Allergy Med Management Discussion

Hey Doc!  There are so many allergy and sinus medications. Which ones are right for me?

Have you ever walked down the aisle in the pharmacy looking for an otc allergy or sinus medicine? If you are like most of my patients, it’s not fun. There are so many choices. The boxes describe what symptoms they are for, and hide the actual ingredients in the small print on the back. Every brand name comes in several versions with different ingredients. So confusing. And you know what? Most of what is on the shelves is composed of the same few ingredients in different combinations over and over. But there are some really good medications that you can get over the counter if you know what to look for.

Which ones are right for me?

This is a common question and depends on several factors; mainly, what kinds of symptoms are you having?  You also need to consider the age of the patient and whether the symptoms are mild or severe, constant or intermittent, and of course, side effects.

The most effective way to manage allergy symptoms is of course to avoid allergens, but that is a topic for another day and isn’t always possible anyway. Most allergy sufferers will need medication at least some of the time.

The main classes of medications that help allergy are: antihistamines, steroids, decongestants. We will discuss that one by one below. There are also mucolytics, cough suppressants, and others. Pain relievers are also included in many multi-symptom cold/flu and allergy/sinus medicines because headaches and face pain are frequently a part of the symptoms most people have. There are many and varied combinations and formulations of these combo medicines, but they are all made from the same basic few ingredients. I generally recommend people stick with single-ingredient formulations, to avoid unwanted side effects from unneeded extra ingredients.

Short-acting Antihistamines – The oldest antihistamines are referred to as short-acting or first-generation antihistamines, and several of these are still used today, available either OTC or prescription. They are pretty effective but short-acting, usually begin to wear off in 4 to 6 hours, and have lots of side effects. In fact, the sedative side effect is so strong in these that they are frequently marketed as sleeping pills (but they actually disrupt restful sleep). They also frequently cause dry eye, nose and throat side effects, and urinary retention, and prostate problems. They are not recommended when operating a car as they cause loss of mental clarity even when people feel like they have no effect.  In geriatric populations, they can cause mental confusion as well. But, if you are sick enough that you are staying home, they may be appropriate.  Diphenhydramine (Benedryl), Chlorpheniramine (Clor-tabs, Coricidin),  Brompheniramine (Dimetapp, Bromfed), Hydroxyzine (prescription only). These meds are frequently also found as ingredients in combination allergy/sinus/cold/flu medications. Reading labels carefully will tell you which of these you are getting. 

Long-acting antihistamines – These have less sleepiness, dry eye, dry mouth, and urinary symptoms than older antihistamines and are generally for once daily use. Use as needed when symptoms occur. Typically work better if taken before exposure. (like mowing the yard). Can be taken year-round, but best rotated every month or two as they lose effectiveness over time. Generally OK for young children. They include Fexofenadine (Allegra), Loratadine (Claritin), Desloratadine (Clarinex), Cetirizine (Zyrtec), Levocetirizine (Xyzal). Fexofenadine is the only one of these that is best taken on an empty stomach. These newer antihistamines have also now been around quite a while, and while not quite as strong, they last much longer and actually control symptoms better without as many side effects. These are generally better tolerated and more effective for daily use. In oral form, they generally work well for all the symptoms BUT nasal congestion. Because of this they are frequently combined with DECONGESTANTS. (Think, Claritin-D) If you don’t feel stuffiness or head pressure, don’t buy the D formulation. In fact, I feel it is better to take Decongestants as a separate pill, in case the different side effects are poorly tolerated. 

In nasal spray form antihistamines also work pretty well on congestion, in addition to all the other symptoms discussed above, and without some of the systemic side effects. They can improve eye symptoms as well. Nasal spray antihistamines include Azelastine and Olopatadine (Patanase). These two are also available in eye drop form.

2.) Decongestants have also been around for a long time. There are currently only 3 on the market, as others have been withdrawn due to serious side effects in those who overused them. They are Pseudoephedrine (Sudafed) – oral form only, Phenylephrine (Neosynephrine, Sudafed PE) – oral or nasal spray,  and Oxymetazoline (Afrin, Sinex, many others) – nasal spray only. These are marketed under various brand names as pills, liquid, or sprays, and added to multi-symptom cold and “sinus” medications and allergy eye drop. They constrict swollen blood vessels in nasal tissue, eyes, and throughout your body. So, they temporarily relieve nasal stuffiness and reduce secretions from those same tissues. They are also stimulants. They cause sleeplessness, irritability, and can raise blood pressure. They are also more or less addictive, as when they wear off the constricted vessels will swell more for a while than before the medication. This is particularly true of decongestant nasal sprays.

3.) Steroids- Strong anti-inflammatory medications, they can stop allergy outbreak symptoms. They work by preventing the influx of the cells that release all the inflammatory chemicals (called mediators) that keep the allergy reaction going.

Steroid tablets – may be prescribed to reduce inflammation or shrink polyps. Side effects are common including irritability, stomach upset, weight gain, and others.  Failure to taper down off the medication as prescribed can have severe consequences.  Please contact the doctor if you experience any concerns with this type of medication.

Steroid injections – sometimes erroneously referred to as “allergy shots”, are administered at physicians’ offices or emergency centers for rapid relief of severe allergy or sinus inflammatory symptoms, hives, asthma attacks. These can feel great, but wear off quickly and can have sometimes severe side effects, including permanent loss of blood flow to the hip ball joint, which can require a hip replacement. 

Topical nasal steroids – If used regularly prevent many major allergies and sinus outbreaks, reduce congestion, drainage, and even itching.  Improper use can result in nosebleeds. Most are available OTC. Frequently used in compounded nasal rinses to treat polyps or chronic infections. Some are OK for young children. Please see my separate discussion on my favorite topical steroid and proper use of these medications. 

4.) Miscellaneous

Saline spray, drops, or rinses – Of course, these are not actually medication at all, but are extremely good at getting rid of thick mucous, and cleaning allergens out of the nose, throat, and even eyes. Headaches are frequently caused by nasal dryness and frequently respond to saline nasal Gel sprays (Neil med NasoGel, or AYR nasal Gel). These can be used many times daily with no ill effects. See separate discussion on nasal saline rinses, sprays, and gels. 

Cromolyn – topical spray which reduces many allergy symptoms. Stabilizes Mast cells to prevent histamine release in the nose or eyes. Good for acute outbreaks or prevention but has to be used frequently to be effective.

Montelukast (Singulair) – Used to treat asthma and sometimes allergies in adults and children as young as 1 year old. Generally low side effects.  Recent FDA data describes suicidal ideation as a rare side effect. Prescription-only.

Guaifenesin (Mucinex, Robitussin) or any preparation containing Guaifenesin – This is an expectorant – help thin and loosen secretions in chest or nose but may increase their quantity.   They are frequently combined in multi-symptom cough and cold meds. Generally for use during acute bronchitis episodes or infections.

Dextromethorphan – OTC cough suppressant found in multi-symptom cough and cold medications, can cause sedative side effects. Has to be taken frequently.

If you feel like an in-depth investigation is what you need, be sure to schedule an initial consultation with me. I can be found at www.CentralParkENT.net in Dallas and Arlington at 817-261-9191. Call us at the main office to schedule.

And for all of your hormone and thyroid care needs, come visit Consultants in Metabolism at our office in North Texas, or sign up for an appointment online at www.danagibbsmd.com.