A Magical Pharmacy Tour: Demystifying the Over-the Counter Medications for Seasonal Allergies

Spring is here……unless we believe that it will snow in May, since the latest measurable (0.1 to 1.0 inch) snowfall for the winter season in Chicago recorded history has occurred as late as May 11^th.  Pollen/mold counts during April have been low to moderate and have even included grass pollen being detected on some days, which is unusual compared to prior years.  The spring allergy season began earlier in the first half of March, based on some patients reporting that their typical allergy nose and eye symptoms returned then.

Denials by insurers of coverage for medications that worked in the past, plus increased costs of some prescription medicines even when covered, have caused people to use over-the-counter medications to treat their seasonal symptoms.  These medications are considered safe by the FDA to buy without a prescription from, what the government calls, a “learned intermediary.”  Yes, these medications can be effective.  Yes, these risks are low; but they are not zero.  What should a patient choose when walking down the aisle of the shelves labeled “Allergy”?

The most commonly recommended categories of medications are (a) antihistamines; (b) nasal corticosteroid sprays (“steroid nasal sprays”); (c) decongestant pills; and (d) eye drops.  Some important things to know about each of these categories are the following:

Antihistamines:

• Antihistamine pills are more likely to help symptoms of sneezing, itching and rhinorrhea.
• There are four products that are called ‘2^nd or 3^rd generation’ antihistamines. These are considered to be much less likely to cause drowsiness or fatigue than Benadryl or Chlortrimeton.  The brand names of these four products are Claritin, Allegra, Zyrtec and Xyzal (the chemical mirror image of Zyrtec).
• The 2^nd – 3^rd generation antihistamines should be chosen over Benadryl and other antihistamines because of the lower potential to be unable to concentrate when operating a motor vehicle or when working.
• There can be side effects on the ability to urinate and of dry mouth. If these occur, a “learned intermediary” should be consulted.

“Steroid Nasal Sprays”

• Starting in 2014, steroid nasal sprays have been approved by the FDA despite concerns from more than some in the allergist community about monitoring for risks—more in a moment.
• Steroid nasal sprays can alleviate the symptoms that antihistamines affect and are also more likely to decrease nasal congestion than antihistamines.
• Steroid nasal sprays block more immunological pathways that are involved in developing symptoms than antihistamines can. Antihistamines only block one molecule made inside the body—as the name indicates:  histamine.  Therefore, steroid nasal sprays are more likely to be effective
• There are currently three steroid nasal sprays available: Nasacort, Flonase and Rhinocort.
• Side effects that can occur with nasal steroid sprays are burning, nose bleeds and headache. The chance of nosebleeds is reduced if one angles the tip of the nose spray toward the side of the inside of the nose instead of towards the middle of the nose.  If these side effects occur, it would be time to consult with a health care professional.
• There are very low, almost remote, risks of nasal steroid sprays affecting the eyes (cataracts or glaucoma) and the bones (bone thinning and, with adolescents, decreased growth velocity by approximately one inch). I think most allergists would agree that starting this class of medication should be reviewed by a health care professional who can assess the risk in the context of the person’s medical history.

Decongestant Pills

• They affect nasal congestion and are unlikely to affect sneezing and itchy nose.
• The chemical names on the sides of the boxes are pseudoephedrine and phenylephrine. The best known brand name is Sudafed.
• They can be part of other medications, such as ‘Advil Allergy Sinus’ and Claritin-D 12 and 24 Hour.
• Purchase of these could require showing a drivers license to the pharmacist after you see a coupon for the drug on the shelf.
• These should be used cautiously because they could cause palpitations, cause men to have difficulty urinating and cause an unacceptable increase in blood pressure.

Decongestant Nasal Sprays (a few words about these)

• The most common brand name for this type of medication is Afrin. The chemical name is oxymetazoline, which is what you would need to find in the ingredient list on the box.
• This type of nose spray is supposed to have the same effect as a decongestant pill.
• However, there is a risk of becoming addicted to it if used for more than 3-5 consecutive days. These should only be used for no more than 3-5 days to get through an upper respiratory infection or another cause that is brief in exposure.

Eye Drops

• These are reasonable to try initially if there is a reason not to use an antihistamine pill.
• There are four categories of eye drops:

1. Antihistamine/mast cell stabilizers (translation of mast cell is that it is a cell triggered by allergens).  Brand products are Zaditor and Alaway.
2. Mast cell stabilizer: e.g. Crolom.
3. Antihistamine/decongestants: e.g. Naphcon-A and Opcon-A
4. Decongestants: e.g. Vasocon

• If one of these four categories does not work well after the first or second use, another category should be tried. One of the categories tried should be an antihistamine/mast cell stabilizer.  If none of these works well, consulting with a health care professional should occur next.

As I walked down the pharmacy aisle, many other products are also on the ‘Allergy’ shelf.   These deserve some mention about their safety and effectiveness, but they will be part of the tour in next month’s blog.

Dr. Klein