Antihistamines – The First Line of Defense
First-Generation Antihistamines: Diphenhydramine: It has a rapid onset of action and is effective in reducing itching. However, it often causes drowsiness, which can limit daytime activities. It may also lead to dry mouth, blurred vision, and urinary retention. It is commonly used at night due to its sedative effect.
Chlorpheniramine: Similar to diphenhydramine, it provides relief from itching and swelling. It has a moderate sedative effect and is available in various formulations, making it accessible for different patients.
Second-Generation Antihistamines
Loratadine: It offers a long-lasting effect, usually providing relief for 24 hours. It has minimal sedation, allowing patients to carry out their normal routines. It is available over the counter and is well-tolerated, suitable for mild to moderate urticaria cases.
Cetirizine: This antihistamine has a relatively quick onset and provides relief for up to a day. It has a lower likelihood of causing drowsiness compared to first-generation ones. It is available both by prescription and over the counter and can also help with associated nasal symptoms if present.
Corticosteroids – For Severe Cases
Oral Corticosteroids: Prednisone: It is commonly prescribed for short courses to quickly reduce inflammation and itching. However, long-term use is associated with significant side effects, including weight gain, osteoporosis, increased susceptibility to infections, and adrenal suppression. It is usually reserved for acute, severe flare-ups.
Topical Corticosteroids: Hydrocortisone Cream: Can be applied directly to the affected skin areas to provide local relief. It is less likely to cause systemic side effects but should be used with caution, especially on sensitive skin or for prolonged periods, as it can lead to skin thinning and other local adverse reactions.
Immunomodulators – For Chronic and Refractory Urticaria
Cyclosporine: It modulates the immune system by suppressing T-cell activation. It has shown effectiveness in reducing the frequency and severity of hives in some patients with chronic urticaria. However, it requires close monitoring of blood levels and has potential side effects such as kidney toxicity and increased risk of infections.
Methotrexate: This drug interferes with the immune system’s cell proliferation. It may be used in selected patients with chronic urticaria, but regular blood tests are necessary to monitor liver function and other potential adverse effects.
Leukotriene Receptor Antagonists
Montelukast: It blocks the action of leukotrienes, which are involved in the inflammatory process. It can help reduce itching and the occurrence of hives, particularly in patients with comorbid asthma or allergic rhinitis. It is generally well-tolerated, with few side effects reported.
Biologics – The New Frontier
Omalizumab: It is a monoclonal antibody that targets IgE, reducing the allergic response. Clinical trials have shown its effectiveness in improving symptoms and quality of life in patients who do not respond well to other medications. However, it is expensive and may not be widely available or covered by insurance.
Factors Influencing Medication Choice
Severity of Urticaria: Mild cases may respond well to over-the-counter antihistamines, while severe or persistent cases may require stronger medications such as corticosteroids or immunomodulators.
Patient Age: Children and the elderly may have different tolerances and responses to medications. For example, in children, the choice of medicine should be carefully evaluated to avoid potential adverse effects on growth and development. Elderly patients may be more susceptible to drug interactions and certain side effects.
Coexisting Medical Conditions: Patients with underlying medical conditions, such as liver or kidney disease, may require adjustments in medication dosage or selection. For instance, drugs that are metabolized by the liver may accumulate in patients with liver impairment.
Allergen Avoidance: Identifying and avoiding the triggering allergen is an important aspect of treatment. In some cases, if the allergen can be effectively avoided, a less potent medication may be sufficient.
Cost and Accessibility: The cost of the medication and its availability can also impact the choice. Some newer biologics are expensive, while first-generation antihistamines are generally more affordable. Insurance coverage and local availability of medications should be taken into account.
