Cold Urticaria When High-Dose 2nd Generation H1-Antihistamine Has Not Achieved Full Symptom Control
In cold urticaria, the treatment goal is complete, continuous symptom control. When increasing the dose of a 2nd generation H1-antihistamine to the highest recommended level still does not achieve that goal, escalation to a further treatment step is indicated. This page outlines the failure condition and what comes next.
Previous treatment — failure condition
Updosing of the 2nd generation H1-antihistamine — agents studied in this role include bilastine, cetirizine, desloratadine, ebastine, fexofenadine, levocetirizine, and rupatadine — did not achieve complete symptom control with a continuous UAS7 = 0 and a well-controlled disease state, as reassessed after 2–4 weeks. This failure to reach target is the trigger for escalation.
Next treatment step — partial overview
The next step involves adding a targeted biological agent on top of the ongoing 2nd generation H1-antihistamine. The specific agent, how to initiate it, how to adjust if the initial approach proves insufficient, and the reassessment schedule are all defined in the full protocol.
Treatment goal at this stage
Complete symptom control with a continuous UAS7 = 0 and a well-controlled disease state, with adequacy of control reassessed after 6 months.
References
DOI: 10.1111/all.15090
- We recommend adding on omalizumab* for the treatment of patients with CU unresponsive to high dose 2nd generation H1-antihistamines.
- Omalizumab has also been reported to be effective in CIndU including cholinergic urticaria, cold urticaria, solar urticaria, heat urticaria, symptomatic dermographism, and delayed pressure urticaria.
- The recommended initial dose in CSU is 300 mg every 4 weeks.
- Studies support the use of omalizumab treatment at doses up to 600 mg and intervals of 2 weeks, in patients with insufficient response to standard-dosed omalizumab.
- The goal of treatment is to treat the disease until it is gone and as efficiently and safely as possible aiming at a continuous UAS7 = 0, complete control and a normalization of quality of life.
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