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Allergy Medication Overview

Mark E. Reiber, MD, FACS, FAAOA

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. This overview is for general education and does not replace consultation with your physician. Package inserts contain detailed information about medications and web links are provided to sites with reviews of medications.

Topical Nasal Steroid Sprays: (Flonase®, Nasacort®, Nasonex®, Rhinocort® Veramyst®)

These are the "work horses". More than a decade ago, I coined the phrase "toothpaste for the nose" to emphasize their safety and importance. Even though they are "steroids", they have limited absorption outside of the nose making them safe for daily use. They are much less effective when used "as needed".

Nasal steroids target many sites of the immune response and are like using multiple medications at once. This is one reason they are more useful than antihistamines that block only histamine.

Proper technique is critical to limiting side effects. Direct the spray toward the outside of the nose, away from the midline (septum) and the nose's blood vessels. We call this technique "cross your heart" using the opposite hand from the side of nose (right hand, left nostril, and vice versa). This minimizes nosebleeds and trauma to the septum.

Nasal steroids are typically first line therapy for chronic symptoms of congestion, runny nose, ear fullness, and polyps. They are also valuable for a special condition called allergic fungal sinusitis. Seasonal allergy patients benefit from starting before symptoms begin and continuing through the season.

Topical Antihistamines: (Astepro® Patanase®)

These nasal sprays provide fast relief from drainage, congestion, and "itchy" nose. They're best used prior to exposure. They're are "rescue" drugs for times of heavy exposure and symptoms and effective for non-allergic triggers such as cigarette smoke, perfume, soaps and other strong odors/irritants. Unpleasant taste is reported.

Topical Nasal Decongestants: (Afrin®, Neo-Synephrine®)

These over the counter sprays are for short-term use only, usually 3 days or less. Longer use can lead to rebound congestion and dependency (rhinitis medicomentosa). They are ideal during colds and sinus infections and for stopping active nosebleeds.

Topical Mast Cell Stabilizers: (Nasalcrom®)

This over the counter spray has limited side effects, but requires four times per day dosing and must be used prior to exposure. Its usefulness is very limited (occasional exposures such as pets at relatives you rarely visit).

Topical Anti-Cholinergics: (Atrovent®)

Vasomotor rhinitis is a watery nose after eating, in cold weather, with viral infections, during times of stress, or simply chronically without response to antihistamines or steroid nasal sprays. It is common in older patients but exclusively. It may accompany allergies and combining Atrovent® with steroid nasal sprays is often beneficial. This spray is 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)

Oral antihistamines are the most commonly used allergy medications. Diphenhydramine (Benadryl) is one of the oldest . Newer generation anti-histamines have reduced sedation while maintaining effectiveness.

Non-sedating antihistamines are much safer than older anti-histamines that cause significant cognitive and reflex impairment, and sedation. Studies have shown significant effects on school and job performance and driving impairment. Patients often use diphenhydramine as a sleep aid, and while it does cause sedation, studies have shown it provides a very poor quality of sleep and causes a significant hang-over effect.

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

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

Leukotriene Inhibitors: (Singulair®, Accolate®)

Originally introduced for asthma, they now have indications for allergic rhinitis and are suitable for patients with both problems. They specifically address 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)

Systemic steroids are available as injections or tablets. 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 treated with steroids. Nasal polyps, allergic fungal sinusitis and asthma are other conditions for steroids. Caution must be used in diabetic patients and other medical conditions.

Ophthalmic Preparations: (Patanol®, Optivar®, Zaditor®, Pataday®)

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.