CIndU Treatment Algorithm: Antihistamine Up-Titration and Unmet Needs

In "CIndU Treatment Algorithm: Antihistamine Up-Titration and Unmet Needs," the panel walks through how Dr. Finklea sequences antihistamine therapy for symptomatic dermatographism.

Dr. Finklea says she starts with cetirizine or levocetirizine rather than fexofenadine, because they seem better for skin and pruritus. She acknowledges this is anecdotal and partly a habit formed in residency. If a patient becomes sedated, she moves to fexofenadine, especially when up-titrating. She notes that the expert consensus update released in February, like the one before it, advises sticking with a single antihistamine rather than combining agents. Her up-titration plan starts with one tablet in the morning. After three or four days of persistent symptoms, she adds a night dose, then doubles the night dose two or three days later. Three or four days after that, she moves to two tablets in the morning and two at night. She aims to finish within two to three weeks, because guidelines suggest offering advanced therapy after two to four weeks.

Dr. Dasilva agrees and stresses explaining the plan and expectations up front. He observes that therapy often does not advance quickly because partially improved patients are content, since a patient who is 50% better may not realize 90% is possible. Dr. Finklea adds that patients play defense, taking antihistamines only after a hive appears, and some hope for remission. She emphasizes that daily dosing is needed to prevent hives. On unmet needs, she notes that most patients do not improve on H1 antihistamines and that no FDA-approved medication exists for CIndU, so clinicians extrapolate from CSU. She welcomes the spotlight on CIndU as a separate disease with many subtypes. After four-times dosing fails, she chooses among dupilumab, omalizumab, and remibrutinib based on age and comorbidities.

In "CIndU Pathophysiology: Mast Cells, BTK Signaling, and Targeted Inhibition," the experts turn to what is known about the biology that drives CIndU and why a BTK inhibitor makes sense.