From the Guidelines
Urticaria can be effectively treated with antihistamines, and the most recent guidelines recommend a stepped approach to treatment, starting with standard-dosed second-generation antihistamines and stepping up to higher doses or adding omalizumab or cyclosporine as needed. According to the latest guidelines, published in 2022 in the Journal of Allergy and Clinical Immunology 1, the treatment algorithm for chronic spontaneous urticaria has been streamlined to feature three steps: first-line treatment with antihistamines, second-line treatment with omalizumab, and third-line treatment with cyclosporine.
First-Line Treatment
The recommended first-line treatment is a standard-dosed second-generation antihistamine, such as cetirizine (Zyrtec) 10mg, loratadine (Claritin) 10mg, or fexofenadine (Allegra) 180mg taken once daily. If the patient's symptoms are not completely controlled, the dose can be increased up to four-fold higher 1.
Second-Line Treatment
If the patient's symptoms are still not controlled, omalizumab can be added as a second-line treatment. The recommended starting dose is 300 mg every 4 weeks, and the dose can be increased if needed, up to a maximum of 600 mg every 14 days 1.
Third-Line Treatment
If the patient's symptoms are still not controlled, cyclosporine can be added as a third-line treatment. However, cyclosporine has potential risks, including hypertension, epilepsy, hirsutism, gum hypertrophy, and renal failure, and requires regular monitoring of blood pressure and renal function 1.
Additional Measures
In addition to pharmacologic treatment, patients with urticaria can benefit from general measures such as avoiding known triggers, applying cool compresses to affected areas, and wearing loose-fitting clothing to reduce irritation. For immediate relief of itching, calamine lotion or 1% hydrocortisone cream can be applied to affected areas up to four times daily. If hives persist beyond a few days, are accompanied by difficulty breathing, facial swelling, or fever, seek medical attention immediately as you may need prescription-strength medications like prednisone or an epinephrine auto-injector for severe reactions.
Key points to consider when treating urticaria include:
- Using an "as much as needed and as little as possible" approach to treatment, stepping up and stepping down treatment based on levels of disease control assessed with the UCT 1
- Monitoring patients regularly to assess disease control and adjust treatment as needed
- Considering individual patient needs and implementing step-down protocols with prudence and patience 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.
Dosage of XOLAIR in patients with chronic spontaneous urticaria (CSU) is not dependent on serum IgE (free or total) level or body weight
The treatment for chronic spontaneous urticaria (CSU) is omalizumab (XOLAIR) for adults and adolescents 12 years of age and older who remain symptomatic despite H1 antihistamine treatment 2.
- Key points:
- XOLAIR is indicated for CSU treatment
- Treatment is for adults and adolescents 12 years and older
- Patients should remain symptomatic despite H1 antihistamine treatment
- Dosage is not dependent on serum IgE level or body weight
- Important consideration: XOLAIR is not indicated for the treatment of other forms of urticaria 2.
From the Research
Treatment Options for Urticaria
- The primary treatment for urticaria involves the use of antihistamines, specifically second-generation, non-sedating histamine type 1 (H1)-receptor antihistamines 3, 4, 5.
- These antihistamines are preferred due to their effectiveness and lower risk of central nervous system (CNS) side effects compared to first-generation antihistamines 3.
- Second-line treatment options for uncontrolled chronic urticaria include omalizumab, a monoclonal anti-immunoglobulin E (IgE) antibody 6, 4, and cyclosporine 6, 7.
Antihistamine Therapy
- Second-generation antihistamines such as terfenadine, astemizole, loratadine, and cetirizine hydrochloride are effective in treating chronic urticaria 3.
- High-dose antihistamine therapy (at least four times a day) can be effective in close to half of the patients with chronic spontaneous urticaria (CSU) 6.
- The use of antihistamines in high doses is recommended for patients who do not respond to standard doses 5.
Alternative Therapies
- Omalizumab has been shown to be effective in treating antihistamine-resistant cases of urticaria, with a success rate of 65-80% 6.
- Cyclosporine can be used as an alternative therapy for patients who do not respond to antihistamines and omalizumab, with a success rate of 70-80% 6, 7.
- Other immunomodulating drugs such as hydroxychloroquine, dapsone, sulfasalazine, and methotrexate have been tried in chronic urticaria patients, but their efficacy has not been proven in large controlled studies 7.