Current and emerging pharmacotherapy for chronic spontaneous urticaria: a focus on nonbiological therapeutics

Urticaria is characterized by pruritic wheals of the skin’s superficial layers, which occurs for six weeks or longer, with no apparent cause. It is a condition that reduces the quality of life of the patient and may have a significant economic and social burden. The objective of this revision was to review the guidelines for urticaria management.

According to the joint initiative of the EU-founded network of excellence, the Global Allergy and Asthma European Network, the European Academy of Allergology and Clinical Immunology, the World Allergy Organization, and the European Dermatology Forum, management of urticaria should be done in a stepwise manner. Second-generation H1-antihistamines are considered first-line treatment. Whenever symptoms are not adequately controlled, treatment should follow the algorithm. This algorithm includes an increase of the dose of second-generation H1-antihistamines, alongside first-generation H1-antihistamines, H2 antagonists, omalizumab, ciclosporin A, or short-term corticosteroids if needed. New treatments on development include spleen tyrosine kinase inhibitor, Bruton tyrosine kinase inhibitor, prostaglandin D2 receptor inhibitor, H4-antihistamines, and biologics. Alternative agents include leukotriene receptor antagonists, anticoagulant and antifibrinolytic agents, antidepressants, vitamin D, and other anti-inflammatory or immune-suppressing agents.

According to the authors, second-generation H1-antihistamines should always be considered the first-line therapeutic option for urticaria management. For those who do not respond to a higher dose of H1-antihistamines, guidelines recommend adding omalizumab. Well-designed trials are required to draw clear conclusions.