New medications on the market might offer you better relief and lower risks for side effects
By Wendy Haaf
Allergy season is upon us, and with it come the usual remedies. However, you may not know that the range of options—both over the counter (OTC) and prescription—has grown, often with better relief and lower risks for side effects. Dr. Anne K. Ellis, a professor and the chair of the Division of Allergy and Immunology at Queen’s University in Kingston, ON, spearheaded a webinar on this subject. “I was perpetually surprised at how many people would wind up in my office not having tried anything other than over-the-counter antihistamines.”
For instance, nasal corticosteroid sprays are now considered a firstline treatment for people with mild or intermittent symptoms such as itchy, water eyes and runny nose, as well as for those with more troubling nasal congestion (e.g., congestion that interferes with sleep). “It’s more anti-inflammatory than an antihistamine,” explains Dr. Paul Keith, a professor of medicine at McMaster University in Hamilton, ON, who specializes in allergy and immunology.
Note that nasal corticosteroid sprays aren’t the same as OTC decongestant sprays, which temporarily shrink tissues inside the nose by constricting blood vessels. When used for more than a few days, decongestant sprays can cause rebound swelling and tip off a potentially permanent cycle called tachyphylaxis, which, as Dr. Jason Lee, a Toronto physician, explains, means you need more and more of the medication to get the same effect.
Since it can take several days for a nasal steroid to take full effect, experts recommend beginning to take it a week or two earlier than your symptoms typically appear and taking it consistently for a month before deciding whether or not it’s working for you. Proper technique is also important: Ellis says that many people use inhaled medications incorrectly and advises instead to point the applicator towards the ear when spraying the medication into the nose. “Then, just inhale gently; don’t snort the medication or you’ll lose it down the back of your throat.”
If you’re already suffering with symptoms when you try a nasal steroid for the first time, you can add an OTC antihistamine for more immediate relief. The Canadian Society of Allergy and Clinical Immunology strongly recommends avoiding first-generation antihistamines— such as diphenhydramine (e.g., Benadryl), chlorpheniramine (e.g., Chlor-Tripolon) and hydroxyzine (Atarax)—which are no more effective and far less safe than their non-sedating cousins. In addition, these older medications “can cross-react with other drugs,” Keith explains. They’re also associated with decreased alertness, thinking ability and motor performance. Other side effects include dry mouth, increased appetite, dizziness and potentially fatal heart arrhythmias.
While all second- and third-generation OTC antihistamines are considered safe and effective, there are some nuances to choosing the right one. “Data we generated shows that cetirizine [e.g., Reactine] probably kicks in faster than the others,” Ellis says. On the other hand, desloratadine (e.g., Aerius) may work better for nasal congestion, while fexofenadine (Allegra) is the least likely to cause sleepiness. (All newer OTC antihistamines may cause mild sedation in a small percentage of people, but the degree of drowsiness is nowhere near that found with the older drugs.)
There’s one nasal steroid spray— fluticasone furoate, available under the brand name Avamys—that may be easier to use than others. “It has a different applicator: the part you put in your nose is much smaller, and it gives you a finer mist that spreads more broadly across your nasal tissues,” says Ellis.
Let’s say you’ve tried a nasal steroid spray but you’re still suffering from symptoms such as stuffiness, itching, runny nose and sneezing. “There’s now a combination steroid/antihistamine nasal spray called Dymista,” says Keith. The antihistamine component starts taking effect within 30 minutes— much more rapidly than a steroid alone. “You’re delivering the medication to the area where you’re itchy,” Keith adds. However, the cost— roughly $100 for 120 doses—may put it out of reach for some people, and it’s not covered by provincial health plans.
In some cases, one of two newer prescription antihistamines may offer an advantage. For instance, Keith notes, rupatadine (e.g., Rupall) may work better on nasal obstructions. And bilastine (e.g., Blexten) seems to have the lowest potential to cause drowsiness and related side effects. For example, Lee, who suffers from allergies, has noticed other antihistamines affect fine motor movements involved in playing video games. “I’ve found bilastine is the only one that doesn’t.”
If itchy, watery eyes are your main allergy annoyance, Lee cautions to be wary of OTC eye drops. Many so-called allergy eye drops, including those with antihistamines, contain medications that work on the same principle as decongestant nasal sprays—and have the same potential for lasting problems. One exception: OTC drops with sodium cromoglycate (brand names include Opticrom) as the active ingredient. While antihistamines work by blocking histamine, sodium cromoglycate and other drugs in the same class curb the activity of mast cells, which release histamine and a number of other substances involved in allergic reactions.
As for prescription eye drops, there’s a much wider and more varied selection. In addition to antihistamine-only products and those containing mastcell stabilizers, there are dual-action drops combining these two classes. According to Ellis, bepotastine besilate (e.g., Bepreve)—one of the newer antihistamine eye drops—may cause less of a burning sensation than others. In some circumstances, drops containing steroids or other drugs that suppress immune-cell activity may be helpful.
Immunotherapy Versus Medications
All these medications, however, target symptoms only. By contrast, immunotherapy can retrain the immune system to respond differently to an allergen. (Asthma Canada’s website features a tool that can help you and your doctor weigh the risks and benefits of immunotherapy versus medications—go to asthma.ca and search for “Immunotherapy” to access it.)
For years, allergy shots—known medically as subcutaneous immunotherapy, or SCIT—have been the mainstay of desensitization treatments for seasonal allergies. Containing minute amounts of the allergen(s) in question, these are typically given weekly for six months in increasing dosages, followed by monthly injections for three to five years. While SCIT isn’t a magic fix, “seventy to 90 percent of patients will as a result use far less medication, or no medication at all, during allergy season,” Ellis says.
If symptoms don’t start to improve within roughly a year, treatment is typically discontinued.
“We can also desensitize people with the use of a tablet that dissolves under the tongue,” says McMaster University’s Dr. Keith. “We have those for grass pollen, ragweed pollen, birch pollen and dust mites.” The main advantage of this approach, which is called sublingual immunotherapy (SLIT), is convenience: since the risk for anaphylaxis is very slight, only the first dose is given in a doctor’s office. A patient starts taking daily tablets two to four months before the specific allergen is expected to begin circulating and continues until the allergen-specific season is over.
Similar to immunotherapy injections, “if you benefit, you take [the treatment] for three to five years; then you can stop, and the benefit persists,” Keith says.
Another selling point for SLIT is the time it saves, because multiple allergens can be targeted at once. However, only five provincial drug plans list at least one of three products for coverage— Oralair, for five types of grass pollen; Ragwitek, for ragweed pollen; and Grastek, for Timothy-grass or cross-reactive grass pollens.
If you’re not feeling relief from symptoms after any of the previously described treatments, it may be time to consider seeing an allergy specialist, who can look into complications such as associated ear problems, sinus infections and asthma. You may also need to undergo testing to identify which allergens may be causing your immune system to overreact.
With all of these new options, it’s more important than ever for allergy sufferers to confer with their primary care providers. “We love to see patients with these types of issues, because we have so many effective therapies and we can make people feel better,” Ellis says. “It makes us feel good as practitioners, knowing we’re having such a good impact on somebody’s quality of life.”