Treatment for Histamine Intolerance
The most effective treatment for histamine intolerance involves a combination of H1 and H2 antihistamines along with a low-histamine diet to reduce symptoms and improve quality of life. 1
Pharmacological Management
First-Line Medications
- Nonsedating H1 antihistamines (such as fexofenadine and cetirizine) are the preferred initial treatment and can be increased to 2-4 times the standard dose for better symptom control, particularly for dermatologic manifestations like flushing and pruritus 1
- H2 blockers (famotidine, cimetidine) should be added as first-line therapy for gastrointestinal symptoms and help enhance the effectiveness of H1 antihistamines when used in combination 1
- Antihistamines should never be used as monotherapy for severe reactions with cardiovascular or respiratory symptoms, as they have a slower onset of action compared to epinephrine 2
Additional Pharmacological Options
- Cromolyn sodium (oral formulation) at 200 mg 4 times daily (before meals and at bedtime) is effective for reducing abdominal bloating, diarrhea, and cramps 1
- Leukotriene inhibitors (montelukast or zileuton) may reduce bronchospasm or gastrointestinal symptoms, particularly when used with H1 antihistamines 1
- Cyproheptadine, a sedating H1 antihistamine with antiserotonergic activities, is particularly helpful for gastrointestinal symptoms 1
- Doxepin, a potent H1 and H2 antihistamine with tricyclic antidepressant activity, may reduce central nervous system manifestations but should be used cautiously due to sedation potential 1
Management of Severe Reactions
- For patients with a history of systemic anaphylaxis or airway angioedema, an epinephrine autoinjector is essential, as epinephrine is the cornerstone of management for severe reactions 2, 1
- Albuterol should be available for symptoms of bronchospasm 1
- Patients with recurrent hypotensive episodes should be placed in a supine position during reactions 1
Dietary Management
Low-Histamine Diet
- A low-histamine diet is considered the treatment of choice for histamine intolerance 3, 4
- Fermented foods should be universally avoided as they consistently contain high histamine levels 5
- Foods to eliminate include:
- Fish and seafood 5, 3, 4
- Aged cheeses 5, 3, 4
- Hard cured sausages and processed meats 5, 3, 4
- Fermented vegetables like pickled cabbage 5, 3, 4
- Alcoholic beverages, particularly wine and beer 5, 3, 4
- Certain fruits like citrus and bananas that may contain putrescine, which interferes with histamine degradation 5
Diamine Oxidase (DAO) Supplementation
- DAO enzyme supplementation is being investigated as a potential treatment option to improve histamine degradation 6
- Current research suggests a possible synergistic effect between low-histamine diet and DAO supplementation, though more definitive studies are needed 6
Clinical Considerations and Pitfalls
Diagnostic Challenges
- Histamine intolerance symptoms can mimic allergic reactions, making diagnosis difficult 7
- It's essential to rule out IgE-mediated allergies before confirming histamine intolerance, as skin-prick testing and specific IgE to food allergens are typically negative in histamine intolerance 3, 7
- Histamine intolerance can coexist with true allergies, complicating the clinical picture 7
Treatment Monitoring
- Symptom improvement should be assessed after 4 weeks on a low-histamine diet 3, 4
- Reintroduction of histamine-rich foods can be used as a challenge to confirm diagnosis, as symptoms are often reproducible and can be alleviated with antihistamines 3
- Long-term corticosteroid use should be avoided despite potential short-term benefits due to side effects 1
Special Considerations
- The histamine-1 receptor antagonist ebastine has shown promise in clinical trials for visceral hypersensitivity and may be beneficial for abdominal pain in histamine intolerance 2
- For patients with overlapping irritable bowel syndrome symptoms, an integrated approach addressing both conditions may be necessary 2