Treatment of Allergic Rhinitis

Medications for Hay Fever

Hay Fever Treatment: Use of Medicines for Allergies

When avoidance measures fail or are not possible, many people will require medications to treat their allergic rhinitis symptoms. The choice of medication depends on numerous questions to be answered by the person or person’s physician:

1. How severe are the symptoms?

2. What are the symptoms?

3. What medication can the person get (over the counter, prescription)?

4. What medication will the person take?

5. Is the medication needed daily or intermittently?

6. What side effects might the person experience from the medications?

Oral antihistamines. This is the most common class of medications used for allergic rhinitis. The first generation antihistamines, which includes Benadryl®, are generally considered too sedating for routine use. These medications have been shown to affect work performance and alter a person's ability to operate an automobile.

Newer, second-generation antihistamines have now become first-line therapy for people with allergic rhinitis. These prescription medication include cetirizine (Zyrtec®), fexofenadine (Allegra®), and desloratadine (Clarinex®). Loratadine (Claritin®, Alavert® and generic forms) is now available over the counter.

These medications have the advantage of being relatively inexpensive, easy for people to take, start working within a few hours, and therefore can be given on as “as needed” basis. The medications are particularly good at treating sneezing, runny nose, and itching of the nose as a result of allergic rhinitis. Side effects are rare, and include a low-rate of sedation or sleepiness, but much less than the first-generation antihistamines.

Topical nasal steroids. This class of allergy medications is probably the most effective at treating nasal allergies, as well as non-allergic rhinitis. There are numerous topical nasal steroids on the market, and are all available by prescription. Some people note that one smells or tastes better than another, but they all work about the same.

This group of medications includes fluticasone (Flonase®), mometasone (Nasonex®), budesonide (Rhinocort Aqua®), flunisolide (Nasarel®), triamcinolone (Nasacort AQ®) and beclomethasone (Beconase AQ®).

Nasal steroids are excellent at controlling allergic rhinitis symptoms. However, the sprays need to be used daily for best effect and therefore don’t work well as needed. Side effects are mild and limited to nasal irritation and nose bleeds. The use of these nasal sprays should be stopped if irritation or bleeding is persistent or severe.

Other prescription nasal sprays. There are two other prescription nasal sprays available, a nasal antihistamine and a nasal anti-cholinergic. The anti-histamine, azelastine (Astelin®), is effective at treating allergic and non-allergic rhinitis. It treats all nasal symptoms similar to nasal steroids, and should be used routinely for best effect. Side effects are generally mild and include local nasal irritation and some reports of sleepiness, as it is a first-generation antihistamine.

Nasal ipratropium (Atrovent nasal®) works to dry up nasal secretions, and is indicated at treating allergic rhinitis, non-allergic rhinitis and symptoms of the common cold. It works great at treating a “drippy nose”, but will not treat nasal itching or nasal congestion symptoms. Side effects are mild and typically include local nasal irritation and dryness.

Over-the-counter nasal sprays. This group includes cromolyn nasal spray (NasalCrom®) and topical decongestants such as oxymetazoline (Afrin®) and phenylephrine (Neo-Synephrine®). Cromolyn works by preventing allergic rhinitis symptoms only if used before exposure to allergic triggers. This medication therefore does not work on an as-needed basis.

Topical decongestants are helpful in treating nasal congestion. These medications should be used for limited periods of 3 days every 2-4 weeks; otherwise there can be a rebound/worsening of nasal congestion called rhinitis medicamentosa.

The side effects of the above are both generally mild and include local nasal irritation and bleeding, but topical decongestants should be used with caution in patients with heart or blood pressure problems.

Oral decongestants. Oral decongestants, with or without oral antihistamines, are useful medications in the treatment of nasal congestion in people with allergic rhinitis. This class of medications includes pseudoephrine (Sudafed®), phenylephrine, and numerous combination products. Decongestant/antihistamine combination products (such as Allegra-D®, Zyrtec-D®, Clarinex-D® and Claritin-D® are indicated for treating allergic rhinitis in people 12 years of age and older.

This class of medication works well for occasional and as-needed use, but side effects with long-term use can include insomnia, headaches, elevated blood pressure, rapid heart rate and nervousness.

Leukotriene blockers. Montelukast (Singulair®), was originally developed for asthma approximately 10 years ago, and is now approved for the treatment of allergic rhinitis as well. Studies show that this medication is not as good at treating allergies as the oral anti-histamines, but may be better at treating nasal congestion. In addition, the combination of montelukast and an oral antihistamine may be better at treating allergies than either medication alone.

Montelukast may be of particular benefit for people with mild asthma and allergic rhinitis, since it is indicated for both medical conditions. The medication must be taken daily for best effects, and usually takes a few days before it starts working. Side effects are usually mild and include headaches, abdominal pains and fatigue.

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Dykewicz MS, Fineman S, editors. Diagnosis and Management of Rhinitis: Complete Guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology.

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