Pediatric ENT

Allergy Treatment Medications and Immunotherapy

One out of five Americans suffer from allergies. For some, allergies are simply a short lived nuisance; however for millions it’s a life altering disease.

There are a number of ways to treat our allergy patients, ranging from managing symptoms through the use of medications, to treating the root cause through immunotherapy and avoidance measures and environmental control. We can help you explore the benefits of each so you can choose which option is best for you. Both of these therapies require a 3 to 5 year patient commitment. Many patients report a decrease in needed medication after immunotherapy begins.

Medications

There are a number of over-the-counter (OTC) and prescription medications available that help relieve hay fever symptoms. They include pills, liquids, nasal sprays and eye drops. Many people get the best relief from a combination of allergy medications. You may need to try several medications to identify what works best for you. OTC medications may be enough to relieve your symptoms; or, you may need a prescription one. Some medications are approved for use in children, while others are only approved for adults. If you want to try an OTC medication for your child, be sure to read the labels carefully.

Medications for allergies include:

Nasal corticosteroids. These nasal sprays are only available by prescription and help prevent and treat the inflammation caused by allergies. For many people they're the most effective hay fever medications, and they're often the first medication prescribed. Examples include fluticasone (Flonase), fluticasone (Veramyst), mometasone (Nasonex), Triamcinalone (Nasacort AQ) and budesonide (Rhinocort AQ). Although these medications can start to work after a few days of treatment, you may not notice any improvement until after you've used them for a week or so. Nasal corticosteroids are a safe long-term treatment for most people. Side effects can include an unpleasant smell or taste and nose irritation.

Intramuscular Cortisone (Kenalog). This a long acting corticosteroid, whose effect, which takes a day or so to begin, lasts from 4 to 6 weeks. It is extremely effective in controlling severe hayfever symptoms that often occur in the spring and summer, and which do not respond well to either antihistamines or intranasal steroids. If used only during the peak allergy season, the long term side effects in healthy adults are minimal.

Oral corticosteroids. Corticosteroid medications in pill form, such as prednisone, are sometimes used to relieve severe allergy symptoms and require a prescription. Because the long-term use of oral corticosteroids can cause serious side effects such as cataracts, osteoporosis and muscle weakness, they're usually prescribed only for short periods of time.

Antihistamines. These oral medications can help with itching, sneezing and runny nose, but have less effect on nasal congestion, although the newer intranasal antihistamine sprays are better in decreasing congestion. They work by blocking histamine, an inflammatory chemical released by your immune system during an allergic reaction. Older OTC antihistamines such as diphenhydramine (Benadryl) and clemastine (Tavist) work as well as newer ones, but can make you drowsy. The newer oral antihistamines are less likely to make you drowsy. Some of these are now available OTC and include loratadine (Claritin, Alavert), cetirizine (Zyrtec). Fexofenadine (Allegra), levocetirizine (Xyzal) and desloratadine (Clarinex) are available by prescription. The prescription antihistamine intranasal sprays, azelastine (AstePro), olapatadine (Patanase) may relieve symptoms, including congestion rapidly after use.

Note: Intranasal corticosteroids and oral or intranasal antihistamines can be used in combination when symptoms are more severe and a more effective treatment is needed.

Decongestants. These medications are available OTC and by prescription. They can be liquids, tablets and nasal sprays. OTC oral decongestants are Sudafed. They are often combined with an antihistamine such as Actifed and Drixoral. Longer acting decongestants (12 to 24 hours) are available OTC or by prescription in combination with antihistamines e.g. Claritin D and Zyrtec D. Because oral decongestants can raise blood pressure, avoid them if you have high blood pressure (hypertension). They can also worsen the symptoms of prostate enlargement, making urination more difficult.

Nasal spray decongestants include phenylephrine (Neo-Synephrine) and oxymetazoline (Afrin). Don't use a decongestant nasal spray for more than two or three days at a time as they can cause chronic rebound congestion when used longer and therefore can become “addictive”. With long term use they can cause severe nasal irritation and bleeding. Prescription nasal sprays containing steroids or antihistamine don't cause this rebound effect, so they can be used on a daily basis for years. These sprays may be useful when flying with nasal congestion from a cold or allergies. They should be used before decent and thus may relieve ear or sinus pressure buildup.

Cromolyn sodium. This medication (NasalCrom) is available as an OTC nasal spray that must be used several times a day. It helps relieve hay fever symptoms if used prior to symptoms developing and is therefore most effective when started before signs and symptoms develop.

Leukotriene modifiers. Montelukast (Singulair) is a prescription tablet taken to block the action of leukotrienes — immune system chemicals that cause allergy symptoms such as excess mucus production. Like antihistamines, this medication is not as effective as inhaled corticosteroids for long term allergy control. It's often used when nasal sprays cannot be tolerated, or when mild asthma is present. It can be used in combination with other allergy medication.

Nasal atropine, ipratropium bromide (Atrovent) is a prescription nasal spray that is not truly an allergy medication. It helps relieve a severe runny nose by preventing the glands in your nose from producing excess fluid. (Vasomotor rhinitis). It's not effective for treating congestion, sneezing or postnasal drip. Mild side effects include nasal dryness, nosebleeds and sore throat. It is not recommended for people with glaucoma or men with an enlarged prostate.

Other treatments for nasal allergies include:

  • Nasal lavage. To help with irritating nasal symptoms, your doctor may recommend that you rinse your nose with salt water. Use an over-the-counter nasal saline spray or prepare your own saltwater solution using 1/2 teaspoon of salt mixed with 1 cups of warm water.

Immunotherapy

The only "cure" for any inhaled allergy is desensitization, which involves the gradual delivery of the substances that trigger allergies to acclimate and increase the immune system's tolerance to allergens over time. This treatment can be administered in either allergy injections (allergy shots) or allergy drops (sublingual Immunotherapy or SLIT). Several offending antigens may be in one vial. Over 85% of patients who receive regular immunotherapy over the recommended period of time experience significant improvement or complete relief from their symptoms and a meaningful reduction of their allergy medications.

Immunotherapy may be especially effective if you're allergic to cat dander, dust mites, or pollen produced by trees, grass and weeds. In children, immunotherapy may help prevent the development of asthma.

The Allergy Center at SacENT Treatment Program

Allergy injections (shots)

A series of weekly injections are administered for a three to five year period. In the beginning there is a gradual build up every week of the dose strength of the injection until reaching your maintenance dose, where the dose strength is constant. This build up can take up to 3 months depending on the severity of your symptoms. Shots are tapered off during the final 1-2 years. Most patients find their treatment takes three to five years to complete.

Note: Patients taking injections must wait in the office for 10 - 20 minutes after their shot to monitor for any adverse reaction.

Most insurance companies cover injections, though co-pays may apply.

Allergy drops (Sublingual immunotherapy or SLIT)

Allergy drops work much like shots, slowly desensitizing you to your allergies. They're delivered under the tongue in a drop form that patients can take at home. With today's busy lifestyles, drops are an ideal solution for many of our allergy patients who can’t find the time to come in for a weekly shot. Because of their safety profile they are also the ideal way to administer immunotherapy to children, those patients highly reactive to shots, asthmatics and those with “needle phobia. Like shots, most patients find their treatment takes three to five years to complete.


There is a build up period which takes 3 to 6 weeks depending on the severity of your allergies. During this period the dose strength is gradually advanced. You start with 1 drop daily for the first week, 2 drops daily for the second week and 3 drops daily for the third week. If you need a second build up period (in stronger reacting patients), the schedule is the same as with the first build up period, with another gradual increase in dosage strength. On reaching maintenance, the dose is 3 drops a day until completion. Like injections the most patients find their treatment takes three to five years to complete.

The many benefits of sublingual immunotherapy

  • Easy to use. Allergy drops are simply placed under the tongue, and are used on a daily basis.
  • Fewer office visits - compared to shots, allergy drops require few office visits.
  • More convenient - you can take allergy drops at home or wherever you are – even while travelling as they need no special storage, thus making it much easier to stick with treatment. Studies have shown that more patients stay on immunotherapy treatment using drops as compared to injections.
  • Infants and children. Allergy drops have proven especially helpful for children with eczema and recurrent ear infections, which often have underlying allergic causes. Research shows that many children with untreated allergies develop asthma and other chronic conditions later in life, so treating them early can have lifelong benefits.
  • Highly sensitive patients and severe asthmatics. Drops can now provide desensitization to even severe asthmatics who, for mostly safety reasons, were unable to tolerate injections.
  • Chronic sinusitis patients. In many patients, chronic sinus and allergies are related. Treating the underlying allergic disease with drops has shown favorable results in reducing the frequency of their sinus infections.

Safety. The World Health Organization has endorsed sublingual immunotherapy as a viable alternative to injection therapy.

The well-respected Cochrane Collaboration, the world's most-trusted international organization dedicated to reviewing healthcare treatments, recently concluded allergy drop immunotherapy significantly reduced allergy symptoms and use of allergy medications.

The safety profile for sublingual immunotherapy is superior to injection based on research studies and patient treatment experience. Systemic reactions rarely with sublingual, and there has never been a severe anaphylactic reaction (life threatening) recorded over the 30 years of sublingual treatment.

Lower cost. Though drops are not covered by insurance, they may actually cost less than injections depending on your copayment most patients feel the modest investment is well worth the improvement in their health, reduction in allergy related expenses and overall quality of life

Note: The Allergy Center at SacENT does not submit the charges for sublingual immunotherapy drops to insurance companies. The cost of allergy drops is considered patient pay. Consider health savings accounts or healthcare flexible spending accounts to help cover the costs of drops.

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