Nasal Allergy Medications (cont.)

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The oral form of decongestants is the preferred choice for most cases of nasal congestion, particularly when people expect to use them for more than 3 to 5 days. They can also be taken for Eustachian tube blockage, infected ears, and sinusitis. Oral decongestants rarely cause rebound nasal congestion even if taken for long periods.

What are side effects of decongestants?

Topical sprays sometimes cause burning or dryness in the nose. The most notorious side effect of topical decongestants is rebound nasal congestion. The longer someone uses the spray, the less effective it becomes and the more they need to use it in order to obtain the desired effect (virtually an addictive quality if used excessively). After prolonged use, the spray begins to cause more congestion than it relieves. The only way to break this cycle is to stop the medication. If the cycle is not broken, permanent changes can occur on the nasal membranes, which lead to a condition known as rhinitis medicamentosa. Rhinitis medicamentosa refers to an inflammation in the nose that is caused by the use of medications. Symptoms include severe stuffiness, burning, bleeding, and dryness of the nose.

Side effects from oral decongestants are more common and potentially more dangerous. They can stimulate the nervous system causing palpitations, insomnia, nervousness, and irritability. Some people may have trouble with urination and a decreased appetite. Although frequently mentioned, high blood pressure is not commonly caused or worsened by these drugs. However, any concerns regarding the side effects of these drugs should be discussed with the doctor.

What about combination antihistamine/decongestant preparations?

Pharmacy shelves are packed with combination preparations. They are useful for runny, itchy, and stuffy noses and are available OTC or by prescription. The liquid preparations are convenient for children as well as the elderly who may need a lesser dosage than is available in tablet forms. 12- and 24-hour preparations are available to make taking the medications more practical. Interestingly, the stimulant effect of the decongestant may counteract the drowsiness effect of the antihistamine and make the combination well tolerated; however, this may not occur in everyone so caution is indicated.

Common Antihistamine/Decongestant Preparations
Generation Brand Name R = Rapid Release; S= Sustained Release Antihistamine Decongestant
First Drixoral R dexbrompheniramine pseudoephedrine
ChlorTrimenton S chlorpheniramine pseudoephedrine
Second Allegra D S fexofenadine pseudoephedrine
Claritin D 12-hour S loratadine pseudoephedrine
Claritin D 24-hour S loratadine pseudoephedrine
Semprex D S acrivastine pseudoephedrine

Two broad categories of decongestants are available. Rapid release products need to be taken 3 to 4 times a day and provide a lower dose of both the antihistamine and decongestant. These medicines help people who are more troubled by side effects but they are less practical than the sustained release preparations, which need to be taken only once or twice per day.

Some combinations of these drugs may be more effective in some individuals, If an individual wants to try a new OTC antihistamine/decongestant combination, they should carefully read the label. Make sure the ingredients and the dosages are different from the ones they used to take. Otherwise, the person may be buying the same medication they took previously, only with a different name, color, shape, and price.

Nasal steroid sprays

Steroids are naturally-occurring hormones that are produced by the adrenal glands. The corticosteroids have potent anti-inflammatory effects and are very effective in treating allergic inflammation in the nose. They are a "controller" type medication and work best when used on a regular "preventative" basis. They are usually only available by prescription. With seasonal allergies, daily use of these sprays should begin 1 to 2 weeks before the allergy season and continue throughout the season. In people with relatively constant or perennial allergic rhinitis, particularly if symptoms have been unresponsive to OTC or other treatments, daily use of intranasal steroids has been found very effective in controlling symptoms, particularly nasal congestion. The addition of antihistamines to this nasal spray will likely give even better results.

Nasal steroids may also help improve the sense of smell, which is frequently diminished in allergic rhinitis. The medication may work by reducing swelling high up in the nose, where the area for smell is located. Decreasing the swelling allows more air (containing the odors) to reach the nerves that are responsible for the sense of smell.

Bag-like collections of fluid in the nasal membranes, called nasal polyps, are not uncommonly found in allergic rhinitis. Nasal steroids are helpful in shrinking nasal polyps and in preventing them from recurring.

Nasal steroids are available in two forms, aerosol and a spray pump (aqueous). The aerosol form resembles an asthma spray that delivers a predetermined dose of "dry" medication when activated. The more commonly used pump delivers a "water-based" spray, which may provide some moisturizing and soothing effect as well as an anti-inflammatory action. Patients who feel that the drip in their nose and throat increases when using the spray form may prefer the aerosol. In contrast, the spray is favored if the aerosol causes irritation or excessive drying of the nasal membranes.

In 1960, the first nasal steroid spray, Decadron Turbinaire, was introduced in the United States. Although very effective, too much of the drug was absorbed into the bloodstream, which resulted in side effects and limited its use. A different medication, beclomethasone (Qvar), was initially marketed in the 1970s and has been well tolerated. Others have been developed over the years, each having some variable effects on several types of cells that have a role in nasal inflammation.

Common Intranasal Steroids
Generic Name Brand Name
beclomethasone Beconase AQ
flunisolide Brands discontinued in the U.S.
triamcinolone Nasacort AQ
budesonide Rhinocort
fluticasone Flonase
mometasone Nasonex
ciciesonide Omnaris
fluticasone furoate Veramyst

Most of these intranasal steroids - budesonide, fluticasone, mometasone, ciciesonide, and fluticasone furoate - are faster acting and more potent than the other nasal steroids, with no significant difference in side effects.

The safety record of nasal steroids at the recommended dosages is excellent. Several studies conducted in the U.S., Canada, and Europe have documented the lack of significant systemic (general body) side effects. The common side effects occur locally in the nose, such as burning, stinging, dryness, and sneezing, and are usually reported with the use of dry aerosol sprays. Less common effects include headache and mild nasal bleeding. The latter can be avoided by proper spray technique. Shallow nasal ulcers are rare and can also be avoided by the use of proper technique.

Oral or injectable corticosteroids are occasionally prescribed for a few days in cases of severe allergic rhinitis with almost total obstruction of the nasal passages. In these cases, antihistamines, decongestants, and certainly nasal sprays are not likely to help. After the nasal passages have opened, however, the nasal sprays can be used to prevent further swelling.

Other nasal sprays that might help

Ipratropium bromide spray (Atrovent)

Ipratropium bromide blocks the effects of acetylcholine, which is a chemical that, among other actions, signals the mucous glands in the nose to produce mucous. Allergic reactions can trigger excessive acetylcholine activity on the mucous glands. Ipratropium bromide occupies the same receptor on the glands as does acetylcholine and in this way reduces mucous secretion because ipratropium brobide does not stimulate mucus secretion.

Ipratropium bromide is available as a spray pump and comes in two strengths. It is only effective for runny noses and can literally "turn off the faucet." The drug does not help itchy or stuffy noses and does not usually take the place of an intranasal steroid, but rather is used along with it. Typically, two sprays 3 to 4 times per day in each nostril are required to control symptoms. Once improvement is seen, the dose can often be lowered to one spray 3 to 4 times per day or two sprays 2 times per day.

Side effects of ipratropium bromide are infrequent but include dry nose, nasal irritation, and nose bleeding. If accidentally sprayed into the eyes, the drug may cause temporary blurred vision.

Ipratropium bromide nasal spray can dry up mucous, regardless of the cause. The spray may be effective in non-allergic rhinitis and even with the common cold (usually at the higher 0.06% dose).

Cromolyn sodium nasal spray (Intal, Opticrom, Gastrocrom)

Cromolyn works to reduce nasal inflammation without the use of steroids. It acts on mast cells to stabilize them, thereby preventing the release of histamine and other mediators. Since cromolyn is strictly a "controller" medication, it must be taken before allergic exposure, usually at least 2 weeks prior, due to its slow onset of effectiveness. The drug tends to be more effective in younger people with higher levels of IgE. It is given at doses of one to two sprays in each nostril 4 times per day. Cromolyn appears to be helpful in reducing runny nose, sneezing, and congestion in milder cases, but may not be effective at all in more severe cases. The medicine became available OTC in 1997. It is a particularly well tolerated medication with minimal side effects (usually sneezing, nasal irritation, or stinging. Rare cases of nasal bleeding or residual bad taste are reported.) There are no systemic, or body-wide, side effects. Cromolyn nasal spray is safe for pregnancy, lactation, and children under the age of 6 years old.

Tips for proper use of nasal sprays

Using a good technique in applying nasal sprays will help you achieve the maximum benefits from the medications and avoid certain side effects, such as nasal bleeding. The following are guidelines for proper spray technique:

  • Clear your nasal passages with gentle nose blowing or a nasal decongestant for a few days when starting nasal steroids.
  • Shake the container
  • Place one finger over one nostril to close it off.
  • Place the tip of the spray into the open nostril pointing away from the nasal septum (midline) and direct the spray straight back, not up into the tip of your nose.
  • Activate the spray, sniffing in gently and deeply as you do so.
  • Exhale through the mouth.
  • Repeat these steps for the other nostril.
  • Never "double" spray: always spray one nostril at a time and alternate nostrils each time.

REFERENCES: Allergic Rhinitis. Allergic Rhinitis Treatment & Management.

Last Editorial Review: 7/26/2012

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