What is the current treatment for urticaria?

Current Treatment for Urticaria

The current treatment for urticaria follows a stepwise approach, starting with standard-dose second-generation H1-antihistamines, increasing to up to 4 times the standard dose if needed, followed by omalizumab as add-on therapy for refractory cases, and cyclosporine as a third-line option. 1

First-Line Treatment: Second-Generation H1-Antihistamines

• Standard dosing options:

  • Fexofenadine 180mg daily
  • Cetirizine 10mg daily
  • Loratadine 10mg daily
  • Desloratadine 5mg daily
  • Bilastine 20mg daily
  • Levocetirizine 5mg daily 1

• These medications should be used regularly, not just when hives occur

• Second-generation antihistamines are preferred over first-generation due to less sedation and fewer anticholinergic effects

Step-Up Approach for Inadequate Response

Step 1: Standard dose second-generation H1-antihistamine

Step 2: Increase dose up to 4 times standard dose if inadequate response

Step 3: Add additional therapies for resistant cases:

• Omalizumab (300mg every 4 weeks or 600mg every 2 weeks) 1, 2
• Cyclosporine (up to 5mg/kg body weight) 1
• Leukotriene receptor antagonists (e.g., montelukast) 1

Treatment Monitoring

• Use validated tools like the Urticaria Control Test (UCT) and Urticaria Activity Score (UAS7) to monitor disease control
• A UCT score of 4 indicates poorly controlled disease, whereas a score ≥12 indicates well-controlled disease 1
• Consider step-down only after at least 3 consecutive months of complete control, with gradual reduction of antihistamine dose (not more than 1 tablet per month) 1

Special Considerations

For Anaphylaxis

If urticaria is accompanied by signs of anaphylaxis:

1. Epinephrine 0.3 mg IM in the mid-antrolateral thigh (first-line treatment)
2. Combined H1+H2 blockade (diphenhydramine 25-50 mg IV plus ranitidine 50 mg IV)
3. Seek immediate emergency medical attention 1

Adjunctive Treatments

• H2 antagonists (e.g., ranitidine, cimetidine) can be combined with H1 antihistamines for better efficacy, particularly for symptomatic dermographism 1
• First-generation antihistamines (e.g., diphenhydramine) may be useful for nighttime symptoms due to their sedative effects, but should be used cautiously 1
• Topical doxepin may provide relief but should be limited to 8 days and 10% of body surface area (maximum 12g daily) due to risk of allergic contact dermatitis 1

For Refractory Cases

• Omalizumab is FDA-approved for chronic spontaneous urticaria in adults and adolescents 12 years and older who remain symptomatic despite H1 antihistamine treatment 2
  • Monitor for anaphylaxis, which can occur with omalizumab administration
• Cyclosporine requires monitoring of blood pressure and renal function (BUN and creatinine) every 6 weeks 1
  • Potential risks include hypertension, epilepsy in predisposed individuals, hirsutism, gum hypertrophy, and renal failure

Pediatric Considerations

• Start with age-appropriate dosing of second-generation H1-antihistamines
• Medication dosing must be weight-based
• Food allergies are a common cause of urticaria in infants and may require evaluation by an allergist 1

Treatment Duration

• For chronic urticaria, treatment may need to be continued for months to years
• More than half of patients with chronic urticaria will have resolution or improvement of symptoms within a year 3
• The principle of "as much as needed and as little as possible" should guide treatment decisions 1