Thank you for your inquiry.
I believe that you have done due diligence in searching out alternative therapies for your patient, and have in essence covered “most of the bases” in this regard.
Of the drugs that you have mentioned, my first choice would be omalizumab if you can get over the payment issue. My second choice would be hydroxychloroquine. However, there is another reasonably good alternative that I would favor over hydroxychloroquine. This is mycophenolate mofetil. This is one of the drugs that are mentioned in two excellent reviews, both entitled “Therapeutic Alternatives for Chronic Urticaria, an Evidence-Based Review.” The publications appeared in successive issues of the Annals of Allergy, Asthma, and Immunology. The references are:
1. Morgan and Kahn. Therapeutic alternatives for chronic urticaria, an evidence-based review, Part 1. Annals of Allergy, Asthma and Immunology, Volume 100 (Number 5), pages 403-412, May 2008.
2. Morgan and Kahn. Therapeutic alternatives for chronic urticaria, an evidence-based review, Part 2. Annals of Allergy, Asthma and Immunology ,Volume 100 (Number 6), pages 517-526, 2008.
I might mention parenthetically that there may be some significance of her eosinophilia. You did not mention the drugs that she was taking, but I assume that all drugs that can be substituted have been substituted, and all that can be discontinued have been discontinued. It is of course possible that her urticaria is related to a drug and, as you know, one of the etiologies of eosinophilia is a drug reaction.
With this observation in mind, if drugs have not been discontinued or substitutions for each drug where possible, this is something that I would consider as well.
Thank you again for your inquiry and we hope this response is helpful to you.
Phil Lieberman, M.D.