How do you choose which antihistamine to use in a newly diagnosed patient?

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.

Answer

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

    Werner Aberer is Professor of Dermatology and Chairman at the Department of Dermatology, Medical University of Graz, Austria.

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  • References

    1. Risk of first-generation H1-antihistamines: a GA(2)LEN position paper. Church MK, Maurer M, Simons FE, Bindslev-Jensen C, van Cauwenberge P, Bousquet J, et al.  Allergy. 2010;65:459‒66.
    2. The EAACI/GA2LEN/EDF/WAO Guideline for the definition, classification, diagnosis and management of urticaria: the 2013 revision and update. Zuberbier T, Aberer W, Asero R, Bindslev-Jensen C, Brzoza Z, Canonica GW, et al. Allergy. 2014;69:868‒87.
    3. The effectiveness of levocetirizine and desloratadine in up to 4 times conventional doses in difficult-to-treat urticaria. Staevska M, Popov TA, Kralimarkova T, Lazarova C, Kraeva S, Popova D, et al. J Allergy Clin Immunol. 2010;125:676‒82.

     

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