Allergy Treatment Options

ALLERGY TREATMENT involves three key elements, each of which is explained below

1) allergen avoidance
2) symptom management
3) desensitization

ALLERGEN AVOIDANCE

POLLEN avoidance: Trees and grasses pollinate in spring and into summer. Ragweed pollinates from August until the first hard freeze of winter. All pollen blows for miles in the wind and are very difficult to avoid outdoors. Please keep your windows and doors shut at all times and filter your air through an allergy or high efficiency filter placed in your central heat and air system. Look for an efficiency rating of around 12 or 1200 for your filter (which should be clearly displayed on the filter and its packaging) and change the filter monthly or according to the manufacturer’s recommendations. If you have to mow the grass, please wear a face mask with a vent (such as the 3M 8511 mask available at Home Depot or Lowe’s) and shower immediately afterwards.

DUST MITE avoidance: In order to decrease your exposure to dust and dust mites we recommend you use specially designed dust mite covers for your pillows and mattress. You can find these online at allergycontrol.com or missionallergy.com. Wash sheets, pillowcases, and blankets in hot water at least once a week. Avoid using ceiling or floor fans. Dust your headboard, nightstand, and any objects such as lamps, books, etc. on your headboard or nightstand every day. Avoid dry dusting; instead, dust regularly with a dusting product such as Endust or Pledge.

MOLD avoidance: Mold grows in areas of increased humidity, low light and cool temperatures. The areas of the home where mold grows best are the basement, the area around the clothes dryer, and bathrooms. In addition, potted plants, mulch, leaves and other decaying matter have high levels of mold. If your carpet has ever been wet, you will have heavy mold growth under the carpet for the life of the carpet (do not steam clean or otherwise wet clean your carpets). Placement of a dehumidifier, especially in your bedroom, can be helpful (ideal humidity level is 40%-50%).

PET DANDER avoidance: Since cats and dogs are most often beloved members of the family, we do not consider it mandatory that you get rid of your pet(s), but there are steps you can take that will help minimize your allergic response when there are pets in the home. Bathing/rinsing your cat or dog will temporarily remove animal dander. It is best to do this at least once a week if possible. Keeping your pets out of your bedroom and off of your bed and upholstered furniture is also an effective way to reduce exposure to pet dander. If possible, keep your pets in rooms without carpets.

SYMPTOM MANAGEMENT

If avoidance of allergens is not enough to prevent or relieve your symptoms, there are a variety of medications that can often be effective in helping achieve symptom control. These medications include nasal sprays, oral antihistamines, and oral leukotriene modifiers. Many of these medications are available OTC and in generic form making them relatively inexpensive. Keep in mind that there have been many studies done that have sought to compare the effectiveness of the different allergy symptom relief medications and all of these studies showed that the nasal sprays are the most effective. Nonetheless, many people have experienced significant relief with antihistamines and/or leukotriene modifiers with or without a nasal spray. All of these
options are discussed below:

STEROID NASAL SPRAYS – There are a variety of nasal sprays available for the treatment of the nasal symptoms associated with allergies. Steroid sprays include fluticasone (Flonase) triamcinolone (Nasacort), budesonide Rhinocort), mometasone (Nasonex), and others. Intranasal steroids prevent the release of substances in the body that cause inflammation. These medications are used to treat nasal symptoms
such as congestion, sneezing, and runny nose caused by seasonal or year-round allergies. Major side effects are nasal irritation, nose bleeds, and mild headaches. These sprays should generally be avoided if you have been diagnosed with increased eye pressure such as glaucoma.

ANTIHISTAMINE NASAL SPRAYS – There are two available antihistamine nasal sprays: azelastine (Astelin, Astepro), and olopatadine (Patanase). These are H1 receptor antagonists indicated for relief of symptoms of seasonal allergic rhinitis which include stuffy/runny/itchy nose and sneezing. Side effects may include bitter taste, headache, SEDATION, or nose bleeds. Spraying the medication without sniffing may reduce its side effects.

NASAL SALINE – These are OTC non-medicated sprays that can be used for the following: 1) to relieve nasal congestion caused by allergies and colds, 2) to help loosen and clear nasal mucus, 3) to reduce sneezing caused by hay fever or irritants like smoke, 4) to relieve postnasal drip (mucus draining down the back if the throat) caused by colds or sinus infections, or 5) to moisturize the nasal passages, especially in dry
climates (though see below for more specialized sprays specifically formulated for moisturizing).

NASAL MOISTURIZING SPRAYS – To help with nasal dryness, use Neil Med NasoGel nasal moisturizing Spray or Ayr Saline Gel spray in addition to your prescription nasal spray(s). Drink plenty of water. Use this at least 5 minutes AFTER any medicated nasal spray(s).

ANTICHOLINERGIC NASAL SPRAY – ipratropium bromide nasal spray (Atrovent) is designed specifically to decrease nasal drainage and runny nose, but not specifically due to allergies. It should only be used when you have severe dripping/drainage. Its main side effects include severe drying of nasal passage, bitter taste and/or sore throat. This medication should be avoided if you have closed-angle glaucoma.

COMBINATION STEROID AND ANTIHISTAMINE NASAL SPRAYS – There are two nasal sprays available that contain both a steroid and an antihistamine: fluticasone-azelastine (Dymista) and mometasone-olopatadine (Ryaltris). Thesesterpoid/antihistamine sprays are very potent combination in managing allergic and nonallergic nasal symptoms. Side effects may include: bitter taste, mild headache, nose
bleeds, as well as potential drowsiness. Spraying the medication without sniffing may reduce its side effects.

LONG-ACTING ORAL ANTIHISTAMINES – These include OTC cetirizine (Zyrtec), levocetirizine (Xyzal) 5mg, fexofenadine (Allegra) 180mg, or loratadine (Claritin) 10mg, or prescription desloratadine (Clarinex). These are mostly non-sedating, type-1 antihistamines that are used AS NEEDED for treatment of seasonal allergies and chronic urticaria (hives). They help relieve symptoms of nasal stuffiness, runny nose, sneezing, itchy/watery eyes, as well as hives and generalized itching. It often takes
higher doses of these medications to manage skin issues than it does to relieve nasal symptoms. The main side effects are dryness of the mouth and a slight headache, and they may occasionally cause drowsiness despite being considered “non-sedating.” Keep in mind that prolonged use of any one of these drugs can lead to tolerance whereby the drug becomes less effective. In order to prevent this, use antihistamines
only as needed for symptom control. If you require prolonged use of any of these drugs, try switching to a different long-acting antihistamine for at least 3 weeks every 3 to 6 months. Be aware however that cetirizine and levocetirizine (Zyrtec and Xyzal) are essentially the same drug so you will need to switch to Allegra or Claritin if you are currently taking either one of these.

LEUKOTRIENE MODIFIER – The primary drug in this class is montelukast (Singulair). This is a once a day nonsteroidal asthma medication that will also help with some allergy symptoms (primarily congestion). It is usually well tolerated, but occasionally may cause changes in mood, nightmares, or headaches. There is a black box warnings on Singulair for children as it can cause agitation, depression, sleeping problems, and
suicidal thoughts and actions.

ALLERGY EYE DROPS – There are a number of eye drops available to help control itchy, watery eyes caused by allergies. Antihistamine drops include olopatadine (Pataday), azelastine (Optivar), bepotastine (Bepreve), and others. Mast cell stabilizer eye drops include as ketotifen (Alaway, Zaditor, and others). Some antihistamine drops, such as olopatadine (Pataday), may also help to stabilize mast cells. All these drops can provide relief from allergy eye symptoms alone or along with nasal sprays and/or oral antihistamines.

DESENSITIZATION (ALLERGY SHOTS)

When allergen avoidance and symptom-control medications fail to adequately control allergy symptoms, it is sometimes necessary to desensitize the patient to the allergens causing the symptoms. Allergy desensitization therapy, better known as allergy shots or allergy immunotherapy, is the only way to “turn off” the allergies.

This is done by gradually increasing the dose of the allergens injected (up to a maximum dose called the maintenance dose) then slowly increasing the time interval between shots. The ultimate goal is to get to the point where you receive your shots once a month for at least a year then consider stopping the shots depending on how you are doing with the therapy. Allergy shots are the most effective treatment we have for reducing and possibly eliminating your allergies to pollen, dust mites, molds, and pets and the vast majority of patients respond well to this treatment.

In addition to allergy shots, there are other methods to desensitize to allergens, including sublingual allergy drops and tablets
which have been developed for select allergens, but these methods are typically significantly less effective than allergy shots. Additionally, in the case of allergy drops, though they have been available for many years, they have never been FDA approved and thus are rarely covered by health insurers in the U.S.