Posted By RichC on June 8, 2017
A lot of people struggle with seasonal allergies, but for me it seems to be something I’m noticing later in life? As with most minor health issues, we deal with it and move on when it goes away.
This past month or so the runny-nose and watery eyes symptoms have bothered me enough to take whatever we’ve had in the medicine cabinet, Zyrtec-D (Cetirizine HCl 5 mg plus the decongestant Pseudoephedrine HCl 120 mg) in my case, but am starting to realize this is becoming an ongoing issue. Besides bugging my wife (a pharmacist who likely is too tired to deal with the same questions from her husband at home as at work), I checked with my daughter (a Pediatrician) for advice on dealing with allergy symptoms. Both of them were helpful, but after Googling, felt the article on Iodine was the most informative and likely will be of help to someone else too … therefore linking and archiving.
If you have seasonal allergies, how can you be sure you’re on the right med? Based on my experience seeing patients, talking to my friends about what they use, and reading some of what’s out there online, I think a lot of people are barking up the wrong tree and suffering needlessly from runny noses, sneezing, congestion, and itchy eyes.
Is your allergy medicine cutting it? Read on and find out.—
Everyone’s heard of antihistamines
You’re probably most aware of a drug class called antihistamines. Antihistamines block histamine, a chemical involved in inflammatory reactions. Histamine makes tiny blood vessels called capillaries permeable to white blood cells and fluid so that the cells can move out of your blood and into surrounding tissue to fight infection. Of course, with seasonal allergies, your immune system is reacting to pollen, which isn’t really a threat, and those leaky capillaries are what make you all stuffed up, so taking an antihistamine can block your immune system from overreacting and causing unpleasant inflammation.
First-generation antihistamines such as diphenhydramine (aka Benadryl) have been on the market for decades. They work beautifully — 98% of Iodine user reviews of Benadryl say it works well or somewhat well, and 86% say it’s worth it overall — but they’re incredibly sedating. Pop a Benadryl, and you’d better be okay going down for a long nap.
Fortunately, some pharma folks found a way to make non-sedating antihistamines in the 1980s, so we’ve had options like Claritin (loratadine), Allegra (fexofenadine), and Zyrtec (cetirizine) ever since. These second-generation antihistamines are made so that they don’t cross from your blood into your brain but still work on the rest of your body, so they cause little drowsiness or other neurological effects. Some people don’t think they work quite as well as Benadryl (38% of Claritin reviews and 46% of Zyrtec reviews say that they work well, versus 53% for Benadryl), but they do the job without the sleepies.
But that’s not the end of the story. There are other (better) meds available for mild to moderate allergies. Choosing what’s right for you hinges, in part, on how long your allergy symptoms last.
Better options for long-term symptoms
How long do my allergy symptoms last? This is the MOST clinically-important question that you’re probably not asking yourself about your allergies. Probably because you’re not a doctor or pharmacist. The fact is that different allergy meds work in very different ways, and that can have a big impact on how helpful they are for your symptoms.
Say you spent the evening having dinner at a friend’s house, and her cat’s dander turned your face into a big, leaky faucet. Or you have seasonal allergies that really only flare up once in a while when the pollen count is particularly high. By all means, help yourself to an antihistamine. Even the second-generation ones like Claritin have been available over-the-counter (and in generic, which works just as well but is much cheaper) for years, and they’re great options for short-term relief of allergy symptoms.
But for longer-term, daily allergy symptoms, you’ll do better with a drug that takes a different approach entirely. Nasal steroids — such as Flonase (fluticasone), Nasonex (mometasone), Nasacort (triamcinolone), and Rhinocort Aqua (budesonide) — work way upstream in your inflammatory process. They regulate gene expression via protein synthesis, which is a lot of jargon that just means they tell cells in your nasal passages to stop making proteins that cause inflammation, such as our friend histamine, and on the flip side to start making proteins that suppress immune responses. So instead of trying to stop a runaway train (your inflammatory response), nasal steroids use their one-two punch to prevent the train from leaving the station in the first place. Antihistamines do help with the early, histamine-release stage of inflammatory response, but anti-inflammatory medicines take a more holistic approach and inhibit the later stages, too. Among healthcare providers they’re well-known to be the most effective maintenance therapy for nasal allergies.
Another example is Singulair (montelukast), which is an oral medication that’s slightly downstream from steroids in your inflammatory process, but is a good option for people who have breathing problems or asthma along with their allergies.
Why doesn’t everyone use nasal steroids for allergies?
So why doesn’t everyone use these other options for seasonal allergies? Well, they’re bigger guns, so they potentially cause more side effects — and that’s a cost-benefit analysis you have to talk through with your doctor. Side effects are minimal at the recommended doses.
But another important reason is that they take longer to start working. “Regulating gene expression via protein synthesis” sounds like it might take at least a few days, right? The drug has to make its way into your cells and alter the way your DNA gets translated into proteins. If you’ve got a runny nose and watery eyes from your friend’s cat, or you’re just having a couple bad allergy days from what’s floating around in the air, your symptoms are likely to pass before the drug kicks in.
But if you’ve got daily symptoms all season long, please consider a nasal steroid! It pains me to see so many people taking antihistamines every day for months. Plenty of research studies suggest that nasal steroids are significantly more effective at relieving long-term allergy symptoms than antihistamines (see this meta-analysis of RCTs, this systematic review of RCTs, and this study which found evidence that nasal steroids were actually more effective even on a short-term, as-needed basis). To boot, some research has suggested that first-generation antihistamines become less effective in just three weeks of daily use, and while this hasn’t been proven in second-generation antihistamines, it’s consistent with my anecdotal experience, which you can take with a grain of salt, of course. Nasal steroids even seem to work better for itchy, watery, red eyes (allergic conjunctivitis) than oral antihistamines, which is a little counterintuitive but pretty cool.
Then again, Iodine’s ratings of oral antihistamines versus nasal steroids seem to show similar scores for effectiveness and hassle, but lower overall “worth it” scores. Perhaps some people don’t like shooting liquid up their nostrils every day and prefer the relative ease of swallowing a pill. I’m not sure. You’re also supposed to use nasal steroids every day whether you have symptoms or not, or else they don’t work so well.
I can’t find good data on what percentage of allergy sufferers overall are taking antihistamines versus nasal steroids (one scientific article claimed that antihistamines are prescribed three times as often as nasal steroids, but it’s from 2001, so who knows). But when I talked to my patients during medical training and to my non-doctor friends, I got the sense that a lot of folks just aren’t aware of allergy treatment options beyond antihistamines or, for much more severe symptoms, allergy shots. In the non-scientific study I just did right now, the #1 search result on Google for “seasonal allergies” is a Mayo Clinic article that, remarkably, doesn’t even mention anti-inflammatories as a treatment. It skips straight from oral antihistamines and decongestants to allergy shots. Even this week’s Vox article about seasonal allergies that mentions Iodine’s new allergy app (thanks!) does the same: nothing about anti-inflammatories in general or nasal steroids in particular.
Perhaps this is a result of direct-to-consumer advertising — who doesn’t remember the old Claritin ads with the song “I can see clearly now (the rain is gone)”? Or maybe it’s because nasal steroids are relatively newer drugs, and they’ve only been available over the counter in the last year or so. Nasacort was approved in late 2013, and Flonase just went OTC in early 2015 (Nasonex and Rhinocort Aqua are still prescription-only). So they’re a little late to the game, didn’t have quite the same marketing push, and are still somewhat inaccessible over the counter, but it also seems that at least some prominent resources online aren’t up-to-date on clinical research or guidelines and are, therefore, missing information that could be useful to millions of people.
I don’t take money from Flonase et al and I don’t even have seasonal allergies, so I don’t have a dog in this fight, but I want all of you out there with allergies to know about your options so that you can find whatever works best for you. Give the new Iodine allergy app a try to see what meds might work for your symptoms, and remember to filter the results by how long your symptoms last. As you now know, what’s best for a quick fix isn’t necessarily what’ll help you all season long.