A 32-year-old woman has had hives (uicaria) for 8 weeks. She has not staed any new medications. Her hives are not painful and do not leave behind any pigmentation or other marks when individual resolve (within 24 hours). She has not had respiratory symptoms or lip or tongue swelling. She is frustrated with the amount of pruritis, but does not want to take any medications that make her “sleepy.” Which of the following medications would you recommend?

**Core Concept**
The patient's symptoms of hives (urticaria) without new medications, respiratory symptoms, or lip/tongue swelling suggest an allergic reaction. The goal is to identify a medication that can effectively manage pruritis (itching) without causing sedation.

**Why the Correct Answer is Right**
The patient's symptoms are consistent with chronic idiopathic urticaria (CIU), a condition characterized by recurrent episodes of hives lasting more than 6 weeks without a clear etiology. For patients with CIU who want to avoid sedating medications, antihistamines are the preferred treatment. **Fexofenadine** is a non-sedating second-generation antihistamine that can provide effective relief from pruritis without significant sedative effects.

**Why Each Wrong Option is Incorrect**
**Option A:** **Diphenhydramine** is a first-generation antihistamine that can cause significant sedation, making it an undesirable option for this patient.
**Option B:** **Prednisone** is a corticosteroid that can be used to treat urticaria, but it is not the first-line treatment for chronic idiopathic urticaria and is associated with various side effects, such as weight gain and mood changes.
**Option C:** **Montelukast** is a leukotriene receptor antagonist used primarily to treat asthma and allergic rhinitis. It is not typically used to treat urticaria.

**Clinical Pearl / High-Yield Fact**
When treating chronic idiopathic urticaria, it's essential to start with non-sedating antihistamines like fexofenadine or loratadine and consider adding corticosteroids or cyclosporine if symptoms persist.

**Correct Answer:** C. Fexofenadine.

✓ Correct Answer: C. Loratadine