Sandbox:Mounika

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mounika Lakhmalla, MBBS[2]

Chronic Spontaneous Urticaria

• Patients with chronic spontaneous urticaria are often frustrated and anxious
• Although no external cause is identified in most patients, numerous factors can aggravate the condition.
• Understanding these triggers and learning to avoid those that are relevant to the individual patient are critical components of successful management. Education should begin as soon as the diagnosis is made.
• H1 antihistamines are recommended as initial therapy for all patients with chronic spontaneous Urticaria.
• Less-sedating, second-generation agents (eg, cetirizine, levocetirizine, fexofenadine, loratadine, desloratadine)are more recommended over older first-generation agents (eg, hydroxyzine, diphenhydramine, chlorpheniramine, or mizolastine)

Treatment Response

• Around 50% of the patients may not achieve complete control of symptoms using standard doses of second-generation H1 antihistamines alone.
• a stepwise approach to increasing therapy is appropriate for this patient group(Non Responders).
• As we increase doses or as different agents are introduced, it is important to discontinue any that have not been beneficial, so that medications do not accumulate

One or more of the following interventions are recommended for those who have persistent symptoms:

1. Increasing the dose of the second-generation H1 antihistamine to up to four times the standard dose (after which, international guidelines suggest adding Omalizumab)
2. Adding a different second-generation antihistamine
3. Adding an H2 antagonist
4. Adding a leukotriene-receptor antagonist
5. Adding a first-generation H1 antihistamine at bedtime

For patients whose symptoms persist, increasing the dose of first-generation H1 antihistamine gradually is suggested. These patients need to be informed about sedation and anticholinergic side effects.
Usage of Systemic glucocorticoids should be reserved for short-term control of refractory symptoms.
Symptoms that persist despite step 3 therapy or who are intolerant of dose advancement of first-generation H1 antihistamines are considered to have refractory disease.
Once symptoms are controlled, we continue the drug(s) required for control for a minimum of1 to 3 months before attempting to taper or discontinue medications.
We recommend extending this maintenance period even longer in patients whose symptoms were particularly difficult to suppress.