Therapies

Allergy Relief Options Expanding

OTCs are improving, but prescription medications still have a significant edge.

By René Luthe, contributing editor

For all the vaunted, proven efficacy of prescription medications, many allergy sufferers may prefer their over-the-counter cousins — after all, OTCs don’t require a doctor’s visit, which require concomitant co-pays and time off from work. You can find OTCs at any supermarket and they’re perceived as less expensive. Yet this may be one of those instances of getting what you pay for. The advantages of prescription allergy medications include greater specificity in addressing symptoms, the ability to avoid side effects and irritation, and again, that demonstrated efficacy — which surely must matter to allergy sufferers.

Potential Problems of OTCs

Whether they are motivated by a belief that a doctor’s expertise isn’t necessary (“It’s only hay fever”) or a desire to save money, many allergy sufferers will cruise the supermarket or drugstore aisles looking for relief.What they choose may be worse than taking nothing, in the view of some ophthalmologists. For instance, the oral antihistamines that many allergy sufferers take to address nasal symptoms can lead to, or heighten, tear film problems. Certain patient demographics, such as the elderly or perimenopausal, are already vulnerable to dry eye. Be sure to ask these patients if they’re taking oral antihistamines.

Even if patients are using a site-specific medication, their OTC choice could lead to a more severe problem. A product selected to clear up bloodshot eyes, for instance, does not address the underlying problem causing the redness; similarly, burning eyes won’t be helped by an artificial tear if the patient has an allergy. Or a patient may misuse a drug.

Preservatives in OTC medications can be a source of irritation as well. While television commercials for prescription drugs include a litany of possible side effects, people are often less mindful of the side effects that OTCs can present. It’s important to question patients about all medications they are taking — for any issue, whether they are OTC or prescription or a nutritional supplement.

What They’ll Find in the Stores

Oral antihistamines and Visine are not the only options patients will find OTC. Ketotifen fumarate (Zaditor, Novartis) went over-the-counter in 2006. Other manufacturers have launched their own versions of combination topical antihistamine/mast cell stabilizer. These new drugs represent a step up in allergy relief, notes cornea specialist Jodi Luchs, MD, of North Shore Jewish Medical Center in New Hyde Park, NY, and a private practitioner in Wantagh, NY.

Among their other advantages, “They do not have the associated rebound phenomenon, where patients can get rebound redness thanks to the vasoconstrictor wearing off, which can make them more uncomfortable,” explains Dr. Luchs. “They then start to use more of the medication, and patients can actually become somewhat toxic on these medications as they use more and more.”

Since the ketotifen preparations have gone over the counter, Dr. Luchs says he finds more patients have success with the nonprescription allergy treatments. “I think there are some excellent prescription drugs that have advantages compared to some of the OTC drugs. But if they are going OTC, I will tell them to reach for a ketotifen preparation.”

Going the Prescription Route

Of course, if patients come into your practice for allergy, they have almost certainly tried the OTC route for relief and found it wanting. You can give them the good news that the currently available prescription therapies for allergy are “excellent medications,” says Dr. Luchs. There’s an option for nearly everyone. The therapies include:

Shown is a patient presenting with allergic conjunctivitis.

■ Antihistamine/mast cell stabilizers. These are first-line therapies that deliver the speedy relief of antihistamine plus the extended duration of action of a mast cell stabilizer. Mast cells can release the inflammatory mediators in the eye, so stabilizing them inhibits a pathway of inflammation involved in ocular allergies.

In addition to providing immediate relief, topical antihistamine/mast cell stabilizers do not have the drying effects that oral antihistamines so often do. The topical antihistamine/mast cell stabilizers currently available are:

Bepreve (Bausch + Lomb), Elestat (epinastine 0.05%, Merck), Optivar (azelastine 0.05%, Meda Pharmaceuticals), Lastacaft (alcaftadine ophthalmic solution 0.25%, Allergan) and Pataday (olopatadine hydrochloride ophthalmic solution, Alcon). Pataday and Lastacaft both offer oncedaily dosing.

■ Nonsteroidal anti-inflammatory drugs. Topical NSAIDs also have been used, although less commonly for itch relief. Duration of action varies among the available NSAIDs, with some drops requiring three or four doses a day. Frequent dosing, of course, often results in less compliance.

Currently, Allergan’s Acular (ketorolac tromethamine ophthalmic solution 0.5%) is the only NSAID indicated for allergies, but Bromday (bromfenac 0.9%, Bausch + Lomb) and Nevanac (nepafenac 0.1%, Alcon) are also occasionally prescribed.

■ Steroids. The heavy artillery in allergy treatment, steroids are generally reserved for more severe cases. While they are effective in fighting ocular inflammation, their serious potential side effects, including induced cataract and glaucoma, mean they should be used on a strictly short-term basis.

Alrex (loteprednol etabonate ophthalmic suspension 0.2%, Bausch + Lomb) is specifically indicated for ocular allergies. It offers a less severe side effect profile. Predforte (prednisolone acetate ophthalmic suspension 1%, Allergan) and Pred Mild is another option.

Where Support Staff Comes In

Support staff play an important role in combating allergies, notes Dr. Luchs.

■ For one, though many patients have some sort of allergic disease, it may not be their primary complaint when, for example, they come in for annual exams. A technician who takes the time to conduct a thorough history, however, “can alert the doctor to a component of allergy that we might otherwise have missed,” Dr. Luchs says. Be sure to ask detailed questions. For instance, when do they occur? Are they unilateral or bilateral? Do other family members have allergies?

■ Additionally, staff can remind patients that allergies are often chronic. Reinforce the message that they may need to take medication on an ongoing basis, even if their symptoms aren’t that apparent, in order to control allergies. “This is important for patients who have prolonged seasonal allergic disease or perennial allergic disease,” Dr. Luchs says.

■ Connect them to coupons. Getting manufacturer-provided incentives to patients can take some “sting” out of co-pays. OP