. 2011 Mar 22;4:10. doi: 10.1186/1756-8722-4-10

Table 5.

Treatment options for mast cell activation disease.

Basic therapy (continuous oral combination therapy to reduce mast cell activity)	• H₁-histamine receptor antagonist (to block activating H₁-histamine receptors on mast cells; to antagonize H₁-histamine receptor-mediated symptoms) • H₂- histamine receptor antagonist (to block activating H₂-histamine receptors on mast cells; to antagonize H₂-histamine receptor-mediated symptoms) • Cromolyn sodium (stabilising mast cells) • Slow-release Vitamin C (increased degradation of histamine; inhibition of mast cell degranulation; not more than 750 mg/day) • If necessary, ketotifen to stabilise mast cells and to block activating H₁-histamine receptors on mast cells
Symptomatic treatment options (orally as needed)	• *Headache⇒ paracetamol; metamizole; flupirtine • Diarrhea⇒ colestyramine; nystatin; montelukast; 5-HT₃receptor inhibitors (eg. ondansetron); incremental doses (50-350 mg/day; extreme caution because of the possibility to induce mast cell degranulation) of acetylsalicylic acid; (in steps test each drug for 5 days until improvement of diarrhea) • Colicky abdominal paindue to distinct meteorism ⇒ metamizole; butylscopolamine • Nausea⇒ metoclopramide; dimenhydrinate; 5-HT₃receptor inhibitors; icatibant • Respiratory symptoms(mainly increased production of viscous mucus and obstruction with compulsive throat clearing) ⇒ montelukast; urgent: short-acting ß-sympathomimetic • Gastric complaints⇒ proton pump inhibitors (de-escalating dose finding) • Osteoporosis, osteolysis, bone pain⇒ biphosphonates ([51]; vitamin D plus calcium application is second-line treatment in MCAD patients because of limited reported success and an increased risk for developing kidney and ureter stones; [52]) • Non-cardiac chest pain⇒ when needed, additional dose of a H₂-histamine receptor antagonist; also, proton pump inhibitors for proven gastroesophageal reflux • Tachycardia⇒ verapamil; AT1-receptor antagonists; ivabradin • Neuropathic pain and paresthesia⇒ α-lipoic acid • Interstitial cystitis⇒ pentosan, amphetamines • Sleep-onset insomnia/sleep-maintenance insomnia⇒ triazolam/oxazepam • Conjunctivitis⇒ exclusion of a secondary disease; otherwise preservative-free eye drops with glucocorticoids for brief courses • Hypercholesterolemia⇒ (does not depend on the composition of the diet) therapeutic trial with HMG-CoA reductase inhibitors (frequently ineffective) • Elevated prostaglandin levels, persistant flushing*⇒ incremental doses of acetylsalicylic acid (50-350 mg/day; extreme caution because of the possibility to induce mast cell degranulation)

Basic therapy (continuous oral combination therapy to reduce mast cell activity)

• H₁-histamine receptor antagonist (to block activating H₁-histamine receptors on mast cells; to antagonize H₁-histamine receptor-mediated symptoms)
• H₂- histamine receptor antagonist (to block activating H₂-histamine receptors on mast cells; to antagonize H₂-histamine receptor-mediated symptoms)
• Cromolyn sodium (stabilising mast cells)
• Slow-release Vitamin C (increased degradation of histamine; inhibition of mast cell degranulation; not more than 750 mg/day)
• If necessary, ketotifen to stabilise mast cells and to block activating H₁-histamine receptors on mast cells

Symptomatic treatment options (orally as needed)

• Headache⇒ paracetamol; metamizole; flupirtine
• Diarrhea⇒ colestyramine; nystatin; montelukast; 5-HT₃receptor inhibitors (eg. ondansetron); incremental doses (50-350 mg/day; extreme caution because of the possibility to induce mast cell degranulation) of acetylsalicylic acid; (in steps test each drug for 5 days until improvement of diarrhea)
• Colicky abdominal paindue to distinct meteorism ⇒ metamizole; butylscopolamine
• Nausea⇒ metoclopramide; dimenhydrinate; 5-HT₃receptor inhibitors; icatibant
• Respiratory symptoms(mainly increased production of viscous mucus and obstruction with compulsive throat clearing) ⇒ montelukast; urgent: short-acting ß-sympathomimetic
• Gastric complaints⇒ proton pump inhibitors (de-escalating dose finding)
• Osteoporosis, osteolysis, bone pain⇒ biphosphonates ([51]; vitamin D plus calcium application is second-line treatment in MCAD patients because of limited reported success and an increased risk for developing kidney and ureter stones; [52])
• Non-cardiac chest pain⇒ when needed, additional dose of a H₂-histamine receptor antagonist; also, proton pump inhibitors for proven gastroesophageal reflux
• Tachycardia⇒ verapamil; AT1-receptor antagonists; ivabradin
• Neuropathic pain and paresthesia⇒ α-lipoic acid
• Interstitial cystitis⇒ pentosan, amphetamines
• Sleep-onset insomnia/sleep-maintenance insomnia⇒ triazolam/oxazepam
• Conjunctivitis⇒ exclusion of a secondary disease; otherwise preservative-free eye drops with glucocorticoids for brief courses
• Hypercholesterolemia⇒ (does not depend on the composition of the diet) therapeutic trial with HMG-CoA reductase inhibitors (frequently ineffective)
• Elevated prostaglandin levels, persistant flushing⇒ incremental doses of acetylsalicylic acid (50-350 mg/day; extreme caution because of the possibility to induce mast cell degranulation)

All drugs should be tested for tolerance in a low single dose before therapeutic use, if their tolerance in the patient is not known from an earlier application.