Intranasal corticosteroids are immunosuppressants, and they act by decreasing the influx of inflammatory cells and inhibiting the release of cytokines, thereby reducing inflammation of the nasal mucosa. Recent news says the FDA approved Nasacort(R) Allergy 24hr, an intranasal corticosteroid spray, as an over-the-counter treatment for seasonal and year-round nasal allergies for adults and children 2 and older. Nasacort would be the first of its class to become available OTC. Intranasal corticosteroids contain small doses of the active ingredient and are very effective in treating the symptoms with minimal side effects. The main side effect concern about this drug is suppression of growth in children, however most studies have shown no or limited HPA suppression at recommended doses.
Histamines increase vascular permeability, causing fluid to escape from capillaries into tissues, which leads to the classic symptoms of an allergic reaction (runny nose, watery eyes). Histamines also cause itching and sneezing, so antihistamines would help with these symptoms. Antihistamines can generally be broken down into 1st and 2nd generation. An example of a 1st generation is diphenhydramine (Benadryl) but the problem with 1st generations is they also have anticholinergic properties and tend to cause drowsiness due to being more lipid-soluble and more readily crossing the blood-brain-barrier than 2nd generations. 2nd generations and such as loratidine (Claritin), fexofenadine (Allegra) and cetirizine (Zyrtec) are therefore less drowsy formulations.
Another alternative for congestion are oral decongestants such as pseudoepherine (Sudafed). Decongestants work by acting on adrenergic receptors, which causes vasoconstriction, shrinking the swollen mucosa and improving ventilation. Side effects include tremors, insomnia, and because of possible elevated blood pressure and tachycardia, patients with underlying cardiovascular conditions should use decongestants cautiously.
Cromolyn is generally safe, but not very effective. Cromolyn is a mast cell stabilizer, preventing mediator release. It has no direct antihistaminic or anticholinergic properties so it does not directly treat the symptoms. It also takes a couple weeks to take effect, therefore it is not considered for first-line therapy of allergic rhinitis. But because it is relatively safe, it is recommended as a preventative therapy for children, elderly and pregnant patients.
Keep an eye out for the new intranasal corticosteroid, Nasacort, as a first-of-its-kind to be OTC. The anticipated release of Nasacort is expected to be around April 2014. Current prices for the prescription Nasacort is roughly $100 for the generic, and $130 for the brand name. Prices for the OTC are not yet released.
Posted by: Adrian Lee; PharmD Candidate 2014
www.uptodate.com - Pharmacotherapy of allergic rhinitis