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Corticosteroid Nasal Sprays

The big revolution in allergy treatment involves the use of steroid nasal sprays. Allergists have known for decades that cortisone-like drugs (prednisone, for example) can dampen the reactions of an overactive immune system and calm allergy symptoms amazingly well. The trouble is that relief comes at a stiff price. So many side effects are associated with oral corticosteroids that few physicians would ever consider prescribing such medications for nasal allergy symptoms except as a last resort. Even then, cautious doctors prescribe medications like prednisone for the shortest period of time necessary. Adverse reactions can include irritability, insomnia, anxiety, high blood pressure, potassium depletion, headache, nausea, and dizziness.
Not surprisingly, people wanted the benefits of steroids without the risks. That’s where nasal sprays come in. There are about a half- dozen different intranasal corticosteroids available by prescription. Most experts would say that these formulations are the most effective allergy treatment available. Although it may take a week for the benefits to reach peak effect, these sprays should relieve allergy symptoms such as itching, sneezing, and congestion quite well. They are pricey, however. A small bottle can run $85 to $95. At the time of this writing, generic flunisolide costs around $40. We cannot say whether one spray is better or safer than another.
The general consensus is that there are few, if any, systemic side effects associated with topical steroids. In other words, the experts do not believe people absorb enough of the drugs into the system to cause much, if any, concern.55 One study did report growth suppression in children, but other research has not confirmed this complication. There have been rare reports of nasal perforation (creating a hole between the nostrils) and increased pressure within the eyes. More common are local reactions such as irritation and burning in the nose, sore throat, nasal dryness, nosebleed, and headache.
GENERIC/BRAND NAME
Beclomethasone
Beconase AQ
Budesonide
Rhinocort Aqua
Flunisolide
Nasarel
Fluticasone
Flonase
Mometasone
Nasonex
Nasacort AQ
Triamcinolone

Still generic Singulair is widely prescribed to ease the breathing problems because of asthma.

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Antihistamines

Antihistamines have been the mainstay of allergy treatment for decades. The so-called first-generation drugs like diphenhydramine (Benadryl), brompheniramine (Dimetane, Dimetapp), and chlorpheniramine (Chlor-Trimeton) are linked to drowsiness and cognitive impairment 47 Second-generation antihistamines such as cetirizine (Zyrtec), desloratadine (Clarinex), fexofenadine (Allegra), and loratadine (Claritin) have been promoted as nonsedating. Because they were supposed to be so much safer and better tolerated than the old-fashioned drugs, many came with a very steep price tag ($2 to $3 per pill). But there is growing concern that when given in doses that are adequate to relieve allergy symptoms, even these newer compounds may cause some sedation in some patients and produce mild impairment.48 Researchers now believe that “a clear and consistent distinction between sedating and nonsedating antihistamines does not exist.”‘
What this means is that the allergy victim is truly caught on the horns of a dilemma. Suffering with allergies makes you spacey, sleepy, and irritable and can impair your ability to function. Antihistamines can also cause sedation and impair performance. If such drugs only partially control symptoms (a fairly common situation), then you may end up with the worst
Claritin used to be the most widely prescribed antihistamine on the market. When it lost patent protection, the company took it OTC. Compared to many of the older nonprescription antihistamines, loratadine is probably less likely to cause drowsiness at recommended doses. We have seen no data to suggest that it is less effective than pricier prescription antihistamines.

Side effects: Headache, sleepiness, dry mouth, fatigue, jitteriness, and stomach upset. Liver problems may be a rare adverse reaction. Downside: More expensive than old-fashioned antihistamines. Insurance companies may deny you affordable access to drugs like Allegra now that loratadine is available OTC. Loratadine may cause sedation and impair driving in susceptible people. Do not assume you are safe behind the wheel. Cost: Approximately $5 to $10 for a month’s supply when purchased generically in bulk. The brand-name Claritin can cost two to four times that much.

In such a confusing situation, we would normally suggest that the allergy sufferer experiment with a variety of antihistamines to try and determine which one works best and is least troublesome in terms of side effects. The difficulty is that people are notoriously bad at assessing their level of impairment. There is a warning on the label of Benadryl and many other OTC allergy medicines reminding users that “marked drowsiness may occur” and urging them to “be careful when driving a motor vehicle or operating machinery.” Such cautions are as meaningless as telling a drunk to be careful behind the wheel. In fact, researchers have reported that diphenhydramine”had a greater impact on driving than alcohol did. These scientists discovered that “drowsiness ratings were not a good predictor of impairment, suggesting that drivers cannot use drowsiness to indicate when they should not drive.”
By the way, did you know that you could be arrested for driving while impaired after taking an OTC allergy pill? If your driving skills are not up to par, an officer can give you a ticket even though you have no alcohol in your system.
So, dear reader, we have no easy answers. We would like to say, if you have allergies, do not drive, especially if you are taking antihistamines. That would be the only prudent thing. We know that some people will disobey such a suggestion, however. Some experts believe that fexofenadine (Allegra) may be one of the least sedating and safer antihistamines to take if you must drive. Others point out that even this non-sedating antihistamine may pose problems at higher doses. If driving or operating machinery is essential or if you must make important decisions, we encourage you to look for other options besides oral antihistamines.
There is now a prescription antihistamine nasal spray called azelastine (Astelin). It is fairly fast acting but has the disadvantage of requiring twice-daily nasal spritzing. Some data suggest it may be as effective as oral antihistamines. Side effects may include a bitter taste in the mouth (20 percent of patients), headache, drowsiness (11 percent of patients), nasal burning or inflammation, sore throat, dry mouth, sneezing, fatigue, and dizziness. A 1 -ounce bottle can cost $75 to $85. Not exactly a perfect solution to the problem, eh?

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Butterbur (Petasites hybridus)

Another interesting allergy treatment involves the herb butter-bur. This botanical medicine has been used to treat symptoms of migraine headaches, asthma, and allergy. It has anti-inflammatory activity and blocks the formation of compounds called leukotrienes (pronounced lew-co-TRY-eens). These rascals cause all sorts of mischief in the nose, including itching, sneezing, swelling, and congestion. In some respects, leukotrienes may be even more of a problem than histamine. Leukotrienes contribute to the inflammatory cascade that underlies both allergy and asthma. The prescription asthma and allergy drug Singulair (montelukast) also works by inhibiting leukotriene formation. Swiss researchers compared butterbur with the antihistamine cetirizine (Zyrtec) in a randomized, double-blind study. They found that both products were equally effective at controlling symptoms, but butterbur was significantly less sedating than Zyrtec.

Q. I have suffered from chronic sinusitis, which in turn led to bronchitis and frequently into pneumonia. My physician put me on Allegra and then switched me to Clarinex.
I continued to have sinusitis and pneumonia annually for 5 years, so my doctor sent me to an allergist. He diagnosed several allergies and added a prescription for Nasacort to the Clarinex.
Two years ago, having suffered through another bout of sinusitis and pneumonia, I saw an integrative alternative medicine physician. He took me off Clarinex and prescribed butterbur, stinging nettles, and quercitin instead. I’ve taken this combination for 2 years and it has reduced the frequency of the sinusitis.I read that I should take butterbur only 6 weeks a year. Now I am concerned about the danger of liver damage.

A. Pharmacologist David Kroll, PhD, offered this clarification on butterbur. “I wanted to follow up on a reader who wrote to your newspaper column regarding the potential liver toxicity of butterbur (Petasites hybridus), an herb that’s become popular due to positive efficacy trials in migraine prevention and allergic rhinitis. While the herb is potentially toxic to the liver, it shouldn’t be a problem with high-quality products like Petadolex. I do-fear that some less honorable companies may latch onto this herb and not take such care with the high-tech extraction process that is necessary to reduce the risk. That might lead to some major liver injury cases.”
There is one fly in the ointment, however. Concerns have been raised about potential liver toxicity associated with compounds in butterbur. If the herbal preparation is not manufactured under very stringent quality-control conditions, there could be problems. As a result, we suggest that people use butterbur only temporarily (say, for 6 weeks during hay fever season) and that they monitor their liver enzyme activity with medical supervision. One product that should be safe is Petadolex. The German manufacturer is Weber and Weber, and it is available in the United States.

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Allergy is a general term applied to certain types of hypersensitivity reactions, some of which such as hayfever are well known, but the factors that cause such reactions vary widely in their nature. In brief, an allergic reaction is immunologically mediated, and originates in an exposure to an excitatory substance referred to as an antigen, which in sensitive individuals is followed by the production of antibodies. Antigens are often protein in nature, and eggs, peanut products, wasp and bee stings, as well as drugs, can function as antigens. Subsequent re-exposure to the antigen may give rise to an antigen-antibody reaction, which is linked with the release of cell-bound histamine and other spasmogens, which in turn act upon various tissues to produce the allergic response. The response may manifest itself in several ways, such as hayfever, rhinitis, bronchoconstriction and rash or urticaria. In severe allergic reactions (anaphylactic shock), an alarming fall in blood pressure may occur with respiratory distress, and requires the immediate i.m. injection of adrenaline solution (0.5-1 ml) together with i.v. hydrocortisone 200 mg and resuscitation measures.
It should be noted that the anaphylactic reactions that occur after the first dose of certain drugs, including contrast media, are more in the nature of an idiosyncratic-toxic reaction than an immunologically mediated response, but may be no less severe, and resuscitation facilities should always be available.

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In less severe allergic reactions such as hayfever and allergic rhinitis, antihistamines are widely used for symptomatic relief. They do not interrupt the chain of antigen-antibody-histamine release, but block the access of the released histamine to the sensitized tissues. Their action is palliative and not curative, and the response to treatment is often variable.
They are usually effective in hayfever, urticaria and insect bites, but are of no value in allergic asthma. Some antihistamines also have a sedative action, which may be useful in urticaria, but undesirable in other conditions. This sedative side-effect is less marked with some of the newer antihistamines. In overdose they may cause convulsions in young patients. The extended local application of antihistamines should be avoided, as antihistamines may themselves cause an allergic-type dermatitis. Side-effects include dry mouth, blurred vision and occasional gastrointestinal disturbances. Patients should be warned that drowsiness is a common side-effect that may affect car-driving ability. Attempts have been made to desensitize susceptible patients by injections of specific antigens, such as grass pollens. The method is not without risk, particularly in asthmatic patients, and should be carried out only by experts.

Approved names               Brand names                            Daily dose range

acrivastine*                       Semprex                                  24 mg
asternizole*                      Hismanal, Pollen-Eze              10 mg
azatadine                          Optimine                                  2-4 mg
brompheniramine             Dimotane                                 12-32mg
cetrizine*                          Zirtek                                       10 mg
chlorpheniramine              Piriton                                     12-24mg
clemastine                        Tavegil                                     1-2 mg
cyproheptadine                 Periactin                                   8-32 mg
loratadine*                        Clarityn                                    10 mg
mezquitazine                    Primalan                                   5-10 mg
phenindamine*                 Thephorin                                 75-150 mg
pheniramine                     Daneral SA                                 75-150mg
promethazine                   Phenergan                                 20-75 mg
terfenadine*                     Triludan                                    60-120 mg
trimeprazine                    Vallergan                                   30-100 mg
triprolidine                      Actidil, Pro-Actidil                     7.5-15 mg

*Antihistamine with reduced sedative effects

Generic Antiallergic Medicine and Their Active Ingredients

Product Name Active Ingredient
allegra fexofenadine hcl
allegra-d fexofenadine-pseudophedrine
aristocort triamcinolone
atarax hydroxyzine
clarinex desloratadine
claritin loratadine
danocrine danazol
dexone dexamethasone
elocon mometasone
optivar azelastine
periactin cyproheptadine
singulair montelukast
tavist clemastine
zyrtec cetirizine
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