What is used to treat urticaria?

Treatment of Urticaria

Second-generation H1 antihistamines are the first-line treatment for urticaria, with a stepwise approach that includes up-dosing to 4 times the standard dose for inadequate response, followed by omalizumab or cyclosporine for refractory cases. 1

Stepwise Treatment Algorithm

First-Line Treatment

• Start with standard-dose second-generation H1 antihistamines:
  • Fexofenadine 180mg
  • Cetirizine 10mg
  • Loratadine 10mg
  • Desloratadine
  • Bilastine
  • Levocetirizine 1

Second-Line Treatment

• If inadequate response, increase dose up to 4 times the standard dose
• Evidence shows that up-dosing improves symptoms in approximately 75% of patients with difficult-to-treat chronic urticaria without compromising safety 2
• Among second-generation antihistamines, bilastine and levocetirizine may be safely up-dosed to four times the standard dose, while fexofenadine has been studied at three times the conventional dose 3
• Note: Cetirizine up-dosing may increase the risk of dose-related sedation 3

Third-Line Treatment

For patients who remain symptomatic despite up-dosed antihistamines:

• Omalizumab: 300mg every 4 weeks or 600mg every 2 weeks
  • FDA-approved for chronic spontaneous urticaria in adults and adolescents 12 years and older
  • Monitor for anaphylaxis 1

Fourth-Line Treatment

• Cyclosporine: Up to 5mg/kg body weight
  • Requires monitoring of blood pressure and renal function every 6 weeks
  • Potential risks include hypertension, epilepsy in predisposed individuals, hirsutism, gum hypertrophy, and renal failure 1

Additional Treatment Options

Adjunctive Therapies

• Leukotriene receptor antagonists (e.g., montelukast) 1
• H2 antagonists (e.g., cimetidine, ranitidine) in combination with H1 antihistamines
  • Particularly effective for symptomatic dermographism 1, 4
• Topical doxepin for localized urticaria (limit to 8 days and 10% of body surface area) 1
• First-generation antihistamines (e.g., diphenhydramine) for nighttime symptoms, used cautiously due to sedative effects 1, 5

Special Considerations

Anaphylaxis Management

• If urticaria is accompanied by signs of anaphylaxis:
  • Epinephrine 0.3 mg IM in the mid-antrolateral thigh is the first-line treatment 1, 6
  • Epinephrine alleviates pruritus, urticaria, and angioedema through its action on alpha and beta-adrenergic receptors 6
  • Follow with combined H1+H2 blockade (diphenhydramine 25-50 mg IV plus ranitidine 50 mg IV) 1
  • Seek immediate emergency medical attention 1

Pediatric Patients

• Start with age-appropriate dosing of second-generation H1-antihistamines
• Weight-based dosing is essential
• Evaluate for food allergies, which are common causes of urticaria in infants 1

Monitoring and Assessment

• Use validated tools like the Urticaria Control Test (UCT) and Urticaria Activity Score (UAS7) to monitor disease control
• Consider step-down only after at least 3 consecutive months of complete control
• Reduce antihistamine dose gradually (not more than 1 tablet per month) 1

Common Pitfalls and Caveats

1. Avoid first-generation antihistamines as first-line therapy due to their significant sedative and anticholinergic effects 5

2. Don't undertreat with standard doses when patients remain symptomatic - up-dosing to 4 times the standard dose is safe and effective for most patients 2, 3

3. Monitor for cardiovascular side effects with certain antihistamines, especially when used at higher doses or with concomitant medications that increase serum antihistamine levels 5

4. Don't continue ineffective treatments - approximately 80-90% of chronic urticaria cases are idiopathic, and more than half of patients will have resolution or improvement within a year 7

5. Avoid extensive laboratory workups for chronic urticaria unless specific underlying conditions are suspected based on history or physical examination 7