What is the recommended treatment for chronic urticaria?

Treatment of 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-wise 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 up to 4 times the standard dose:
  • Cetirizine up to 40 mg/day
  • Loratadine up to 40 mg/day
  • Fexofenadine up to 720 mg/day
  • Desloratadine up to 20 mg/day 1

Third-line Treatment

• For patients who remain symptomatic despite high-dose antihistamines, add:
  • Omalizumab 300 mg subcutaneously every 4 weeks (65-87% response rate) 1, 2
  • Alternative: Leukotriene receptor antagonists (e.g., montelukast) 1

Fourth-line Treatment

• For refractory cases:
  • Cyclosporine (up to 5 mg/kg body weight)
    • Requires monitoring of blood pressure and renal function every 6 weeks 1

Important Considerations

Diagnostic Workup

• Include thyroid autoantibodies (anti-TPO) and thyroid function tests, particularly for patients with more severe disease not responding to H1 antihistamines
  • Thyroid autoantibodies are present in 14-36% of chronic urticaria patients compared to 6% in the general population 1

Monitoring Treatment Response

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

Safety Considerations

• Avoid first-generation antihistamines for long-term use due to sedation, impaired driving ability, and cognitive decline, particularly in elderly patients 1
• For omalizumab, be aware of anaphylaxis risk:
  • Initiate therapy in a healthcare setting
  • Observe patients for an appropriate period after administration
  • Anaphylaxis can occur after the first dose or beyond 1 year of treatment 2

Special Situations

• If urticaria is accompanied by signs of anaphylaxis:
  1. Administer epinephrine 0.3 mg IM in the mid-antrolateral thigh as first-line treatment
  2. Follow with combined H1+H2 blockade (diphenhydramine 25-50 mg IV plus ranitidine 50 mg IV)
  3. Seek emergency medical attention immediately 1

Pediatric Considerations

• For adolescents 12 years and older: Follow adult dosing guidelines
• For children 6-12 years: Use weight-based dosing of second-generation H1-antihistamines
• Omalizumab is indicated for chronic spontaneous urticaria in adolescents 12 years and older 1, 2

Duration of Treatment

• Chronic urticaria may resolve spontaneously in 30-55% of patients within 5 years, but can persist for many years 3
• Periodically reassess the need for continued therapy based on disease severity and symptom control 1, 2