From the Guidelines
The recommended treatment for urticaria begins with non-sedating H1 antihistamines, such as cetirizine (10mg daily), loratadine (10mg daily), or fexofenadine (180mg daily), as the first line of treatment, according to the most recent guidelines 1. These medications block histamine receptors to reduce itching and hives. For inadequate symptom control, dosing can be increased up to four times the standard dose (e.g., cetirizine 40mg daily) 1. Some key points to consider in the treatment of urticaria include:
- The use of antihistamines as the mainstay of therapy, with over 40% of hospitalized patients showing a good response to them 1.
- The potential for adding H2 antihistamines like famotidine (20mg twice daily) or ranitidine (150mg twice daily) for severe or refractory cases, although the evidence for this is not as strong 1.
- The consideration of short courses of oral corticosteroids, such as prednisone (starting at 40mg daily for 3-5 days with tapering), for severe acute urticaria or angio-oedema affecting the mouth 1.
- The potential use of omalizumab (300mg subcutaneous injection every 4 weeks) for chronic urticaria unresponsive to antihistamines, with the recommendation to start treatment with 300mg every 4 weeks and consider updosing if necessary 1.
- The importance of avoiding identified triggers, maintaining good skin care with gentle, fragrance-free products, and keeping a symptom diary to help identify potential triggers.
- The use of cool compresses and lukewarm baths with colloidal oatmeal to provide temporary relief. Treatment typically continues until symptoms resolve, which may be days for acute urticaria or months to years for chronic cases. It is essential to note that the treatment approach should be individualized, and patients should be instructed to err on the side of caution when it comes to injecting epinephrine in cases of anaphylaxis, as prompt administration is key 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 recommended dosage for CSU is not dependent on serum IgE (free or total) level or body weight. Patients who received XOLAIR 150 mg or 300 mg had greater decreases from baseline in weekly itch severity scores and weekly hive count scores than placebo at Week 12.
The recommended treatment for chronic spontaneous urticaria (CSU) is XOLAIR (omalizumab) 150 mg or 300 mg administered subcutaneously every 4 weeks, in addition to baseline H1 antihistamine therapy, for adults and adolescents 12 years of age and older who remain symptomatic despite H1 antihistamine treatment 2.
From the Research
Treatment Options for Urticaria
- The international EAACI/GA2LEN/EDF/WAO urticaria guideline advises standard-dose, second-generation H1-antihistamines as first-line therapy for urticaria 3.
- Updosing of second-generation H1-antihistamines (up to fourfold) can improve response, but many patients remain symptomatic 3, 4.
- Add-on omalizumab, ciclosporin A (CsA), or montelukast are recommended as third-line treatment in patients with an inadequate response to high-dose H1-antihistamines 3, 4.
- Omalizumab is currently the only licensed systemic biologic for use in chronic spontaneous urticaria (CSU) and has a better safety profile than CsA 3.
Antihistamines in Urticaria Treatment
- Non-sedating, second-generation H1-antihistamines (nsAHs) are recommended as the first-line treatment for urticaria 4, 5, 6.
- Older antihistamines, such as chlorpheniramine and hydroxyzine, are effective but have marked sedative and anticholinergic effects 5.
- Newer non-sedating antihistamines, such as loratadine, cetirizine, and mizolastine, have reduced adverse effects and are preferred for chronic idiopathic urticaria 5, 6.