With emerging therapies, what is your general treatment ladder for chronic spontaneous urticaria (CSU)?

Antihistamines remain the first-line therapy for chronic spontaneous urticaria (CSU), and doses should be optimized before turning to other therapies. If patients fail a trial of adequately dosed first- and second-generation antihistamines, montelukast is a reasonable adjunct. For patients with high immunoglobulin E (IgE), omalizumab is an excellent choice. For patients with significant atopic diathesis or pruritus out of proportion to exam, dupilumab is a reasonable option. For patients with a type IIb CSU phenotype (IgE under approximately 40, anti-thyroid peroxidase antibody positive, antinuclear antibody positive, etc.), remibrutinib is likely a better option than omalizumab or dupilumab. I reserve cyclosporine for short-term use, mostl...

Cetirizine 10 mg a day at bedtime.

In 2 to 4 weeks, if there are still symptoms 2 twice a day of 10 mg cetirizine.

If in 2 to 4 weeks still S/S, the omalizumab 300 mg a month.

If still not controlled over 3 months, increase to 300 mg every 2 weeks or 600 mg every month.