Posted tagged ‘hay fever’

Spring is here! Allergy therapy update

March 4, 2019

The Pediatric Insider

© 2019 Roy Benaroch, MD

Ah, the sounds of spring. Birds tweeting, bees buzzing, and noses sniffling and sneezing. Fortunately, there are some great medicines out there to help reduce the symptoms of spring allergies, and most of them are inexpensive and over-the-counter. Here’s an updated guide to help you pick the medicines that are best to relieve your family’s suffering.

But first: before medications, remember non-medical approaches. People with allergies should shower and wash hair after being outside (though it’s not practical or good to just stay inside all spring!) You can also use nasal saline washes to help reduce pollen exposures.

For my medicine guide this year, I’ve included some photos to make these easier to find. A new trend seems to be color coding, with generics matching the brands in color and “look and feel”. That’s good if it makes the cheaper generics easy to find — they work just as well, and really should be your first choice for any of the options below.

Antihistamines are 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. There are better choices. Benadryl products are usually packaged in a pink, hidden sad and lonely in the bottom row.

Pink Benadryl makes people sleepy. There are better options.

It’s better to use a more-modern, less-sedating antihistamine like Zyrtec (cetirizine), Claritin (loratidine), or Allergra (fexofenidine.) All of these are OTC and have cheap generics. They work taken as-needed, or can be taken every day. Antihistamines don’t relieve congested or stuffy noses—for those symptoms, a nasal steroid spray is far superior.

Zyrtec and cetirizine come boxed in springtime green.

 

If Claritin’s for you, it comes in friendly blue.

 

Very few words rhyme with purple. This is Allegra.

There are a just a few differences between the modern OTC antihistamines. All are FDA approved down to age 2, though we sometimes use them in younger children. They all come in syrups, pills, or melty-tabs. Zyrtec is the most sedating of the three (though far less than Benadryl). Zyrtec and Claritin are once a day, while Allegra, for children, has to be taken twice a day. A 2017 study showed that Zyrtec is marginally more effective than Claritin, so I’ve been recommending that one first.

This year, there is one new player among the OTC antihistamines, called “Xyzal.” OK, I admit the name is cool — but it is therapuetically identical to Zyrtec. I don’t think it’s worth its typically-higher price.

Arresting orange says “XYZAL!”

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 hidden in back.

Nasal Steroid Sprays include many choices, all of which are essentially equivalent in effectiveness: OTC Nasacort, Flonase, Rhinocort, Sensimist, and many generics are available. All of these products are essentially the same. They all 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.

Lots of steroid nasal sprays. They’re all essentially the same.

Some minor distinctions: Nasacort is approved down to age 2, Flonase to 4, and Rhinocort to 6, though there’s no reason to think any are more or less safe for children. Flonase is scented (kind of an odd, flowery scent, which seems weird in an allergy medicine), and seems to be a little more burny to some people than the others. My personal favorite is Nasacort or its generic version. Here’s a quirk: Nasacort comes in 2 differently-packaged versions, for adults and for children. But the product itself is the same. The pediatric version sells for less, but it’s a smaller bottle. I guess because children are smaller. Weird.

Children’s and regular Nasacort (and generic triamcinolone) are the same product in a different-sized bottle.

Nasal oxymetazolone (brands like Afrin) are best avoided. Sure, they work, 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. Steroid nasal sprays are much safer than OTC Afrin.

Eye allergy medications include the oral antihistamines, above; and the topical nasal spray 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. There’s a generic version, though some people have told me the generic stings a bit.

Zaditor? Who names these things?

Bottom line: for mild eye or nose symptoms, a simple oral antihistamine is probably the best first line. For more severe symptoms OR symptoms dominated by clogging and stuffiness, use a steroid nasal spray. You can also use both, in combination, an antihistamine PLUS a steroid spray, for really problematic symptoms. Anything not improving on that combo needs to see a doctor.

This is an updated version of previous posts.

 

 

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Get ready for spring! Allergy therapy update, 2015

March 9, 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?

Allergy scams at the doctor’s office

March 25, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

Andy wrote in about something new that’s been offerred at his pediatrician’s office:  “I’m curious to know your thoughts on allergy treatment companies.  They offer testing through Pediatricians offices and share results looking to offer treatments in cases where symptoms can be relieved.  My two children were tested and are susceptible to 22 out of 48 areas.  They recommend injections at a rate of 2 shots 3X/week for 8 months then 2 shots 2X/week for 4 months.  That’s 276 injections in the first year.  In year two they may reduce the injections with the hope that they eliminate allergies ‘for life.’  My question is: what are your thoughts on this and what’s worse, the allergies or potentially injecting my children 276 times in a year?”

I’ve been offered to set up a similar system at my office– doing allergy testing and then getting allergy injection material from a single company. Their promotional material heavily emphasized the profit angle. If their numbers are right, a doc could make a fortune doing this. All of those shots are given at billable encounters, and the reimbursement looks, well, obscene (in a good way. I mean, good for the doc. Maybe not so good for whomever is paying the bill.) In contrast, the material they sent to me was actually quite light on the science, so I looked into it in detail thru their website. They’re using “proprietary” allergy testing that is not FDA approved and is, to put it mildly, non-standard. I have no way of knowing if their testing accurately predicts allergy or not. On their website they offer zero independent collaborative studies of their testing or their reagents. Is it effective? Who knows?

I’m not going to put my patients thru what’s essentially an undisclosed, uncontrolled, and very expensive clinical study to see if this works.

I have no way of knowing if the testing done on your family was reliable or not, or if what you’ve been offered is the same as what I’ve looked into. Could be a completely different system. But I’d be somewhat skeptical of investing this much time, money, and pain into something that may not be as reliable as you’ve been told.

There are great, very effective allergy medications out there now, at least for environmental allergies. Long before I’d suggest testing I’d have a child on a daily antihistamine + a daily inhaled nasal steroid, and maybe a few other things. Most of the time, if these aren’t working it’s because the child isn’t actually taking the medications every day. If the meds are truly being used and there are still problematic symptoms that are directly causing decreased quality of life, then I refer to an allergist for state-of-the-art, reliable testing and immunotherapy.