Table 4.

Urticaria treatment algorithm

First line
Second-generation non-impairing non-sedating antihistamines if symptoms persist after 2 weeks	Standard dosing. Desloratadine 5 mg OD. Loratadine 10 mg OD. Cetirizine HCI 10 mg OD. Fexofenadine HCI 60 mg BID
↓
Second-line
Increase dosage up to four-times the standard dose1,2 of a second-generation non-impairing non-sedating antihistamine or, if symptoms persist after 4 further weeks, add montelukast for a 3–4 week trial	Up-dosing to the limit specified, eg. Desloratadine up to 20 mg OD. Cetirizine HCI up to 40 mg OD3. Montelukast 10 mg OD
Exacerbation: oral corticosteroid	Re-evaluate response to treatment every 3 months
↓	Omalizumab 150 mg or 300 mg, SC Q4 wks. Cyclosporine A 2.5-5 mg/kg/day and taper with response
Third line	Oral corticosteroids, for example, 0.3-0.5 mg/kg of prednisone or equivalent, followed by tapering of the dose in half every 3–7 days over a maximum duration of 2–4 weeks
Add-on to second-line treatment: omalizumab, cyclosporine A, consider specialist referral to allergist/dermatologist. Exacerbation: oral corticosteroid

¹Standard dose means the usual recommended dose.

²Double the initial recommended pediatric dose in case of non-response.

³Can cause sedation at these doses.