Author: Mary Barna Bridgeman, PharmD, BCPS, CGP, and Rupal Patel Mansukhani, PharmD
Case 1—Seasonal Allergies
ML is a 38-year-old woman who comes to the pharmacy and asks where the herbal products are located. She says her seasonal allergies have been terrible for the past few weeks. She has itchy and watery eyes, and her symptoms have gotten worse over the last few days, so she went to see her primary care physician. He diagnosed her with seasonal allergies and recommended she take an OTC product called cetirizine. Her friend who also has seasonal allergies takes a natural product called milk thistle, which cures the friend’s allergies. The friend told ML that this product worked instantly for her and recommended that ML try this natural product first. ML says she is not against conventional medicine but since milk thistle is working for her friend, she figured she would try it. What would you recommend to ML regarding treatment for her seasonal allergies?
ML is a candidate for self-treatment, especially since her physician advised her to self-treat her allergies. There are some data suggesting that milk thistle may be effective for allergies when used in combination with cetirizine. In 1 study, researchers found 140 mg of milk thistle 3 times daily in combination with cetirizine decreased the severity of allergies compared with cetirizine alone.1
However, there are currently no data suggesting that milk thistle alone would be beneficial. Since ML is not opposed to conventional medicine, it might be beneficial to educate her on the research regarding milk thistle. She should be advised not to use milk thistle as monotherapy to treat her seasonal allergies. Since there are good data supporting the use of cetirizine to treat seasonal allergies, it would be appropriate to recommend cetirizine 10 mg daily. It is also important to monitor ML for allergy symptoms. If her symptoms improve, it would be appropriate to continue cetirizine as monotherapy. If they do not improve, she could consider using a combination of products. Other nonpharmacologic therapies such as saline mists and avoiding pollen may also be beneficial for ML.
Case 2—Allergy and Ear Infection
GM is a 31-year-old woman who comes to the pharmacy looking for a recommendation for her 8-year-old daughter SK. GM is very concerned about her daughter, who has had 6 ear infections in the past 3 months due to uncontrolled allergies. SK’s symptoms include runny nose, watery eyes, and occasional congestion. GM reports that SK’s symptoms begin in March and last all summer. GM thinks SK has allergies because both she and her husband have seasonal allergies, which require daily medication. upon questioning, however, GM says that her daughter has never formally been diagnosed with seasonal allergies and that she forgets to mention it whenever they see the pediatrician. GM says her friend’s daughter is taking loratadine syrup and recommended that SK do the same to prevent ear infections. GM is hesitant to start SK on a medication because she does not want her to take it every day. What recommendations would you make for SK?
Since SK is only 8 years old, it would be appropriate to refer her to her primary care physician for treatment of allergic rhinitis. Typically, patients who are younger than 12 years should be referred to a physician. Other patients who should be referred to a physician are those who are pregnant or lactating; show signs of a current infection; have symptoms of nonallergic rhinitis, undiagnosed or non-controlled asthma, COPD, or moderate to severe allergic rhinitis; or are experiencing severe side effects of treatment.2
Since GM is concerned about her daughter taking a medication every day, it may be beneficial for the daughter to undergo allergy testing. The primary care physician can determine whether it would be appropriate for SK to take her medication during the allergy season. Since SK has had multiple infections due to her allergies, it may be beneficial to discuss with her primary care physician whether SK should see a pediatric ear, nose, and throat physician.
Case 3—Allergies and Depression
RP is a 45-year-old woman who comes to the pharmacy in August complaining of itchy eyes, frequent sneezing, and runny nose. She plays in a softball league with all her friends and loves it. She says that 2 years prior, she was very depressed and on multiple antidepressants. Since she joined the softball league, her physician has discontinued her depression medications and she is feeling wonderful. She now feels like she is part of a team and thinks of her teammates as part of her family. Now that her symptoms are getting worse, she has been unable to participate in the activities she wants to on a daily basis. She claims she wants to relieve her symptoms, but she is opposed to taking any medications because she believes that all medications are eventually associated with an increased risk of heart attack. She wants to know if there are any nonpharmacologic therapies that would help relieve her symptoms so she can start playing softball again.
RP would be a candidate for self-treatment of seasonal allergies. She can use any of the second-generation antihistamines. However, since she is not keen on using pharmacologic therapy, it may be appropriate to help her control her symptoms through education. It may be beneficial to tell RP to stay indoors and avoid playing softball when the pollen count is high and when most patients have symptoms. However, since she says taking part in the softball league has helped decrease her depression, it would be inappropriate to advise her to stay indoors all the time. Nasal wetting agents such as saline may be beneficial for RP as a means to relieve nasal mucosal dryness, thus decreasing nasal stuffiness, rhinorrhea, and sneezing. If her symptoms continue to worsen, she may have to weigh the risks and benefits of taking medication and also consider whether she wants to continue to play softball.
Case 4—Asthma and Allergies
ML is a 32-year-old man who comes to the pharmacy to refill his prescriptions. He has been taking lisinopril 10 mg and loratadine 10 mg. Upon questioning, he states his allergies were well controlled for the past year so he decided to stop taking his loratadine. He understands the importance of taking medications as prescribed, and says he takes his blood pressure medication every day. He claims the reason he stopped taking the loratadine was that his friend told him loratadine is an as-needed medication and that if he had no symptoms, there was no reason to continue it. However, this past week has been horrible, and his allergies are acting up. He says that in the past he has used Primatene Mist with loratadine but is having difficulty locating it. Upon questioning, he says he has been short of breath every day for the past 2 weeks. He claims that when his allergies are bad, his asthma acts up. His doctor in the past always recommended Primatene Mist for his asthma and allergies. What recommendations would you make to ML regarding management of his asthma?
ML appears to have allergy-induced asthma. According to the expert Panel Report 3: Guidelines for the diagnosis and Management of asthma, TY’s asthma severity would be classified as persistent moderate.3
Primatene Mist has not been available since December 31, 2011, as part of a phase-out of epinephrine inhalers containing chlorofluorocarbons (CFCs). Since no equivalent is available OTC for asthma control, ML should be referred to his primary care physician to discuss other options. Ideally, ML should be prescribed a short-acting beta agonist to help relieve his shortness of breath until his allergy symptoms are controlled. If ML appears to have daily shortness of breath after his allergies are controlled, additional drug therapy may be necessary to control his asthma. Additionally, ML should be advised to take his loratadine daily even when he feels better, to prevent his allergies from acting up.
Dr. Mansukhani is a clinical pharmacist in South Plainfield, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University. Dr. Bridgeman is an internal medicine clinical pharmacist in New Brunswick, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University.
Bakhshaee M, Jabbari F, Hoseini S, et al. Effect of silymarin in the treatment of allergic rhinitis. Otolaryngol Head Neck Surg. 2011;145:904-909.
Disorder related to colds and allergy. In: Krinsky DL, Berardi RR, Ferreri SP, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 17th ed. Washington, DC: American Pharmacists Association; 2011:194.
Expert panel report 3 (EPR-3): Guidelines for the diagnosis and management of asthma. Bethesda, MD: National Institutes of Health. www.nhlbi.nih.gov/guidelines/asthma/asthsumm.htm. Accessed March 6, 2013.