Allergy Asthma Immunol Res.  2012 Nov;4(6):326-331. 10.4168/aair.2012.4.6.326.

Treatment of Chronic Spontaneous Urticaria

• Kaplan AP

• KMID: 2167015
• DOI: http://doi.org/10.4168/aair.2012.4.6.326

Abstract

Chronic spontaneous urticaria is defined as persistent symptoms of urticaria for 6 weeks or more. It is associated with autoimmunity in approximately 45 percent of patients. Therapy is often difficult however the initial approach should employ high-dose non-sedating antihistamines; 4-6 tablets/day may be necessary. It has been shown that the response to 4 tablets/day exceeds 3, and exceeds 2, which exceeds 1. However the dose that corresponds to the maximal dose of first generation antihistamines (hydroxyzine, diphenhydramine) used previously, is 6/day. Yet over half the patients are refractory to antihistamines and other agents should be tried next. Whereas current guidelines (published) often add leukotriene antagonists and/or H2 receptor antogonists next, these are of little utility. Likewise drugs effective for urticarial vasculitis (colchicine, dapsone, sulfasalazine, hydroxychloroquine) are effective in a small percentage of patients and no study suggests that the response rate of any of them exceeds the 30% placebo responses seen in most double-blind, placebo controlled studies. The drugs that are effective for antihistamine-resistant chronic spontaneous urticaria are corticosteroids, cyclosporine, and Omalizumab. Use of steroids is limited by toxicity. If used at all, a dose of no more than 10 mg/day should be employed with a weekly reduction of 1 mg. The response rates to cyclosporine and Omalizumab are each close to 75%. Cyclosporine can be used effectively if care is taken to monitor blood pressure, urine protein, blood urea nitrogen, and creatinine, every 6 weeks. Omalizumab has the best profile in terms of efficacy/toxicity and, once approved by federal agencies for use in chronic spontaneous urticaria, a dramatic change in the treatment paradigm, whether associated with autoimmunity or not, is predicted. A phase 3 trial is currently in place. Refractoriness to both Omalizumab and cyclosporine is expected to be less than 5 percent of patients. Other agents, can then be tried.

Keyword

Urticaria; anti IgE receptor; antihistamine; cyclosporine; omalizumab

MeSH Terms

Adrenal Cortex Hormones
Antibodies, Anti-Idiotypic
Antibodies, Monoclonal, Humanized
Autoimmunity
Blood Pressure
Blood Urea Nitrogen
Creatinine
Cyclosporine
Dapsone
Histamine Antagonists
Humans
Hypogonadism
Leukotriene Antagonists
Mitochondrial Diseases
Ophthalmoplegia
Organothiophosphorus Compounds
Steroids
Sulfasalazine
Urticaria
Vasculitis
Omalizumab
Adrenal Cortex Hormones
Antibodies, Anti-Idiotypic
Antibodies, Monoclonal, Humanized
Creatinine
Cyclosporine
Dapsone
Histamine Antagonists
Hypogonadism
Leukotriene Antagonists
Mitochondrial Diseases
Ophthalmoplegia
Organothiophosphorus Compounds
Steroids
Sulfasalazine

Figure

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  Figure (A) Response of 7 patients to Omalizumab demonstrating progressive relief of symptoms, all of whom remit between 1 month and 4 months of a monthly injection. In this study, 4 additional patients improved, but did not remit, and one did not respond. (B) Composite symptom score for patients showing the mean and standard error at each time point. A significant difference is noted by 4 weeks.

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