<description>&lt;p&gt;It’s one of the most common—and most frustrating—complaints in the Emergency Department: the patient covered head-to-toe in hives, miserable, itching, and desperate for relief. In this episode of &lt;b&gt;EM Pulse&lt;/b&gt;, we welcome back ED Clinical Pharmacist &lt;b&gt;Haley Burhans&lt;/b&gt; to tackle the &amp;#8220;uncomfortable&amp;#8221; topic of urticaria. We move past the myths of one-and-done doses and explore why your standard allergy dosing might be leaving your patients itching for more.&lt;/p&gt; &lt;p&gt;&lt;b&gt;The Power of Second-Generation Antihistamines&lt;/b&gt;&lt;/p&gt; &lt;p&gt;Haley explains why second-generation antihistamines (cetirizine, levocetirizine, fexofenadine) should be your first-line ED therapy, rather than the old school standard, diphenhydramine (Benadryl).&lt;/p&gt; &lt;ul&gt; &lt;li&gt;&lt;b&gt;Xyzal vs. Zyrtec:&lt;/b&gt; We break down the L-enantiomer (levocetirizine) and whether it actually beats its predecessor in preventing drowsiness.&lt;/li&gt; &lt;li&gt;&lt;b&gt;The &amp;#8220;Double Dose&amp;#8221; Pearl:&lt;/b&gt; For acute urticaria in the ED, 10mg of cetirizine isn&amp;#8217;t enough. Haley recommends starting with &lt;b&gt;20mg for adults&lt;/b&gt; (or doubling the weight-based dose for kids) to see relief within 20–60 minutes.&lt;/li&gt; &lt;li&gt;&lt;b&gt;The 4x Rule:&lt;/b&gt; Guidelines now support up to &lt;b&gt;four times the standard daily dose&lt;/b&gt; for refractory cases (usually split BID). We discuss the safety data behind these higher regimens and why they are tolerated so well.&lt;/li&gt; &lt;/ul&gt; &lt;p&gt;&lt;b&gt;The Steroid Trap and the Rebound Effect&lt;/b&gt;&lt;/p&gt; &lt;p&gt;Patients often come in requesting steroids but they are NOT the primary cure for urticaria.&lt;/p&gt; &lt;ul&gt; &lt;li&gt;&lt;b&gt;The Antihistamine Backbone:&lt;/b&gt; Steroids treat inflammation, but the antihistamine treats the underlying stimulus. If a patient stops their antihistamines and only takes a steroid burst, they are set up for a miserable rebound.&lt;/li&gt; &lt;li&gt;&lt;b&gt;Dosing Strategies:&lt;/b&gt; If you do use steroids, keep it to a burst or taper of 10 days or less. We discuss the utility of methylprednisolone (Medrol Dosepak) versus a simple prednisone burst/taper or a course of longer-acting dexamethasone.&lt;/li&gt; &lt;/ul&gt; &lt;p&gt;&lt;b&gt;Beyond the Basics: Benadryl and the MABs&lt;/b&gt;&lt;/p&gt; &lt;ul&gt; &lt;li&gt;&lt;b&gt;The Danger of &amp;#8220;Dirty&amp;#8221; Drugs:&lt;/b&gt; Why diphenhydramine has fallen out of favor due to its sodium channel blocking side effects, anticholinergic toxicity, and psychiatric risks.&lt;/li&gt; &lt;li&gt;&lt;b&gt;The Future of Itch:&lt;/b&gt; A look at emerging biologics like omalizumab. While these IgE-blockers shouldn’t be started in the ED, it’s important to know about them to treat patients who are taking them, or who present with rebound urticaria after recently stopping them.&lt;/li&gt; &lt;/ul&gt; &lt;p&gt;&lt;b&gt;Key Takeaways&lt;/b&gt;&lt;/p&gt; &lt;ul&gt; &lt;li&gt;&lt;b&gt;Go Big on Second Generation Antihistamines:&lt;/b&gt; Start with a double dose of cetirizine in the ED. It’s safe, effective, and less sedating than first-generation alternatives. Discharge patients on that double dose twice a day.&lt;/li&gt; &lt;li&gt;&lt;b&gt;Think Long-Term:&lt;/b&gt; Urticaria pathways need time to &amp;#8220;cool down.&amp;#8221; Advise patients to stay on the prescribed meds/doses for &lt;b&gt;1–2 months&lt;/b&gt;, not 1–2 days.&lt;/li&gt; &lt;li&gt;&lt;b&gt;Steroids are Adjuncts:&lt;/b&gt; Use a short burst (&amp;#60;10 days) for severe distress, but never as monotherapy.&lt;/li&gt; &lt;li&gt;&lt;b&gt;The Taper is Key:&lt;/b&gt; Encourage a slow taper of medications to prevent symptom recurrence.&lt;/li&gt; &lt;li&gt;&lt;b&gt;Managing Expectations:&lt;/b&gt; Most urticaria has no identifiable cause (often viral or idiopathic). Reassure the patient that while we may not find the why, we can help manage the itch.&lt;/li&gt; &lt;/ul&gt; &lt;p&gt;How do you handle the &amp;#8220;itch that won&amp;#8217;t quit&amp;#8221;? Do you have a favorite antihistamine cocktail? Share your experience with us on social media &lt;b&gt;@empulsepodcast&lt;/b&gt; or at &lt;b&gt;ucdavisem.com&lt;/b&gt;&lt;b&gt;&lt;/b&gt;&lt;/p&gt; &lt;p&gt;&lt;b&gt;Hosts:&lt;/b&gt;&lt;b&gt;&lt;/b&gt;&lt;/p&gt; &lt;p&gt;&lt;a href="http://Twitter.com/julmagana"&gt;Dr. Julia Magaña&lt;/a&gt;, Professor of Pediatric Emergency Medicine at UC Davis&lt;/p&gt; &lt;p&gt;&lt;a href="https://health.ucdavis.edu/boldly-learning/featured/sarah-medeiros.html"&gt;Dr. Sarah Medeiros&lt;/a&gt;, Professor of Emergency Medicine at UC Davis&lt;/p&gt; &lt;p&gt;&lt;b&gt;Guests:&lt;/b&gt;&lt;/p&gt; &lt;p&gt;&lt;a href="https://www.linkedin.com/in/haley-burhans?utm_source=share&amp;#38;utm_campaign=share_via&amp;#38;utm_content=profile&amp;#38;utm_medium=ios_app"&gt;Haley Burhans, PharmD&lt;/a&gt;, Emergency Medicine Clinical Pharmacist at UC Davis&lt;/p&gt; &lt;p&gt;&lt;b&gt;Resources:&lt;/b&gt;&lt;/p&gt; &lt;p&gt;&lt;a href="https://eaaci.org/guidelines-position-papers/the-international-eaaci-ga%C2%B2len-euroguiderm-apaaaci-guideline-for-the-definition-classification-diagnosis-and-management-of-urticaria/"&gt;The international EAACI/ GA²LEN/ EuroGuiDerm/ APAAACI guideline for the definition, classification, diagnosis, and management of urticaria&lt;/a&gt;&lt;/p&gt; &lt;p&gt;&lt;a href="https://www.chop.edu/clinical-pathway/urticaria-angioedema-clinical-pathway"&gt;Emergency Department and Primary Care Clinical Pathway for Evaluation/Treatment of Children with Urticaria or Angioedema (CHOP)&lt;/a&gt;&lt;/p&gt; &lt;p style="text-align: center;"&gt;***&lt;/p&gt; &lt;p&gt;Thank you to the &lt;a href="http://www.ucdmc.ucdavis.edu/emergency/"&gt;UC Davis Department of Emergency Medicine&lt;/a&gt; for supporting this podcast and to Orlando Magaña at &lt;a href="http://www.orlandomagana.com/"&gt;OM Productions&lt;/a&gt; for audio production services.&lt;/p&gt; &lt;p&gt;&amp;#160;&lt;/p&gt;</description>

EM Pulse Podcast™

UC Davis Department of Emergency Medicine

Stop the Itch (Urticaria Edition)

MAY 5, 202618 MIN
EM Pulse Podcast™

Stop the Itch (Urticaria Edition)

MAY 5, 202618 MIN

Description

<p>It’s one of the most common—and most frustrating—complaints in the Emergency Department: the patient covered head-to-toe in hives, miserable, itching, and desperate for relief. In this episode of <b>EM Pulse</b>, we welcome back ED Clinical Pharmacist <b>Haley Burhans</b> to tackle the &#8220;uncomfortable&#8221; topic of urticaria. We move past the myths of one-and-done doses and explore why your standard allergy dosing might be leaving your patients itching for more.</p> <p><b>The Power of Second-Generation Antihistamines</b></p> <p>Haley explains why second-generation antihistamines (cetirizine, levocetirizine, fexofenadine) should be your first-line ED therapy, rather than the old school standard, diphenhydramine (Benadryl).</p> <ul> <li><b>Xyzal vs. Zyrtec:</b> We break down the L-enantiomer (levocetirizine) and whether it actually beats its predecessor in preventing drowsiness.</li> <li><b>The &#8220;Double Dose&#8221; Pearl:</b> For acute urticaria in the ED, 10mg of cetirizine isn&#8217;t enough. Haley recommends starting with <b>20mg for adults</b> (or doubling the weight-based dose for kids) to see relief within 20–60 minutes.</li> <li><b>The 4x Rule:</b> Guidelines now support up to <b>four times the standard daily dose</b> for refractory cases (usually split BID). We discuss the safety data behind these higher regimens and why they are tolerated so well.</li> </ul> <p><b>The Steroid Trap and the Rebound Effect</b></p> <p>Patients often come in requesting steroids but they are NOT the primary cure for urticaria.</p> <ul> <li><b>The Antihistamine Backbone:</b> Steroids treat inflammation, but the antihistamine treats the underlying stimulus. If a patient stops their antihistamines and only takes a steroid burst, they are set up for a miserable rebound.</li> <li><b>Dosing Strategies:</b> If you do use steroids, keep it to a burst or taper of 10 days or less. We discuss the utility of methylprednisolone (Medrol Dosepak) versus a simple prednisone burst/taper or a course of longer-acting dexamethasone.</li> </ul> <p><b>Beyond the Basics: Benadryl and the MABs</b></p> <ul> <li><b>The Danger of &#8220;Dirty&#8221; Drugs:</b> Why diphenhydramine has fallen out of favor due to its sodium channel blocking side effects, anticholinergic toxicity, and psychiatric risks.</li> <li><b>The Future of Itch:</b> A look at emerging biologics like omalizumab. While these IgE-blockers shouldn’t be started in the ED, it’s important to know about them to treat patients who are taking them, or who present with rebound urticaria after recently stopping them.</li> </ul> <p><b>Key Takeaways</b></p> <ul> <li><b>Go Big on Second Generation Antihistamines:</b> Start with a double dose of cetirizine in the ED. It’s safe, effective, and less sedating than first-generation alternatives. Discharge patients on that double dose twice a day.</li> <li><b>Think Long-Term:</b> Urticaria pathways need time to &#8220;cool down.&#8221; Advise patients to stay on the prescribed meds/doses for <b>1–2 months</b>, not 1–2 days.</li> <li><b>Steroids are Adjuncts:</b> Use a short burst (&#60;10 days) for severe distress, but never as monotherapy.</li> <li><b>The Taper is Key:</b> Encourage a slow taper of medications to prevent symptom recurrence.</li> <li><b>Managing Expectations:</b> Most urticaria has no identifiable cause (often viral or idiopathic). Reassure the patient that while we may not find the why, we can help manage the itch.</li> </ul> <p>How do you handle the &#8220;itch that won&#8217;t quit&#8221;? Do you have a favorite antihistamine cocktail? Share your experience with us on social media <b>@empulsepodcast</b> or at <b>ucdavisem.com</b><b></b></p> <p><b>Hosts:</b><b></b></p> <p><a href="http://Twitter.com/julmagana">Dr. Julia Magaña</a>, Professor of Pediatric Emergency Medicine at UC Davis</p> <p><a href="https://health.ucdavis.edu/boldly-learning/featured/sarah-medeiros.html">Dr. Sarah Medeiros</a>, Professor of Emergency Medicine at UC Davis</p> <p><b>Guests:</b></p> <p><a href="https://www.linkedin.com/in/haley-burhans?utm_source=share&#38;utm_campaign=share_via&#38;utm_content=profile&#38;utm_medium=ios_app">Haley Burhans, PharmD</a>, Emergency Medicine Clinical Pharmacist at UC Davis</p> <p><b>Resources:</b></p> <p><a href="https://eaaci.org/guidelines-position-papers/the-international-eaaci-ga%C2%B2len-euroguiderm-apaaaci-guideline-for-the-definition-classification-diagnosis-and-management-of-urticaria/">The international EAACI/ GA²LEN/ EuroGuiDerm/ APAAACI guideline for the definition, classification, diagnosis, and management of urticaria</a></p> <p><a href="https://www.chop.edu/clinical-pathway/urticaria-angioedema-clinical-pathway">Emergency Department and Primary Care Clinical Pathway for Evaluation/Treatment of Children with Urticaria or Angioedema (CHOP)</a></p> <p style="text-align: center;">***</p> <p>Thank you to the <a href="http://www.ucdmc.ucdavis.edu/emergency/">UC Davis Department of Emergency Medicine</a> for supporting this podcast and to Orlando Magaña at <a href="http://www.orlandomagana.com/">OM Productions</a> for audio production services.</p> <p>&#160;</p>