Is the use of alternative agents for chronic hives safe?

Published online: October 13, 2016

Chronic hives, medically known as chronic idiopathic urticaria (CIU), is a condition where hives are present for more than 6 weeks without a known cause.  Antihistamines are first line treatment for CIU.  Some patients may also be treated with H2 blockers or leukotriene receptor agonists.  Patients may sometimes require steroids for treatment.  Unfortunately, a subset of patients does not respond to first line therapy and may require frequent steroids or suffer with poorly controlled symptoms.  The only other FDA approved agent for CIU is omalizumab, which is indicated for symptoms resistant to the usual therapies.  There are additional alternative agents that have been used to treat CIU off label and the data on them are limited.  Given the limited data, the safety of these alternative agents at the doses used to treat CIU has not been well studied.

In a retrospective chart review recently published in The Journal of Allergy and Clinical Immunology: In Practice, Seth and Khan evaluated the adverse effects of patients with CIU treated with alternative agents.  During the investigation, 126 patient charts were reviewed from the electronic medical records of an allergy and immunology clinic at a major academic hospital.  These patients had failed first line therapy of CIU and were treated with one or more of the following medications: dapsone, sulfasalazine, tacrolimus, hydroxychloroquine, mycophenolate, cyclosporine, or omalizumab.  The study primarily looked at the adverse effects of these agents.  

The authors found that adverse effects were reported in 39 of 73 (53%) of patients on dapsone, 19 of 47 (40%) of patients on sulfasalazine, 15 of 36 (42%) of patients on tacrolimus, 7 of 45 (16%) of patients on hydroxychloroquine, 9 of 27 (33%) of patients on mycophenolate, 6 of 8 (75%) of patients on cyclosporine, and 3 of 24 (4%) of patients on omalizumab.  Most of these adverse effects were mild, did not require discontinuation of the medication, and resolved after stopping the medication or decreasing the dose.

The authors concluded that the use of alternative agents for the treatment of CIU in patients who have not responded to first line therapy is generally safe when proper laboratory and clinical monitoring is observed.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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