Medication Summary
At one time or another, most patients with allergies require pharmacologic intervention.
Many classes of medications are available; the use of each must be tailored to the individual patient's symptoms.
Antihistamines
Class Summary
These medications are H1 receptor antagonists and relieve sneezing, itching, and rhinorrhea.
Chlorpheniramine (Chlor-Trimeton, Aller-Chlor, Chlo-Amine)
A representative first-generation antihistamine; competes with histamine for H1 receptor sites on effector cells in blood vessels and in the respiratory tract.
Loratadine (Claritin)
Selectively inhibits peripheral histamine H1 receptors.
Fexofenadine (Allegra)
A representative third-generation antihistamine; competes with histamine for H1 receptors in the GI tract, blood vessels, and respiratory tract, reducing hypersensitivity reactions; does not cause sedation.
Azelastine (Astelin)
Topical antihistamine nasal spray; competes with histamine for H1 receptor sites in the blood vessels, GI tract, and respiratory tract.
Desloratadine (Clarinex)
Long-acting tricyclic histamine antagonist selective for H1 receptor. Relieves nasal congestion and systemic effects of seasonal allergy. Is a major metabolite of loratadine, which, after ingestion, is metabolized extensively to active metabolite 3-hydroxydesloratadine.
Olopatadine (Patanol)
Topical antihistamine ophthalmic solution.
Corticosteroids
Class Summary
These agents have a potent anti-inflammatory action. Oral preparations affect late-phase reactions. Intranasal preparations reduce both acute and late-phase reactions after several days of use. These medications relieve rhinorrhea, sneezing, itching, and congestion. Many physicians currently consider intranasal steroid use to be the first-line therapy for allergic rhinitis.
Mometasone (Nasonex)
Nasal spray; demonstrated no mineralocorticoid, androgenic, antiandrogenic, or estrogenic activity in preclinical trials. Decreases rhinovirus-induced up-regulation in respiratory epithelial cells and modulate pretranscriptional mechanisms.
Ciclesonide (Omnaris)
Corticosteroid nasal spray indicated for allergic rhinitis. Prodrug that is enzymatically hydrolyzed to pharmacologic active metabolite C21-desisobutyryl-ciclesonide following intranasal application. Corticosteroids have a wide range of effects on multiple cell types (eg, mast cells, eosinophils, neutrophils, macrophages, lymphocytes) and mediators (eg, histamines, eicosanoids, leukotrienes, cytokines) involved in allergic inflammation. Each spray delivers 50 mcg.
Prednisone (Deltasone, Orasone, Sterapred)
Immunosuppressant for treatment of allergic reactions; may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity; dosage and tapering schedule vary.
Triamcinolone (Kenalog-40)
Injectable corticosteroid used to treat inflammatory dermatosis responsive to steroids; decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.
Beclomethasone (Beconase AQ, QNASL)
Topical nasal steroid spray that inhibits bronchoconstriction mechanisms and produces direct smooth muscle relaxation; may decrease number and activity of inflammatory cells, decreasing airway hyper-responsiveness. QNASL available as intranasal dry powder.
Fluticasone propionate (Flonase)
Topical nasal steroid spray. Has an extremely potent vasoconstrictive and anti-inflammatory activity. Has weak HPA axis inhibitory potency when applied topically.
Mast cell stabilizer
Class Summary
Mast cell stabilizers inhibit mast cell degranulation and influence granulocyte chemotaxis. They are most effective when used prophylactically, and they have an excellent safety profile.
Cromolyn sodium, intranasal (NasalCrom)
Inhibits degranulation of sensitized mast cells after exposure to specific antigens; available over the counter; may require several days to work.
Anticholinergic
Class Summary
These drugs relieve rhinorrhea but have no effect on other symptoms of allergy.
Ipratropium (Atrovent)
Chemically related to atropine; has antisecretory properties; when applied locally, inhibits secretions from serous and seromucous glands lining the nasal mucosa; available in 0.03% and 0.06% strengths; also effective in relieving rhinorrhea from other causes (eg, cold air, gustation).
Decongestants
Class Summary
Decongestants are available in oral and topical preparations. These drugs act on alpha-adrenergic receptors in the nasal mucosa, causing vasoconstriction that concomitantly reduces turbinate edema and rhinorrhea.
Oxymetazoline (Afrin)
A representative topical decongestant applied directly to mucous membranes, where it stimulates alpha-adrenergic receptors and causes vasoconstriction. Decongestion occurs without drastic changes in BP, vascular redistribution, and cardiac stimulation.
Pseudoephedrine (Sudafed)
A representative oral decongestant; stimulates vasoconstriction by directly activating alpha-adrenergic receptors in the respiratory mucosa; also induces bronchial relaxation and increases the heart rate and contractility by stimulating beta-adrenergic receptors.
Allergy Extracts
Class Summary
Immunotherapy with daily sublingual (SL) tablets may be able to replace weekly injections in some individuals, depending on the offending allergens. SL tablets must be initiated 4 months before the allergen season that is being treated.
Grass pollens allergen extract (Oralair)
SL immunotherapy is indicated for grass pollen–induced allergic rhinitis (with or without conjunctivitis) confirmed by positive skin test or in vitro testing for grass pollen–specific immunoglobulin E antibodies for any of the 5 grass species contained in the product. It consists of 5 purified and calibrated pollen extracts: Perennial Ryegrass (Lolium perenne), Kentucky bluegrass (Poa pratensis), Timothy grass (Phleum pratense), Orchard grass (Dactylis glomerata), and Sweet Vernal grass (Anthoxanthum odoratum).
Timothy grass pollen allergen extract (Grastek)
SL immunotherapy is indicated for allergic rhinitis (with or without conjunctivitis) confirmed by positive skin test or in vitro testing for Timothy grass pollen-specific IgE antibodies.
Ragweed allergen extract (Ragwitek)
SL immunotherapy is indicated for allergic rhinitis (with or without conjunctivitis) confirmed by positive skin test or in vitro testing for ragweed (Ambrosia artemisiifolia) grass pollen-specific IgE antibodies.
House dust mite immunotherapy (Odactra)
The SL tablet consists of standardized extract with consistent biological potency (although the precise mechanisms through which allergen immunotherapy works are unknown). It is indicated for dust mite–induced allergic rhinitis with or without conjunctivitis in people aged 12-65 years, with the allergy confirmed using in vitro testing for IgE antibodies to the house dust mite D farinae or D pteronyssinus or through skin testing using licensed house dust mite allergen extracts.
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Boggy inferior turbinate in an allergic patient.
