Severe hives or chronic spontaneous urticaria is classified as hives with or without swelling that occurs for 6 weeks or more with an unknown cause. The prevalence of chronic hives (also known as chronic idiopathic urticaria) is approximately 0.5% to 5% of the population. Chronic hives may be active for 1-5 years at a time, but in some cases in can relapse, lasting several years. Although guidelines outline several options for chronic hives, some patients with severe hives may resort to last-line therapies. The 2 mainstay treatments for these cases of severe hives are, Xolair (omalizumab) and cyclosporine.
First line treatment for chronic hives is the use of a second generation antihistamine (i.e. cetirizine, fexofenadine) up to 4 times a day. In addition, an H2-receptor antagonist (Zantac) and a leukotriene receptor antagonist (Singulair) is often used. If this fails, a potent (but sedating) antihistamine such as hydroxyzine or doxepin can be tried. If all of this fails, the next step for severe hives are omalizumab (which is FDA approved) or cyclosporine.
Stepwise approach to Chronic Urticaria (Chronic Hives)
Xolair is a monoclonal antibody against IgE and it is the first biologic agent approved for chronic spontaneous urticaria. It is administered at a dose of 150mg or 300mg every 4 weeks. The duration of treatment has not been determined, so patients should be monitored for resolution of urticaria. IgE levels during treatment is not recommended. Patients should be monitored for adverse drug reactions, including anaphylaxis and injection site reactions on administration.
Cyclosporine is an immunosuppressant that is used off label for severe hives that has been studied at a dose of 1 to 5 mg/kg daily. Cyclosporine is available in modified and unmodified versions. Unmodified has less absorption than the modified version, making them not interchangeable. Before starting treatment, blood pressure needs to be checked on 2 separate occasions and baseline labs needed are; blood urea nitrogen, serum creatine, CBC, magnesium, lipids, potassium and uric acid. Throughout treatment, labs should be drawn monthly. Adverse effects that need to be monitored are gum hyperplasia, hypertension, renal dysfunction, tremor and hirsutism. Patients are also at an increased risk of infections and should be monitored. Other treatments that have less supporting evidence are hydroxychloroquine, dapsone, methotrexate, sulfasalazine or IVIG.
In conclusion, both agents are effective for seer hives. Xolair is most effective at 300 mg every 4 weeks and cyclosporine 1 to 5 mg/kg daily. Both drugs should be used as last line option for severe hives. Xolair is approved by FDA for chronic hives, whereas cyclosporine is not. Both are feasible options for severe hives. The cost though is vastly different. Xolair at 300mg a month, will be approximately $2000 monthly, including medication and administration fees. Cyclosporine would be around $100/month, including medication costs and lab fees. As always, speak to your allergy doctor to see which medication is right for you if your hives are persisting despite step 1 therapy.
Alternative Agents for Refractory Chronic Urticaria Patients
FDA approves Xolair for Chronic Urticaria