Therapeutic target
- The goal of treatment is complete symptom control
Therapy recommendations
- Acute urticaria (acute spontaneous urticaria, asU):
- Sedating antihistamines (2nd generation): initiation of therapy as i.v. therapy; oral maintenance therapy for 1-2 weeks).
- If no symptom control after 2 to 4 weeks or earlier* Increase dosage of antihistamine (up to 4 times daily dose; weight-adjusted in children)
- If no symptom control after six weeks or earlier* see under chronic urticaria.
- If generalized skin changes and angioedema, immediate i.v. therapy with a glucorticosteroid (50-250 mg prednisolone).
- Sedating antihistamines (2nd generation): initiation of therapy as i.v. therapy; oral maintenance therapy for 1-2 weeks).
- Chronic urticaria (chronic spontaneous urticaria, csU):
- Plus omalizumab* (recombinant humanized monoclonal antibody to immunoglobulin E; primary indication: asthma allergica), an antibody to immunoglobin E (anti-IgE), is also effective in urticaria patients for whom usual therapy with H1 antihistamines has not helped. It achieves a reduction of lesions in chronic spontaneous urticaria (CSU) within one to two weeks. After one month, significant and sustained symptom relief can also be achieved with antibody therapy under real-world conditions.
- Indications: chronic spontaneous urticaria or combined forms.
- Dosage recommendations:
- 300 mg/week subcutaneously every 4 weeks (from the age of 12).
- If no improvement within 6 months or earlier for severe pain → ciclosporin (see below).
- Note: The agent (150 mg omalizumab for four weeks at a time) is apparently also an effective alternative in cold urticaria when antihistamines do not help sufficiently. The critical temperature threshold had decreased by 10.6 °C ± 2.4 °C (p = 0.001), but in the placebo group only by 0.3 °C ± 1.1 °C.
- Caveat.
- Omalizumab has a slightly increased risk of cardiovascular and cerebrovascular events (EXCELS study).
- For the use of omalizumab there is currently no recommendation for pregnancy and lactation!
- Plus ciclosporin (cyclosporin A) (for refractory chronic course) [off-label use]* .
- Plus omalizumab* (recombinant humanized monoclonal antibody to immunoglobulin E; primary indication: asthma allergica), an antibody to immunoglobin E (anti-IgE), is also effective in urticaria patients for whom usual therapy with H1 antihistamines has not helped. It achieves a reduction of lesions in chronic spontaneous urticaria (CSU) within one to two weeks. After one month, significant and sustained symptom relief can also be achieved with antibody therapy under real-world conditions.
* In exacerbation short-term cortisone surge (prednisolone equivalent 0.5-1 mg/kg bw, no tapering) for a few days.
Further notes
- Avoiding foods high in histamine can improve symptoms of chronic spontaneous urticaria (intervention study; 56 patients). The authors recommend the low-histamine diet for a duration of 3 to 4 weeks for symptom reduction as well as for reduction of antihistamine consumption.
- Isolated angioedema are not only compatible with the diagnosis of chronic spontaneous urticaria (CSU) (after exclusion of other differential diagnoses), but even very likely. These are treated in the same way as CSU in the setting of CSU.
