What is the treatment for hives (urticaria)?

Treatment for Hives (Urticaria)

The first-line treatment for hives is second-generation non-sedating H1 antihistamines, which can be increased up to 4 times the standard dose if symptoms persist, followed by omalizumab as second-line therapy and cyclosporine as third-line therapy for chronic cases. 1, 2

First-Line Treatment: Antihistamines

• Start with standard dose of second-generation non-sedating H1 antihistamines (cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine, or mizolastine) 1, 2
• Patients should be offered at least two different non-sedating antihistamines as responses and tolerance vary between individuals 1, 2
• For inadequate symptom control after 2-4 weeks (or earlier if symptoms are intolerable), increase the antihistamine dose up to 4 times the standard dose 1, 2, 3
• Higher than standard dosing of antihistamines has been shown to improve symptoms in approximately 75% of patients with difficult-to-treat urticaria without compromising safety 3, 4

Second-Line Treatment (for Chronic Urticaria)

• If symptoms persist despite high-dose antihistamines, add omalizumab (anti-IgE monoclonal antibody) 1, 2
• Standard dosing is 300 mg every 4 weeks, with the option to increase to 600 mg every 2 weeks if needed 1, 2
• Allow up to 6 months to assess response to omalizumab before considering alternative treatments 1, 2

Third-Line Treatment (for Chronic Urticaria)

• For patients who do not respond to high-dose antihistamines and omalizumab, add cyclosporine 1, 2
• Effective dosage is up to 5 mg/kg body weight 1, 2
• Regular monitoring of blood pressure and renal function is required due to potential side effects 2

Acute Urticaria Management

• For mild cases (hives covering <10% body surface area), standard dose of oral antihistamines is usually sufficient 5
• For moderate to severe cases or inadequate response, increase antihistamine dose up to 4 times the standard dose 5
• For severe cases (>30% body surface area) or inadequate response to increased antihistamine dosing, short-term systemic corticosteroids may be considered 5, 6
• Corticosteroids should be used for short periods only, with careful consideration of the benefit-risk ratio 7, 6

General Measures

• Identify and minimize aggravating factors such as overheating, stress, alcohol, and certain medications (aspirin, NSAIDs, codeine) 1, 2, 5
• NSAIDs should be avoided in aspirin-sensitive patients with urticaria 1, 2
• ACE inhibitors should be avoided in patients with angioedema without wheals 1, 2
• Cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) can provide symptomatic relief 1, 2

Treatment Approach Algorithm

1. Start with standard dose of second-generation H1 antihistamine 1, 2
2. If inadequate control after 2-4 weeks (or earlier if symptoms are intolerable), increase dose up to 4 times standard dose 1, 2
3. For chronic urticaria with inadequate control on high-dose antihistamines, add omalizumab 1, 2
4. If inadequate response to omalizumab within 6 months, consider adding cyclosporine 1, 2
5. For acute severe urticaria, short courses of systemic corticosteroids may be used while continuing antihistamines 5, 6

Special Considerations

• In patients with renal impairment, avoid acrivastine in moderate impairment, and halve the dose of cetirizine, levocetirizine, and hydroxyzine 2
• In hepatic impairment, avoid mizolastine in significant impairment, and avoid alimemazine, chlorphenamine, and hydroxyzine in severe liver disease 2
• For urticaria with angioedema, assess for airway compromise and consider epinephrine for severe symptoms affecting breathing 5, 8

The "as much as needed and as little as possible" approach is recommended, with stepping up and stepping down treatment based on disease control 1. When control is achieved for at least 3 consecutive months, consider gradual step-down by not reducing the daily dose by more than 1 tablet per month 1.