Patients who experience allergic rhinitis are eager to find relief. The condition’s most common symptoms include repetitive sneezing, nasal congestion, rhinorrhea, and itchy and watery eyes. The degree of severity of these symptoms varies from patient to patient, and can be so severe that patients’ quality of life is affected, causing impairment of daily activities, fatigue, and sleep disturbances.1 In the United States, AR affects an estimated 10% to 30% of adults and about 40% of pediatric patients, representing approximately 60 million individuals; its prevalence is increasing each year.1-3 The symptoms commonly associated with AR typically present in patients after 2 years of age.3 AR is a prevalent condition among pediatric patients and among individuals aged 18 to 64 years.3 The condition appears to be more prevalent in the southern parts of the United States than elsewhere in the country.3
Types of Allergic Rhinitis
Allergic rhinitis can be classified as seasonal (hay fever) or perennial.3,4 Seasonal allergic rhinitis (SAR) symptoms may occur in the spring, summer, and early fall, and are caused by allergic sensitivity to pollen from trees, grasses, weeds, or airborne mold spores.3,4 Perennial allergic rhinitis (PAR) symptoms typically occur year round and are caused by hypersensitivity to dust mites, animal dander, cockroaches, or mold spores.1,3,4 Patients may experience 1 or more of the following symptoms: episodes of repetitive sneezing, rhinorrhea, postnasal drip, nasal congestion, loss of smell, headaches, earache, excessive tearing, red itchy eyes, eye swelling, fatigue, drowsiness, and malaise.3,5
In some cases, patients may experience both types of allergic rhinitis, exhibiting more severe symptoms during specific pollen seasons.3 Allergic rhinitis can be associated with complications such as otitis media, sinusitis, recurring sore throat, cough, headache, changes in sleep patterns, sleep apnea, depression, fatigue, anxiety, irritability, poor school performance, and impaired cognitive function.3,4-6
According to the American Academy of Allergy, Asthma & Immunology, an estimated 1 of 3 individuals with rhinitis do not have allergies.7 Causes of nonallergic rhinitis may include hormones (eg, pregnancy, puberty, thyroid conditions), structural defects (eg, septal deviation, adenoid hypertrophy), lesions (eg, nasal polyps and neoplasms), and the use of certain medications such as beta-blockers, oral contraceptives, clonidine, angiotensin-converting enzyme inhibitors, aspirin and other nonsteroidal anti-inflammatory drugs, or overuse of topical decongestants.4-7
Although the ideal treatment for the management of AR is avoidance of allergy triggers, some allergy triggers are unavoidable. Typically, AR is treated in 3 steps: environmental control measures and allergen avoidance, pharmacologic therapy, and immunotherapy. 3,5 Many patients may have to try several different treatment options before finding the ideal treatment. The factors to be considered when selecting therapy include the patient’s medical and medication history, specific symptoms and their severity, and the cost and frequency of treatments.
There is a range of nonprescription agents marketed for the management and relief of allergic rhinitis symptoms, including oral and ocular antihistamines; oral, nasal, and ocular decongestants; and mast cell stabilizers.3 These products are available as single entity or multiple ingredient products in a variety of dosage forms, including immediate- and sustained-release formulations, to meet the needs of a variety of patients, including adults and children.
Antihistamines are considered the standard therapy for providing symptomatic relief of AR. They are indicated for the relief of itching, sneezing, and rhinorrhea symptoms. First-generation antihistamines (sedating antihistamines) are associated with drowsiness/ sedation, impaired mental alertness, and anticholinergic effects.2 The second- generation nonprescription antihistamines (nonsedating antihistamines), including loratadine and cetirizine, usually do not cause significant drowsiness. 3 These medicines are quickly absorbed after oral administration with time-to-peak plasma concentrations in the 1-to-3-hour range.
Because congestion commonly occurs with allergic rhinitis, many patients may elect to use a decongestant as well.3 Nonprescription decongestants include pseudoepedhrine and phenylephrine. Decongestants are indicated for the temporary relief of nasal and eustachian tube congestion and cough associated with postnasal drip.3
Common adverse effects associated with the use of oral decongestants include insomnia, nervousness, and tachycardia. Patients should be advised that the use of decongestants may also exacerbate medical conditions that are sensitive to adrenergic stimulation (eg, hypertension, diabetes, coronary artery disease, prostatic hypertrophy, and elevated intraocular pressure).3 Patients should also be reminded about the potential of rhinitis medicamentosa (rebound congestion) when using topical decongestants for more than 3 to 5 days.3
Many products on the market contain a combination of an antihistamine and a decongestant. Patients should be advised to only use combination products when warranted to avoid unnecessary drug use. Because antihistamines and decongestants interact with several medications and are contraindicated in various patient populations, pharmacists are key in identifying potential drug–drug interactions or contraindications.
Another nonprescription option for allergy suffers is the nasal spray cromolyn sodium, which is indicated for preventing and treating symptoms associated with allergic rhinitis.3 Cromolyn sodium is approved for those 5 years and older and should be administered as 1 spray in each nostril 3 to 6 times daily. Treatment is more effective if initiated at least a week before seasonal symptoms occur.3 It may take 3 to 7 days for initial treatment efficacy to become apparent and 2 to 4 weeks of continued therapy to achieve optimal effect.3 Patients should be instructed to administer 1 spray in each nostril 3 to 6 times daily and treatment should be initiated at least a week before seasonal symptoms occur.
Some patients with AR who also suffer from watery and itchy eyes may elect to use an ocular antihistamine product. OTC ophthalmic antihistamines include pheniramine maleate and antazoline phosphate. These products are available in combination with the decongestant naphazoline. The most common adverse effects associated with the use of ophthalmic antihistamines include burning, stinging, and discomfort upon instillation. 6
Ketotifen 0.025% is the only nonprescription antihistamine ophthalmic product on the market to relieve ocular itching without the use of a decongestant. Ketotifen is classified as a noncompetitive H1-receptor antagonist and mast cell stabilizer that inhibits the release of mediators from cells involved in hypersensitivity reactions.6,8,9 It is indicated for use in patients 3 years and older and is classified as pregnancy category C.8,9 It is indicated for the temporary relief of itchy eyes due to exposure to ragweed, pollen, grass, animal hair, and dander.
The recommended dosage is 1 drop to the affected eye(s) every 8 to 12 hours, but no more than twice daily.6,8,9 Common adverse reactions include headache, dry eyes, and rhinitis.6,8,9 Ketotifen is not indicated for treatment of contact lens–related inflammation. Patients who wear contacts should be instructed to wait at least 10 minutes after instillation of ketotifen before inserting their lenses.8,9
Prior to recommending any OTC products for AR, pharmacists should evaluate the patient’s medication profile and medication history for potential drug– drug interactions and contraindications, including allergy sensitivities, and refer patients with severe symptoms for further medical evaluation. During counseling, patients should always be advised to adhere to the manufacturer’s directions and be aware of potential adverse effects.
Pharmacists can also present various nonpharmacologic approaches, such as using nasal saline solutions to relieve nasal irritation and dryness or nonmedicated nasal strips for congestion.3,4 They can also suggest recommendations for decreasing allergy triggers including washing bedding in hot water every week, vacuuming carpets and upholstery regularly, using allergy covers on pillows and mattresses, lowering the humidity level in the home to reduce the incidence of mold, keeping car and home windows closed (especially when pollen and mold levels are high), and regularly checking pollen and mold counts in the local area.3,10-13
1. Lambert M. Practice Parameters for Managing Allergic Rhinitis. Am Fam Physician. 2009 Jul 80(1).
2. Allergy Statistics. America Academy of Allergy Asthma and Immunology website. http://www.aaaai.org/media/statistics/allergy-statistics.asp Accessed March 3, 2012.
3. Scolaro K. Disorders Related to Colds and Allergy. In: Krinsky D. Berardi R, Ferreri S. et, et al, eds. Handbook of Nonprescription Drugs 17th ed. Washington, DC: American Pharmacists Association; 2012
4. Rhinitis. The American Academy of Allergy, Asthma and Immunology website http://www.acaai.org/public/advice/rhin.htm. Accessed March 3, 2012
5. Sheikh J and Najib U. Rhinitis, Allergic. eMedicine website. http://emedicine.medscape.com/article/134825-overview. Accessed March 3 2012.
6. Fiscella R and Jensen M. Ophthalmic Disorders. In: Krinsky D. Berardi R, Ferreri S. et, et al, eds. Handbook of Nonprescription Drugs 17th ed. Washington, DC: American Pharmacists Association; 2012
7. Rhinitis (Hay Fever). The American Academy of Allergy, Asthma and Immunology website. http://www.aaaai.org/conditions-and-treatments/allergies/rhinitis.aspx. Accessed March 3,2012
8. Zaditor Product Information. Alcon website. http://www.alcon.com/en/docs/zaditor-drug-facts.pdf .Accessed March 2, 2012.
9. Alaway Product Information. Bausch and Lomb website. http://alaway.com/index.html?utm_source=Google&utm_medium=Paid%2bSearch&utm_content=Brand&utm_campaign=Alaway Accessed March 1, 2012.
10. Allergy Management Tips. Schering Plough Claritin Healthcare Products website. http://www.claritin.com/claritin/en/manage/tips.jspa Accessed March 1,2012
11. Allergy Information. Pfizer Consumer website. www.alavert.com/allergy_info.asp. Accessed March 1,2012
12. Manage Your Allergy Environment. McNeil PPC website. www.zyrtec.com/my-allergy-guide/manage-allergy-environment Accessed March 1, 2012
13. Allergic Rhinitis. United States National Library of Medicine website. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001816/ Accessed March 1, 2012
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