What are the treatment options for hives after stopping Quetiapine (Seroquel) 50mg at night?

Treatment of Hives After Stopping Quetiapine (Seroquel)

For hives that develop after stopping quetiapine, the first-line treatment is non-sedating H1 antihistamines, which should be offered with a choice of at least two different options as responses vary between individuals. 1

Initial Assessment and Management

• Evaluate the severity of the hives: mild (less than 3 hives), moderate (3-10 hives), or severe (generalized involvement) 2
• Check for signs of anaphylaxis including respiratory symptoms, hypotension, or gastrointestinal symptoms, which would require immediate emergency treatment 2
• Rule out other potential causes of hives, though in this case, the temporal relationship with quetiapine discontinuation strongly suggests a withdrawal reaction 3

First-Line Treatment

• Begin with a non-sedating H1 antihistamine such as cetirizine, desloratadine, fexofenadine, levocetirizine, or loratadine 1
• Cooling antipruritic lotions such as calamine or 1% menthol in aqueous cream can provide symptomatic relief 1
• Avoid potential aggravating factors such as overheating, stress, and alcohol 1

For Inadequate Response

• Increase the dose of the non-sedating H1 antihistamine above the licensed recommendation when benefits outweigh risks 1
• Consider adding a sedating antihistamine at night (e.g., chlorphenamine 4-12 mg or hydroxyzine 10-50 mg) to help with sleep disruption 1
• The addition of an H2 antihistamine may sometimes provide better control than an H1 antihistamine alone 1

For Severe or Refractory Cases

• Short courses of oral corticosteroids such as prednisolone may be necessary for severe cases 2
• Consider adding montelukast (an antileukotriene) for refractory cases 2
• If symptoms persist or worsen, referral to an allergist or dermatologist is recommended 4

Important Considerations

• Be aware that some patients may paradoxically develop urticaria in response to antihistamines themselves (though this is rare) 5
• Discontinuation symptoms from quetiapine are documented but uncommon, and may include nausea, vomiting, agitation, restlessness, diaphoresis, irritability, anxiety, dysphoria, sleep disturbance, insomnia, tachycardia, hypertension, and dizziness in addition to the hives 3
• Medication adjustments should consider that quetiapine has a relatively short half-life of approximately 6 hours 6

Prognosis and Follow-up

• Provide reassurance that the prognosis for urticaria is generally favorable 4
• Schedule follow-up visits to assess treatment response 2
• Advise the patient that recurrent urticaria may occur over 1-2 days following the initial episode 2
• If considering restarting quetiapine, a slower tapering schedule should be implemented to minimize withdrawal symptoms 3

Prevention of Future Episodes

• If quetiapine needs to be discontinued in the future, implement a gradual tapering schedule rather than abrupt discontinuation 3
• Document the reaction in the patient's medical record to inform future medication decisions 4