Mold Allergy Medication

Updated: Sep 18, 2017
  • Author: Shih-Wen Huang, MD; Chief Editor: Harumi Jyonouchi, MD  more...
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Medication

Medication Summary

Various drugs are used for the treatment of upper airway diseases. For allergic rhinitis and conjunctivitis, antihistamine/decongestant and/or intranasal corticosteroid and anticholinergic nose sprays are the treatments of choice. For allergic asthma, short-acting or long-acting bronchodilators, mast-cell stabilizers, antileukotriene agents, corticosteroid inhalers, oral corticosteroids, anticholinergic inhalers, or theophylline may be indicated, depending on the stage of the disease. For allergic fungal sinusitis (AFS), allergic bronchopulmonary aspergillosis (ABPA), allergic bronchopulmonary mycosis (ABPM), and extrinsic allergic alveolitis (EAA), an oral corticosteroid is the treatment of choice; in AFS, it may be supplemented with a corticosteroid inhaler. In ABPA and ABPM, it may be supplemented with a corticosteroid inhaler or theophylline. In EAA, it may be supplemented with a bronchodilator.

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Antihistamines, oral

Class Summary

These agents compete with histamine to bind to H1 receptors on the endothelium and smooth muscle. Histamine is a central vasoactive mediator in allergic rhinitis, and prophylactic use of antihistamines typically provides substantial control of symptoms. Dosage of traditional (first-generation) antihistamine classes is limited by the appearance of undesirable adverse effects including sedation, restlessness, dry mouth, urinary retention, constipation, and blurred vision. For this reason, new-generation antihistamines that are mostly free of such adverse effects are welcome options for treatment. Many first-generation antihistamines are available without a prescription, and loratadine, a second-generation antihistamine, is currently available over-the-counter (OTC).

Loratadine (Claritin)

Loratadine is a nonsedating second-generation antihistamine. It has fewer adverse effects than first-generation medications. It selectively inhibits peripheral histamine H1 receptors.

Desloratadine (Clarinex)

Desloratadine relieves nasal congestion and the systemic effects of seasonal allergies. It is a long-acting tricyclic histamine antagonist selective for the H1-receptor. It is a major metabolite of loratadine, which, after ingestion, is extensively metabolized to the active metabolite 3-hydroxydesloratadine.

Cetirizine (Zyrtec)

Cetirizine selectively inhibits histamine H1 receptor sites in blood vessels, the GI tract, and the respiratory tract, which, in turn, inhibits the physiologic effects that histamine normally induces at H1 receptor sites. Once-daily dosing is convenient. Bedtime dosing may be useful if sedation is a problem.

Levocetirizine (Xyzal)

Levocetirizine is a histamine1-receptor antagonist. It is an active enantiomer of cetirizine. Peak plasma levels are reached within 1 hour and the half-life is about 8 hour. It is available as a 5-mg breakable (scored) tablet and a 0.5-mg/mL oral solution. It is indicated for seasonal and perennial allergic rhinitis.

Fexofenadine (Allegra)

Fexofenadine is a nonsedating second-generation medication with fewer adverse effects than first-generation medications. It competes with histamine for H1 receptors in the GI tract, blood vessels, and the respiratory tract, reducing hypersensitivity reactions. It does not sedate, and it is available in daily or twice-daily preparations.

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Antihistamines with decongestants, oral

Class Summary

Antihistamines are most useful for symptoms of itching, sneezing, tearing, or postnasal drip. Decongestants relieve nasal congestion, reducing symptoms of sniffling. Many are available OTC in various combinations of an antihistamine plus pseudoephedrine.

Pseudoephedrine/loratadine (Claritin-D)

Pseudoephedrine/loratadine is a second-generation long-acting antihistamine/decongestant combination with 120 mg or 240 mg of pseudoephedrine.

Cetirizine/pseudoephedrine (Zyrtec-D)

Cetirizine selectively inhibits histamine H1 receptor sites in blood vessels, the GI tract, and the respiratory tract, which, in turn, inhibits the physiologic effects that histamine normally induces at H1 receptor sites. Once-daily dosing is convenient. Bedtime dosing may be useful if sedation is a problem.

Pseudoephedrine stimulates vasoconstriction by directly activating alpha-adrenergic receptors of the respiratory mucosa. It also induces bronchial relaxation and increases heart rate and contractility by stimulating beta-adrenergic receptors.

Pseudoephedrine/fexofenadine (Allegra-D)

Fexofenadine is a nonsedating second-generation medication with fewer adverse effects than first-generation medications. It competes with histamine for H1 receptors in the GI tract, blood vessels, and respiratory tract, reducing hypersensitivity reactions. It does not sedate.

Pseudoephedrine stimulates vasoconstriction by directly activating alpha-adrenergic receptors of the respiratory mucosa. It also induces bronchial relaxation and increases the heart rate and contractility by stimulating beta-adrenergic receptors.

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Antihistamine nasal sprays

Class Summary

These agents locally relieve nasal symptoms more effectively than oral antihistamines. They are often used with oral antihistamine.

Azelastine (Astelin, Astepro)

Azelastine is an aqueous nasal spray used to treat seasonal and perennial allergic rhinitis.

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Mast-cell stabilizers

Class Summary

These agents prevent mast-cell activation and, thus, degranulation. Degranulation releases mediators (eg, histamine), which causes tissue swelling and chemotactic factors to attract eosinophils to the site. This leads to delayed-phase inflammation. This process is obvious in allergic rhinitis and allergic asthma but may also be involved in other clinical conditions related to mold allergy. Nedocromil may have more anti-inflammatory effect than other agents.

Cromolyn sodium (NasalCrom)

NasalCrom (5.2 mg per spray, nasal solution) is used for mast-cell stabilization in allergic rhinitis. The cromolyn sodium nebulizer solution (20 mg/2 mL, nebulizer solution) is used to prevent asthma.

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Antihistamine and mast cell stabilizer eye drops

Class Summary

Although oral antihistamines are useful for allergic conjunctivitis, ophthalmic drops offer immediate relief of eye symptoms from allergies (eg, itching, tearing, conjunctival swelling). Not indicated to relieve an acute asthma attack.

Olopatadine (Patanol, Pataday)

Olopatadine is an ophthalmic antihistamine solution indicated for temporary prevention of ocular itching due to allergic conjunctivitis. It is an inhibitor of histamine release from mast cells and is devoid of effects on serotonin, alpha-adrenergic, muscarinic, and dopamine receptors. Patanol is available as an ophthalmic solution 0.1%. Pataday is available as an ophthalmic solution 0.2%.

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Corticosteroid nasal sprays

Class Summary

Corticosteroids are potent anti-inflammatory agents that affect activation of many cells (eg, mast cells, eosinophils, macrophages, lymphocytes) and effect of mediators (eg, histamine, eicosanoids, interleukins [ILs], cytokines) that are important in allergic inflammatory process or hypersensitivity reactions. Therefore, they are important for treatment of the various diseases attributable to mold allergy.

Mometasone (Nasonex)

Mometasone has demonstrated no mineralocorticoid, androgenic, antiandrogenic, or estrogenic activity in preclinical trials. It decreases rhinovirus-induced up-regulation in respiratory epithelial cells and modulates pretranscriptional mechanisms. It reduces intraepithelial eosinophilia and inflammatory cell infiltration (eg, eosinophils, lymphocytes, monocytes, neutrophils, plasma cells). It is available as an aqueous nasal spray of 50-mcg per spray.

Fluticasone intranasal (Flonase, Veramyst)

Fluticasone intranasal is used to treat allergic rhinitis. It is available as an aqueous nasal spray. The propionate (Flonase) delivers 50 mcg per actuation, whereas the furoate (Veramyst) delivers 27.5 mcg per actuation. Fluticasone furoate is well tolerated compared with the older propionate version, particularly in children.

Budesonide inhaled (Rhinocort Aqua)

Budesonide inhaled inhibits bronchoconstriction mechanisms, produces direct smooth muscle relaxation, and may decrease the number and activity of inflammatory cells, in turn decreasing airway hyperresponsiveness. It has extremely potent vasoconstrictive and anti-inflammatory activity. It alters the level of inflammation in airways by inhibiting multiple types of inflammatory cells and decreasing the production of cytokines and other mediators. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability. It is used for the treatment of allergic rhinitis.

Flunisolide

Flunisolide inhibits bronchoconstriction mechanisms, produces direct smooth muscle relaxation, and may decrease number and activity of inflammatory cells, in turn decreasing airway hyperresponsiveness. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability. It does not depress the hypothalamus.

Ciclesonide (Omnaris)

Ciclesonide is a corticosteroid nasal spray indicated for allergic rhinitis. It is a prodrug that is enzymatically hydrolyzed to the 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. It is well tolerated in children.

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Corticosteroid oral inhalers

Class Summary

These are potent anti-inflammatory agents because of their effects on several cell types (eg, mast cells, eosinophils, neutrophils, macrophages, lymphocytes) and on the production and secretion of mediators (eg, histamine, eicosanoids, leukotriene, cytokines) in inflammatory process. Inhalers listed below are valuable for the treatment of mild-to-moderately persistent or severe forms of allergic asthma and are used as supplemental therapy for ABPA, ABPM, and EAA. Oral inhaled corticosteroids allow avoidance of severe adverse effects associated with systemic corticosteroids.

Fluticasone inhaled

Fluticasone inhaled is indicated for the maintenance and treatment of asthma as prophylaxis; it is also used in patients requiring long-term systemic corticosteroid treatment to attempt gradual tapering and discontinuation of oral corticosteroids. It is available as Flovent MDI (44, 110, or 220 mcg per actuation), Flovent Rotadisk (50, 100, or 250 mcg per actuation), and dry powder in blister packs for inhalation with an inhalation device.

Budesonide inhaled (Pulmicort Flexhaler)

Budesonide inhaled inhibits bronchoconstriction mechanisms, produces direct smooth muscle relaxation, and may decrease the number and activity of inflammatory cells, in turn decreasing airway hyperresponsiveness. It has extremely potent vasoconstrictive and anti-inflammatory activity. It alters the level of inflammation in airways by inhibiting multiple types of inflammatory cells and decreasing the production of cytokines and other mediators. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability. It is used for the treatment of allergic rhinitis.

It is available as Pulmicort Flexhaler (90 mcg per actuation or 180 mcg per actuation delivers 80 mcg per inhalation or 160 mcg/inhalation) or Pulmicort Respules inhalation suspension (0.25 mg/2 mL, 0.5 mg/2 mL).

Triamcinolone inhaled (Azmacort)

Triamcinolone inhaled is indicated for the maintenance and treatment of asthma as prophylaxis; it is also used in patients requiring long-term systemic corticosteroid treatment to attempt gradual tapering and discontinuation of oral corticosteroids. It is available as Azmacort (75 mcg per actuation) and MDI with an attached Aerochamber device.

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Bronchodilators, short term

Class Summary

Short-term bronchodilators are beta2-agonists that act to relieve bronchospasm by elevating cyclic adenosine monophosphate (AMP) in cells. They are used for acute relief of bronchospasm and for prophylaxis, especially prior to exercise.

Albuterol (Proventil, Ventolin, Proair)

Albuterol is a beta-agonist for bronchospasm refractory to epinephrine. It stimulates adenyl cyclase to convert ATP to cAMP and causes bronchodilation. It relaxes bronchial smooth muscle by action on beta2-receptors, with little effect on cardiac muscle contractility. It may decrease mediator release from mast cells and basophils and inhibit airway microvascular leakage.

The frequency may be increased. Institute a regular schedule in patients on anticholinergic drugs who remain symptomatic.

The following list of albuterol products are for acute relief of asthma in various stages. It is most commonly used alone in intermittent asthma or as prophylaxis, especially before exercise.

It is available as a tablet at 2 or 4 mg, extended-release tablets are 4 or 8 mg, syrup at 2 mg/5 mL, hydrofluoroalkane (HFA) MDI 90 mcg per actuation, and inhalation solution for nebulization 0.083% (0.83 mg/mL, 2.5 mg/3 mL) or 0.5% (5 mg/mL).

Pirbuterol (Maxair)

Pirbuterol directly acts on beta 2-receptors to relax bronchial smooth muscle, relieving bronchospasm and reducing airway resistance.

Levalbuterol (Xopenex)

Levalbuterol is used for acute relief of asthma in various stages. It is used alone more commonly in intermittent asthma or as prophylaxis for asthma, especially before exercise.

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Inhaled long-acting bronchodilator/corticosteroid combinations

Class Summary

One of the advantages of long-acting beta-agonists is prolonged relief for patients with obstructive lung disease (eg, asthma). They are especially useful for patients with nocturnal cough. However, long-acting beta(2)-adrenergic agonists including salmeterol and formoterol have a black box warning regarding an increase in risk of asthma-related deaths. Because of this risk, salmeterol use is contraindicated without a concomitant long-term asthma control medication such as an inhaled corticosteroid. To ensure compliance with therapy, a fixed-dose combination product containing both an inhaled corticosteroid and LABA is recommended in pediatric and adolescent patients. [29]

Salmeterol/fluticasone inhaled (Advair)

Fluticasone inhibits bronchoconstriction mechanisms, produces direct smooth muscle relaxation, and may decrease the number and activity of inflammatory cells, in turn decreasing airway hyper-responsiveness. It also has vasoconstrictive activity.

Salmeterol relaxes the smooth muscles of the bronchioles in conditions associated with bronchitis, emphysema, asthma, or bronchiectasis, and can relieve bronchospasms. Effects may also facilitate expectoration.

Adverse effects are more likely to occur when administered at high or more frequent doses than recommended. Two delivery mechanisms are available (ie, powder for inhalation [Diskus], metered-dose inhaler [MDI]). Diskus is available as a combination of salmeterol 50-mcg with fluticasone 100 mcg, 250 mcg, or 500 mcg. MDI is available as 21 mcg salmeterol with fluticasone 45 mcg, 115 mcg, or 230 mcg.

Budesonide/formoterol (Symbicort)

Formoterol relieves bronchospasm by relaxing the smooth muscles of the bronchioles in conditions associated with asthma.

Budesonide is an inhaled corticosteroid that alters level of inflammation in airways by inhibiting multiple types of inflammatory cells and decreasing production of cytokines and other mediators involved in the asthmatic response.

It is available as an MDI in 2 strengths; each actuation delivers formoterol 4.5 mcg with either 80 or 160-mcg of budesonide

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Systemic corticosteroids

Class Summary

These are potent anti-inflammatory agents because of their effects on many cell types (eg, mast cells, eosinophils, neutrophils, macrophages, basophils, lymphocytes) and on the production and secretion of mediators (eg, histamine, eicosanoids, leukotrienes, cytokines) in inflammation. Many conditions related to mold allergy (eg, allergic asthma, ABPA, AFS, ABPM, EAA) require systemic corticosteroids from the onset of disease.

When disease activity decreases, reducing the dose to the lowest effective level and trying to further taper it to an every-other-day schedule are advisable. Also, a oral inhaled corticosteroid may be used to replace a systemic steroid to reduce adverse effects.

For allergic asthma, systemic corticosteroids are indicated when patients have a severe form of asthma resistant to other forms of therapy.

Prednisone

Prednisone remains the mainstay oral systemic corticosteroid. Starting doses in each condition or different stages of same disease may differ. The main concerns with systemic corticosteroids, especially with long-term use, are adverse effects, which are more apparent than those of oral inhaled corticosteroids. Various tablet strengths and liquids are available to customize doses and ease tapering.

Prednisolone (Pediapred, Prelone, Millipred)

Starting doses in each condition or in different stages of the same disease may differ. The main concern with systemic corticosteroids, especially with long-term use, is their adverse effects, which are more apparent than those of oral inhaled corticosteroids. Various tablet strengths and liquids are available to enable customized doses and tapering ease.

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Leukotriene antagonists/5-lipoxygenase inhibitors

Class Summary

In asthma, leukotriene is an important mediator released in the airway that causes constriction of smooth muscle. This is most apparent in a delayed-phase reaction. Therefore, use of leukotriene antagonists is an important part of treatment to control asthma. These agents are indicated for forms of asthma ranging from mild intermittent to severe. For children, it is a valuable treatment for the night cough or wheeze. Inhibition of lipoxygenase reduces production of leukotriene at peripheral tissue and achieves results similar to those of leukotriene antagonists.

Montelukast (Singulair)

Montelukast is a leukotriene receptor antagonist indicated for the long-term treatment of asthma. It is available as 4- and 5-mg chewable tablets, 4-mg granules, 10-mg oral tablets.

Zafirlukast (Accolate)

Zafirlukast is indicated for prophylaxis and long-term treatment of asthma. It is a leukotriene receptor antagonist.

Zileuton (Zyflo, Zyflo CR)

Zileuton is indicated for prophylaxis and long-term treatment of asthma. It is a 5-lipoxygenase inhibitor.

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Theophylline derivatives

Class Summary

These agents directly relax smooth muscles of bronchial airways and pulmonary blood vessels, acting as bronchodilators and smooth muscle relaxants. They are used to supplement other asthma drugs, typically in moderately severe or severe asthma. Their effects in other forms of pulmonary diseases (eg, ABPA, ABPM, EAA) are unknown, though anecdotal evidence indicates that they have been tried in the chronic stage of the diseases.

Theophylline (Theo-24, Theolair)

Theophylline is available in a wide variety of dosage forms (tab, cap, extended release [ER], sprinkles, liquid), which enables ease of dosing. It is indicated for treatment of asthma, especially moderate-to-severe forms, as a supplement to other anti-inflammatory drugs.

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Monoclonal antibodies

Class Summary

These agents bind selectively to human IgE on the surface of mast cells and basophils.

Omalizumab (Xolair)

Omalizumab is a recombinant, DNA-derived, humanized IgG monoclonal antibody that selectively binds to the Fc portion of free IgE and thereby blocks binding to receptors on mast cells and basophils. It reduces mediator release, which promotes an allergic response. It is indicated for moderate-to-severe persistent asthma in patients who react to perennial allergens in whom symptoms are not controlled by inhaled corticosteroids.

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Anticholinergic nasal sprays and oral inhalers

Class Summary

An increase of local production of acetylcholine may cause tissue reaction in the case of hypersensitivity. This is most common in IgE-mediated hypersensitivity. Anticholinergic agents may be useful for allergic rhinitis or allergic asthma.

Ipratropium bromide (Atrovent)

Ipratropium bromide is available as a 0.03% (21 mcg per spray) or 0.06% (42 mcg per spray) nasal spray. It is suitable for allergic rhinitis. It is also available as an oral inhaler (18 mcg per actuation) indicated for moderate persistent or severe persistent asthma.

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