Medications for Allergy

THE QUESTION Does the herb butterbur relieve hay fever symptoms as effectively as do antihistamines?

PAST STUDIES have shown that antihistamines can relieve some of the symptoms of hay fever, such as runny nose and sneezing, but these drugs may also cause drowsiness.

THIS STUDY, which was double-blind, compared the effectiveness of the herbal extract butterbur to cetirizine (Zyrtec) in relieving hay fever symptoms. The researchers randomly assigned 125 people with hay fever to receive daily doses of either butterbur or cetirizine. After two weeks, the people in both groups experienced similar amounts of symptom relief.

WHO MAY BE AFFECTED BY THESE FINDINGS? People who experience hay fever.

CAVEATS Zeller AG of Switzerland, a manufacturer of herbal remedies, funded the study. In addition, the long-term effects of butterbur are not known. Finally, the results are partially based on self-reports of symptoms by the participants.

BOTTOM LINE People with hay fever who would like to avoid the drowsiness caused by antihistamines may wish to consult their doctor about using butterbur. (They should also be aware that supplies of this herb may not have guaranteed purity and potency, and that experts advise users to be sure that the extract has been processed to remove potentially dangerous chemicals called pyrrolizidine alkaloids.)

FIND THIS STUDY Issue of the British Medical Journal.

Q. I’m taking steroid pills (prednisone) for a medical condition but am concerned about possible side effects. I have diabetes, and after taking prednisone for a couple of months I noticed my legs began to swell. Is this a side effect of the prednisone? If so, is there some treatment to counteract it?

A. Steroids are powerful drugs doctors use to treat a wide variety of medical problems. Because long-term use can sometimes lead to serious side effects, it’s important that the benefits outweigh the possible risks.

Steroids like prednisone resemble substances your body makes to help fight disease and respond to stress. These kinds of steroids shouldn’t be confused with the so-called anabolic steroids some body builders use, which have their own potential side effects.

Taken for short periods-a week or so-steroids are generally safe. But long-term use can cause problems, including swelling and fluid retention, obesity, thinning of the skin, excessive hair growth, glaucoma, cataracts, higher blood pressure, intestinal ulcers, bone thinning (osteoporosis), stunted growth in children, mood changes, muscle weakness and lower resistance to certain infections, such as tuberculosis.

A potentially life-threatening risk of long-term steroid use is that your body will not be able to respond properly to the stress of serious infection, major surgery or critical injury. During these times of increased stress, you may need greater doses of steroids. For this reason, I advise people taking long-term steroid pills to wear a bracelet identifying them as steroid users.

Steroids can also raise your blood sugar level, making diabetes more difficult to treat. The swelling in your legs is a likely side effect of prednisone, and if you needed to continue taking it, might be helped by fluid pills. In addition, you can lower your risk of harmful side effects depending on the way you take steroid pills. Of course, the proper dosage is something only your doctor can decide.

When possible, here are some ways to lower your risk:

Take the lowest dose necessary to control your illness, and for the shortest time.

Take steroids every other day, not daily.

Take a single dose in the morning, rather than several doses throughout the day.

Use inhaled sprays, instead of pills, for certain conditions such as asthma that can be treated this way. Inhaled steroid sprays pose virtually none of the risks of long-term steroid pills.

When stopping long-term steroids, it’s important to reduce the dose gradually. This will allow your body to adjust to its own natural production of steroids and avoid the problem of not being able to respond to stressful illness appropriately.

Q. Every spring it starts all over again-the runny nose, watery eyes, sneezing and other symptoms of hay fever. My bouts usually last six to eight weeks. I buy over-the-counter hay fever medicines, but the antihistamines make me sleepy. I’ve tried every remedy in the drugstore, but they either make me drowsy or don’t work. I’ve been going through this for seven years now and wonder how else I can get some relief.

A. Hay fever, which has nothing to do with hay or fevers, is a seasonal allergic reaction to the pollen of trees, grasses, weeds or mold spores.

In susceptible people, these pollens trigger an allergic reaction that includes the release of histamines-substances in the body that produce many well-known symptoms of hay fever: runny nose; watery discharge from the eyes; itching in the ears, eyes, nose and throat; sneezing and crankiness.

The best treatment is avoiding the pollen you’re allergic to, but that’s easier said than done. Staying home with your air conditioner on during the worst parts of the season is one step. Another is using electrostatic precipitators, which filter the air of pollen, dust and other particles.

Antihistamines help hay fever symptoms by blocking some of the effects of histamines that are released in the sensitive linings of the eyes, nose and throat. Their main side effect is drowsiness. Because there are several classes of antihistamines, it’s worth trying one or more from each group before deciding they don’t work for you.

Examples of different types of antihistamines are 1) diphenhydramine (Benadryl), usually very sedating; 2) PBZ, a prescription drug; 3) chlorpheniramine (Chlor-Trimeton); 4) Periactin, a prescription drug or Nolahist, a nonprescription drug; and 5) Seldane, a prescription drug that has less sedating effects than other antihistamines. Ask your doctor or pharmacist to recommend a type of antihistamine you haven’t tried yet.

Besides antihistamines, you can try decongestants, which tend to have a stimulating effect, or combinations of antihistamines and decongestants, whose side effects tend to offset each other. Most cold and allergy products are combination remedies.

If over-the-counter treatments don’t work, you might need one of several prescription medications. Cromolyn blocks the release of histamine and reduces allergy symptoms. It comes in two forms for hay fever therapy: a nasal spray and eyedrops.

For severe cases, steroid medicines are sometimes needed. The safest is a nasal spray, which has little or no internal side effects. In rare cases, oral steroids are used. When taken for months at a time, these powerful medicines can have troublesome or serious side effects.

Finally, since your symptoms are closely related to specific times of the year, it’s likely that you’re allergic to specific pollens or other triggering substances. An allergist could test you to find out what you’re allergic to. If a precise cause can be found, you may benefit from allergy shots.

A helpful book about allergies, written especially for parents of an allergic child, is “The Complete Book of Children‘s Allergies: A Guide for Parents,” by Dr. B. Robert Feldman (Times Books, New York, 1986).

The Washington Post

1. How far away are we from identifying the main allergens?

Unfortunately, that’s impossible to predict. Advances in medical science often occur in spurts, with research in one area leading to breakthroughs in apparently unrelated fields. We do have the tools to figure this out, so hopefully it won’t be too long before we can identify the key proteins and find a way to remove them, leaving a viable latex product.

2. Do alternative materials offer protection as effectively as latex?

The ones that are most affordable and easily available, vinyl products, are not as effective as latex. The products that do measure up, like tactylon, are very expensive, used primarily by surgeons. That’s why latex is still so valuable. Some people in the medical field feel that all latex products should be banned from hospitals, but we need to recognize the benefits of latex for the general population. The challenge is to identify people at risk for latex sensitivity.

3. How common are allergic reactions to condoms, and how severe?

We don’t see it as often as with gloves. Although they’re made in the same way, by dipping, condoms are much thinner and it’s easier to leach the proteins out, while gloves retain more proteins even after leaching. If someone does react to condoms, however, the severity runs across the spectrum from a few hives or itching to full-blown anaphylactic shock. You can’t predict how someone will react.

4. Is airborne latex a problem?

Aerosolized latex, which adheres to the lubricating powders used in gloves and then becomes airborne, is a critical issue. We’re concerned about people developing asthma due to latex allergen, which can become severe, chronic and irreversible lung disease. Preliminary studies show that if you change the patient’s environment early enough, respiratory symptoms can be reversed, so it’s vital to identify sensitized people before it’s too late. I think switching to powder-free gloves, a fairly painless and inexpensive move, is the single most important step to eliminate the aerosolized latex allergen in hospitals and clinics.

1. How useful is nedocromil sodium (Tilarin) to people who suffer from year-round allergic rhinitis?

Nedocromil sodium nasal spray has proven efficacy against seasonal bouts of allergic rhinitis and is most effective when dosed regularly throughout the pollen seasons. People who are allergic to several pollens (birch, grass, ragweed, etc.) may suffer more than one bout of seasonal allergic rhinitis during the year and on each occasion nedocromil sodium nasal spray can be used with confidence throughout the period of exposure to pollen allergens. There is no evidence of any loss of activity with continued use, or of any accumulation of the drug in the body tissues. Information regarding the use of the nasal spray in non-seasonal (house dust) allergic rhinitis is limited at the present time.

2. Which symptoms are most and least affected by nedocromil sodium (Tilarin)?

In general, itching and running of the nose and sneezing are most rapidly improved by nedocromil sodium nasal spray; stuffy nose may be less readily affected in some patients.

3. Is nedocromil sodium more effective in milder cases of rhinitis, or can it help even the worst sufferers?

Our clinical trials were carried out in patients with mild or moderate allergic rhinitis, and nasal corticosteroids are recommended to control more severe symptoms. However, nedocromil sodium nasal spray used in combination with antihistamine tablets can be a very effective additive therapy for allergic rhinitis.

4. Is this primarily an asthma drug that’s also useful for allergic rhinitis, or is it a rhinitis drug that’s also useful for asthma?

Nedocromil sodium reduces the allergic inflammatory reaction which occurs after sensitive tissues are exposed to allergens such as pollen, but it is also effective against inflammatory reactions to non-specific stimuli such as chemical air pollutants. Because of its anti-inflammatory properties when applied to the surface of the affected tissue, whether in the lung, the nose or the eye, nedocromil sodium is useful in asthma, allergic rhinitis and allergic conjunctivitis.

1. Is there a place for antihistamines in combination with corticosteroids?

Absolutely, both alone and in combination with nasal steroids. It depends on the nature of the symptoms. For instance, a patient with a congested nose and itchy eyes would benefit from both. The steroid will be effective for the nasal obstruction but not very good at dealing with itchy eyes; while antihistamines are effective against the eye symptoms but less so against the nasal congestion. This study looked at patients with predominantly nasal symptoms. We found that the nasal steroid was better at dealing with nasal problems, particularly congestion. But antihistamines can be better for itching, eye symptoms, and possibly sneezing.

2. Would fluticasone propionate (Flonase)be safe in patients already taking corticosteroids for asthma?

We use them together often. If a patient has rhinitis and asthma, and they’re on a fairly extensive regimen for asthma which includes inhaled corticosteroids, it would still be appropriate to consider topical nasal steroids. These medicines are very effective at the low doses we use because we’re applying them directly to the affected tissues. The inhaled steroid goes directly to the lungs with very little direct application to the nasal mucus membrane. Of course, both the lungs and the nasal membrane only absorb some of the medication, and the rest is swallowed into the gastrointestinal system, from which it can be absorbed across the gut into the body. At very high doses there must be accounting for the total load to make sure you don’t overload the system. But normally we are using relatively low doses.

3. Do you think prolonged therapy with fluticasone propionate (Flonase) could lead to hypercorticism?

In this case, none of the patients’ adrenal glands were affected. In patients with moderate asthma, only low to moderate doses are required, and these are unlikely to produce adverse effects. In more severe asthma, where larger doses are needed, there are studies that have shown some risk of these symptoms developing.

4. Is fluticasone propionate a safe drug for children in view of reports of growth inhibition among children on corticosteroid therapy?

Fluticasone (Flonase) is approved at the moment only for use in children over 12. A one-year study using fluticasone in mild to moderate asthma in children showed very little if any growth suppression in the vast majority. The final answer is not yet determined as not all the data has been fully analyzed, but it appears that the low doses needed to control mild to moderate asthma in children are probably very safe.

1. Why is it that nasal priming can cause a worsening of symptoms as the allergy season progresses?

When repeated nasal provocations are performed the number of pollen grains required to elicit a positive response is markedly reduced. This priming of the nasal mucosa is thought to be due to the influx of inflammatory cells attracted to the lining following the initial challenge. The clinical importance of this phenomenon is that patients allergic to tree pollens may be “primed” during the springtime and develop marked grass pollen-induced symptoms, even following exposure to very low pollen counts.

2. What are mast cells and what role do they play in the symptoms that allergy sufferers feel?

Mast cells are found in the loose connective tissue of all organs except the brain. They are particularly found in the skin, airway and gastrointestinal tract. They contain a number of secretory granules including histamines, leukotrienes and prostaglandins which are released under a number of circumstances, in particular exposure to an allergen. This is known as degranulation and results in the immediate symptoms of rhinitis – itching and sneezing, watery discharge and nasal congestion.

3. Why has there been a change in treatment strategy from using systemic medication to topical medication?

We have available to us a range of topical medications which are extremely effective at the site of administration, cause negligible local side effects, and no detectable effects in the rest of the body. Systemic medication, by its very nature, has an effect on the whole body, when only one or two areas are actually affected. It therefore seems more logical to target the affected area.

4. What factors do you think might explain the great disparities in allergy rates between urban and rural areas, and between different countries and regions?

The reasons for these differences are still not completely understood but there is increasing evidence that it may relate to air pollution, in particular to exposure to diesel particulate matter which can sensitize the nose and cause the manifestation of allergic symptoms in susceptible individuals.

5. Is the general prevalence of allergic rhinitis growing, and if so, why might that be happening?

Again, it is difficult to be certain as changing patterns of behaviour, diagnostic fashion and research methods may explain much of the variation. However, it does seem that in general, the prevalence of allergic rhinitis is growing, probably for the reasons already stated.

Question: Nobel Laureate Linus Pauling made a mention of the fact that vitamin C has some effect on allergic reactions. What is the latest on that?

Answer: Scientifically it has not been proven that vitamin C has any effect, beneficial or detrimental, on allergies. It is not harmful, at least in reasonable doses, but it will not help the disease.

Question: How are food allergies effectively identified and then treated?

Answer: Dr. Dean Metcalfe, here at the National Institute of Allergy and Infectious Diseases, screened adults for food allergy, and he found that when people came in and said, “I’m allergic to strawberries,” they were likely to be allergic to strawberries. If people came in and said, “I’m allergic to food,” they were almost never allergic to food. When people come in and can identify the food to which they are sensitive, we can confirm that by skin testing. In the case of a specific allergen, the skin tests are positive almost all the time. And, if we do a double-blind food challenge. It is frequently positive.

We have many examples where people have said, “I haven’t been able to eat eggs for 25 years,” and we skin tested them and the tests were negative. We did a provocation challenge, and the only response was they did not care for the taste of eggs. So, the skin test plus a good history is how we screen for food allergies.

Question: Have you ever observed any ophthalmological effects from allergies such as double vision?

Answer: The eye is always involved in allergy, but the symptoms are generally itching, swelling, and redness. Eye movement and visual acuity are not affected.

Question: What advice would you give to parents, both of whom suffer from allergies, regarding the introduction of foods for their infant children?

Answer: Our instructions are very simple. We would recommend, especially if you have two allergic parents, that solids not be introduces until the children are at least 6 months of age. We recommend exclusive breast-feeding through at least 6 months. There is some suggestion that very allergenic foods, like cow’s milk and peanuts, should be avoided by the mother during breast-feeding because she can transfer some allergens in breast milk. But the opportunity for a child to become allergic to allergens in breast milk is very limited versus drinking cow’s milk. Thus, breast-feeding is highly recommended .

Question: I have two questions. First, what are the possible side effects of allergy medications and how often do they occur? Second, I read that in some cases either asthma or hay fever, or some combination, can be due to emotional problems. Is there any information about that?

Answer: It has often been claimed that asthma is a psychological disease. That is not the case. Asthma is a real, very important disease that can kill you. It may be worsened by psychological stresses, but it is not caused by stress. It is not psychological. The parents of asthmatics often feel very guilty that their child has asthma, and they wonder if it is their fault in some way that influenced their child‘s asthma. That is not the case.

The side effects for drugs is a very broad question, very hard to answer, but I can tell you that the agents that we use today have been selected from many others because of their efficacy versus their very limited side effects. And the reason that theophylline is being used less today is because it has some side effects we wish to avoid.

Question: I would like your comment on sinusitis. Is it associated with allergies?

Answer: Sinusitis is an infection of the sinus areas of the skull, which are between the eyes, on either side of the cheeks, in the forehead, and center of the head. They are frequently associated with allergies and the development of sinus congestion; sinus infections are frequent accompaniments of allergy.

Question: What about the long-term effects of corticosteroids? Did I understand you to say that that was no problem?

Answer: Corticosteroids have major complications associated with them. In the past, we balanced the use of oral corticosteroids, which have systemic side effects, with the effects of the disease. When the disease was bad enough, we gave oral steroids and accepted the side effects if we had to. Now, with topical, inhaled steroids we have little or no systemic effects, so we get all the beneficial capabilities of steroids with none of the unwanted side effects.

Question: Why do some medications like Benadryl, which you might give a child for hives, say, “Do not give to a child with asthma”? Is it dangerous to give a child Benadryl when he or she has hives and not asthma?

Answer: That is an interesting and good question. The classical (older) antihistamines, like Benadryl, if you read the label, are not supposed to be used in asthma. Testing in the early 1950′s suggested that antihistamines made asthma worse. So there is a label insert that says they should not be used in asthma. We do not use any of the classical or older antihistamines for the treatment of asthma because they do not work very well. Despite the labeling , however, we do not believe they have any danger for people with asthma.

Some of the new, nonsedating antihistamines do have some efficacy in asthma, and they are being used cautiously for asthma treatment. These new asntihsitamines have no limitations on their use in asthma and may, indeed, be useful.

Question: I wondered if there has ever been a program to eradicate ragweed.

Answer: Yes, there has been. A woman in the Pennsylvania area and her family had terrible ragweed allergies and she organized the community to eradicate ragweed. It did not make any difference because ragweed moves through the air for such a long distance.

Question: Many of the over-the-counter antihistamines say, “Do not take it for more than seven days.” If I want to take them longer, should I get a prescription from a doctor?

Answer: Antihistamines have been available since the 1940′s and many people have taken antihistamine for more than 30 years. They have been among the world’s safest drugs. That does not mean that you should use an over-the-counter antihistamine without caution. By and large, we would recommend that everyone would benefit from an appropriate diagnosis and proper therapy, which might include over-the-counter drugs, but might also include prescription drugs, which are really quite a bit more potent and maybe more specific.

What is Allegra?

Allegra is a nonsedating antihistamine that relieves seasonal nasal allergy symptoms like sneezing, runny nose, and itchy, watery eyes in patients 12 and older.

How does Allegra work?

Allegra is an antihistamine. Histamine is a chemical in your body that causes allergy symptoms. Allegra blocks the histamines and relieves allergy symptoms such as sneezing, runny nose, and itchy, watery eyes.

How long does it take Allegra to work?

Relief of allergy symptoms may occur at 1 hour after taking a dose of Allegra.

How do I take Allegra?

Allegra is available as a 60-mg capsule. The recommended dose for patients 12 years of age or older is one capsule (60 mg) twice daily. It may be taken as one capsule in the morning and one capsule in the evening.

Can I take Allegra with food?

Allegra can be taken with or without food.

What are the side effects of Allegra?

In tests conducted by allergists, the incidence of drowsiness in people who took Allegra was similar to placebo (sugar pill), 1.3% vs 0.9%. The most commonly reported adverse experiences for Allegra and placebo are cold or flu (2.5% vs 1.5%), nausea (1.6% vs 1.5%), menstrual pain (1.5% vs 0.3%).

Will Allegra interact with other medications?

Make sure to let your doctor or pharmacist know of any other prescription or non-prescription medications you are taking. Your doctor or pharmacist can advise you about appropriate combinations of drugs.

Do I need to see my doctor to get Allegra?

Allegra is only available with a prescription from your doctor or other authorized health care provider.

How much does Allegra cost?

Retail prices may vary. However, the wholesale price of Allegra is below that of other available nonsedating antihistamines to provide nondrowsy allergy symptom relief at an economical price.