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Table 3 Summary of clinical guidelines for the treatment of urticaria in adults and childrena

From: Insights into urticaria in pediatric and adult populations and its management with fexofenadine hydrochloride

Therapy Guidelines
EAACI/GA2 LEN/ EDF/WAO 2018 [1] JTF AAAAI/ACAAI 2014 [55] AADV 2010 [56] AFP 2014 [57] JDA 2018 [58]
Step I Monotherapy with second-generation, non-sedating H1-antihistaminesb Monotherapy with second-generation H1-antihistaminesb Avoidance of triggers and physical stimuli Avoidance of triggers and physical stimuli Non-sedative second-generation H1-antihistamine
• As appropriate, change to another drug, increase the dose up to 2 times, or combine the two types
Step II Up-dosing of non-sedating H1-antihistaminesc
(up to 4 times approved dose; weight adapted)
One or more of the following:
• Up-dosing of second-generation H1-antihistaminesc
• Add another second-generation H1-antihistamine
• Add H2-antagonist
• Add leukotriene receptor antagonist
• Add first generation H1-antihistamine
Monotherapy with second-generation, non-sedating H1-antihistamines H1-antihistamines:
• First generation
• Non-sedating second-generation
H2-antihistamines
Add an alternative agent:
• H2–antihistamine
• Anti-leukotriene
Step III Add an alternative agent:
Omalizumab
Up-dosing of potent antihistaminec Up-dosing of non-sedating H1-antihistaminesc
(up to 4 times approved dose; weight adapted)
• Corticosteroids
• Doxepin
• Narrowband ultraviolet B light
Add an alternative agent:
• Oral corticosteroid
• Omalizumab
• Cyclosporine
Step IV Add an alternative agent:
• Cyclosporine A
Add an alternative agent:
• Omalizumab or cyclosporine
• Other anti-inflammatory agents
• Immunosuppressants
• Biologics
Change to:
• Different non-sedating H1-antihistamines, or
• First generation sedating antihistamine
Add an alternative agent:
• Leukotriene antagonist
• Cyclosporine • Trial treatment
Step V Add an alternative agent:
Cyclosporine A
Second-generation, non-sedating H2-antihistamine
Dapsone
Omalizumab
Dapsone,
Intravenous immunoglobulin
Methotrexate
  1. JTF AAAAI Joint task force of the American Academy of Allergy, Asthma & Immunology, AADV Asian Academy of Dermatology and Venereology; ACAAI American College of Allergy, Asthma & Immunology, AFP Australian Family Physician, EAACI European Academy of Allergology and Clinical Immunology, EDF European Dermatology Forum, GA2LEN Global Allergy and Asthma European Network, JDA Japanese Dermatological Association, WAO World Allergy Organization
  2. aAn interval of 2 to 4 weeks should be allowed before changing therapy
  3. bAvoidance of triggers and physical stimuli is considered only as commentary and not included in the step-wise approach
  4. cOff-label use