For most of us, spring is an eagerly anticipated part of the year. But for millions of people, spring represents the beginning of the dreaded allergy season. Rather than looking forward to the blossoming of flowers, many of us are looking forward to sneezing, sniffling, a runny nose and itchy eyes, all associated with what is commonly known as hay fever and is technically known as allergic rhinitis.
There are three general approaches to treat hay fever symptoms: avoidance, preventive and symptomatic treatment and immunotherapy. Although there is no cure for allergic rhinitis, most people can gain significant relief of their symptoms by applying some common sense and a wiser use of drug therapy.
The first and most logical approach is avoidance. Simply don't expose yourself to whatever causes symptoms. Unfortunately, this may be easier said than done. The National Institute of Allergy and Infectious Diseases recommends the following:
- Complete avoidance of allergenic pollen or mold means moving to a place where the offending substance does not grow and where it is not present in the air. But even this extreme solution may offer only temporary relief. If you are sensitive to a specific pollen or mold, you may develop an allergy to a new pollen or mold after repeated exposure.
- There are other ways to evade the offending pollen: remaining indoors in the morning, for example, when the outdoor pollen levels are highest. Sunny, windy days can be especially troublesome.
- Mold allergens can be difficult to avoid, but some steps can be taken to at least reduce exposure to them. The lawn should be mowed and leaves should be raked up, but someone other than the allergic person should do these chores. If such work cannot be delegated, wearing a tightly fitting dust mask can greatly reduce exposure and resulting symptoms.
- People with dust mite allergy should pay careful attention to dust-proofing their bedrooms. The worst things to have in the bedroom are wall-to-wall carpets, Venetian blinds, down-filled blankets, feather pillows, heating vents with forced hot air, dogs, cats and closets full of clothing. Shades are preferred over Venetian blinds because they do not trap dust. Curtains can be used if they are washed periodically in hot water to kill the dust mites. Most important, bedding should be encased in a zippered, plastic, airtight and dust-proof cover. Vacuuming can contribute to the amount of dust, unless the vacuum is equipped with a special high-efficiency particulate air (HEPA) filter.
- The best way for a person allergic to pets, especially cats, to avoid allergic reactions is to find another home for the animal. There are, however, some suggestions to help lower the levels of cat allergens in the air: Bathe the cat weekly and brush it more frequently (ideally, this should be done by someone other than the allergic person), remove carpets and soft furnishings, and use a vacuum cleaner with a high-efficiency filter and a room air cleaner. Wearing a face mask while cleaning the house and cat, and keeping the cat out of the bedroom are other methods that allow many people to live more happily with their pets.
- Irritants such as chemicals can worsen allergy symptoms and should be avoided as much as possible. For example, during periods of high pollen levels, people with pollen allergy should try to avoid unnecessary exposure to irritants such as insect sprays, tobacco smoke, air pollution, and fresh tar or paint.
If you don't know what is causing the problem or simply cannot avoid it, drug therapy is the next step. Here are our recommendations:
Decongestants — Decongestant drugs (including pseudoephedrine, phenylephrine, oxymetazoline and others) all work in the same way and provide temporary relief from nasal stuffiness. Decongestant can be taken by mouth either alone or in combination with antihistamines. These drugs should be used with some caution by people with heart disease and other chronic illnesses. It is important to read the label before you use them. Decongestant nasal sprays are also available. Decongestant sprays should not be used for more than a few days. Longer-acting forms (such as oxymetazoline, the active ingredient in Afrin) can cause a rebound form of nasal congestion if used for longer periods of time.
Antihistamines — Over-the-counter antihistamines should be used as the first step for people who have more than occasional symptoms. There are some trade-offs to be considered. The older antihistamines such as Chlor-Trimeton (also known as chlorpheniramine) and Benadryl (also known as diphenhydramine) are very inexpensive but can cause sleepiness. The feeling of sleepiness does not occur in everyone.
The drowsiness seen with the over-the-counter antihistamines is usually seen in the first few hours after taking it, so my recommendation is to take the first few doses at bedtime. After about a week, most people can take the drugs during the day and not experience any drowsiness. The drowsiness declines over a brief period of time. About one out of every 12 people will have drowsiness on an ongoing basis.
Most of the nonsedating antihistamines are available with a prescription. They include:
- Loratadine (sold under the brand names Claritin, Alavert and Tavist ND as well as store brands)
- Fexofenadine (Allegra)
- Cetirizine (Zyrtec)
Loratadine and fexofenadine are more expensive than the older antihistamines but do not cause drowsiness and work as well in relieving symptoms. Zyrtec, however, can sometimes cause as much drowsiness as the older drugs.
Prescription-only antihistamines do not work any better than over-the-counter loratadine, fexofenadine or cetirizine. Store brands of loratadine work as well as the brand-name versions.
- None of the newer antihistamines is any better than the older and less expensive over-the-counter antihistamines such as chlorpheniramine.
- Drowsiness can be a problem with the older, over-the-counter antihistamines, but the drowsiness can be reduced by taking them at bedtime for the first week. Most people build up a tolerance to the drowsiness by the end of a week.
- Brand-name over-the-counter antihistamines are no better than the store brand and are much more expensive.
- Loratadine is less likely to produce drowsiness and works as well at relieving symptoms as the older and far less expensive antihistamines.
- Prescription antihistamines do not work any better than over-the-counter products and are more expensive than the over-the-counter products if you are paying out-of-pocket.
Leukotriene antagonists — Montelukast (also known as Singulair) is a member of a group of drugs called leukotriene antagonists. These drugs work to reduce inflammation, but in a different way than do the nasal steroids. Singulair is used most commonly for asthma and also can be prescribed for allergic rhinitis. Although it works, there is no evidence that it is any better than antihistamines or nasal steroids. A month's supply will cost about $80.
Nasal steroids — The next logical step in dealing with allergic rhinitis, if over-the-counter antihistamines don't work, is the use of a group of drugs called corticosteroids. These drugs reduce inflammation and secretions. The safest way to use corticosteroids for allergies is by nasal spray. The medication works directly on the nasal passages, and you avoid the majority of the troublesome side effects that are seen when a corticosteroid is taken by mouth.
There are lots of drugs to choose from in this category. The nasal corticosteroids include Vancenase AQ, Beconase AQ DS, Nasacort, Rhinocort, Rhinocort Aqua, Nasarel, Nasalide and others. The nasal corticosteroids are available only by prescription.
Nasal corticosteroids are certainly a bit more difficult to use than simply swallowing a pill, but the extra effort is worth it if you have mostly nasal symptoms. The secret is getting the medication where it is needed. If your nose is stuffed up, the nasal spray can't get to the lining of the nose and sinuses. So, early in treatment, especially if a person has waited for symptoms to appear, many need to use a decongestant as well. Decongestant nasal sprays should not be used for more than five consecutive days.
- Nasal corticosteroids are better at preventing symptoms than are the antihistamines.
- Different brands, including generic versions of nasal corticosteroids, have very similar benefits.
- Headache and nosebleeds can sometimes occur with the use of nasal corticosteroids, especially during the first few days.
- Nasal corticosteroids need to be taken continually during the allergy season to prevent symptoms. If your nose is very congested, you also will need a decongestant at the start of therapy.
Patients who have undergone an adequate trial of nasal corticosteroids and who still have troublesome symptoms may benefit by the addition of a nonsedating antihistamine.
For treatment-resistant patients, immunotherapy represents a therapeutic option. Immunotherapy is the only available treatment that has a chance of reducing the allergy symptoms for a longer period of time. Patients receive injections of increasing concentrations of the substances they are allergic to, such as pollen or mold. These injections reduce the amount of IgE antibodies in the blood and cause the body to make a protective antibody called IgG.
Many patients with allergic rhinitis will have a dramatic reduction in their hay-fever symptoms and in their need for medication within 12 months of starting immunotherapy. Patients who benefit from immunotherapy may continue it for three years and then consider stopping. Although many patients are able to stop the injections with good, long-term results, some do get worse after immunotherapy is stopped.
Howard LeWine, M.D., is chief editor of Internet Publishing at Harvard Health Publications. He is recognized as an outstanding clinician and teacher and is a recipient of the Internal Medicine Teacher of the Year award at Brigham and Women’s Hospital. Dr. LeWine continues to practice Internal Medicine; most recently he became a hospitalist after practicing primary care for over 20 years.