Shared decision making is essential in chronic spontaneous urticaria (CSU), especially when making treatment decisions such as those relating to escalating second-generation nonsedating H₁ antihistamine doses or selecting targeted therapy. As symptoms wax and wane unpredictably and the duration of CSU is uncertain, discussions about expectations, response timelines, and individualized definitions of improvement can be important to help guide treatment choices.

It is very important for clinicians to have discussions with patients to make sure that they are comfortable with the treatment choices for CSU. All the second-generation H₁ antihistamines are options as an initial treatment choice. An advantage to the use of fexofenadine is that, even at 4-fold the licensed dose, there is no significant crossing of the blood-brain barrier, so patients do not experience sedation. With cetirizine and loratadine, I would caution patients that, although they are generally nonsedating, there is some sedation and impairment when you start increasing the dose. It is not the same level of sedation as first-generation H₁ antihistamines, but if they cannot tolerate either one of these options, you might switch them to fexofenadine.

If second-generation H₁ antihistamines alone do not control a patient’s CSU, discussing their treatment preferences with them is also very important. Does the patient prefer oral or injectable options? What can they afford based on their insurance? We should also discuss with patients how the drugs work, their historical response rates, and their short- and long-term safety. As noted previously, clinicians need to have these conversations with patients to make sure that they are comfortable with whatever choice they make because therapy could continue long-term, and patients need to know that.

Everybody wants rapid improvement (ie, to get rid of the hives quickly). There are certain patients who respond very rapidly to omalizumab, but, unfortunately, we have not been able to definitively say which biomarkers predict who will respond. If they have higher baseline IgE levels, they might fit into that category. The data with remibrutinib look impressive for patients to improve pretty rapidly, within a couple of weeks. With dupilumab, we see time-dependent improvement as well, but improvement may be a little bit slower than what we see with omalizumab and remibrutinib. There are also physicians who may consider using corticosteroids for the rapid improvement of CSU, but I would not recommend doing this because we now have these newer drugs, and putting somebody on multiple bursts of oral corticosteroids is not the safest thing to do (especially as this is a chronic condition and the patient population tends to be older).

How long do you treat before someone should see improvement? That depends on the medicine used. With omalizumab, the XTEND-CIU study showed that the response rate may continue to increase over time. Defining response and duration of treatment are some of the things that we look at and discuss with patients. And if a patient is saying that their biologic is not working, the next question should be, “What do you mean by ‘not working’?” This may be based on the individual patient’s perception of response. Getting rid of 75% to 80% of the hives might look pretty good to a clinician, but if patients are not satisfied, then we have to decide together what else to try to make things even better.