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									Scientific Reference Guide Allergic Rhinitis


What are the best treatments?
Description of Condition
Allergic rhinitis (AR) or “hay fever” is characterized by nasal itching, clear nasal discharge, nasal congestion,
and sneezing. Watery, red, itchy eyes are also very common. The prevalence of AR in Western countries
exceeds 10%. Symptoms may be intermittent (seasonal) or persistent (perennial) and can be triggered by
both indoor and outdoor allergens. Severe AR can adversely affect work, learning, recreation, and sleep.
The diagnosis is usually made on clinical grounds, but diagnostic allergy testing is indicated if the test results
could alter the decision to treat. In clinical practice, this means that patients should undergo allergy testing
only when the clinical picture is very uncertain or when initial empirical therapy has failed. Puncture skin
tests, intradermal skin tests, and well-performed second-generation in vitro tests all have similar diagnostic
performance.

Nonprescription Interventions and When to Seek Help
The major treatment options for AR are allergen avoidance, drug therapy, and immunotherapy (allergy
shots). These treatment options may need to be combined for successful therapy.
Reducing exposure to allergens (e.g., by using special vacuum cleaners to reduce dust mite exposure or by
staying indoors during pollen season) may be effective for some patients, but implementation of such strate-
gies is difficult and evidence of their clinical effectiveness is limited.
The two major classes of pharmacologic agents used to treat AR are oral antihistamines and intranasal cor-
ticosteroids, which can be used either alone or in combination. Alternative agents, such as intranasal or oral
decongestants, intranasal antihistamines, antileukotrienes, intranasal or oral anticholinergic agents, and
intranasal mast cell stabilizers, may be indicated in some patients. Currently available over-the-counter
(OTC) medications include “older” oral antihistamines (e.g., diphenhydramine, clemastine) and one
“newer” oral antihistamine, loratadine (Claritin). Intranasal cromolyn sodium (a mast cell stabilizer) is also
available as an OTC drug. Pseudoephedrine (available over the counter as Sudafed, Sinutab) reduces nasal
congestion but has little effect on other symptoms of AR.
Patients with mild, transient symptoms may safely try allergen avoidance. OTC antihistamines are effective
but, with the possible exception of loratadine, can be sedating, and should be used with caution by persons
who drive or operate machinery. Patients with more severe or persistent symptoms should seek medical atten-
tion to confirm the diagnosis of AR and to begin more intensive treatment.

Categories of Prescription Pharmaceutical Treatments (i.e., Drug Classes)
Prescription drugs used to treat AR include intranasal corticosteroids; oral, intranasal, and ocular antihis-
tamines; leukotriene modifiers; intranasal anticholinergic agents; and intranasal mast cell stabilizers.
Immunotherapy is another option for patients who do not respond or are intolerant to med-
ications. The relative costs of first- and second-generation antihistamines and other treatments
are shown in the Table.




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Scientific Reference Guide Allergic Rhinitis




Intraclass Comparisons
 I Based on indirect evidence, all available intranasal corticosteroids have similar efficacy and safety. The
   main side effects are mild local reactions (nasal dryness, irritation, and occasional bleeding).
 I Clemastine and loratadine are similarly effective in the treatment of both seasonal and perennial AR.

 I Based on limited evidence, there are no substantial differences in effectiveness among the “newer” anti-
   histamines (loratadine, cetirizine, fexofenadine, desloratadine) for treating the nasal symptoms of season-
   al AR.
 I All antihistamines have been shown to cause more sedation than placebo. However, there is good evi-
   dence that diphenhydramine causes more sedation than the newer antihistamines. For the newer agents,
   the Food and Drug Administration has issued a warning label regarding sedative effects associated with
   cetirizine use.
 I Two small studies found no notable difference in nasal symptoms between intranasal (azelastine, levo-
   cabastine) and oral antihistamines (cetirizine).
 I There is no direct evidence that any antihistamine has an advantage in efficacy or safety in any age, sex,
   or ethnic group. However, it may be prudent for older patients to begin antihistamine treatment at lower
   doses to reduce the risk of falls.
 I There is no direct evidence that oral antihistamines cause birth defects. However, “older” oral antihista-
   mines may be preferred over “newer” oral antihistamines based on their longer history.

Interclass Comparisons
 I Intranasal corticosteroids are superior to antihistamines for the treatment of nasal congestion, nasal itch,
   and postnasal drip, and they are as good as antihistamines for the treatment of itchy eyes.
 I Antihistamine-decongestant combinations relieve symptoms of AR better than either class of drug alone.
   However, combination therapy is more stimulating than an antihistamine alone; hence, many clinicians
   recommend that the decongestant component be avoided at night.
 I Montelukast (an oral leukotriene modifier) reduces symptoms of AR and improves quality of life.
   Limited evidence suggests that nasal corticosteroids are more effective than leukotriene modifiers. The
   combination of a leukotriene modifier plus an antihistamine appears to be no more effective than either
   agent alone.
 I Injectable immunotherapy is effective for AR but requires regular physician visits and is associated with
   a low risk of anaphylaxis. Sublingual immunotherapy can relieve symptoms of AR, but it is unknown
   whether it is as effective as injections.




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Scientific Reference Guide Allergic Rhinitis




Conclusions
 I Intranasal corticosteroids represent first-line treatment for patients seeking medical attention because of
   AR (except for those with mild, intermittent symptoms, for whom an oral antihistamine may be appro-
   priate).
 I Newer, less sedating antihistamines are a viable alternative to intranasal corticosteroids. Compared with
   loratadine and fexofenadine, cetirizine may be less attractive owing to a higher potential for sedation.



    Methods Note
    This scientific reference guide is a product of the Prescription Drug Information Project, a collaborative ven-
    ture between the University of California and the California HealthCare Foundation. This summary is based
    on a report on the effectiveness and safety of second-generation antidepressants performed by the Drug
    Effectiveness Review Project (DERP). The DERP report is based on a rigorous method of systematic litera-
    ture reviews, ensuring inclusion of relevant studies of high quality. Another team of researchers, at the
    University of California (UC), Davis, prepared a supplementary report on other drug and nondrug treatments
    for depression. Both reports (DERP and UC Davis) were reviewed by two outside experts and subse-
    quently evaluated by a panel of highly regarded physicians and pharmacists from the University of California.
    These reports are available at www.chcf.org.




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  Scientific Reference Guide Allergic Rhinitis


Relative Costs of First- and Second Generation Antihistamines and Other Treatments*

 Drug Name (generic)               Cost†              Low ($1 - 50)        Medium ($51 - 100)          High ($101 +)

First Generation Antihistamines (available OTC, commonly in combination with pseudoephedrine)
Drixoral, OTC               $15 per 1-week box             
(Dexbrompheniramine/
pseudoephedrine)
Chlortrimeton, OTC                 $10                     
(Chlorpheniramine)
Chlortrimeton D, OTC        $15 per 1-week box             
(Chlorpheniramine/
pseudoephedrine)
Actifed, OTC                $10 per 1-week box             
(Triprolidine/
pseudoephedrine)
Tavist, (Clemastine) OTC    $10 per 1-week box             
Tavist D, OTC               $15 per 1-week box             
(Clemastine/
pseudoephedrine)
Benedryl, OTC                      $10                     
(Diphenhydramine)

Second Generation Antihistamines (nonsedating)
Zyrtec (Cetirizine)                $60                                             
Clarinex (Desloratadine)           $70                                             
Allegra (Fexofenadine)             $85                                             
Claritin/Alavert, OTC           $15 per                    
(Loratadine)                  2-week supply

Nasal Antihistamines/Anticholinergics
Astelin (Azelastine)               $65                                             
Afrin, OTC                    $10 per 1- to                
(Oxymetazoline)               2-week supply
Ipratropium bromide‡               $70                                             
 ‡ Generic
   OTC, over the counter.
 * Only the most common first-generation generation antihistamines are listed. As products are available under multiple
   names and strengths without a prescription, a pharmacist should be consulted before selecting a treatment.
 † Prices noted are for a 1-month supply unless otherwise stated. Prices are from drugstore.com.




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  Scientific Reference Guide Allergic Rhinitis


Relative Costs of First- and Second Generation Antihistamines and Other Treatments* (cont.)
 Drug Name (generic)               Cost†              Low ($1 - 50)        Medium ($51 - 100)          High ($101 +)

Nasal Steriods
Rhinocort Aqua                     $65                                             
(Budesonide)
Nasonex (Mometasone)               $65                                             
Flonase (Fluticasone)              $65                                             
Nasarel (Flunisolide)              $50                     
Beconase AQ                        $75                                             
(Beclomethasone)
Nasacort AQ                        $65                                             
(Triamcinolone)

Leukotriene Receptor Antagonists
Singulair (Montelukast)            $90                                             
Mast Cell Stabilizers
Nasalcrom, OTC                     $17                     

 ‡ Generic
   OTC, over the counter.
 * Only the most common first-generation generation antihistamines are listed. As products are available under multiple
   names and strengths without a prescription, a pharmacist should be consulted before selecting a treatment.
 † Prices noted are for a 1-month supply unless otherwise stated. Prices are from drugstore.com.




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