From the Guidelines
The treatment for urticaria should start with non-sedating antihistamines, such as cetirizine (10mg daily), loratadine (10mg daily), or fexofenadine (180mg daily), and can be increased up to four times the standard dose for persistent symptoms, as recommended by the latest guidelines 1. The choice of antihistamine should be individualized, considering the patient's response and tolerance, with the option to switch to a different antihistamine if necessary 1.
- Key considerations in the management of urticaria include:
- Identifying and avoiding triggers, such as certain foods, medications, heat, cold, pressure, or stress
- Using cool compresses and calamine lotion for immediate relief of itching and inflammation
- Considering the addition of an H2 blocker, such as famotidine (20mg twice daily), for additional relief
- Reserving oral corticosteroids, such as prednisone (40-60mg daily for 3-5 days), for severe or unresponsive cases
- Considering second-line treatments, such as montelukast (10mg daily), cyclosporine, or omalizumab injections, for chronic urticaria lasting more than six weeks 1
- It is essential to monitor patients for signs of anaphylaxis, such as difficulty breathing or throat tightness, and to seek emergency care if these symptoms occur.
- The latest guidelines recommend an "as much as needed and as little as possible" approach, with step-up and step-down treatment based on disease control assessed with the Urticaria Control Test (UCT) 1.
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. The treatment for urticaria is omalizumab (XOLAIR), specifically for chronic spontaneous urticaria (CSU) in adults and adolescents 12 years of age and older who remain symptomatic despite H1 antihistamine treatment 2, 2, 2.
- Key points:
- Age: 12 years of age and older
- Condition: Chronic spontaneous urticaria (CSU)
- Previous treatment: H1 antihistamine treatment
- Medication: Omalizumab (XOLAIR)
From the Research
Treatment Options for Urticaria
- Antihistamines are the mainstay of treatment for urticaria, with second-generation antihistamines being preferred due to their reduced sedative and anticholinergic effects 3, 4, 5
- Second-generation antihistamines, such as loratadine, cetirizine, and fexofenadine, are effective in treating chronic idiopathic urticaria 3, 5, 6
- For acute urticaria, there is limited evidence to suggest the superiority of any particular antihistamine, but loratadine or cetirizine may be considered as treatment options 3
- In cases of symptomatic dermatographism, the combination of an antihistamine and an H2 antagonist may be effective 3
- Leukotriene receptor antagonists, such as montelukast, may also be effective in treating chronic urticaria, particularly in patients with intolerance to food additives and/or acetylsalicylic acid 7
Pharmacotherapy
- First-line pharmacotherapy for urticaria is second-generation H1 antihistamines, which can be titrated to greater than standard doses 4
- First-generation H1 antihistamines, H2 antihistamines, and leukotriene receptor antagonists may be used as adjunctive treatment 4
- In refractory chronic urticaria, patients may be referred to subspecialists for additional treatments, such as omalizumab or cyclosporine 4
Efficacy and Safety
- Second-generation antihistamines have improved peripheral H1-receptor selectivity and decreased lipophilicity, resulting in reduced CNS adverse effects 5
- The evidence for the safety and efficacy of second-generation antihistamines is of high quality, leading to a strong recommendation for their use in chronic urticaria 5
- Montelukast has been shown to be effective and safe in treating chronic urticaria due to food additives and/or ASA 7