Management of chronic urticaria: Treatment options when omalizumab fails

Substantial progress in our understanding of chronic urticaria has been accomplished in recent years. We now recognize the heterogeneity of this condition, which is comprised of a number of endotypes and phenotypes. Laboratory testing to identify a cause for chronic urticaria has been discouraged, as this does not lead to improved outcomes and is not cost-effective; however, evidence has shown selected laboratory tests are important for their prognostic value. Therapeutic options for chronic urticaria, particularly for patients who are antihistamine-resistant, have also improved. Despite this, chronic urticaria has continued to be a vexatious condition for both patients and health care providers, and many patients continue to experience unmet needs. Guidelines recommend a step-care approach for management of chronic urticaria that can encourage substantial improvement in clinical course and quality of life. Use of anti-IgE therapy for more than the past decade has enabled many patients with antihistamine-resistant chronic urticaria to achieve improved outcomes; however, a substantial proportion continue to experience ongoing symptoms and impaired quality of life. The armamentarium for management of patients with refractory chronic urticaria has recently expanded, and will soon expand further. This article focuses on the approach to management of antihistamine-resistant patients who continue to experience poorly controlled chronic urticaria despite anti-IgE therapy prescribed at FDA-approved doses.