What is the treatment for urticaria?

Treatment of Urticaria

Second-generation non-sedating H1 antihistamines are the mainstay of therapy for both acute and chronic urticaria, with dose escalation up to 4 times the standard dose recommended for inadequate symptom control. 1, 2, 3

First-Line Treatment

• Second-generation non-sedating H1 antihistamines are recommended as initial therapy, with options including cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine, and mizolastine 1, 2, 3
• Patients should be offered at least two different non-sedating antihistamines, as responses and tolerance vary between individuals 1, 3
• For acute urticaria symptoms, cetirizine may be advantageous due to its shorter time to maximum concentration 2
• For inadequate symptom control after 2-4 weeks, increase the dose up to 4 times the standard dose when potential benefits outweigh risks 1, 2, 3

Second-Line Treatment

• Omalizumab (anti-IgE monoclonal antibody) is recommended for chronic spontaneous urticaria unresponsive to high-dose antihistamines 1, 3, 4
• The standard starting dose is 300 mg administered subcutaneously every 4 weeks 4
• The dose can be increased up to 600 mg every 2 weeks in patients with insufficient response 1, 2
• Allow up to 6 months for patients to respond to omalizumab before considering alternative treatments 1, 2
• In clinical trials, 36% of patients treated with omalizumab 300 mg reported complete resolution of symptoms (no itch and no hives) at 12 weeks 4

Third-Line Treatment

• Cyclosporine is recommended for patients who do not respond to high-dose antihistamines and omalizumab 1, 2, 3
• Effective in about 65-70% of patients with severe autoimmune urticaria at doses of 4-5 mg/kg daily for up to 2 months 1, 2
• Regular monitoring of blood pressure and renal function is required due to potential side effects 1, 2, 3

Adjunctive Treatments

• First-generation antihistamines may be added at night for additional symptom control, but their sedating effects should be considered 2, 3
• Oral corticosteroids should be restricted to short courses (3-10 days) for severe acute exacerbations but should not be used chronically due to cumulative toxicity 2, 3
• For urticaria with angioedema affecting the mouth, short courses of corticosteroids may be beneficial 3
• Cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) can provide symptomatic relief 1, 2

Special Considerations

Renal Impairment

• Avoid acrivastine in moderate renal impairment 1, 3
• Halve the dose of cetirizine, levocetirizine, and hydroxyzine in moderate renal impairment 1, 3
• Cetirizine, levocetirizine, and alimemazine should be avoided in severe renal impairment 1

Hepatic Impairment

• Avoid mizolastine in significant hepatic impairment 1, 3
• Avoid alimemazine, chlorphenamine, and hydroxyzine in severe liver disease 1, 3

Pregnancy

• Avoid antihistamines during pregnancy if possible, especially during the first trimester 1, 3
• Choose chlorphenamine if necessary due to its long safety record 1, 3
• Loratadine and cetirizine are FDA Pregnancy Category B drugs 1

General Measures

• Identify and minimize aggravating factors such as overheating, stress, alcohol, and certain medications (aspirin, NSAIDs, codeine) 1, 2, 3
• NSAIDs should be avoided in aspirin-sensitive patients with urticaria 1, 3
• ACE inhibitors should be avoided in patients with angioedema without wheals 1, 3

Treatment Algorithm

1. Start with standard dose of second-generation H1 antihistamine 1, 2, 3
2. If inadequate control after 2-4 weeks, increase dose up to 4 times the standard dose 1, 2, 3
3. If still inadequate control, add omalizumab 300 mg every 4 weeks (can increase to 600 mg every 2 weeks if needed) 1, 2, 4
4. If inadequate response to omalizumab within 6 months, add cyclosporine (up to 5 mg/kg body weight) 1, 2, 3

Common Pitfalls and Caveats

• Avoid first-generation antihistamines like diphenhydramine as primary therapy due to sedation and potential to convert minor reactions into hemodynamically significant events 5
• Avoid long-term use of oral corticosteroids due to well-known side effects 2, 3
• Do not discontinue omalizumab too early; allow up to 6 months for full response 1, 2
• Remember that approximately 50% of patients with chronic urticaria presenting with wheals alone will be clear by 6 months, but those with wheals and angioedema have a poorer outlook 3