What is the best second-line treatment for chronic urticaria?

Chronic urticaria is characterized by recurring episodes of spontaneous transient dermal wheals and pruritus, with or without angioedema, which persist for longer than 6 weeks.

Chronic urticaria definitely impairs quality of life and can be quite disturbing to patients who have it. Effective treatment is needed. Professional societies recommend the use of second-generation antihistamines as a first-line therapy.

This study started with a Medline search that included articles from the last 10 years and found 10 management guidelines/expert opinions.

There was a universal agreement that low-sedating, second-generation antihistamines should be prescribed as a first-line treatment of chronic urticaria.

For refractory urticaria, however, recommendations varied and included:

- dose escalation of second-generation antihistamines (up to 4-6 times the regular daily dose)
- adjunctive treatments with other agents of the same class, such as sedating antihistamines
- leukotriene receptor antagonists (montelukast)

More research into effective second-line treatments is needed.

Chronic Urticaria Treatment (click to enlarge the image):


Chronic urticaria: a comparison of management guidelines. Expert Opin Pharmacother. 2011 Dec;12(17):2683-93. Epub 2011 Oct 29.
Hives (urticaria) and angioedema (patient information)
Image source: Urticaria, Wikipedia, public domain.

Comments from Twitter:

Dr. Ellis @DrAnneEllis: Treatment of chronic urticaria: j.mp/IDHxjk via @Allergy US antihistamine names but still great content & advice #allergy #hives

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