From the Guidelines
The treatment for recurrent urticaria typically involves a stepwise approach starting with second-generation antihistamines like cetirizine (10mg daily), loratadine (10mg daily), or fexofenadine (180mg daily), as recommended by the most recent guidelines 1.
Key Considerations
- If symptoms persist, the antihistamine dose can be increased up to four times the standard dose, with the goal of achieving complete control of symptoms as assessed by the Urticaria Control Test (UCT) score 1.
- For patients who don't respond adequately, adding omalizumab (300mg subcutaneous injection every 4 weeks) is often effective, with the option to updose if necessary, up to a maximum of 600mg every 14 days 1.
- Other second-line options include cyclosporine (3-5mg/kg/day in divided doses) for patients who do not respond to higher than standard doses of omalizumab, with careful monitoring of blood pressure and renal function 1.
Identifying and Avoiding Triggers
- Identifying and avoiding triggers is essential; common triggers include certain foods, medications (especially NSAIDs), physical stimuli like pressure or cold, and stress.
- Keeping a symptom diary can help identify patterns and guide treatment decisions.
Underlying Mechanism and Treatment Strategies
- The underlying mechanism of urticaria involves mast cell activation and histamine release, which causes the characteristic wheals, itching, and sometimes angioedema.
- Most cases of chronic urticaria are idiopathic or autoimmune in nature, which explains why antihistamines and immunomodulatory therapies are effective treatment strategies.
Treatment Approach
- The treatment approach should follow an "as much as needed and as little as possible" principle, stepping up or down treatment based on disease control and patient needs 1.
- Step-down protocols should be implemented with prudence and patience, considering individual patient needs and the risk of losing disease control.
From the Research
Treatment Options for Recurrent Urticaria
- First-line treatment for recurrent urticaria is based on antihistamines, specifically non-sedating second-generation antihistamines 2, 3, 4, 5, 6
- For patients who do not respond to standard doses of antihistamines, the daily dosage can be increased up to fourfold 2, 5, 6
- Alternative therapeutic approaches for patients with refractory urticaria include:
- Systemic corticosteroids, but their use is limited due to cumulative toxicity 2, 3
- Leukotriene receptor antagonists, although their efficacy is not well supported by literature 3
- Immunomodulatory drugs such as omalizumab, which has been shown to be effective in 70% of antihistamine-refractory patients 3, 5
- Cyclosporine, which is recommended for patients unresponsive to antihistamines and omalizumab 3
- Other agents such as dapsone or sulfasalazine, which can be tried for patients unresponsive to other treatments 2, 3
Special Considerations
- In patients with chronic spontaneous urticaria, routine laboratory investigation is not cost-effective unless there are clinical suggestions of autoimmune diseases 5
- Non-pharmacotherapeutic means to minimize hyper-responsive skin, such as preventing skin from drying and avoiding hot showers, are also important and recommended 5
- For patients with urticaria and angioedema, drug associations such as acetyl esterase inhibitors and non-steroidal anti-inflammatory drugs should be excluded 5