What medications can be given to a patient experiencing an acute hive breakout?

Medications for Acute Hive Breakout Management

For acute urticaria (hives), first-line treatment should be second-generation non-sedating H1 antihistamines, with the option to increase dosing up to four times the standard dose for inadequate symptom control. 1

First-Line Treatment

• Non-sedating second-generation H1 antihistamines are the mainstay of therapy for acute urticaria:

  • Cetirizine 10 mg daily
  • Loratadine 10 mg daily
  • Fexofenadine
  • Desloratadine
  • Levocetirizine 1, 2

• For mild cases (hives covering <10% body surface area):

  • Continue with standard dose of oral antihistamines
  • Add topical corticosteroids if needed (Class I for body, Class V/VI for face) 2

Second-Line Treatment (Moderate Cases)

• For moderate cases (10-30% body surface area) or inadequate response to standard dose:
  • Increase antihistamine dose up to 4 times the standard dose when benefits outweigh risks 1, 3
  • Continue oral antihistamines (cetirizine/loratadine 10 mg daily or hydroxyzine 10-25 mg QID) 2
  • Consider adding H2-receptor antagonists (ranitidine, cimetidine) which may provide additional relief when combined with H1 antihistamines 4, 5

Third-Line Treatment (Severe Cases)

• For severe cases (>30% body surface area) or inadequate response to increased antihistamine dosing:

  • Systemic corticosteroids (prednisone 0.5-1 mg/kg/day) until hives resolve to grade 1 2, 6
  • Consider same-day dermatology consultation 2
  • Rule out systemic hypersensitivity with CBC with differential and CMP 2

• For intense or widespread pruritus:

  • Add GABA agonists (pregabalin 25-150 mg daily or gabapentin 100-300 mg TID) 2
  • Consider dermatology referral 2

Special Considerations

• For cases with angioedema:

  • Assess for airway compromise
  • Consider epinephrine for severe symptoms affecting breathing 2, 7
  • Patients with angioedema alone may require less up-dosing of antihistamines compared to those with wheals or wheals with angioedema 3

• For refractory cases:

  • Consider higher than fourfold dosing of antihistamines in selected patients, which has shown effectiveness in 49% of patients unresponsive to standard up-dosing with minimal increase in side effects 3

Adjunctive Measures

• Identify and minimize aggravating factors:

  • Overheating
  • Stress
  • Alcohol
  • Certain medications (aspirin, NSAIDs, codeine) 1

• Consider cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) for symptomatic relief 1

Potential Side Effects

• Most common side effects of antihistamines include:

  • Sedation and drowsiness (particularly with first-generation antihistamines and higher doses) 5
  • Dry mouth
  • Constipation

• Side effects after up-dosing higher than fourfold are reported in approximately 10% of patients 3

• For patients on systemic corticosteroids:

  • Consider proton pump inhibitor for GI prophylaxis
  • Add PCP prophylaxis if treatment exceeds 3 weeks at >30 mg prednisone equivalent/day 2