Approach to Urticaria and Angioedema in the Older Patient

Chronic spontaneous urticaria (CSU) and angioedema in the older population (typically >65 years) present unique diagnostic and management challenges due to physiological aging, frequent comorbidities, and polypharmacy. Although international guidelines for the general population are applied to older adults, specialized approaches are necessary to ensure safety and efficacy for currently approved and future novel therapies to treat this condition. Diagnosis of CSU in older adults requires a careful history and physical examination to differentiate mast-cell-mediated CSU from other mimicking conditions. A focused laboratory workup is recommended for older adults similar to the general CSU population with an emphasis on identifying age-related comorbidities or underlying malignancies. Nonsedating second-generation H1-antihistamines remain the first-line treatment, though they should be used with caution regarding potential sedation, especially when updosing up to 4-fold the recommended dose for refractory cases. Omalizumab has been demonstrated to be an effective and safe second-line therapy for older patients with CSU, even in those with multiple comorbidities. The newly approved biologic dupilumab and small-molecule Bruton's tyrosine kinase inhibitor remibrutinib are also both considered safe and effective, leading to their guideline-recommended use as alternative second-line agents but more real-world experience is required in the older population. Managing CSU in the older population requires a high index of suspicion for underlying comorbidities and a personalized, stepwise treatment approach focusing on safety and prompt transition to advanced therapeutics for refractory cases. Once CSU is controlled, consideration for stepping-down therapy is recommended over time, if possible, to avoid unnecessary medications.