Alternative Therapies - Immunosuppressants

Reviewed by: HU Medical Review Board | Last reviewed: July 2023

If antihistamines and biologics do not control your chronic hives symptoms, your doctor may try alternative therapies. One category of these drugs works by reducing your immune system activity. These are called immunosuppressants.1

How do immunosuppressants work?

Immunosuppressants may improve symptoms of chronic hives. They work in different ways to lower the activity of your immune system. This is because an overactive immune system may cause symptoms for some people with chronic hives. Autoimmune conditions are common among people with chronic hives.2

However, the US Food and Drug Administration (FDA) has not approved any immunosuppressants for chronic hives. Instead, the FDA has approved them for some allergic and autoimmune conditions. Your doctor must prescribe these drugs "off-label" for chronic hives.2,3

An off-label drug is one that is used to treat a different condition than the one it was approved by the FDA. This also means the FDA has not yet determined the drug is safe when used the way you are taking it.3

Off-label does not mean the drug is unsafe to take. Often, it means there has not been an official clinical trial to test the drug for this specific disease. You should always talk to your doctor about any questions you have about your treatments.3

Doctors will only suggest immunosuppressants if antihistamines and omalizumab do not control symptoms. There is less evidence of efficacy and a higher risk of side effects with immunosuppressants. However, they are more beneficial and less risky than long-term steroids.1,2

Examples of immunosuppressants

Which immunosuppressant your doctor will suggest depends on a number of factors, such as the severity of your symptoms. Immunosuppressants that may be effective for chronic hives include:1,4,5

  • Cyclosporine (Gengraf®, Neoral®)
  • Tacrolimus (Astagraft XL®, Prograf®, Protopic®)
  • Mycophenolate (CellCept®, Myfortic®)
  • Methotrexate (Otrexup®, Rasuvo®)

There is not yet enough evidence to know which one is the best. Expert guidelines recommend starting with cyclosporine. This is because there is better clinical trial evidence for the benefits of cyclosporine.2

What are the possible side effects?

Side effects of immunosuppressants can vary depending on the specific drug you are taking. For example, cyclosporine and tacrolimus may cause:1

  • High blood pressure
  • Kidney problems
  • Burning or prickling sensation
  • Nausea
  • Headache
  • Excessive hair growth
  • Excessive growth of gum tissue around teeth

Cyclosporine has a higher risk of side effects than tacrolimus. Your doctor will monitor your blood pressure and kidney function while you are taking these drugs.1

Many immunosuppressants have boxed warnings, the strictest warning from the FDA. Immunosuppressants have these warnings because they can cause serious side effects. Because these drugs "turn down" the immune response, your body may have a harder time fighting off infection. Serious and life-threatening infection can occur, including:6

  • Blood infections, like sepsis
  • Fungal infections, like thrush
  • Skin infections
  • Respiratory infections, like colds, flu, or pneumonia

These are not all the possible side effects of immunosuppressants. Talk to your doctor about what to expect when taking these drugs. You also should call your doctor if you have any changes that concern you when taking immunosuppressants.

Other things to know

Take these drugs as your doctor prescribes. Some people respond well within 1 to 2 weeks. Others improve within 3 months.1

Do not change your treatment schedule or stop treatment without talking to your doctor. Your doctor may prescribe 1 dose until your symptoms are controlled. They may then slowly reduce the dose over several months.1

Some immunosuppressants may harm unborn babies and are unsafe to take while pregnant or breastfeeding. Talk to your doctor about your options for birth control and breastfeeding while taking immunosuppressants.6

Before beginning treatment for chronic hives, tell your doctor about all your health conditions and any other drugs, vitamins, or supplements you take. This includes over-the-counter drugs.

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