Seasonal advice, treatment and prevention
Allergy Advisor - Seasonal Update  WINTER/ SPRING/ SUMMER/FALL
Limiting Exposure to Allergens in the Home 
Prevention of Allergy and Asthma in Children
Treatment of Allergy and Asthma
Skin Testing and Allergy Injection Treatment
Inhalers for Asthma
Spacers for Asthma Inhalers
Inhalers for Rhinitis
Tricks for - children to swallow pills
                  - eye drops
Mexican Medications

Treatment of Allergy and Asthma

Allergic rhinitis and asthma may be effectively treated by a number of medications supplemented by allergen avoidance, and by allergen immunotherapy (allergy injections) when medications and avoidance are inadequate.   Rational basis for treatment rests on the understanding of the mechanisms that underlie allergic  inflammation (see Mechanisms of Respiratory Allergy).  Treatment is most effectively given by an allergist who is certified by the American Board of Allergy and Immunology. 

Oral Drug Therapy of Allergic Rhinitis

• Drugs for allergic rhinitis may include antihistamines, decongestant drugs, and  anti-inflammatory nasal sprays and eye drops. 
• Antihistamines work best for itching, sneezing and nasal discharge, whereas nasal stuffiness responds better to decongestants such as pseudoephedrine, phenylephrine and phenylpropanolamine.  Antihistamines and decongestants are frequently combined in the same medication. 
• Over-the-counter, non-prescription antihistamines are often effective, but they are usually sedating and may increase risk of accident when driving or operating hazardous machinery.  Antihistamines that are not classed as "non-sedating" can reduce the reflex reaction time or speed of performance and impair classroom learning even when there is no obvious drowsiness.  It is often necessary to restrict their use to bed-time dosing.  Alcohol greatly increases the sedative effects of antihistamines.
• Does the medication available over the counter contain a potentially sedating antihistamine?  Look for any of the following active ingredients:                      
                       brompheniramine
                       carbinoxamine
                       cetirizine (mild sedation)
                       chlorpheniramine
                       clemastine
                       dexbrompheniramine
                       diphenhydramine (moderate to severe sedation)
                       triprolidine
  Loratadine, available over the counter, is non-sedating for adults in 10 mg doses.
• The newer non-sedating prescription antihistamines do not have these risks but their improved efficacy is still under investigation.   Some prescription-only antihistamines may be sedating: ask about them when given new prescriptions. 
• Phenylpropanolamine use in high doses has been associated with hemorrhagic stroke (bleeding in the brain) in women. Men may also be at risk, but men have not been studied extensively for incidence of stroke after taking this drug.  In the USA, preparations containing phenylpropanolamine have been withdrawn from the market.

Nasal Spray Therapy of Allergic Rhinitis

• Nasal decongestant sprays, particularly the long acting type, may become ineffective with regular use, and cause rebound nasal congestion that is worse than the pre-treatment situation.  Occasional use once a day does not carry this risk.  Regular use should be for no longer than one week.  
• Anti-inflammatory nasal sprays e.g., nasal corticosteroids, do not cause rebound congestion and are not "habit forming."  Nasal steroids are safe and are more effective in preventing and treating symptoms of allergic rhinitis than are any of the antihistamines.  Other types of nasal spray that are not steroids or decongestants may be effective for some patients:  these include ipratropium and olopatadine.
  
  When drug therapy is inadequate, allergen immunotherapy (allergy injections) given by a qualified allergist is usually indicated and often reduces the need for medications.

Sinusitis

• Acute sinusitis usually does not require antibiotic therapy unless it persists for more than a week.  When antibiotics are prescribed it is vitally important to continue the treatment until all of the prescribed medication has been taken, because the main cause of antibiotic drug resistance, an increasingly serious problem, is caused by stopping antibiotic treatment too soon.   If sinus infections recur several times a year, consultation with an allergist may help to find a cause such as allergic rhinitis.

Nasal Irrigation

• Nasal ("sinus") irrigation or snorting with water or saline solution is commonly used for chronic rhinitis and/or sinusitis, and has been shown to be more effective than saline nasal sprays in giving relief from persistent nasal stuffiness and thick nasal discharge.  Irrigation is done by flowing water or saline into one nostril and draining from the other.
• In the Tucson area (and possibly elsewhere) this could be dangerous if done with water that has not been sterilized, because of the recent discovery of Naegleria fowleri in ground water.   This is a species of amoeba that has caused fatal brain infection (meningoencephalitis) in children and young adults after swimming in lakes commonly contaminated by the amoeba.  Although no cases of brain infection have yet been attributed to nasal irrigation with unsterile water, the possibility exists in Tucson.  If you irrigate the nose with solutions made with tap water, be sure to sterilize it by boiling first.

Asthma

• Treatment of persistent asthma with over-the-counter medications or with unsupervised occasional use of prescription medications is a risk for irreversible lung damage and, in some cases, death.
  
• Although oral medications such as theophylline, Accolate and Singulair are useful for treatment of some patients with asthma, most patients need inhaled medications.  Recognition of the different types of inhaled medication is important.

• Warnings that asthma needs immediate medical care is when
  - a canister of bronchodilator (rapid reliever) lasts for only 4 weeks or less
  - when asthma causes night time awakenings once a week or more often
  - when there is increasing shortness of breath on exercise 
  - when the peak expiratory flow measured by a peak flow meter falls to or below 50% of your personal best value
     
• Persistent asthma requires treatment by regular dosing with anti-inflammatory medications (also called controller medications), taken every day as prescribed, with the goals of -

• sleeping every night with no awakenings by asthma symptoms
• no limitation by asthma of physical activity, e.g., running or stair climbing
• reduction of use of rapid-relieving  bronchodilator drugs (so-called reliever medications) to twice a week or less
• return of lung function measurements to normal 
• attaining a desirable lifestyle not limited by asthma, with no lost time from school or work 

Do not reduce your anti-inflammatory medication dose or frequency without consultation with your physician, even if all the goals are achieved.

Persistent asthma, when not accompanied by a significant component of allergy, is best managed by a Board- Certified allergist or a Board-Certified pulmonologist.

Further Reading
AAAAI:   Asthma and allergy medications
National Heart Lung and Blood Institute Expert Panel Report 3 Guidelines for the Diagnosis and Management of Asthma 2007 (written for health professionals)    http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm
Rachelefsky G, Garrison P: Free your child from asthma.  McGraw Hill, New York, 2006
Calderon MA. Alves B. Jacobson M. Hurwitz B. Sheikh A. Durham S. Allergen injection immunotherapy for seasonal allergic rhinitis.[Review] [316 refs] Cochrane Database of Systematic Reviews. (1):CD001936, 2007.

Disclaimer:   This site is for educational purposes only.  Any information that you have found in this web site is not intended to replace medical care or advice given to you by your own physicians. You should consider consulting your local medical library and other web sites for additional information. 

Comments and suggestions welcome!   Email: schumach@u.arizona.edu
Content Owner:  Michael J. Schumacher, MB, FRACP, The University of Arizona
Updated 3/2012