What is the treatment for recurrent hives (urticaria)?

From the Guidelines

The treatment for recurrent hives (chronic urticaria) should begin with second-generation antihistamines, with the option to increase the dose up to four times the standard dose if needed, as recommended by the most recent guidelines 1. The goal of treatment is to control symptoms and improve quality of life, as chronic urticaria often resolves spontaneously within 1-5 years.

• Second-generation antihistamines like cetirizine (10mg daily), loratadine (10mg daily), or fexofenadine (180mg daily) are the first line of treatment.
• For persistent symptoms, adding an H2 antihistamine such as famotidine (20mg twice daily) or ranitidine (150mg twice daily) may help, as suggested by previous guidelines 1.
• If hives continue despite these measures, a short course of oral corticosteroids like prednisone (20-40mg daily for 3-5 days) can provide temporary relief during severe flares.
• For long-term management of refractory cases, omalizumab (Xolair) injections (150-300mg every 4 weeks) are highly effective, with the option to increase the dose up to 600mg every 14 days if needed, as recommended by the latest guidelines 1.
• Avoiding identified triggers is essential, as is maintaining a symptom diary to help identify patterns.
• Stress management techniques may also help, as stress can worsen hives. The Urticaria Control Test (UCT) should be used to guide treatment decisions and assess disease control, with a cutoff of 12 points for well-controlled disease, 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 treatment for recurrent hives (urticaria) is Omalizumab (XOLAIR), which 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 2, 2, 2.

• Key points:
  • XOLAIR is not indicated for the treatment of other forms of urticaria.
  • XOLAIR should be used in conjunction with other treatments, such as H1 antihistamines.
  • The dosage of XOLAIR for CSU is not dependent on serum IgE level or body weight.

From the Research

Treatment Options for Recurrent Hives (Urticaria)

• The primary treatment for chronic spontaneous urticaria (CSU) is standard-dose, second-generation H1-antihistamines, as recommended by the international EAACI/GA2LEN/EDF/WAO urticaria guideline 3.
• H1-antihistamines such as cetirizine, desloratadine, levocetirizine, and rupatadine have been shown to be effective in reducing symptoms of urticaria, with some studies demonstrating complete suppression of urticaria 4, 5.
• However, some patients may experience paradoxical exacerbation of urticaria symptoms when taking H1-antihistamines, which may be due to cross-reactivity between metabolites of these drugs 6, 7.
• In cases where H1-antihistamines are ineffective or cause exacerbation, add-on treatments such as omalizumab, ciclosporin A (CsA), or montelukast may be considered, with omalizumab being the only licensed systemic biologic for use in CSU 3.
• Immunomodulatory drugs like ciclosporin and azathioprine have also been shown to be effective in treating refractory chronic urticaria, suggesting an autoimmune/autoreactive mechanism underlying the disease 7.

H1-Antihistamine Comparison

• A systematic review of 73 studies found that cetirizine, desloratadine, and levocetirizine were effective in completely suppressing urticaria, with no single H1-antihistamine standing out as most effective 5.
• The review also found that the quality of evidence was affected by the small number of studies in each comparison and the small sample size for many of the outcomes, prompting a downgrade of the quality of evidence for imprecision.

Important Considerations

• Patients with recurrent hives should be closely monitored for potential adverse events and treatment response, as some may experience exacerbation of symptoms or inadequate response to H1-antihistamines 6, 3, 7.
• The choice of H1-antihistamine and dosage should be individualized based on the severity of symptoms and patient response, with consideration of potential cross-reactivity between metabolites of different H1-antihistamines 6, 4, 7.