What is the recommended treatment for a patient with hives and itching, considering potential comorbidities such as diabetes, hypertension, or osteoporosis?

Prednisone for Hives and Itching

For acute urticaria (hives) with significant itching, add a short 4-day burst of prednisone (20-40 mg daily) to antihistamine therapy, as this combination provides faster and more complete symptom resolution than antihistamines alone, particularly in patients with moderate antihistamine responsiveness. 1, 2

First-Line Treatment: Antihistamines

• Start with second-generation non-sedating H1 antihistamines (cetirizine 10 mg, fexofenadine 180 mg, desloratadine 5 mg, or levocetirizine 5 mg) as the foundation of treatment 3
• Antihistamines should be used regularly on a scheduled basis, not just after hives appear 4
• Doses can be increased up to four times the standard dose if symptoms are inadequately controlled 3
• Cetirizine has the shortest time to maximum concentration, making it advantageous when rapid relief is needed 3
• Avoid first-generation sedating antihistamines (diphenhydramine, hydroxyzine) as first-line therapy due to significant sedation and cognitive impairment without superior efficacy 3

When to Add Prednisone

Add prednisone when antihistamines alone provide insufficient control. The decision depends on the patient's baseline probability of responding to antihistamines alone:

• For patients with low-to-moderate antihistamine responsiveness (17.5%-64% chance of improvement): Adding prednisone provides a 14-15% absolute improvement in urticaria activity (NNT = 7) 2
• For patients with high antihistamine responsiveness (>95% chance of improvement): Adding prednisone provides only a 2.2% absolute improvement (NNT = 45), making the benefit marginal 2

Prednisone Dosing Protocol

Use a short burst regimen to minimize adverse effects while maximizing efficacy:

• Prednisone 20-40 mg daily for 3-4 days 1, 5
• Effect should be appreciable within 24 hours of the first dose 5
• Do NOT taper for short courses of 4 days or less 1
• This approach induces remission in approximately 47% of antihistamine-resistant cases after a single course 5
• If temporary response occurs (good initial response but relapse after stopping), consider a second course, which induces remission in an additional 9% of patients 5

Special Considerations for Comorbidities

Diabetes: Use prednisone cautiously as it causes reversible abnormalities in glucose metabolism 6. Monitor blood glucose closely during treatment. Short 4-day bursts minimize this risk compared to longer courses 1

Hypertension: Prednisone causes fluid retention and can worsen blood pressure 6. Monitor blood pressure during treatment. The short duration (4 days) limits this risk 1

Osteoporosis: Avoid prolonged corticosteroid use, which causes bone loss 6. Short bursts (4 days) do not require bone protection, but repeated courses or longer durations necessitate calcium, vitamin D, and consideration of bisphosphonates 6

Important Caveats and Pitfalls

• Systemic corticosteroids increase adverse events by approximately 15% (NNH = 9) compared to antihistamines alone 2
• Never use corticosteroids as maintenance therapy for chronic urticaria—they should only be used for short-term control during acute flares 6, 4
• Avoid long-term or repeated corticosteroid courses due to risks of adrenal suppression, growth interference in children, dermal thinning, hypertension, diabetes, Cushing syndrome, cataracts, muscle weakness, and impaired immune function 6
• Do not use prednisone if contraindications exist: active peptic ulcer disease, uncontrolled diabetes, or recent herpes virus infections 6, 1

Adjunctive Symptomatic Measures

• Apply cooling antipruritic lotions (calamine or 1% menthol in aqueous cream) for symptomatic itch relief 3
• Use emollients regularly for any associated dry skin 3
• Identify and minimize aggravating factors: overheating, stress, alcohol, aspirin, NSAIDs, and codeine 3

Escalation Strategy if Prednisone Fails

If two courses of prednisone fail to induce lasting remission:

1. Omalizumab 300 mg subcutaneously every 4 weeks is the next step for chronic urticaria unresponsive to high-dose antihistamines 6, 3
2. Allow up to 6 months for omalizumab response before considering alternatives 6
3. Cyclosporine is reserved for patients who fail both high-dose antihistamines and omalizumab, requiring blood pressure and renal function monitoring every 6 weeks 6, 3