Efficacy of Second-Line Treatments in Chronic Urticaria Refractory to Standard Dose Antihistamines
Mi‐Ae Kim, Jeong‐Hee Choi, Yoo Seob Shin, Hae‐Sim Park, Young‐Min Ye, KAAACI Work Group on Urticaria/Angioedema/Anaphylaxis
Abstract
Purpose:The prevalence of chronic urticaria (CU) is increasing worldwide, and it imposes a major burden on patients.Few studies have evaluated the efficacy of second-line treatments of CU, particularly for patients being considered for costly third-line treatments such as omalizumab.We compared the efficacy and safety of second-line treatments of CU refractory to standard doses of nonsedating H 1 -antihistamines (nsAHs).Methods: This 4-week, prospective, randomized, open-label trial divided patients into 4 treatment groups: 4-fold updosing of nsAHs, multiple combination of 4 nsAHs, switching to other nsAHs, and adjunctive H 2 -receptor antagonist.The clinical outcomes included urticaria control status, symptoms, and rescue medication use.Results: This study included 109 patients.After 4 weeks of second-line treatment, urticaria was well-controlled, partly controlled, and uncontrolled in 43.1%, 36.7%, and 20.2% of patients, respectively.Complete control of CU was achieved in 20.4% of patients.Among the patients with high-dose nsAHs, the proportion with well-controlled status was higher compared to the patients who received standard doses (51.9% vs. 34.5%,P = 0.031).No significant difference was observed in the proportion of well-controlled cases between the updosing and combination treatment groups (57.7% vs. 46.4%,P = 0.616).However, increasing the dose of nsAHs 4-fold was associated with a higher rate of complete symptom control compared to multiple combination treatment with 4 nsAHs (40.0% vs. 10.7%,P = 0.030).Logistic regression analysis confirmed the higher efficacy of updosing of nsAHs for complete control of CU compared to the other treatment strategies (odds ratio, 0.180; P = 0.020).Conclusions: In patients with CU refractory to standard doses of nsAHs, both updosing of nsAHs 4-fold and multiple combination treatment with 4 nsAHs increased the rate of well-controlled cases without causing significant adverse effects.Updosing of nsAHs is more effective for complete CU control than combination treatment.