Urticaria

Prescribing Notes:

• See NICE CKS: guidance on Managing Urticaria.
• Recommendations for allergic rhinitis, nasal allergies and vasomotor rhinitis are contained in the Ear, nose and oropharynx chapter of the formulary.
• Antihistamines should be taken for at least two weeks for the full effect to be seen. Change to an alternative antihistamine after 4-6 weeks if symptoms have not improved.
• Night time dosing may be effective for patients whose sleep is disturbed by itching.
• Chlorphenamine may be added at night if sleep is disturbed by itching.
• Cimetidine or ranitidine may also be added for resistant cases.
• Topical treatments may be helpful see section on pruritis for more information.
• Fexofenadine 180mg may be used when cetirizine and/or loratadine have been ineffective or where sedation is a problem.
• Antihistamines should be taken regularly for best control. However, if urticarial flares occur at specific times, then they may instead be taken 1 hour before the anticipated exacerbation.
• Chlorphenamine may be given by slow intravenous injection for emergency treatment of severe angioedema. For more information, see prescribing notes on allergic emergencies in the Respiratory chapter of the formulary for more information.
• Antihistamines (including non-sedative antihistamines) can cause day time somnolence, and patients should be aware of this potential side-effect, particularly in relation to driving or operating machinery
• Refer to local RefHelp guidance for more information on the management of urticaria and when to refer.

Up dosing of oral antihistamines (if licensed dose is ineffective)

• Provided there are no contra-indications, local specialists recommend a trial of gradual dose increase up to a maximum of four times the licensed daily dose of either cetirizine, fexofenadine, desloratadine or levocetirizine.
• Recommended step wise increments - begin with the standard licensed once daily dose. Then increase stepwise if tolerated until symptoms improve - twice daily, three times a day, then up to a maximum of four times daily.
• Refer to the links at the start of the section for supporting information for the off-label dosing.
• Advise the patient regarding the unlicensed dose regime and document in the notes that the discussion has taken place.

Prescribing Notes:

• SMC have advised that omalizumab (Xolair) is accepted for restricted use within NHS Scotland as add-on therapy for the treatment of chronic spontaneous urticaria in adult and adolescent (12 years and above) patients with inadequate response to H1 antihistamine treatment.

Prescribing Notes:

• See NICE CKS: guidance on Managing Urticaria.
• Recommendations for allergic rhinitis, nasal allergies and vasomotor rhinitis are contained in the Ear, nose and oropharynx chapter of the formulary.
• Antihistamines should be taken for at least two weeks for the full effect to be seen. Change to an alternative antihistamine after 4-6 weeks if symptoms have not improved.
• Night time dosing may be effective for patients whose sleep is disturbed by itching.
• Chlorphenamine may be added at night if sleep is disturbed by itching.
• Cimetidine may also be added for resistant cases.
• Topical treatments may be helpful see section on pruritis for more information.
• Fexofenadine 180mg may be used when cetirizine and/or loratadine have been ineffective or where sedation is a problem.
• Antihistamines should be taken regularly for best control. However, if urticarial flares occur at specific times, then they may instead be taken 1 hour before the anticipated exacerbation.
• Chlorphenamine may be given by slow intravenous injection for emergency treatment of severe angioedema. For more information, see prescribing notes on allergic emergencies in the Respiratory chapter of the formulary for more information.
• Antihistamines (including non-sedative antihistamines) can cause day time somnolence, and patients should be aware of this potential side-effect, particularly in relation to driving, cycling, or operating machinery.
• Refer to local RefHelp guidance for more information on the management of urticaria and when to refer.

Up dosing of oral antihistamines on specialist advice (if licensed dose is ineffective)

• Provided there are no contra-indications, consider with advice from a dermatologist a trial of gradual dose increase up to a maximum of four times the licensed daily dose of either cetirizine, fexofenadine, desloratadine or levocetirizine.
• Recommended step wise increments - begin with the standard licensed once daily dose. Then increase stepwise if tolerated until symptoms improve - twice daily, three times a day, then up to a maximum of four times daily.
• Refer to the links at the start of the section for supporting information for the off-label dosing, there is limited evidence for this approach in children.
• Advise the patient regarding the unlicensed dose regime and document in the notes that the discussion has taken place.

Prescribing Notes:

• SMC have advised that omalizumab (Xolair) is accepted for restricted use within NHS Scotland as add-on therapy for the treatment of chronic spontaneous urticaria in adult and adolescent (12 years and above) patients with inadequate response to H1 antihistamine treatment.