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Urticaria

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18 Figure 3. Step-care Approach to the Treatment for CU STEP 1 • Monotherapy with 2 nd generation antihistamine • Avoidance of triggers (e.g., NSAIDs) and relevant physical factors if physical urtcaria/angioedema syndrome is present STEP 2 One or more of the following : • Dose advancement of 2 nd generation antihistamine used in Step 1 • Add another second generation antihistamine • Add H 2 -antagonist • Add leukotriene receptor antagonist • Add 1st generation antihistamine to be taken at bedtime STEP 3 Dose advancement of potent antihistamine (e.g., hydroxyzine or doxepin) as tolerated STEP 4 Add an alternative agent • Omalizumab or cyclosporine • Other anti-inflammatory agents, immunosuppressants, or biologics • Begin treatment at step appropriate for patient's level of severity and previous treatment history • At each level of the step-approach, medication(s) should be assessed for patient tolerance and efficacy • "Step-down" in treatment is appropriate at any step once consistent control of urticaria/angioedema is achieved Nonpharmacologic Therapies Î NSAIDs, heat, and tight clothing can exacerbate CU in some patients, and avoidance of these factors might be beneficial. (C) Î Avoidance of pseudoallergens in the diet is NOT recommended. (C) Topical Therapies ÎPotent topical corticosteroids can improve symptoms from delayed pressure urticaria but have limited utility in the treatment of diffuse CU. (C) H 1 –Antihistamines Î H 1 -antagonists are effective in the majority of patients with CU but might not achieve complete control in all patients. (C) Î There are no definitive studies that demonstrate that patients with refractory CU and a positive ASST result respond differently to certain medication regimens compared with those patients with CU with a negative ASST result. (C) Treatment

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