rare but possible cause of urticaria, and should be considered when urticarial lesions worsen after H(1)-antihistamine treatment 7.
• Increasing antihistamine doses up to 4-fold may improve symptoms in difficult-to-treat urticaria patients without compromising safety, although individual responses may vary 6.
• A step-by-step approach to management, including the use of non-sedating H(1) receptor antagonists, corticosteroids, and immunomodulatory drugs, can help achieve remission of urticarial symptoms in most patients 5.