Current and emerging pharmacotherapy for chronic spontaneous Urticaria: a focus on non-biological therapeutics

Chronic spontaneous urticaria (CSU) refers to urticaria (wheals) or angioedema, which occur for a period of six weeks or longer without an apparent cause. The condition may impair the patient's quality of life.

Treatment for CSU is mainly symptomatic. Both AAAAI/ACAAI practice parameters and EAACI/GA2LEN/EDF/WAO guidelines suggest CSU management in a stepwise manner. First-line therapy is with second-generation H₁-antihistamines. Treatment should be stepped up along the algorithm if symptoms are not adequately controlled. Increasing the dosage of second-generation H₁-antihistamines, with the addition of first-generation H₁-antihistamines, H₂ antagonist, omalizumab, ciclosporin A, or short-term corticosteroid may be necessary. New medications are being developed to treat refractory CSU. They include spleen tyrosine kinase inhibitor, Bruton tyrosine kinase inhibitor, prostaglandin D₂ receptor inhibitor, H₄-antihistamine, and other agents. The authors discuss these treatments and provide expert perspectives on the management of CSU.

Second-generation H₁-antihistamines remain the first-line therapeutic options for the management of CSU. For patients not responding to higher-dose H₁-antihistamines, international guidelines recommend the addition of omalizumab. Efficacy and safety data for newer agents are still pending. Large-scale, well-designed, randomized, double-blind, placebo-controlled trials will further provide evidence on the safety profile and efficacy of these agents in patients with CSU.