April Showers Bring May Flowers… and Allergies!

Spring is one of the worst seasons for seasonal allergy sufferers. Patients with seasonal allergies will commonly complain of runny noses, congestion, itchy, watery eyes, and sneezing. However, a chronic cough and sinusitis can also be caused by allergies. 

Have a patient who comes to you for a steroid shot every spring due to sinus congestion? They may be suffering from allergies. The most common culprits for spring allergies are tree and grass pollen. 

The mainstay of treatment is avoiding allergens, but who wants to stay inside on a beautiful spring day? The number of over-the-counter (OTC) medications for allergies is unending, and all of the options can leave patients confused and lost. However, with the guidance of a clinician, patients can take charge of their allergy symptoms with medications found commonly at their local pharmacy.

Tips for Choosing the Right OTC Allergy Medication

1. Try Out Nasal Steroids

   Nasal steroids are the most effective medication for allergies! Intranasal corticosteroids (INCS) not only improve nasal symptoms but ocular allergy symptoms too. Are patients concerned about using a steroid? Studies have shown no clinically significant long-term side effects from intranasal steroids, including hypothalamic-pituitary suppression. There have been case reports of increased ocular pressure and the development of cataracts in older patients who use INCS, but research has not confirmed this risk. 
   
   
2. Bypass First-Generation Antihistamines
   
   Avoid first-generation antihistamines. Diphenhydramine (Benadryl), and chlorpheniramine (Chlor-Trimeton) are out, and second-generation antihistamines are in for the treatment of seasonal allergies.
    
   The major side effect of first-generation antihistamines is sedation, which can impact school and work performance, sleep quality, and impair driving. First-generation antihistamines also come with the risk of anticholinergic side effects, including dry mouth, constipation, and urinary retention. Recent studies have also linked first-generation antihistamines to a high risk of dementia. 
   
   Skip the negative side effects and encourage your patients to pick up cetirizine (Zyrtec), loratadine (Claritin), fexofenadine (Allegra), or levocetirizine (Xyzal) when choosing an oral antihistamine. 
   
   
3. For Quick Relief, Opt for Nasal Antihistamine 
   
   Studies have shown that intranasal antihistamines (INAH) offer similar relief for rhinitis symptoms to oral antihistamines but have a quicker onset of action. INAHs are on the list of first-line monotherapies recommended for seasonal allergic rhinitis by the ACAAI. The good news for patients is that azelastine (Astepro) can now be found over the counter!

Have your patients start their medications two weeks before their symptoms commonly begin. Allergy experts recommend initiating an allergy regimen at least two weeks before expected seasonal allergy symptoms start to build up the medicines before the allergens hit. 

Tips for Severe Allergies

If your patients are still suffering from seasonal allergies even while taking over-the-counter allergy medications, the ACAAI has some recommendations:

1. Take Caution With Oral Leukotriene Receptor Antagonists
   
   Avoid routinely prescribing oral leukotriene receptor antagonists (LTRA) as an initial prescription therapy for seasonal allergies. LTRAs are not as effective as other therapies and carry the risk of neuropsychiatric events, including suicidal ideation. Allergy experts recommend that LTRAs should only be used if other therapies are ineffective. 
   
   
2. Oral Corticosteroids Over Injections
   
   For patients with severe allergic rhinitis requiring a steroid, allergy experts favor a short course of oral corticosteroids over injections to avoid the increased risk of adrenal suppression associated with injectable forms.
   
   
3. When to Consider an Allergy Specialist
   
   If patients are still suffering from persistent allergic rhinitis, It may be time to see an allergy specialist for allergy testing. If allergy testing reveals sensitivities to environmental allergens, allergy immunotherapy but injection or sublingual tablet may be recommended. 

We hope these tips and recommendations from the ACAAI help you to feel more confident when helping your allergy-suffering patients manage their symptoms.