What are the treatment options for chronic urticaria?

From the Guidelines

Treatment for chronic urticaria should begin with second-generation H1 antihistamines, and for patients who don't respond adequately, omalizumab is the recommended second-line treatment, as evidenced by the most recent guidelines 1. The treatment approach for chronic urticaria has been streamlined into a 3-step algorithm, with antihistamines as the first-line treatment, omalizumab as the second-line treatment, and cyclosporine as the third-line treatment 1.

• First-line treatment: second-generation H1 antihistamines like cetirizine (10mg daily), loratadine (10mg daily), or fexofenadine (180mg daily) can be increased up to four times the standard dose if needed for symptom control.
• Second-line treatment: omalizumab (300mg subcutaneous injection every 4 weeks) is recommended for patients who don't respond adequately to antihistamines, with the option to updose to 600mg every 14 days if necessary 1.
• Third-line treatment: cyclosporine (3-5mg/kg/day) can be considered for refractory cases, but its use requires careful monitoring of blood pressure and renal function due to potential risks 1. It's essential to note that treatment should be tailored to individual patient needs, and a step-up and step-down approach should be used to achieve optimal disease control while minimizing treatment burden 1. Key considerations in treatment include:
• Identifying and avoiding triggers such as certain foods, medications, heat, pressure, or stress.
• Using medications to block histamine receptors or reduce the inflammatory response that causes the characteristic itchy wheals and swelling of urticaria.
• Periodically attempting to reduce medication to assess if the urticaria has resolved, which may take months to years. The most recent guidelines 1 provide the best evidence for the treatment of chronic urticaria, and their recommendations should be followed to ensure optimal patient outcomes.

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.

• Treatment options for chronic urticaria include:
  • H1 antihistamine therapy
  • XOLAIR (omalizumab) for patients who remain symptomatic despite H1 antihistamine treatment 2
• The dosage of XOLAIR for chronic spontaneous urticaria is not dependent on serum IgE level or body weight 2
• XOLAIR is not indicated for the treatment of other forms of urticaria 2

From the Research

Treatment Options for Chronic Urticaria

The treatment options for chronic urticaria include:

• Avoidance of triggers, if identified 3
• Second-generation H1 antihistamines as first-line pharmacotherapy, which can be titrated to greater than standard doses 3, 4, 5, 6
• First-generation H1 antihistamines, H2 antihistamines, leukotriene receptor antagonists, and brief corticosteroid bursts as adjunctive treatment 3, 4, 6
• Omalizumab as second-line treatment for antihistamine-refractory chronic spontaneous urticaria 5, 6
• Cyclosporine as third-line treatment for chronic spontaneous urticaria, especially for patients with autoimmune chronic spontaneous urticaria and nonresponse to omalizumab 5

Special Considerations

• In cases of relapse after corticosteroid suspension, leukotriene receptor antagonists may be tried 4
• Prolonged corticosteroid therapy may be needed in some cases, but should be administered at the lowest dose able to control urticarial symptoms to minimize adverse effects 4
• Other immunomodulating drugs, such as hydroxychloroquine, dapsone, sulfasalazine, and methotrexate, may be considered, but their efficacy has not been proven in large controlled studies 4
• Warfarin therapy may also be considered in some patients with chronic urticaria and angioedema unresponsive to antihistamines 4

Stepping Down Treatment

• The goal of chronic spontaneous urticaria treatment is to treat the disease until it is gone as effectively and safely as possible 7
• Treatment should be continued until no longer needed, and stepped down once a patient is free of signs and symptoms, or due to safety concerns, pregnancy, or economic factors 7
• However, there is a lack of controlled trials on the step down and discontinuation of treatments, and guidance is needed for all recommended therapies 7