Treating Allergies with Medications by Timothy J. Patrick-Miller, M.D., Mark B. Levin, M.D. and Louis J. Tesoro, M.D. The Pediatric Group, P.A., Princeton

This is the sixteenth article in a series written for Princeton Online. Click here for an archive of other articles.

As many allergy sufferers know, the pollen count and respiratory allergies have been increasingly intolerable. Eyes have been itching, tearing, swollen and red. Noses have been clogged, running, dripping and sneezing. Ears have been clogged, congested and hurting; and sinuses and heads have been pounding. Many people experience fatigue with loss of energy and concentration. Young children, if they are allergy sufferers, may not verbalize their misery. They may act cranky, sleep fitfully, or misbehave. Whether they verbalize their symptoms or not, they all want relief.

To reduce allergy symptoms, sufferers should minimize exposure to allergens. Allergens, are small proteins, such as pollen, that stimulate the hyper-reactive immune system of susceptible individuals. We can not realistically expect children (or adults) to avoid playing outside during the beautiful spring weather. Washing off the pollen from the skin, nose, eyelashes and hair once inside can be very helpful. If reducing the exposure to allergens does not sufficiently relieve the allergy symptoms, medications can be tried.

The most effective allergy medicines are topical decongestant, allergy cell stabilizers, steroids and oral anti-histamines. Many of the older anti-histamines, now known as first generation anti-histamines, are readily available and can be bought without a prescription. Their effectiveness varies from drug to drug, and from person to person; moreover, their effectiveness may wane over time. Given this variability, substitute oral anti-histamines should be tried before considering the class a failure. Several of the better-known first generation antihistamines include: the ethanolamines – diphenhydramine (Benadryl®), dimenhydrinate (Dramamine®); the alkylamines- chlopheniramine (Chlo-trimeton®), brompheniramine (Dimetane®), the piperazines- hydroxyzines (Atarax®, Vistaril®) and the phenothiazines – promethazine (Phenergan®). Most of these medicines will decrease-- at least to some degree-- the swelling, itchiness, and the dripping nose associated with allergies. Dramamine® and Phenergan® are also noted for countering motion sickness, and Benadryl® for causing sedating. These drugs will usually take 1-2 hours to reach maximal effectiveness and will last for 4-6 hours. A major side-effects of all the first-generation anti-histamines is drowsiness--a major drawback if you must concentrate, drive and work, but a blessing if your child needs sleep! They can also cause intestinal symptoms (diarrhea, constipation, nausea, and vomiting), dry mouth and urinary retention. Many other combination and single component products are available in brand and generic form (Rynatan®, Bromfed®, Tavist®, Dimetapp®, Actifed®, Triaminic Syrup®, etc.)

Newer, "second generation anti-histamines" were designed to avoid these side-effects, especially the drowsiness. Terfenadine (Seldane®) and astemizole (Hismanal®) became infamous when removed from the market because of unacceptable side effects; the others, equally well known, are considered safe, effective and are readily available by prescription. These "non-sedating" anti-histamines include loratadine (Claritin®) and fexofenadine (Allegra®).

In one recent study, Loratadine improved school performance (of children suffering from allergies) to near normal levels (compared to non-allergic children), ostensibly by decreasing fatigue, thereby improving concentration. In this same study, the students treated with loratadine did better than the allergy-sufferers who were left untreated, and much better than the children treated with diphenhydramine, which is sedating. Cetirizine (Zyrtec®), a once-daily anit-histasmine with a low incidence of sedation is approved for children over 2 years old. Loratadine is approved for children over 6 years. Both are available in a flavored liquid or a pill and are dosed once daily. Loratidine, in its combination form with a decongestant (Claritin-D®), is taken once or twice daily, Fexofenadine (Allegra-D®) is dosed twice daily. While investigational studies are ongoing, none of these medicines are currently approved for children under 2 years. The major disadvantage of all the second generation anti-histamines is their expense.

Oral decongestants, such as, pseudophedrine, are approved for long -term use, can be combined with oral anti-histamines, and can relieve congestion by shrinking the vascular lining of the nose and inhibitimg mucus production. The main side- effects of oral decongestants are irritability, nervousness, inability to sleep, heart racing and pounding, and headache. Topical decongestants, such as Afrin Nasal Decongestant® or Neo-synephrine®, are relatively free from the systemic side effects of the oral forms. Since they work rapidly and effectively, they are ideal treatment for the occasional nasal congestion in anyone older than 6 years. But because the topical decongestants cause "rebound congestion", they can not be used for more than a few days.

A topical allergy cell stabilizer, cromolyn (Nasalcrom®), for the nose reduces the nasal itching, dripping, sneezing, and congestion in 60-70% of allergy-sufferers; it is safe and has few side-effects. Cromolyn works by inhibiting release of symptom-inducing chemicals from cells in our body that participate in allergic reactions. It, however, must be given three to four time a day, takes up to a week to work, is expensive and can be difficult to give to a non-compliant child (who may not enjoy anything sprayed up his nose). Topical steroids are more effective, helping more than 90% of allergy-sufferers; moreover, they are more convenient—some requiring only one or two daily doses. But nasal steroids are even more expensive than Nasalcrom® and can also be difficult to spray up a child’s nose. While generally considered safe, some steroids can be partially absorbed and might (more theoretical than proven) interfere with a child’s growth, immune system, and own hormonal production. The more common nasal steroids include beclomethasone (Beclonase®, Vancenase®), triamcinolone (Nasalcort®), mometasone (Nasonex®), fluticasone (Flonase®), and budesonide (Rhinocort®). Recent studies suggest mometasone, fluticasone and budesonide have the greatest topical activity and might have the least systemic absorption. Hence, theoretically, they are safer. As with any drug, the relative risk and the potential side-effects of intra-nasal steroids must be weighed against the potential benefits. Nothing is proven more effective in eliminating nasal symptoms in most patients than steroids. Indeed, for severely affected patients, oral or injectible steroids are sometimes used.

For allergy symptoms of the eyes, cromolyn (Opticrom®, Crolom®), histamine inhibitors (Patanol®, Visine®, and others) and steroid ophthalmic (eye) drops work very well (but may also be difficult to use in an uncooperative child). Non-steroidal anti-inflammatory drops (Acular®) are often effective, but may cause stinging. Steroid eye drops may be risky if there is a concurrent viral eye infection, so we generally avoid these unless he symptoms are severe or chronic.

All the medicines listed above—the anti-histamines, decongestants, cromolyn and steroids have been proven to work --in varying degrees-- in patients with allergies. Their effectiveness in treating the symptoms of the common cold is a different matter. Despite the billions of dollars spent annually on medicines for the common cold (a.k.a. an URI or upper respiratory infection), there is no statistically sound scientific evidence that they work any better than water, rest, chicken soup and T.L.C. (tender loving care). As mentioned above, an anti-histamine may make your child drowsy. A cough suppresant (dextromethorphan or codeine) may temporarily decrease the frequency of the cough, which have some merit if it allows your child to sleep better. Ipatropium (Atrovent®), formerly used primarilly in asthma patients, is now being prescribed in the form of a nasal inhaler by some physicians as treatment for cold symptoms. Its expense limits its use.

The bottom line is: if the medicines make you or your child feel better, and are relatively safe and free of side-effects, there is little harm in using them. Since one preparation might work well for one child but not for another trial and error is the only way to know which medicine in a particular category will work best for your child. For more information about any of these drugs or dosing recommendations, ask your doctor.

©All rights reserved, The Pediatric Group, P.A. 1999

Dr. Timothy Patrick-Miller

Dr. Patrick-Miller has been a member of the staff at The Pediatric Group since 1985. Dr. Patrick-Miller has served on several Departmental and hospital committees. He has published original work while at The Pediatric Group. He and his wife enjoy travel. He also likes hiking, biking, gardening and reading.

Dr. Mark B. Levin 

Dr. Levin has been a member of the staff at The Pediatric Group since 1977. Currently an attending Pediatrician at the Medical Center at Princeton, he has been Chairman, Department of Pediatrics, Medical Center at Princeton, 1984 to 1986, 1989 to 1992, and past President, Medical and Dental Staff, Medical Center at Princeton, 1987 to 1988. Dr. Levin has served on numerous Departmental and hospital committees. He has published original articles both while at Upstate Medical Center in Syracuse and at The Pediatric Group. He has a wife and three children. Dr. Levin enjoys alpine skiing, jogging, hiking and camping, travel, computers and racquetball.

Dr. Louis J. Tesoro

Dr. Tesoro has been a member of the staff at The Pediatric Group since 1988. Dr. Tesoro is Chairman, Department of Pediatrics, Medical Center at Princeton, 1996 to present and Attending Pediatrician, Medical Center at Princeton, 1988 to present. He has served on several Departmental and hospital committees, lectured at the Universiy of Pennsylvania and has published original articles both while at The Children's Hospital of Philadelphia and at The Pediatric Group.