This protocol applies when a patient with chronic urticaria remains symptomatic after a period of regular treatment with a standard-dosed modern 2nd-generation H1-antihistamine, and complete symptom control has not been reached.
The first-line approach — regular use of a standard-dosed modern 2nd-generation H1-antihistamine (such as bilastine, cetirizine, desloratadine, ebastine, fexofenadine, levocetirizine, loratadine, mizolastine, or rupatadine) — did not achieve the treatment targets. Specifically, after 1–2 weeks of treatment, the urticaria activity score (UAS) remained above 0 and/or the urticaria control test (UCT) score remained below 16. This failure to achieve complete symptom control indicates progression to the next protocol.
The protocol involves a modification to the H1-antihistamine approach already in use — the same drug class, applied differently. This adjustment is the recommended second-line step before any other treatments are considered. The complete regimen, including the specific modification and decision algorithm, is available in full via the link below.
The target remains complete symptom control: a continuous urticaria activity score (UAS) of 0 and a urticaria control test (UCT) score of 16, with normalisation of quality of life.
DOI: 10.1111/all.70210
We recommend updosing of a 2nd generation H1-antihistamine up to 4-fold in patients with chronic urticaria unresponsive to a standard-dosed 2nd generation H1-antihistamines as second-line treatment before other treatments are considered.
Studies support the use of up to fourfold standard-dosed bilastine, cetirizine, desloratadine, ebastine, fexofenadine, levocetirizine, mizolastine, and rupatadine.
The goal of treatment is to treat the disease until it is gone, as efficiently and as safely as possible, aiming at a continuous complete control (consistently UAS = 0/UCT = 16) and a normalization of quality of life.
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