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Alternative Therapies In Patients With CU
Î Patients with CU whose symptoms are not adequately controlled on
maximally tolerated antihistamine therapy (e.g., doxepin at a dose of
75–125 mg/d) might be considered to have refractory CU. (E)
Î A number of alternative therapies have been studied for the treatment
of CU. These therapies merit consideration for patients with refractory
CU. (D)
Î Anti-inflammatory agents, including dapsone, sulfasalazine,
hydroxychloroquine, and colchicine, have limited evidence for efficacy
in patients with CU, and some require laboratory monitoring for
adverse effects. (C) These agents are generally well tolerated, might
be efficacious in properly selected patients, and can be considered for
treatment of patients with antihistamine-refractory CU. (D)
Immunosuppressant Agents
Î Several immunosuppressant agents have been used in patients with
antihistamine-refractory CU. Cyclosporine has been studied in several
randomized controlled trials. Taken in the context of study limitations,
potential harms, and cost, the quality of evidence supporting use
of cyclosporine for refractory CUA is low. On the basis of current
evidence, this leads to a weak recommendation for use of cyclosporine
in patients with CUA refractory to conventional treatment. (A)
Î Methotrexate: Experience with methotrexate in patients with CU is
limited (C) to small case reports and case series. (C) Because of the
limited evidence and potential for more serious adverse effects, use of
methotrexate in patients with CU should be considered only in patients
refractory to other anti-inflammatory, immunosuppressant, or other
safer alternative agents. (D)
Biologic Agents
Î Omalizumab: In contrast to other alternative agents for refractory
CU, the therapeutic utility of omalizumab has been supported by
findings from large double-blind, randomized controlled trials
and is associated with a relatively low rate of clinically significant
adverse effects. On the basis of this evidence, omalizumab should be
considered for refractory CU if, from an individualized standpoint,
a therapeutic trial of omalizumab is favorable when balancing the
potential for benefit with the potential for harm/burden and cost, and
the decision to proceed is consistent with the patient's values and
preferences. (A)
Î Several biologic agents, IV immunoglobulin, and anti-TNF agents have
been reported to be efficacious in patients with refractory CU. (C)
Treatment
