Get ready for spring! Allergy therapy update, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

In last year’s Pulitzer Prize winning* post, I reviewed the medications available for treating the symptoms of spring allergies—antihistamines, nasal sprays, prescription and non-prescription goodness. There’s some new information and changes this year, so it’s time for an update!

First, a study just published provides more reassurance about the use of topical nasal spray steroids and growth. About 220 kids aged 3-9 were randomized to receive placebo nasal spray or intranasal triamcinolone (sold OTC as “Nasacort”), and their growth was followed before, during, and after treatment. Growth when the medication started was very slightly slower (by about an eighth of an inch a year), but that difference was quickly erased by catch-up growth after the medication was stopped. In typical practice, these medicines aren’t used year-round anyway. Bottom line: if there is any effect on growth, it’s insignificant, and it’s temporary.

We’ve also got the first FDA-approved sublingual allergy immunotherapy tablet to come to market. Sold as “Grastek”, taken regularly this can help children and adults overcome allergy to one specific plant, Timothy Grass. Downside: it takes a long time to “kick in”, and it only protects against this one specific pollen—when usually, people with polen allergies are allergic to multiple things. So I’m not sure just how useful this is. Still, it’s an interesting foot-in-the-door for home immunotherapy without the shots. I’m sure we’ll be seeing more of this kind of thing.

Here’s the rundown on all of the other medications, updated for 2015:

Antihistamines are still very effective for sneezing, drippy noses, and itchy noses and eyes. The old standard is Benadryl (diphenhydramine), which works well—but it’s sedating and only lasts six hours. Most people use a more-modern, less-sedating antihistamine like Zyrtec (cetirizine), Claritin (loratidine), or Allergra (fexofenidine.) All of these are OTC and have cheapo generics. They work taken as-needed or daily. There are still a few prescription antihistamines, but they have no advantage over these OTC products. Antihistamines don’t work at all to relieve congested or stuffy noses—for those symptoms, a nasal steroid spray is far superior.

Decongestants work, too, but only for a few days—they will lose their punch quickly if taken regularly. Still, for use here and there on the worst days, they can help. The best of the bunch is old-fashioned pseudoephedrine (often sold as generics or brand-name Sudafed), available OTC but hidden behind the counter. Don’t buy the OTC stuff on the shelf (phenylephrine), which isn’t absorbed well. Ask the pharmacist to give you the good stuff he’s got in back.

Nasal cromolyn sodium (OTC Nasalcrom) works some, though not as strongly as prescription nasal sprays. Still, it’s safe and worth a try if you’d rather avoid a prescription.

Nasal oxymetazolone (brands like Afrin) are best avoided. Sure, they work—they actually work great—but after just a few days your nose will become addicted, and you’ll need more frequent squirts to get through the day. Just say no. The prescription nasal sprays, ironically, are much safer than OTC Afrin.

Nasal Steroid Sprays include OTCs Nasacort and now OTC Flonase. There are also many prescription products, like generic fluticasone, Rhinocort, Nasonex, Nasarel, Veramyst, and others. All of these are essentially the same (though some are scented, some are not; some use larger volumes of spray.) All of them work really well, especially for congestion or stuffiness (which antihistamines do not treat.) They can be used as needed, but work even better if used regularly every single day for allergy season.

Antihistamine nose sprays are topical versions of long-acting antihisamines, best for sniffling and sneezing and itching. They’re all prescription-only (though they’re super-safe). They’re marketed as either the Astelin/Astepro twins (Astepro came out later, when Astelin became available as a generic; it lasts longer) or Patanase.

Bonus! Eye allergy medications include the oral antihistamines, above; and the topical steroids can help with eye symptoms, too. But if you really want to help allergic eyes, go with an eye drop. The best of the OTCs is Zaditor, which works about as well as rx Patanol, which they’re trying to replace with rx Pataday.

 

* That post didn’t win a Pulitzer. Does anyone read these footnotes?

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Tags: allergy, hay fever

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