What is the treatment for hives (urticaria)?

Treatment for Hives (Urticaria)

The first-line treatment for hives (urticaria) is second-generation, non-sedating H1 antihistamines, which can be titrated to higher than standard doses if necessary for symptom control. 1, 2

First-Line Treatment: H1 Antihistamines

• Second-generation, non-sedating H1 antihistamines are the mainstay of therapy for both acute and chronic urticaria 2
• Patients should be offered the choice of at least two non-sedating H1 antihistamines as responses and tolerance vary between individuals 1
• Common second-generation antihistamines include:
  • Cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine, and mizolastine (typically taken once daily) 1
  • Acrivastine (taken three times daily due to short half-life) 1

Dosing Considerations

• For inadequate response, it has become common practice to increase the dose above the manufacturer's licensed recommendation when potential benefits outweigh risks 1
• Timing adjustments can help ensure highest drug levels when urticaria is anticipated 1
• Addition of a sedating antihistamine at night (e.g., chlorphenamine 4-12 mg, hydroxyzine 10-50 mg) to a non-sedating antihistamine by day may help patients sleep better 1

Second-Line Treatment

• Omalizumab is recommended as second-line treatment for antihistamine-refractory chronic spontaneous urticaria 3
• The FDA has approved omalizumab for chronic spontaneous urticaria in adults and adolescents 12 years and older who remain symptomatic despite H1 antihistamine treatment 4
• Dosing is not dependent on serum IgE level or body weight for chronic spontaneous urticaria 4
• Important safety note: Anaphylaxis can occur with omalizumab administration, requiring initiation in a healthcare setting with appropriate monitoring 4

Third-Line Treatment

• Cyclosporine can be effective in approximately 54-73% of patients, especially those with autoimmune chronic spontaneous urticaria who don't respond to omalizumab 3
• It was effective in about two-thirds of patients with severe autoimmune urticaria unresponsive to antihistamines at 4 mg/kg daily for up to 2 months 1
• Potential adverse effects include kidney dysfunction and hypertension 3

Additional Treatment Options

• H2 antihistamines may provide better control of urticaria when added to H1 antihistamines, though evidence is limited 1, 5
• Antileukotrienes (e.g., montelukast) may be taken in addition to H1 antihistamines for poorly controlled urticaria but have limited evidence as monotherapy 1
• Short courses of oral corticosteroids may shorten the duration of acute urticaria (e.g., prednisolone 50 mg daily for 3 days in adults) 1
• Long-term oral corticosteroids should not be used in chronic urticaria except in very selected cases under specialist supervision 1

Special Populations

Renal Impairment

• Acrivastine should be avoided in moderate renal impairment 1
• The dose of cetirizine, levocetirizine, and hydroxyzine should be halved 1
• Cetirizine, levocetirizine, and alimemazine should be avoided in severe renal impairment 1
• Loratadine and desloratadine should be used with caution in severe renal impairment 1

Hepatic Impairment

• Mizolastine is contraindicated in significant hepatic impairment 1
• Alimemazine should be avoided in hepatic impairment due to hepatotoxicity 1
• Chlorphenamine and hydroxyzine should be avoided in severe liver disease 1

Pregnancy

• It is best to avoid all antihistamines in pregnancy, especially during the first trimester 1
• Hydroxyzine is specifically contraindicated during early pregnancy 1
• Chlorphenamine is often chosen when antihistamine therapy is necessary due to its long safety record 1
• Loratadine and cetirizine are FDA Pregnancy Category B drugs 1

Children

• No currently licensed antihistamines are contraindicated in children 12 years and older 1
• For younger children, consult relevant data sheets for dosing and age restrictions 1

Management of Severe Symptoms

• Intramuscular epinephrine can be life-saving in anaphylaxis and severe laryngeal angioedema 1
• For adults and adolescents older than 12 years, 0.5 mL of 1:1000 (500 μg) epinephrine by intramuscular injection is recommended 1
• Fixed-dose epinephrine pens (300 μg for adults or 150 μg for children between 15-30 kg) may be carried by patients at risk of life-threatening attacks 1

Prognosis

• More than one-half of patients with chronic urticaria will have resolution or improvement of symptoms within a year 6
• Patients with both wheals and angioedema may have a poorer outlook than those with wheals alone 1

Important Cautions

• Watch for antihistamine-induced urticaria, which can rarely occur and may be due to cross-reactivity between drug metabolites 7
• Consider referral to specialists for refractory cases requiring additional treatments 6