Urticaria Management

First-Line Treatment

Second-generation non-sedating H1 antihistamines are the definitive first-line treatment for urticaria, with cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine, and mizolastine as preferred options 1, 2, 3
Start with standard dosing of a second-generation antihistamine 1, 3
Offer patients at least two different non-sedating antihistamines to trial, as individual responses and tolerance vary significantly 1, 2, 3
Cetirizine reaches maximum concentration fastest, making it advantageous when rapid symptom relief is needed 2, 3

If symptoms persist after 2-4 weeks on standard dosing, increase the dose up to 4 times the standard dose before adding other therapies 1, 2, 3

For chronic spontaneous urticaria unresponsive to high-dose antihistamines, add omalizumab 300 mg subcutaneously every 4 weeks 1, 2, 3
The dose can be increased to 600 mg every 2 weeks in patients with insufficient response 2
Allow up to 6 months for patients to respond before declaring treatment failure 1, 2, 3
Approximately 30% of patients have insufficient response to omalizumab, particularly those with IgG-mediated autoimmune urticaria 3

For patients who fail to respond to high-dose antihistamines and omalizumab within 6 months, add cyclosporine at 4-5 mg/kg daily 1, 2, 3
Cyclosporine is effective in approximately 54-73% of patients, particularly those with autoimmune chronic spontaneous urticaria 3
Treatment duration is typically up to 2 months 1
Regular blood pressure and renal function monitoring is mandatory due to potential nephrotoxicity and hypertension 1, 2

Oral corticosteroids should be restricted to short courses for severe acute urticaria or angioedema only—never for chronic management 1, 3
Corticosteroids have slow onset of action, work by inhibiting gene expression, and are ineffective for acute symptom relief 4
Chronic use leads to cumulative toxicity that outweighs any benefit 3

Never use antihistamines or corticosteroids in place of epinephrine for anaphylaxis 4
Antihistamines take 30-120 minutes to reach peak plasma concentrations and lack the vasoconstrictive, bronchodilatory, and mast cell stabilization properties of epinephrine 4
Avoid first-generation antihistamines in acute infusion reactions, as they can exacerbate hypotension, tachycardia, and shock 5

Identify and minimize aggravating factors including overheating, stress, alcohol, aspirin, NSAIDs, and codeine 1, 2, 3
Avoid NSAIDs in aspirin-sensitive patients with urticaria 1, 2
Avoid ACE inhibitors in patients with angioedema without wheals 1

Avoid acrivastine in moderate renal impairment 1, 3
Halve the dose of cetirizine, levocetirizine, and hydroxyzine in moderate renal impairment 1, 3
Avoid mizolastine in significant hepatic impairment 1, 3
Avoid hydroxyzine in severe liver disease 1, 3
Avoid antihistamines if possible, especially during the first trimester of pregnancy 1
If necessary, choose chlorphenamine due to its long safety record 1

Approximately 50% of patients with chronic urticaria presenting with wheals alone will be clear by 6 months 1, 3
Patients with both wheals and angioedema have a poorer outlook, with over 50% still having active disease after 5 years 1, 3