Professor Aberer of the University of Graz answers the question of which antihistamine to choose in a newly diagnosed patient with CSU, discussing the benefits of second-generation antihistamines and dosing strategies.
The choice of antihistamine for use in a newly diagnosed CSU patient has become quite simple. According to recent publications the older first-generation antihistamines should no longer be used,1 due to pronounced anticholinergic effects and sedative actions on the CNS. The side-effects may last longer than 12 hours, while the antipruritic effects only last for 4‒6 hours. Modern second-generation antihistamines are available worldwide at low cost. They lack the side-effects of the old antihistamines, have a higher efficacy and longer duration of action. Several have been tested extensively in urticaria (cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine, rupatadine, and bilastine). Comparative trials for these substances are lacking, but they all work well and are well tolerated. Furthermore, which patients respond to which antihistamine is variable, so the choice is welcome.
There are numerous studies showing the benefit of a higher dose of modern second-generation antihistamines in individual patients as second line treatment; up to 4-fold higher than the recommended dose, with up-dosing after 2 weeks if symptoms persist.2 A recent study showed beneficial results in the majority of patients, using desloratadine and levocetirizine at doses up to 4-fold higher than the recommended dose.3 If symptoms persist after 1‒4 weeks at the 4-fold dose of modern second generation antihistamines, a third line drug from the Urticaria Position paper should be considered, i.e. omalizumab, ciclosporin A or montelukast.2 Continuous use of second-generation antihistamines at the lowest necessary dose seems to be more favourable than on demand treatment.
A happy and content patient is our goal. Following the WHO constitution, it is recommended to aim for complete symptom control as safely as possible. Use of the validated CU-Q2oL and AE-QoL instruments to measure response to treatment, assess QoL impairment and monitor disease activity, is widely approved.
Werner Aberer is Professor of Dermatology and Chairman at the Department of Dermatology, Medical University of Graz, Austria.
Christian Vestergaard, Associate Professor in the Department of Dermatology at the University of Aarhus, Denmark answers the question, 'How should the UAS7 be used in chronic spontaneous urticaria?'.
Werner Aberer, Professor of Dermatology and Chairman at the Department of Dermatology, Medical University of Graz, Austria answers the question 'When a patient has been started on omalizumab, can you stop antihistamine treatment?'.
Karoline Krause, Assistant Professor of Dermatology at the Department of Dermatology and Allergy, Charité – Universitätsmedizin Berlin, Germany, is posed the question: 'Do IgE levels need to be measured before starting a patient with chronic spontaneous urticaria on omalizumab?'.
Doctor Marta Ferrer of Clínica Universidad de Navarra, Pamplona, discusses how pregnancy affects treatment options for CSU, answering the question, 'Can chronic spontaneous urticaria be treated during pregnancy?'.
Professor Ana Giménez-Arnau, Professor of Dermatology at the Hospital del Mar, Universitat Autònoma, Barcelona discusses how to choose a third-line treatment in a patient who has not responded to antihistamine treatment.
Professor Martin Metz of University Hospital Charité, Berlin discusses when to consider withdrawing treatment in those who no longer have symptoms, answering the question 'When should you stop treating a patient with CSU?'.
Associate Professor Christian Vestergaard addresses the role of topical steroids in chronic spontaneous urticaria, answering the question 'Are topical treatments such as topical corticosteroids recommended in chronic spontaneous urticaria?'.
Associate Professor Emek Kocatürk discusses the investigations that should be carried out when seeing a patient with new onset chronic spontaneous urticaria.
Our expert, Associate Professor Emek Kocatürk, answers the question of what differential diagnoses to consider when confronted with a patient presenting with symptoms of CSU, explaining how to exclude these through a mixture of clinical and laboratory tests.
Take a look at some of the frequently asked questions about the low-pseudoallergen diet, answered by our expert Josefine Grünhagen. Including the effects of pre-cooking meals and the use of raising agents in bread and eggs in cakes.
Josefine Grünhagen discusses the use of low-pseudoallergen diets in relation to patients with chronic spontaneous urticaria symptoms.