Allergy Medication Overview:

Mark E. Reiber, M.D., F. A.C.S., F.A.A.O.A.

Introduction:
There are two critical concepts all allergy patients need to know:

1. The three tenets of allergy treatment: environmental control, medications, and immunotherapy.
2. “prevention is better than rescue”. This second point is especially relevant to this discussion.

This overview covers the major classes of medications used to treat nasal and ocular allergies but not asthma, allergic bronchitis or lower respiratory disorders. Popular trade names and generics are listed, but it’s not a comprehensive list.

You should discuss any medication with your ENT Carolina physician before initiating. Package inserts contain detailed information about medications and web links are provided to sites with reviews of medications in each class.

Topical Nasal Steroid Sprays: (Flonase®, Nasacort®, Nasanex®, Rhinocort® Veramyst®)
http://www.drugs.com/pdr/nasonex.html

These are the “work horse” drugs for allergic rhinitis. More than a decade ago, I coined the phrase “toothpaste for the nose” for nasal steroids to emphasize their safety and importance for consistent use. Even though they are “steroids”, they have limited systemic effects and are best with regular use.

Nasal steroids work at many points of the allergic response and as such are like using multiple medications at once. This is one major reason they are more valuable than antihistamines which block only one allergic mediator, histamine.

Proper spray technique is critical to their effectiveness and in limiting side effects. The spray is directed toward the outside of the nose, away from the midline (septum) and most of the nose’s blood vessels. We call this technique “cross your heart” using the opposite hand from the side of the nose in which the spray is directed (right hand, left nostril, and vice versa). This minimizes the risk of nosebleed and trauma to the septum.

Nasal steroids are typically first choice therapy for chronic symptoms of congestion, runny nose, ear fullness and popping, and nasal polyps. They are also valuable for a special condition called allergic fungal sinusitis. Patients with seasonal allergies benefit from starting these sprays before symptoms begin and continuing through the “at risk” season.

Topical Antihistamines: (Astelin®)
http://www.drugs.com/MTM/A/Astelin.html

This nasal spray provides fast relief for allergic nasal drainage, congestion, and “itchy” nasal symptoms. It’s best used prior to an exposure but does not require daily use like nasal steroids (although it can be). It is often recommend as a “rescue” drug during times of heavy exposures such as a visit to a home with a pet, or before working in the garden. It is also effective for non-allergic triggers such as cigarette smoke, perfume, soaps and other strong odors and irritants. A down side to this drug is its particularly unpleasant taste.

Topical Nasal Decongestants: (Afrin®, Neo-Synephrine®)
http://www.drugs.com/mtm/A/Afrin.html

These over the counter nasal sprays are for short term use only, usually 7 days or less. Longer use can lead to rebound congestion and dependency which “cripples” the nose permanently. They are ideal for opening the nasal airway during colds and sinus infections and for stopping active nose bleeds.

Topical Mast Cell Stabilizers:( Nasalcrom®)
http://www.rxlist.com/cgi/generic/cromnas_ad.htm

This over the counter nasal spray has limited side effects, but requires four times per day dosing and must be used prior to exposure. This limits its use for chronic allergies but makes it suitable for short-term use when you are expecting high allergen exposures (eg. visits to a home with a pet).

Topical Anti-Cholinergics: (Atrovent®)
http://www.mayoclinic.com/health/drug-information/DR202713

Vasomotor rhinitis is a watery nose after eating, in cold weather, viral infections, times of stress, or simply chronically without response to antihistamines or steroid nasal sprays. It is most frequent in older patients but not limited to this population. It may accompany allergies and combining Atrovent® with steroid nasal sprays is often beneficial. It’s available in 0.3% and 0.6% strengths, with the stronger strength indicated for viral infections such as the common cold. Dosing is three times per day.

Oral Anti-Histamines: (Allegra, Clarinex, Zyrtec, Claritin, Benadryl)
http://www.rxlist.com/cgi/generic/fexofen_ad.htm
http://www.medicinenet.com/desloratadine-oral/article.htm
http://www.drugs.com/pdr/zyrtec.html
http://www.healthsquare.com/newrx/ben1050.htm

Oral antihistamines are what most people think of first when they consider allergy medications. Diphenhydramine (Benadryl) is one of the oldest allergy medications still available. Newer generation anti-histamines have reduced sedation while maintaining effectiveness.

Newer non-sedating antihistamines are much safer than older anti-histamines. First generation antihistamines cause significant cognitive and reflex impairment, and sedation which frequently the patient is not aware of the impairment. Studies have shown significant effects on school and job performance and driving impairment. In addition, patients often use diphenhydramine as a sleep aid, and while it does cause sedation, studies have shown that it provides a very poor quality of sleep and causes a significant hang-over effect the next morning.

Non-sedating antihistamines are best used for watery and itchy symptoms, sneezing, and rashes or hives.. They are not particularly effective for nasal congestion or facial/ear pressure, and they tend to thicken chronic post-nasal drainage.

Combination products (“D” after the name) contain a decongestion, usually psuedoephedrine, which may cause palpitations, excitability, insomnia or other side effects.

Leukotriene Inhibitors: (Singulair®, Accolate®)
http://www.drugs.com/singulair.html

These prescription medications were originally introduced for asthma but now have indications for allergic rhinitis. They are suitable for patients with both problems, and specifically address nasal congestion, facial pressure, and cough. Patients may need to combine with nasal steroids or antihistamine for itchy, watery, and sneezing symptoms.

Taken orally once daily, they are well tolerated with few side effects and may be a good substitute for oral decongestants with long term use.

Systemic Steroids: (Medrol®, Decadron®, Kenalog®, prednisone)
http://www.healthsquare.com/newrx/med1251.htm

Systemic steroids are available as intramuscular injections or tablets for short term use. They are the most potent and effective anti-inflammatory medications, but clearly have the greatest potential for side effects. Most side effects are associated with long term use, but rare complications are reported with short term or single dose use.

A severe allergy attack, unrelieved by other medications, may be relieved with systemic steroids in some cases. Nasal polyps, allergic fungal sinusitis and asthma are other conditions for which steroids are used. Extreme care must be used in diabetic patients and other medical conditions.

Ophthalmic Preparations: (Patanol®, Optivar®, Zaditor®, Pataday®)
http://www.drugs.com/Patanol.html
http://www.drugs.com/MTM/O/Optivar.html

Allergy eye drops vary greatly in their mechanisms of action. There are antihistamine, anti-inflammatory, mast cell stabilizer, steroid, decongestant, lubricant, and combination products. Dosing is once or twice a day and specific care may be required for contact lens wearers.
Drops can provide relief from itching, watering and burning of allergic conjunctivitis.

Saline Nasal Spray and Gel: (Ayr®, Ocean®)

Salt water formulations of sprays and gels can be found under various trade names and purchased without a prescription. These are useful to moisturize the nose and rinse or prevent allergens from accumulating in the nasal lining during exposures. Dosing is as needed and safe to use many times a day. Gels work well at night time by coating the lining of the nose for a longer lasting effect.

More information on allergy medications can be found at:
http://www.webmd.com/content/article/61/67462
http://www.aaaai.org/patients/publicedmat/tips/asthmaallergymedications.stm
http://www.mayoclinic.com/health/allergy-medications/AA00037

An essential point to allergy medication use is finding one or a combination that best suits your symptoms. Patients often prefer oral antihistamines due to the ease of taking a pill, but unfortunately this may not be best choice for congestion, headache and facial pressure.

The other factor in success is proper use. Medication is best begun before exposure and before an allergic response has begun. This requires continual use for year long allergies and before the at risk times in seasonal allergies.

Mayo Clinic's Medication Information

2-8-08