If a patient has chronic spontaneous urticaria refractory to Xolair and is already on plaquenil, do you stop plaquenil and then initiate cyclosporine, or do you co-administer and then gradually stop plaquenil over time?

I would first increase the dose of Xolair, actually, up to 600 mg every 2 weeks.

First, make sure you are dealing with CIU. I have had many "refractory CIU" patients referred who had urticarial vasculitis, bullous pemphigoid, pemphigus herpetiformis... who cleared with appropriate treatment. Also, consider alpha-gal testing depending on where you are.

If sure of the disease, hyd...

Cyclosporin, when dosed appropriately, is highly effective and safe. Follow the dose management and precautions in the attachments. In adolescents and young adults, success in hive cessation was greater than with Xolair and associated with prolonged remission, something not associated with Xolair. I...

My wife had CSU poorly responsive to high doses of second generation antihistamines. Went on a Carnivore diet and within 2 weeks the urticaria literally disappeared as did her Irritable bowel syndrome. I believe we changed her gut microbiome and hence the result. The late legend on Urticaria Marcus ...

I'd stop the plaquenil (I don't think it does much anyway) and start cyclosporin or dupilumab.

Dapsone has real AEs (marrow failure, neuropathy) and is mainly a neutrophil drug, so I wouldn't go there for hives.