Chronic urticaria is defined for a period of at least 6 weeks with hives. Patients with chronic urticaria who fail high-dose antihistamines should be referred to an allergy specialist to help manage their condition. We have previously spoke about the stepwise approach to chronic idiopathic/spontaneous urticaria.
Patients with chronic urticaria may benefit symptomatically from systemic steroid use (prednisone), but their long term usage is not recommended because of side effects. There are multiple alternative agents for patients with chronic urticaria. After failure of antihistamines, the next alternative agent that should be used is Xolair.
Some patients will fail Xolair treatment and alternative agents may need to be used. Side effects are common with many of these medications, and patients need to be closely monitored.
Cyclosporine-patient liver and kidney levels need to be monitored along with the patients blood pressure. The starting dose is 3mg/kg/day.
Dapsone-The most common side effect was a predictable asymptomatic drop in hemoglobin level, defined by a drop of at least 5% from baseline. The average decrease in hemoglobin was 20%. Patients on 100mg or less daily experienced less side effects. Patients who have G6PD deficiency should not be treated with Dapsone.
Sulfasalazine-GI symptoms and headaches were the most commonly reported side effects on patients taking sulfasalazine. It is known to cause bone marrow toxicity. White blood counts need to be monitored.
Hydroxychloroquine-Baseline eye exams are recommended within the first year of use for those using hydroxychloroquine. Patients at high risk for retinopathy were generally not started on therapy. GI symptoms have been reported.
Tacrolimus-GI symptoms, increased creatine levels, increased blood pressure and neurologic symptoms are some of the most common symptoms experienced by patients on oral tacrolimus. The average highest dose was 4mg daily.
Mycophenolate mofetil-Most common side effects include GI, genitourinary, neurologic and hematologic symptoms. Average high dose was 2.5 mg daily.
Other agents that have been tried are, colchicine, sirolimus, IVIG, methotrexate, etanercept, stanozolol and heparin.
The overall efficacy for these patients was that 75% were able to decrease or stop systemic steroids while being treated with an alternative agent. These medications have severe side effects and were only used after conventional treatments have failed.
If closely monitored, treatment with alternative medications for chronic urticaria (hives) can be safe. The benefit must always be weighed with the risk. Although not used frequently, there will be times when an alternative agent for chronic urticaria must be used.
Proper lab as well as clinical monitoring is required when using alternative agents for chronic urticaria (hives).
If you are having chronic hives, see your local allergy doctor to discuss the best treatment options for you.