Which allergy medication do you reach for first? | TulsaAllergyNews

Are you unsure which allergy medication to take when your symptoms start acting up? Read this article for a breakdown of the three most common types of treatments.

When it comes to allergies, there are a variety of medicines and treatments available to help manage them. However, with the broad range of choices available, choosing which medicine or treatment to take first can be difficult for patients and even doctors. Right now, we’re fortunate enough to have access to options such as antihistamines, decongestants and corticosteroids–but how do we make sure that our choice is continuing us down the right path? In this blog post we will explore these different medications and examine which one should come first when considering treating your allergies.

When it comes to managing symptoms associated with allergies, antihistamines are the most well-known option. While antihistamines can provide some relief, they often only offer temporary symptom relief and may need to be taken daily. Your recall of antihistamines is probably quite good, as most patients are quick to name Zyrtec, Xyzal, Allegra, and Claritin as potential choices.

  • So what do the next 2 articles tell us about how to use medications to treat allergic rhinitis?
  • Usually patients coming in to our allergy clinic have already tried the OTC antihistamines. No big surprise here. What is important to know is the best results come from adding a nasal spray to antihistamines and even the addition of Singular (montelukast) to give a total of three daily medications. Seriously, does anyone really use 3 medications for the same condition on a consistent basis?
  • When you throw your hands up because you’re frustrated with how much medication you have to use, consider going to an allergy specialist and learning more about Allergy Immunotherapy or allergy shots. Our second article talks about the benefits of specialty care for allergy, and maybe it’s because we will often use allergy shots instead of excessive medications.

Chitsuthipakorn W, Hoang MP, Kanjanawasee D, Seresirikachorn K, Snidvongs K. Combined medical therapy in the treatment of allergic rhinitis: Systematic review and meta-analyses. Int Forum Allergy Rhinol. 2022 Dec;12(12):1480-1502. doi: 10.1002/alr.23015. Epub 2022 May 8. PMID: 35446512.

Background: Antihistamines (ATH) and intranasal corticosteroids (INCS) are primary treatments for patients with allergic rhinitis (AR). When monotherapy of either primary treatment fails to control symptoms, combined medical therapy is an option. In this meta-analysis we assessed the additional effects of different medical combinations compared with primary treatments.

Methods: Systematic searches on PubMed and EMBASE were updated on November 4, 2021. Randomized, controlled trials comparing the effects of combinations with monotherapy were included. There were 7 comparisons: (1) ATH-decongestant vs ATH; (2) ATH-leukotriene receptor antagonist (LTRA) vs ATH; (3) INCS-ATH vs INCS; (4) INCS-LTRA vs INCS; (5) INCS-decongestion vs INCS; (6) INCS-saline irrigation vs INCS; and (7) ATH-saline irrigation vs ATH. Data were pooled for meta-analysis. Outcomes were composite nasal symptom score, composite ocular symptom score, quality of life (QoL), and adverse events.

Results: Fifty-three studies were included. Compared with ATH alone, the ATH-decongestant combination improved composite nasal symptoms; ATH-LTRA improved nasal symptoms in patients with perennial AR; and ATH-nasal saline improved both symptoms and QoL. Compared with INCS alone, the INCS-intranasal ATH combination improved nasal symptoms, ocular symptoms, and QoL; INCS-LTRA improved ocular symptoms but not nasal symptoms; and INCS-nasal saline improved QoL but not symptoms. There were no additional effects observed from adding oral ATH or topical decongestant to INCS.

Conclusion: After ATH monotherapy fails to control symptoms, addition of decongestant, saline, or LTRA can improve the outcomes. When INCS monotherapy is ineffective, addition of intranasal ATH can improve nasal symptoms; LTRA can improve ocular symptoms, and saline irrigation can improve QoL.

Mullol J, Bartra J, del Cuvillo A, Izquierdo I, Muñoz-Cano R, Valero A. Specialist-based treatment reduces the severity of allergic rhinitis. Clin Exp Allergy. 2013 Jul;43(7):723-9. doi: 10.1111/cea.12081. PMID: 23786279.

Background: Although the treatment of allergic rhinitis (AR) is now well established, its impact on severity has not yet been evaluated.

Objective: The aim was to analyse specialist-based treatment on AR severity, nasal symptoms and quality of life.

Methods: A longitudinal observational, prospective, multi-centre study with 4 weeks of follow-up was carried out by 141 allergologists and ENT specialists in Spain. Selection criteria were adult patients with AR, clinically diagnosed at least 2 years before, with a total nasal symptom score (TNSS) ≥5, not receiving either antihistamines within the previous week or nasal corticosteroids during the 2 previous weeks. Disease severity using both original Allergic Rhinitis and its Impact on Asthma (o-ARIA) and modified (m-ARIA) classifications, nasal symptoms, and Quality of Life (ESPRINT-15), were measured at baseline and after 4 weeks of treatment.

Results: Among the recruited AR patients (n = 707, 58% women), 39.3% were intermittent and 60.7% persistent, 40.2% had asthma and 61.4% conjunctivitis. Most patients were treated with second generation antihistamines in monotherapy (63.2%) or in combination with intranasal corticosteroids (31.5%). While using o-ARIA, 96.9% of patients had ‘moderate/severe’ AR, the m-ARIA discriminated between ‘moderate’ (55.4%) and severe (41.5%) AR, at baseline. After 4 weeks of treatment, improvement was found on disease severity (P < 0.0001), TNSS (8.2 ± 1.8 vs. 3.5 ± 2.3, P < 0.0001) and Quality of Life (ESPRINT-15 global score: 3.0 ± 1.2 vs. 1.1 ± 1.0, P < 0.0001).

Conclusions: Specialist-based treatment reduces AR severity, evaluated using the m-ARIA classification for the first time, in addition to the improvement of nasal symptoms and quality of life.

Clinical relevance: Specialist-based treatment improves AR severity, in addition to nasal symptoms and quality of life. However, no matter the treatment option some AR patients remain severe and need further follow-up.

One can see from this illustration that what comes in to the nose will continue onward to cause asthma and lower respiratory symptoms. This is why allergy patients should use their nasal steroids on a consistent basis. Studies have found that intranasal corticosteroids are more effective than antihistamines in every clinical study and require consistent use in order to be effective, but unlike antihistamines do not need to be taken on a daily basis. The good news about STEROIDS is 5 days of an oral corticosteroid burst equals 25 years of using INTRANASAL corticosteroids.

For the best results when it comes to reducing symptoms of allergies over time, however, allergy immunotherapy (AIT) is likely your most promising option; this does take time and commitment for up to three or five years for maximum benefit but many individuals report significant improvement after completing immunotherapy as part of their allergy treatment plan.

Kaszuba SM, Baroody FM, deTineo M, Haney L, Blair C, Naclerio RM. Superiority of an intranasal corticosteroid compared with an oral antihistamine in the as-needed treatment of seasonal allergic rhinitis. Arch Intern Med. 2001 Nov 26;161(21):2581-7. doi: 10.1001/archinte.161.21.2581. PMID: 11718589.

Background: The daily use of either intranasal corticosteroids or histamine(1) (H(1)) receptor antagonists has proved to be efficacious in the treatment of seasonal allergic rhinitis. Most patients, however, use these medications as needed. Our objective was to compare the effectiveness of as-needed use of H(1) receptor antagonists with that of intranasal corticosteroids in the treatment of seasonal allergic rhinitis.

Methods: We performed a randomized, open-label, parallel-group study comparing the as-needed use of an H(1) receptor antagonist (loratadine) with that of an intranasal corticosteroid (fluticasone propionate) in the management of fall seasonal allergic rhinitis in the fall of 1999. Subjects kept a diary of their daily symptoms and were examined at enrollment into the study and biweekly for 4 weeks during treatment. Outcome measures were the Rhinoconjunctivitis Quality of Life Questionnaire score, daily symptom diary scores, and the number of eosinophils and the levels of eosinophilic cationic protein in nasal lavage samples.

Results: Patients in the fluticasone-treated group reported significantly better scores in the activity, sleep, practical, nasal, and overall domains (P<.05) of the Rhinoconjunctivitis Quality of Life Questionnaire. The median total symptom score in the fluticasone-treated group was significantly lower than that in the loratadine-treated group (4.0 vs 7.0; P<.01). After treatment, the number of eosinophils was significantly smaller in the fluticasone-treated group compared with the loratadine-treated group (P =.001). Eosinophilic cationic protein levels followed the same pattern, with a significant correlation between the levels of eosinophilic cationic protein and the number of eosinophils (r(s) = 0.70, P<.01).

Conclusion: As-needed intranasal corticosteroids reduce allergic inflammation and are more effective than as-needed H(1) receptor antagonists in the treatment of seasonal allergic rhinitis.

With many different successful treatments available, you and your allergy specialist can find the best strategy for managing your allergies. Intranasal corticosteroids are safe and the most effective medication currently available, but you still have to take it “forever” as long as you have allergies. If you are interested in a long-term solution that has the potential to “cure” your allergies, then allergy immunotherapy or allergy shots may be right for you. These shots work by slowly injecting increasing amounts of an allergen under the skin; as time goes on, your body becomes less sensitive to the allergen. This treatment requires dedication, as it typically takes 3-5 years to complete the course of injections; however, many people report a decrease in symptoms and eventually no longer needing daily medications once they have finished their shots. Talk to your allergist about whether this option is right for you.

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