Managing Upper Respiratory Diseases

The etiology and pathophysiology of allergic disease serve as useful guides to pharmacotherapy.¹ Before considering prescription medication or recommending over-the-counter (OTC) treatment, specific IgE testing is recommended to confirm the presence of atopy (without which allergy-specific medications have no benefit). Even the most complete history and physical won’t provide the essential evidence you need to get to the true cause of allergy-like symptoms. Testing to rule in or rule out allergy will help get your patients on the most appropriate course of treatment. Ultimately, medication (whether to relieve symptoms or treat the disease) may prove to be the best option, but the side effects, diminishing effectiveness, and high cost of pharmacotherapy make testing before treatment essential.

Medications Used to Manage Allergic Rhinitis ^1-4

• Mast Cell Stabilizers
  • Cromolyn sodium
    
    
• First-generation Oral Antihistamines
  • Diphenhydramine
  • Brompheniramine
  • Chlorpheniramine
  • Clemastine
    
    
    
• Second-generation Oral Antihistamines (non-sedating)
  • Cetirizine
  • Desloratadine
  • Fexofenadine
  • Loratadine
    
    
• Nasal Antihistamines
  • Azelastine
    
    
• Nasal Decongestants
  • Oxymetazoline
  • Xylometazoline
    
    
• Oral Decongestants
• Pseudoephedrine
• Phenylephrine
  
  
• Nasal Corticosteroids
  • Beclomethasone dipropionate
  • Budesonide
  • Flunisolide
  • Fluticasone propionate
  • Mometasone
    
    
• Leukotriene Antagonists
  • Montelukast sodium
    
    
• Anti-IgE
  • Omalizumab

Antihistamines — Oral antihistamines, many available OTC, are frequently used as first-line therapy to reduce itching, sneezing, and rhinorrhea. However, antihistamines do not reduce nasal congestion,¹ which is the number-one complaint of rhinitis sufferers. Decongestants and topical corticosteroids are often added to antihistamines to relieve nasal blockage and reduce inflammation. First-generation antihistamines can cause drowsiness and impair performance. For those reasons, second-generation antihistamines are more often recommended initially by physicians.⁵ It’s important to use specific IgE testing to rule in or rule out allergy before beginning any treatment, since these products are not effective in treating non-allergic conditions.⁶

Decongestants — Oral decongestants constrict blood vessels in the nose, causing the lining to feel less stuffy. Decongestant/antihistamine combination medicines also provide relief, but it is the decongestant, not the antihistamine, that reduces mucus volume and helps relieve congestion. Possible side effects include difficulty sleeping, anxiety, restlessness, agitation, tremor, headache, dry mucous membranes, urinary retention, cardiovascular effects (eg, palpitations, tachycardia, extrasystoles), exacerbation of thyrotoxicosis and/or glaucoma. A "rebound phenomenon" can be seen with nasal spray decongestants, characterized by increased nasal congestion and edema. The combination of an oral decongestant with a non-sedating antihistamine may also cause insomnia.⁷

Nasal Corticosteroids — Inhaled nasal corticosteroids are the most effective class of drugs for controlling the inflammation and symptoms of allergic rhinitis. Systemic absorption is minimal, and patient compliance can minimize side effects. Oral corticosteroids may be used for the most severe nasal symptoms or for nasal polyposis, but experts urge the use of only short-course therapy (3 to 7 days), due to the risk of significant side effects from longer term use.¹ As always, before initiating any pharmacotherapy, question patients about their previous use of and response to OTC medications.⁵

Mast Cell Stabilizers — Mast cell stabilizers such as nasal cromolyn sodium inhibit calcium influx into mast cells, thereby stabilizing cell membranes, inhibiting degranulation, and preventing an allergic reaction.¹ Side effects are minimal. Best results are realized when cromolyn sodium is used before exposure to allergens. Cromolyn sodium is available without a prescription.

Leukotriene Antagonists — Drugs in this class block the action of leukotrienes, an underlying mediator of allergy symptoms and inflammation. These drugs have the ability to obstruct sneezing and an itchy, runny nose, the early response to allergic triggers, if allergies exist. They also obstruct the delayed response—congestion. These medications are mild and have few side effects.³ Like antihistamines, these drugs offer no known benefit to patients with non-allergic rhinitis.

Anti-IgE — Omalizumab is a monoclonal antibody used for the treatment of allergic disorders. Indicated only for allergic asthma, this medication is sometimes prescribed off-label for the treatment of allergic rhinitis. A product of recombinant humanized monoclonal antibody technology, omalizumab is the first anti-IgE monoclonal antibody on the market.⁴ This injectable medication may reduce allergic reactions by eliminating the IgE antibody’s ability to attach to mast cells.⁴

As with all treatment options, medication may be ineffective or simply unnecessary if allergy is not the true cause of symptoms. If allergy is the cause, combining treatment with effective environmental control measures can improve management of the disease. Specific IgE testing can rule in or rule out allergy, and, when specific IgE is detected, can tell you exactly what your patient is allergic to.

Next: Immunotherapy