Executive summary
- First-line: a non-sedating H1 antihistamine regularly (not “PRN only”) for active symptoms.
- Escalation: if inadequate response, up-dose the non-sedating antihistamine (specialist/CKS-style approach can be up to 4× licensed dose in chronic urticaria under guidance and with safety checks).
- Angioedema safety: tongue/throat swelling, voice change, stridor, or breathing difficulty → treat as an emergency (anaphylaxis pathway if systemic features).
Stepwise primary-care approach
- Step 1: regular non-sedating antihistamine (e.g. cetirizine 10 mg OD or fexofenadine 180 mg OD — local formulary varies).
- Step 2: increase dose if needed (often a staged increase) before switching agents; consider trigger review (NSAIDs, infection, alcohol, pressure/heat).
- Rescue for severe flare: short course oral prednisolone (e.g. 20–40 mg OD for 3–5 days) may be used in selected severe episodes.
When to refer
- Chronic urticaria >6 weeks impacting QoL despite optimised antihistamine strategy.
- Recurrent angioedema (especially without urticaria) — consider bradykinin-mediated causes and specialist work-up.
- Any airway involvement or systemic reaction history — urgent allergy/immunology pathway.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.