What is the recommended treatment for chronic urticaria?

Treatment for Chronic Urticaria

The recommended first-line treatment for chronic urticaria is second-generation H1 antihistamines at standard doses, with the option to increase up to 4 times the standard dose if symptoms persist, followed by omalizumab for refractory cases. 1

Step-by-Step Treatment Algorithm

First-Line Treatment

• Start with standard doses of second-generation H1 antihistamines:
  • Cetirizine 10 mg/day
  • Loratadine 10 mg/day
  • Fexofenadine 180 mg/day
  • Desloratadine 5 mg/day 1

Second-Line Treatment

• If inadequate response after 2 weeks, increase the dose of second-generation H1 antihistamines up to 4 times the standard dose 1
• Higher doses have shown efficacy in approximately 75% of patients with difficult-to-treat chronic urticaria without compromising safety 2

Third-Line Treatment

• For patients who remain symptomatic despite high-dose antihistamines, add omalizumab 300 mg subcutaneously every 4 weeks 1, 3
• Omalizumab is FDA-approved for chronic spontaneous urticaria in patients 12 years and older who remain symptomatic despite H1 antihistamine treatment 3
• Response rates to omalizumab range from 65-87% 1

Fourth-Line Treatment

• For refractory cases, consider cyclosporine at dosages up to 5 mg/kg body weight 1
• Monitor blood pressure and renal function every 6 weeks during cyclosporine treatment 1

Important Considerations

Medication Selection

• Avoid first-generation antihistamines due to their sedating and anticholinergic effects, especially in elderly patients 1
• Leukotriene receptor antagonists may be added as adjunctive therapy for resistant cases 1
• Corticosteroids should be reserved for acute exacerbations and used only in short courses (3-10 days) at doses of 0.5-1 mg/kg/day until symptoms resolve to grade 1 1

Monitoring Treatment Response

• Evaluate response after 2 weeks before modifying therapy 1
• Use validated tools such as:
  • Urticaria Activity Score (UAS7)
  • Urticaria Control Test (UCT) 1

Special Situations

• If urticaria is accompanied by signs of anaphylaxis (bronchospasm, hypotension, syncope):
  • Administer epinephrine 0.3 mg IM in the mid-antrolateral thigh as first-line treatment
  • Follow with combined H1+H2 blockade (diphenhydramine 25-50 mg IV plus ranitidine 50 mg IV)
  • Seek immediate emergency care 1

Diagnostic Considerations

• Chronic urticaria is defined as wheals and/or angioedema persisting for >6 weeks 1
• Include thyroid autoantibodies (anti-TPO) and thyroid function tests in the diagnostic workup, as thyroid autoimmunity is present in 14-36% of chronic urticaria patients 1

Safety Warnings

• Omalizumab carries a risk of anaphylaxis that can occur after any dose (including the first), even beyond 1 year of treatment 3
• Initiate omalizumab therapy in a healthcare setting with appropriate monitoring for anaphylaxis 3
• Inform patients about signs and symptoms of anaphylaxis and instruct them to seek immediate medical care if symptoms occur 3

Treatment Duration and Prognosis

• Chronic urticaria resolves spontaneously in 30-55% of patients within 5 years 4
• Periodically reassess the need for continued therapy based on disease severity and symptom control 1
• Refer to secondary care if diagnostic doubt exists or if primary care management does not relieve symptoms 1