There is a new kid of the block to treat Allergic Rhinitis

Nov 16, 2020

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

Change is the only constant in life. That was true before 2020 and it will be true afterward. Ten years ago, I would never have guessed I'd be writing an article in between doing flu shots. I never really wanted to poke people with needles. I got into pharmacy because it was a non-messy health profession. During hospital rotations in school, I'd joke that after the nurses got the patient all cleaned up from puke, blood, poop and other bloodily fluids, then I'd come in and talk about their medications. I certainly don't have the stomach to work in an ER or an operating theatre. But about 8 years ago, the rules changed, pharmacists got some extra training, and now I poke arms.

When things change in the environment, some people's noses respond by running. The medical term for this is allergic rhinitis. Allergic rhinitis is estimated to affect about 20% of the population. Allergic rhinitis is one of three conditions that often go together. Allergic rhinitis, asthma and the skin condition, atopic dermatitis occur together in many people. Allergic rhinitis seems to have a genetic component as it runs in families. What is allergic rhinitis? When a person with allergic rhinitis breathes in an allergen such as pollen, mold, animal dander, or dust their body's immune system overreacts as if these benign substances were attacking the body. The body releases chemicals including histamine that cause inflammation and allergy symptoms. Symptoms may include: sneezing, itchy, watery eyes, stuffy or runny nose, cough, sore throat, and fatigue. Allergic rhinitis can lead to other conditions or make other conditions worse. These might include: sinus infections, ear infections, or sleep apnea.

What can you do about allergic rhinitis? If this is the first time you've ever had any of these symptoms, get assessed by your doctor. Doctors are doing many assessments over the phone now, so call your doctor's office first before just showing up at their office. They will want to rule out other illnesses, and possibly have you sent to a specialist to find out exactly what substances are your triggers. If you and your doctor are sure your problems are just allergies and the symptoms aren't too severe, you can start with trigger avoidance.

To avoid your allergy triggers, you have to know what they are. Allergy testing can determine your triggers, and you can help yourself by keeping an allergy diary. In an allergy diary you list what you did, what you were exposed to, and how your symptoms were in a given day. If it turns out that you are allergic to pollen or outdoor molds you might try to remain inside during pollen season. Or you could watch the pollen counts on the Weather Station and avoid outdoor activities on high pollen count days. You could shower or bathe after outdoor activity to remove pollen from hair and skin and to prevent contamination of bedding. If you have indoor allergies like dust mites, then try to avoid carpeting. The less carpeting in the house, the better, especially the bedroom. Using a central vacuum system that exhausts outside is best for cleaning when someone in the house has allergies. In fact, the allergic person shouldn't even be in the home when the vacuuming is done, if possible. Encase all mattresses, box springs and pillows in zippered, allergen-proof casings. Keep indoor humidity under 50%.

Allergen avoidance isn't always possible or sometimes even desirable. While getting people to not smoke in the house is probably attainable, getting rid of the family cat probably is not. How we treat allergic rhinitis without a prescription has changed over the last couple years. Nasal steroid sprays like fluticasone are available without seeing your doctor. This is great news because nasal steroid sprays are much more effective at treating allergic rhinitis symptoms than antihistamines. Nasal steroids sprays are good at treating all 4 main allergic rhinitis symptoms. They treat sneezing, itching, runny nose and nasal congestion or stuffy nose. Nasal steroid sprays are very good, but they aren't Dristan. They don't work quickly. It may take 2-4 weeks for them to be fully effective and they are designed to be used everyday during allergy season. If you find you need your over-the-counter nasal steroid for more than 2-3 months, it is time to talk to your doctor to see if a prescription might be a good idea.

Over the counter antihistamines can also be effective for allergies. We used to say that someone should take oral antihistamines for a whole allergy season, like from before the snow melts until after the first month or two of spring when the pollen count drops. And that still works. But because the nasal steroids work so well, they are probably a better choice for the moderate to severe allergy sufferers. Now, we'll probably just use loratadine or Claritin, cetirizine or Reactine, and fexofenadine or Allegra for mild allergy symptoms that come and go. Antihistamines start working in about an hour. They are good for itchy eyes and running nose, but they don't do as well for nasal congestion. Because oral antihistamines don't work so well for congested or stuffy noses, sometimes we use a combination of an antihistamine and a decongestant. The upside of a decongestant is it helps with the stuffy nose. The downside of a decongestant is it can raise the blood pressure, which is a problem especially if the person already has high blood pressure. I often point people towards loratadine rather than cetirizine for allergic rhinitis. I think cetirizine actually works better than loratadine for all types of allergies, but cetirizine seems to cause drowsiness in about 10% of people. Cetirizine and loratadine are called second generation antihistamines. We don't recommend first generation ones like chlorpheniramine (Chlor-Tripilon), and diphenhydramine (Benadryl) for allergic rhinitis anymore because they can cause dry mouth, trouble passing urine, and drowsiness.

There is a newer nasal spray on the market called Dymista. It is available by prescription and it contains azelastine, an antihistamine and fluticasone, a steroid. Azelastine is interesting because it is an antihistamine that you can spray up your nose, not one you take orally. Just like the oral antihistamines, nasal azelastine helps with sneezing, runny nose and itchy eyes. However, azelastine also works well for stuffy or congested noses. When you combine azelastine with a steroid like fluticasone you should get really good coverage of all the allergic rhinitis symptoms.

I don't mind doing flu shots anymore. Pharmacists doing flu shots are a change that I hardly notice anymore. I'm no longer freaked out when EMT's, nurses, doctors, surgeons and others who could critique my needle work come by for a flu shot. Just like cleaning fish, confidence and practice go a long way for administering a good flu shot. So okay, I'm going to just clean off your left shoulder with an alcohol swab. Just let your arm hang there all loosy goosy. There. It's done. Hold this cotton ball on your shoulder with your other hand. Perfect. Now, I'm going to put on a tiny spot band aid. There you go. It didn't even hurt did it?

The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.


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