What is the recommended medication for treating urticaria?

Recommended Medication for Urticaria

Second-generation non-sedating H1 antihistamines are the first-line treatment for urticaria, with doses that can be increased up to four times the standard dose for inadequate symptom control. 1, 2

Treatment Algorithm

First-Line Treatment

• Start with standard dose second-generation non-sedating H1 antihistamines (options include cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine, and mizolastine) 3, 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 dose up to 4 times the standard dose 3, 4
• Cetirizine has the shortest time to attain maximum concentration, which may be advantageous when rapid relief is needed 1

Second-Line Treatment

• For urticaria unresponsive to high-dose antihistamines, add omalizumab (anti-IgE monoclonal antibody) 3, 2
• Standard starting dose is 300 mg every 4 weeks, with the option to increase to 600 mg every 2 weeks in patients with insufficient response 3, 2
• Allow up to 6 months for patients to respond to omalizumab before considering alternative treatments 1, 4

Third-Line Treatment

• For patients who do not respond to high-dose antihistamines and omalizumab within 6 months, add cyclosporine 3, 2
• Effective dose is typically 4-5 mg/kg body weight daily 3, 2
• Regular monitoring of blood pressure and renal function is required due to potential side effects 1, 4

Special Considerations

Medication Selection

• First-generation antihistamines should generally be avoided due to sedation and anticholinergic effects 5
• Second-generation antihistamines are just as effective as first-generation antihistamines but with fewer side effects 6
• Up-dosing antihistamines higher than fourfold may be a feasible therapeutic option before moving to third-line therapies, with limited increase in reported side effects 7

Patient-Specific Factors

• Identify and minimize aggravating factors such as overheating, stress, alcohol, and certain medications (aspirin, NSAIDs, codeine) 2, 4
• NSAIDs should be avoided in aspirin-sensitive patients with urticaria 1, 4
• 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, 4

Treatment Monitoring

• Use the Urticaria Control Test (UCT) to assess disease control and guide treatment decisions 3
• For patients with complete disease control, consider step-down after at least 3 consecutive months of complete control 3
• When stepping down, reduce the daily dose by no more than 1 tablet per month 3
• If control is lost during step-down, return to the last dose that provided complete control 3

Evidence Strength

The most recent international urticaria guidelines (2022) recommend an "as much as needed and as little as possible" approach, with step-up and step-down treatment based on disease control 3. Multiple studies support the efficacy of increasing antihistamine doses up to fourfold, with one study showing that approximately 75% of patients with difficult-to-treat chronic urticaria respond to higher than conventional antihistamine doses 8, 7.