From the Guidelines
Chronic urticaria should be treated with a stepped approach, starting with second-generation antihistamines, followed by omalizumab, and then cyclosporine for refractory cases, as recommended by the latest guidelines 1.
Treatment Approach
The treatment of chronic urticaria involves a stepped approach, with the goal of achieving complete control of symptoms while minimizing treatment burden.
- Second-generation antihistamines, such as cetirizine, loratadine, or fexofenadine, are the first-line treatment, with doses that can be increased up to four times the standard dose if symptoms persist 1.
- For patients who do not respond adequately to antihistamines, omalizumab (300mg subcutaneous injection every 4 weeks) is recommended as a second-line treatment, with the option to updose to 600mg every 14 days if needed 1.
- Cyclosporine (3-5mg/kg/day in divided doses) may be considered for refractory cases, with careful monitoring of blood pressure and renal function 1, 2.
Monitoring and Adjustments
- Treatment should be stepped up or down based on levels of disease control, assessed using the Urticaria Control Test (UCT) 1.
- Patients should be monitored regularly for potential side effects of treatment, such as hypertension, renal failure, or hirsutism with cyclosporine 1.
- A symptom diary can help track potential triggers and treatment effectiveness, allowing for adjustments to the treatment plan as needed.
Underlying Mechanism
- The underlying mechanism of chronic urticaria involves mast cell activation and histamine release, with about 40-50% of cases being autoimmune in nature, where antibodies target IgE receptors on mast cells 1, 2.
From the FDA Drug Label
XOLAIR is indicated for the treatment of adults and adolescents 12 years of age and older with chronic spontaneous urticaria (CSU) who remain symptomatic despite H1 antihistamine treatment.
- Chronic Spontaneous Urticaria (CSU): Omalizumab (XOLAIR) is indicated for the treatment of adults and adolescents 12 years of age and older with CSU who remain symptomatic despite H1 antihistamine treatment.
- Limitations of Use: XOLAIR is not indicated for treatment of other forms of urticaria. Omalizumab is used for the treatment of chronic spontaneous urticaria in adults and adolescents 12 years of age and older who remain symptomatic despite H1 antihistamine treatment 3, 4, 5.
From the Research
Definition and Prevalence of Chronic Urticaria
- Chronic urticaria is characterized by recurring episodes of spontaneous transient dermal wheals and pruritus, with or without angioedema, which can persist for ≥ 6 weeks 6.
- It has a lifetime prevalence of about 20% in the general population 7, 8.
- Chronic urticaria is usually idiopathic, with only 10 to 20 percent of patients having identifiable triggers 8.
Diagnosis of Chronic Urticaria
- Diagnosis is made clinically, with a simple laboratory workup unless elements of the history or physical examination suggest specific underlying conditions 7, 8.
- Anaphylaxis must be ruled out in the diagnosis of urticaria 7.
Treatment of Chronic Urticaria
- The mainstay of treatment is avoidance of triggers, if identified 7, 8.
- First-line pharmacotherapy is second-generation H1 antihistamines, which can be titrated to greater than standard doses 9, 7, 6, 8.
- Other treatment options include first-generation H1 antihistamines, H2 antihistamines, leukotriene receptor antagonists, and brief corticosteroid bursts as adjunctive treatment 9, 7, 8.
- Omalizumab, a humanized monoclonal anti-immunoglobulin E, is a therapeutic advance for the treatment of chronic urticaria that is unresponsive to H1 antagonists 9.
- More than one-half of patients with chronic urticaria will have resolution or improvement of symptoms within a year 7, 8.