Urticaria or Angioedema Clinical Pathway, Emergency Department and Primary Care – Antihistamine Regimen

Urticaria or Angioedema Clinical Pathway — Emergency Department and Primary Care

Antihistamine Regimen

  • Steroids not routinely indicated
  • Most children with acute urticaria do not require cetirizine escalation
Goal Keep the child comfortable, may not be urticaria free
Education
  • If symptoms remain intolerable after 1 hr, give additional standard dose of cetirizine, if not on max dose
  • Progress to next step the following day
  • If symptomatic and on max dose, contact pediatrician for next steps
  • Ibuprofen can exacerbate urticaria
Wean
  • When urticaria improve for 3–4 days, can wean dose by steps every 1–2 days, based on symptoms
  • For return of symptoms, go back to previous step
  • If unable to wean after 6 wks, refer to allergy for further management
  • Not necessary to stop antihistamines before allergy visit
Concern for Excessive Drowsiness Alternative antihistamines, such as fexofenadine and levocetirizine, can be used in place of cetirizine

Steps

Step 1 Standard dose of cetirizine once daily
Step 2 Standard dose of cetirizine in morning and evening
Step 3 Standard dose of cetirizine in morning and double standard dose in evening
Step 4
  • Double standard dose of cetirizine in morning and double standard dose in evening
  • This is the max dose
Step 5
  • Add standard dose of famotidine once or twice daily
  • Refer to allergy

Standard and Max Dose

Medication Age Standard Dose Max Dose Per Day
Cetirizine 6 to < 24 mos 2.5 mg/day 10 mg
2–5 yrs 5 mg/day 20 mg
≥ 6 yrs 10 mg/day 40 mg
Fexofenadine 6 to < 24 mos 15 mg twice/day 120 mg
2–11 yrs 30 mg twice/day 240 mg
≥ 12 yrs 60 mg twice/day 480 mg