The Secret of Great Health Care
Allergy Medications
Often times lifestyle modifications and elimination of triggers are not enough to get allergy relief and medications need to be used. To get allergy relief it is important to have a solid handle on your symptoms as some medications work better for specific symptoms. Those with eye symptoms should be treated with allergy eye drops. Oral antihistamines can treat sporadic symptoms. Nasal congestion is best managed with decongestants and some prescription nasal sprays.
Medications typically do not work when they are not taken. Individuals with persistent disease need to be treated continually or symptoms will return.
Oral antihistamines are the most common initial treatment for allergies, mainly because of their availability and ease of use. Antihistamines treat runny nose, red watery eyes, sneezing and itching. They do not treat nasal congestion but many products come combined with decongestants.
Older antihistamines - chlorpheniramine (Chlor-Trimeton), diphenhydramine (Benadryl) and hydroxyzine (Atarax) - are associated with more side effects, particularly sedation, and are less commonly used when compared to newer medications. The most common over the counter first-generation antihistamine is diphenhydramine.
Second-generation medications have improved dosing schedules and are less commonly associated with sedation. There are five, second-generation antihistamines available. Multiple studies have demonstrated that cetirizine (Zyrtec) is the most potent second-generation antihistamine.
Other oral medications
Leukotriene receptor blockers inhibit chemicals in the body that are responsible for allergies. This class of drugs is commonly used on those with asthma. The most popular drug in this class for the treatment of allergies is montelukast (Singulair). It can be used in children over two-years-old for seasonal allergies and over 6 months in those with perennial allergies. This class is not recommended as a first-line drug for allergies, but is often added on to those who have difficult to control allergies. Nasal corticosteroids sprays are more effective in managing allergy symptoms than leukotriene receptor blockers.
Nasal sprays
Multiple types of nasal sprays are helpful in the management of allergies. Some may be more effective than others based on the presenting symptoms.
· Nasal saline
· Nasal corticosteroids
· Nasal antihistamines
· Nasal cromolyn
Nasal Saline
Nasal saline is a frequently overlooked option for allergies. It removes factors that cause allergies and improves mucus clearance. Everyone who has allergies should use nasal saline.
Two primary types of nasal saline are normal saline and hypertonic saline. Hypertonic saline has a higher concentration of salt in it. It is hyped to be more effective at drying the nose than normal saline. It also is more likely to cause a burning and stinging sensation when used.
Nasal corticosteroids
Nasal corticosteroids are recommended as first-line treatment of moderate to severe persistent allergies. Immediate relief will not be noticed with them. Some benefit is usually appreciated by the fourth day of use and it may take a couple of weeks before full effects are noticed. They work by reducing the amount of inflammation in the nose. They are often combined with oral antihistamines, which will provide some immediate relief.
Ideally they should be started about two weeks before exposure to allergens. This may be hard to predict, but those individuals who have a predictable onset of allergies in the spring should start these medications two weeks before.
These medications manage itching, runny nose, nasal congestion and sneezing. In order to provide relieve they must be used regularly. They are not effective for symptoms in the eyes. Side effects include:
· Irritation
· Sneezing
· Nose bleeds
· Headache
· Fungal infections (rare)
· Perforated nasal septum (rare).
One side effect that warrants special attention is growth stunting in children. There is some evidence that there is some growth stunting with the use of nasal corticosteroids. Therefore, all children who take long-term nasal steroids should have their height measured every six months. Some nasal corticosteroids – mometasone and fluticasone - have not shown a reduction in height. Studies done with higher doses of corticosteroids in asthma demonstrated that growth stunting may be seen in children up to 1-2 cm but this does not affect adult height.
Nasal Antihistamines
Spraying antihistamines up the nose is another method to deliver medicine to the allergic patient. Topical antihistamines come in a product called azelastine (Astelin). It is as effective for nasal symptoms as oral antihistamines. It works quickly and is dosed two puffs in each nostril twice a day.
A newer product called Astepro provides the same benefit but it lacks a some of the side effects of the older version of azelastine. It has less of a bitter taste and less somnolence than Astelin. Topical antihistamines are effective at treating sneezing and runny nose. Different than the oral antihistamines, the topical antihistamines are effective at treating nasal congestion.
Nasal Anticholinergic
Anticholinergic medication - ipratropium bromide (Atrovent nasal spray) – can also help dry a runny nose. This medication comes in two strengths 0.03 and 0.06 %. Only the 0.03% is indicated for allergic and nonallergic perennial rhinitis while the 0.06% is indicated for runny nose associated with the common cold. This medicine can be used in those over five and is dosed two sprays, 2 to three times a day.
Nasal Cromolyn
Cromolyn sodium (Nasalcrom) is an over the counter medication used in the management of allergic rhinitis. It requires frequent dosing and is given one puff per nostril every 4-6 hours. It is not as useful for immediate relief and it may take a week before benefit is realized. It is not as potent as nasal corticosteroids.
Eye Symptoms
When allergies affect the eyes, there are two ways to manage them. Take an oral antihistamine (all of which have systemic effects). Second, you may use eye drops to deliver the medication directly in the eye.
Some people are able to use saline eye drops to effectively manage their eye symptoms. Saline eye drops are just salt water that can help flush away allergens, but do not have any medication in them.
Many people with severe eye symptoms need medicated eye drops. Many products are a combination of antihistamines and mast cell stabilizers and effectively treat red, watery and itchy eyes. For eyes that are inflamed and painful the use of ketorolac or a steroid eye drop may be helpful.
Over the counter medications are available for the treatment of allergic eye symptoms. Naphazoline pheniramine (Naphcon A/Opcon A) is a popular over the counter medication that is helpful in the reduction of eye symptoms.
Ketotifen (Zaditor) is an over the counter antihistamine eye drop. It is dosed one drop twice a day in children over three years old.
Stuffy nose
Allergies are often accompanied by nasal stuffiness. Some of the medications already discussed can provide relief from nasal congestion – topical antihistamines and nasal corticosteroids. Effective and rapid relief from nasal congestion can be attained with decongestants.
Decongestants are dangerous in some people. Decongestants have the potential to increase the blood pressure, heart rate and make you feel jittery. Checking with your doctor or health care provider is important if you have high blood pressure, heart disease, heart rhythm problem, diabetes, thyroid problems, an enlarged prostate or glaucoma.
Many allergy medications combine decongestants and antihistamines. When you see the allergy medication with a “D” on the back, for example, Claritin D, this has a decongestant in it.
When your symptoms are a combination of sneezing, runny nose and watery eyes with nasal congestion, than the use of an allergy product with a decongestant will be most helpful in managing symptoms.
Decongestants come in a variety of forms. They can be taken orally, topically (as a nasal spray) and as a vapor.
Severe symptoms
In rare situation, doctors need to use oral corticosteroids. These are powerful anti-inflammatory medications and are used when symptoms are severe. They are typically given for less than 7 days. Allergic rhinitis is not an indication for long-term use of oral corticosteroids.
What should a patient do with allergies?
When you come down with the hallmark symptoms of allergies – sneezing, watery eyes, runny nose and nasal congestion – what should you do?
1. The first thing to do is take an inventory of your symptoms. This is best accomplished by maintaining an allergy log. With the use of this allergy log you can determine when your allergies are worst, which symptoms are most bothersome, what is aggravating them and how effective your treatments are at controlling the symptoms.
2. Attempt to eliminate any factors that may be making the allergies worse.
3. If this does not work, a trail of some over the counter medication is appropriate. The most popular and potent over the counter medication is cetirizine (Zyrtec). If you are plagued by congestion, the addition of decongestants may be helpful. Use caution with the decongestant part if you are affected by high blood pressure, heart disease, thyroid disease, heart rhythm problem, diabetes, prostate enlargement or glaucoma.
4. If symptom control is unsuccessful with over the counter medications, set up an appointment with your health care provider.
5. Continue to work on environmental control and track your symptoms.
6. If after a two or three appointments with your primary doctor your symptoms are not controlled than seeing an allergy specialist is recommended.
What the doctor will do?
If environmental control and over the counter medications have not provided adequate relief than the health care provider may prescribe some of the other medications discussed above.
When this does not adequacy control symptoms than allergy testing or immunotherapy may be indicated.
The primary doctor will provide a complete evaluation and may decide on an earlier referral if other symptoms suggestive of a problem are evident. Certain conditions that would warrant evaluation by a specialist include:
· Nasal polyps which would be suggested by chronic congestion, runny nose, post-nasal drip and reduced smelling and/or taste
· One sided nasal congestion
· Persistent bloody discharge
· Complications of allergies such as recurrent sinus or ear infections
Immunotherapy
Eighty to 90 percent of the cases of allergies can be managed with immunotherapyxlviii. Immunotherapy is considered when symptoms are not adequately managed with environmental control, over the counter medications and prescription medications. They can also be used by those who cannot tolerate or do not want to take long-term medications. It can also be used for those with severe disease.
Immunotherapy is effective, but the onset of effect is slow. It may take up to one year before significant effect is noticed. Therapy is often continued for up to five years. It is indicated for those over five-years-old. There is a risk of severe allergic reaction and you should only have this done in the office of a health care provider who has the ability to handle a severe allergic reaction.
It is useful in those who are allergic to dust mites, pollens and cats and not as effective for mold and dogs.
