Pharmacy Times

Seasonal Allergic Rhinitis

Author: Yvette C. Terrie, BSPharm, RPh


Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.


According to the American Academy of Allergy, Asthma, and Immunology, an estimated 36 million individuals, representing 20% of adults and 40% of children in the United States, are affected by seasonal allergic rhinitis (SAR), commonly referred to as hay fever.1-3 SAR is characterized by repetitive and predictable seasonal symptoms that include episodes of repetitive sneezing, nasal congestion, postnasal drip, and red, itchy, watery eyes.1-3

Typically, symptoms flare up in early spring and again in the fall. Because SAR can negatively impact the quality of life for many patients, prevention or symptom relief is the major goal of therapy. The most prevalent causes of SAR include common outdoor allergens (eg, airborne tree, grass, and weed pollen) or mold.3,4 In general, patients with SAR need medication only during peak pollen or mold season.3

Pharmacologic Therapy

Allergy/sinus medications account for an estimated 58% of OTC drug sales.3 Currently, a variety of OTC products are available for the symptomatic relief of allergic rhinitis that include oral and ocular antihistamines, oral and topical decongestants, and mast cell stabilizers.3 Also, many combination products are available. Selection of therapy often is based on specific symptoms and their severity, as well as cost and frequency of dosing intervals.

Key Counseling Tips

  • Patients should initiate allergy medications at least 1 week before symptoms are anticipated
  • Patients should be counseled on sedating effects associated with the use of some antihistamine products and advised to use these products with caution
  • Patients should avoid the use of alcohol while taking these medications
  • Patients with pre-existing medical conditions or those taking other medications should seek advice from their primary health care provider before using OTC drugs for allergic rhinitis
  • Women who are pregnant or breast-feeding should be referred to their physicians before using any OTC drugs
  • Patients who do not respond to the use of OTC drugs, or those whose symptoms worsen, should be referred for further medical evaluation
  • Patients should be reminded that adherence to medication and not exceeding recommended dosage of the selected product is essential for controlling symptoms

Adapted from reference 3.

Antihistamines
Antihistamines are a key option for providing symptomatic relief of allergic rhinitis and are indicated to relieve itching, sneezing, and rhinorrhea. Available formulations of OTC antihistamines include chewable tablets, oral disintegrating tablets, or medicated thin strips; immediate- or sustained-release capsules, tablets or caplets; and liquid, available in alcohol-, sugar-, and dye-free formulations.

First-generation (sedating) antihistamines are associated with drowsiness, impaired mental alertness, and anticholinergic effects.3 Until recently, loratadine was the only second-generation (nonsedating) OTC antihistamine. In November 2007, however, the FDA approved another OTC second-generation antihistamine, cetirizine hydrochloride (HCl) (Zyrtec), as well as its antihistamine/decongestant combination formulation, cetirizine HCl/pseudoephedrine HCl (Zyrtec-D).5

Decongestants
Because congestion is a prevalent symptom for many allergy patients, the use of a systemic or short-term topical nasal decongestant may be necessary.3 Decongestants are indicated for the temporary relief of nasal and Eustachian tube congestion, as well as cough related to postnasal drip.3

Common adverse effects associated with the use of oral decongestants include insomnia, nervousness, and tachycardia. Decongestants also may exacerbate medical conditions that are sensitive to adrenergic stimulation (eg, hypertension, diabetes, coronary artery disease, prostatic hypertrophy, elevated intraocular pressure).3 Patients also should be reminded about the potential of rhinitis medicamentosa (rebound congestion) when using topical decongestants for >3 to 5 days.3

Combination Products
Many products on the market contain a combination of an antihistamine and a decongestant. Patients should be advised only to use combination products when warranted to avoid unnecessary drug use.

Mast Cell Stabilizer
The nasal spray cromolyn sodium is indicated for preventing and treating the symptoms associated with allergic rhinitis. Patients should be instructed to administer 1 spray in each nostril 3 to 6 times daily, and treatment should be initiated at least 1 week before seasonal symptoms occur. The most common adverse effects include a burning and stinging sensation in the nasal area.3,6

Patient Counseling

Before recommending any OTC products for allergic rhinitis, pharmacists should ascertain the appropriateness of self-treatment and refer patients to seek further medical evaluation when warranted. Pharmacists should screen for possible drug-drug interactions and contraindications, including allergy sensitivities. Patients should be advised to adhere to the manufacturer's directions and be aware of potential adverse effects.

Pharmacists also can offer suggestions on nonpharmacologic measures that may assist allergy patients, such as using the drug-free Breathe Right nasal strips, avoiding allergens when possible, lowering the humidity level in the home to reduce the incidence of mold, keeping car and home windows closed when pollen and mold levels are especially high, and checking pollen and mold counts in the local area.3

Systemic Antihistamine Products

Brand (Manufacturer)

Active Ingredients

Alavert Allergy (Wyeth Consumer Healthcare); Claritin (Schering-Plough HealthCare Products Inc); Dimetapp Children's Non-Drowsy Allergy (Wyeth Consumer Healthcare)

Loratadine

Benadryl (McNEIL-PPC Inc)

Diphenhydramine HCl

Chlor-Trimeton 12-hour Allergy Relief (Schering-Plough HealthCare Products Inc)

Chlorpheniramine maleate

Tavist Allergy (Novartis AG)

Clemastine fumarate

Zyrtec (McNEIL-PPC Inc)

Cetirizine HCl

Systemic Antihistamine/Decongestant Combination Products

Actifed Cold and Allergy (McNEIL-PPC Inc)

Phenylephrine HCl/triprolidine HCl

Advil Allergy Sinus (Wyeth Consumer Healthcare)

Ibuprofen, pseudoephedrine HCl, chlorpheniramine maleate

Allerest PE (Insight Pharmaceuticals Corp); Triaminic Cold and Allergy (Novartis)

Phenylephrine HCl, chlorpheniramine maleate

Benadryl Allergy and Cold (McNEIL-PPC Inc); Tylenol Allergy HCl, Multi-Symptom Nighttime (McNEIL-PPC Inc)

Acetaminophen, diphenhydramine phenylephrine HCl

Benadryl-D Allergy and Sinus (McNEIL-PPC Inc)

Diphenhydramine HCl, phenylephrine HCl

Claritin-D (Schering-Plough HealthCare Products Inc)

Loratadine, pseudoephedrine sulfate

Dimetapp Elixir (Wyeth Consumer Healthcare)

Brompheniramine maleate, phenylephrine HCl

Sudafed Sinus and Allergy (McNEIL-PPC Inc)

Chlorpheniramine maleate, pseudoephedrine HCl

Tylenol Severe Allergy (McNEIL-PPC Inc)

Acetaminophen, diphenhydramine HCl

Tylenol Allergy Multi-Symptom (McNEIL-PPC Inc) maleate, phenylephrine HCl

Acetaminophen, chlorpheniramine

Zyrtec-D (McNEIL-PPC Inc)

Cetirizine HCl, pseudoephedrine HCl

Nasal Sprays

Afrin Nasal Spray (Schering-Plough HealthCare Products Inc); Nostrilla Nasal Decongestant Original Fast Relief (Insight Pharmaceuticals Corp)

Oxymetazoline HCl

NasalCrom Allergy Prevention Nasal Spray (McNEIL-PPC Inc)

Cromolyn sodium

Ophthalmic Drops

Bausch & Lomb Advanced Eye Relief Opcon-A Allergy (Bausch & Lomb); Naphcon-A Allergy Relief Eye Drops (Alcon Laboratories); Visine-A Eye Allergy Relief, Antihistamine & Redness Reliever (Pfizer Inc)

Pheniramine maleate; naphazoline HCl

Homeopathic Products

Iovate Health Sciences Allergy MD Rapid-Tabs (Iovate Health Sciences)
NatraBio Allergy & Sinus Non-Drowsy Tablets (NatraBio)
Similasan Hay Fever Relief Non-Drowsy Formula Nasal Spray (Similasan Corporation)
ZICAM Allergy Relief Liquid Nasal Gel (Matrixx Initiatives, Inc)


References

  1. Ragweed, Allergies and Hay Fever. The American Academy of Allergy, Asthma, and Immunology Web site. www.aaaai.org/patients/topicofthemonth/0806. Accessed March 3, 2008.
  2. Allergic Rhinitis Fact Sheet. The American Academy of Allergy, Asthma, and Immunology Web site. www.aaaai.org/patients/resources/fact_sheets/allergic_rhinitis.pdf. Accessed March 3, 2007.
  3. Scolaro, Kelly. Disorders Related to Colds and Allergy. In: Berardi RR, Kroon LA, McDermott JH, Newton GD, eds. Handbook of Nonprescription Drugs. 15th ed. Washington DC: APhA Publications. 2006:213-227.
  4. Spring and Allergic Rhinitis. The American Academy of Allergy, Asthma, and Immunology Web site. www.aaaai.org/patients/topicofthemonth/0307. Accessed March 7, 2008.
  5. FDA Approves Zyrtec for Nonprescription Use in Adults and Children. FDA Web site. www.fda.gov/bbs/topics/NEWS/2007/NEW01750.html. Accessed March 3, 2007.
  6. NasalCrom [Product Information] Fort Washtington, PA: McNeil-PPC Inc. www.brands2liveby.com/product.aspx?id=419. Accessed March 7, 2008.
  7. Spring Allergy Tips. Schering-Plough Healthcare Products Web site. www.claritin.com/claritin/allergies/spring. Accessed March 3, 2008.

Erratum: The table listing probiotic dietary supplements featured in A Pharmacist's Guide to OTCTherapy (February 2008) should have included the probiotic dietary supplement Florajen (see below).

Examples of Probiotic Dietary Supplements

Brand (Manufacturer)

Active Ingredients

Align Capsules (Procter & Gamble)

Bifidobacterium infantis 35624

Culturelle Capsules (Amerifit Brands)

Lactobacillus rhamnosus GG

Culturelle Capsules for Kids (Amerifit Brands)

L rhamnosus GG

Flora Q Capsules (Kenwood Therapeutics)

Lactobacillus acidophilus, Bifidobacterium, Lactobacillus paracasei, Streptococcus thermophilus

Florajen Capsules (American Lifeline Inc)

Lactobacillus acidophilus

Florajen3 Capsules (American Lifeline Inc)

Lactobacillus acidophilus, Bifidobacterium lactis (bifidum) strain, Bb-12, and Bifidobacterium longum

Natrol BioBeads Probiotic Acidophilus (Natrol Inc)

Proprietary probiotic blend of 1 billion (L acidophilus, Bifidobacterium bifidum, Bifidobacterium longum, L rhamnosus)

Nature's Bounty Chewable Acidophilus with bifidus (Nature's Bounty Inc)

L acidophilus 50 mg, Lactobacillus bifidus 50 mg

Nature's Way Primadophilus Reuteri Pearls (Nature's Way)

Proprietary probiotic blend (L acidophilus, B longum, L rhamnosus, Lactobacillus reuteri)

PhytoPharmica Probiotic Pearls (PhytoPharmica)

L acidophilus, B longum

Sustenex Capsules (Ganeden Biotech Inc)

Bacillus coagulans