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Spring is Springing, and So Are Allergies: A Brief Review of Allergy Medications

By Dr. Arthur Lavin

Every spring, troubles begin to veer away from the constant onslaught of winter colds and stomach flus, and pollen begins to coat our world causing allergies to once again flare.

Many people who have allergies to tree and grass pollen are already sniffling their nose, rubbing their itchy eyes, maybe even coughing or wheezing a bit more.  That will only get more intense very soon.

So let’s take a look at allergy medications.  It is a set of medicines that distinguishes itself as being safer than most, and more effective than most, with essentially no wearing off after lots of use.  A remarkably good record!

What is an Allergy?

To understand what allergy medications do, let’s first describe what they are treating, allergies.  The word allergy has roots in the word for energy.  The idea is that an allergic reaction is a certain type of energy.  In this case to something that is not you.   The two parts go something like this:  all-ergy, all here means other and ergy means energy, which is the part easy to see.   So allergy means that something that is not you contacts your body, and creates a very specific surge of energy, the allergic reaction.

Their are three parts to the allergic reaction:

  1. The thing you are allergic to, the technical term for this is allergen.
  2. An antibody, a type of protein whose one end only attaches to one chemical, the thing you are allergic to, the allergen.
  3. Cells like mast cells.  The antibody has another end, it attaches to such cells, and if enough allergen sticks to their allergen end, the antibody makes the cell release its chemicals, the most famous being histamine.

An allergen is an allergen purely because someone’s body has an antibody to that allergen.  No antibody, no allergy, the item is not an allergen.  But if the antibody to say grass pollen exists in your nose or eyes, then grass pollen is an allergen to you.  That’s because that antibody to grass pollen arms the mast cells, so whenever grass pollen attaches to that antibody, the mast cell releases histamine and like chemicals.  Whenever histamine is released into your tissues, blood vessels in the area inflame, making the area swollen, itchy, and very mucusy.

If this sequence happens in the eye, you get allergic eyes, weepy, crusty in the morning, very itchy, often red- aka allergy pink eye

If this sequence happens in the nose, you get a runny, itchy nose- aka hay fever

If this sequence happens in the lungs, you get wheeze and/or cough- aka asthma

There are many other places and situations these reactions can take place, just consider the world of food allergies, where allergens are foods, and the place of reaction may be the mouth and gut where the food contacts the body, as well as the lungs.

But here we will focus on the airborne allergens and where they hit, eyes, nose, and lungs, because the assault of pollen is gearing up right now.

The Range of Allergy Medicine Strategies

Allergy medicines all work by doing something to block the allergic reaction.

They can only do this by a handful of strategies:

  1. Block the effect of the chemicals the mast cells release to cause the allergic reaction.  Only two chemicals can currently be blocked.
  2. Kill the cells that make the allergic reaction happen.
  3. Keep the allergy antibodies from forming or working.

That’s it.  Do something about the chemicals of allergy, the cells of allergy, or the antibodies of allergy.  Let’s look at each

Blocking the Chemicals of the Allergic Reaction

As noted, today’s allergy medications can only block two of the various chemicals released when one has an allergic reaction.  Those two are histamine and leukotriene.  Histamine is by far the most famous.

The medications that block the actions of histamine are called anti-histamines.  Makes sense.  There are many, many anti-histamines.

The oldest, and by far the most powerful, is diphendhydramine, known to all as Benadryl.

Benadryl is a great medication, it works, and works very, very well.  For more serious allergic reactions, such as anaphylactic reactions to foods such as peanuts, Benadryl is an essential antidote.

Two problems make Benadryl not so useful for mild reactions, it only lasts 4 hours, and it makes many sleepy.  It makes us sleepy because in the brain, histamine is used to activate nerves that sustain our waking.  So if Benadryl enters the brain, out you go.

This is why the most of us take one of three antihistamines when pollen threatens:  Claritin (loratidine), Zyrtec (cetirizine), or Allegra (fenofexadine).  These three are very, very similar.  They are weaker than Benadryl and do not make most people sleepy at all, and they last about 24 hours.  So you can take one dose a day and be helped all day and night long.

The three are truly interchangeable.  Claritin takers can take Zyrtec or Allergra any day they like.  Same goes for Zyrtec users and Claritin and Allegra, and Allegra users and Claritin and Zyrtec.  This is very good news, because most people find that only one or two of these work for them.  So if you have pollen allergies and you try one of them and nothing happens, try the next one.

In addition to Benadryl and the three 24 hour antihistamines, there are many, many older ones.  They can make you drowsy, and most last much less than 24 hours.  They include brand names like Triaminic, Atarax, Dimetapp, and many others.

Most people with pollen allergies rely primarily on Claritin, Zyrtec, or Allegra.  When things get very bad in a moment, Benadryl is always there.  The others are not used as often anymore.

One more form of antihistamine that is such a great part of treating allergies, are anti-histamine eyedrops.  These are incredibly safe, so very, very few side effects.  And they are so very, very effective.  More than any other allergy medication, antihistamine eyedrops for the allergic reactions in the eyes give such immediate relief.   These drops come in many, many brands, including the over the counter brand Naphcon and Opcon and the prescription brands Patanol and Zaditor.  There are many others.

We mentioned there are two chemicals of the allergic reaction that we can block.  The other besides histamine is leukotriene.  The main drug that blocks leukotriene is Singulair (monteleukast).  This is a very helpful medication.  If antihistamines and topical steroids (see below) are not enough, Singulair is a good option to keep in mind.

Killing the Cells that Make the Chemicals of the Allergic Reaction

As you might imagine, wiping out the cells that release the chemicals necessary for an allergic reaction to even happen is a very strong and effective strategy.

The one drug that does this the glucocorticoid, widely known as steroid.

There are two ways to deliver a steroid to your body, and these two ways could not possibly have a different level of risk.   One way is by pill or IV, that is, into the body itself.  The other way is by applying the steroid to the outside layers of the body, a process called topical application, hence topical steroid.

The oral and IV route is called systemic steroid and it has dozens and dozens of side effects, many very, very serious.  These side effects can happen after just a few doses, but a several day course of oral steroid is usually harmless.  But take oral steroids every day for a few weeks, and trouble can begin.  At the same time, doses achieved by oral, and especially IV, routes, wipe out far more allergy cells than topical applications, and so are the foundation of treatment for all very, very serious allergic reactions, those that threaten breathing and blood pressure.  But because of their strength and so many dangerous side effects, we almost never use IV steroids for pollen allergies, or even oral steroids for more than a handful of days.

The main use of steroids for pollen allergies is the topical use, applying the drug to the outer surfaces of the body.  Which surfaces?  Those where the pollen has sparked a reaction.

For the nose there are steroid nasal sprays, such as Rhinocort, Nasanex, Flonase, Veramyst and others.

For the lungs there are Azmacort, Pulmicort, Flovent, and others.

You might say, wait a minute, if you sniff a steroid or inhale a steroid, that enters the body.  Yes and no.  It technically is not away from the body, but very, very little actually enters the bloodstream.  Consider if you get a bead in your nose, it is not outside the body, but it never really enters the bloodstream, it cannot touch or impact the functioning of any of your organs, it only touches the lining of your nose.  When you spray a steroid solution up your nose, some does get absorbed, but such a small amount the impact of the steroid on your body remains quite small.  The same goes for inhaled steroid sprays into the lungs.

This is precisely why we can even use these very powerful drugs, for days and days.  Some allergy sufferers take such a steroid every day year round, and nearly all have no significant side effects.

For people who suffer from pollen allergy that do not find sufficient relief from oral and eyedrop antihistamine, a nasal or lung steroid often provides the needed relief, and safely.

Keep the Allergy Antibodies from Working

This is an area of real hope.  For a very long time scientists have sought ways to keep the whole set of antibodies that cause all true allergies from working.  This is possible because the antibodies that link the thing you are allergic to, the allergen, to the cell that will dump its allergy chemicals, is a special subset of antibodies, it is feasible to hope we could rid ourselves of such, and safely.  There are some leads, but this is far from a routine therapy, yet.

For today, the standard tactic in this strategy is the familiar allergy shot.  Take the allergen you react to, say maple tree pollen, inject it rather than breathe it, and you bypass all the allergy antibodies in your nose.  Better yet, the injected allergen sparks the creation of a non-allergy antibody.  This type of antibody cannot connect to cells like the mast cell, so the whole allergic reaction is blocked.

The trouble is, that to get this relief, you have to get a series of shots, usually one a week, usually for many years, and you never know if your round of allergy shots will work, until you’ve done it for awhile.

This is why allergy shots remain a therapy tried after others have failed.  If it works, it is a great think, and as with all else, when it fails, it is yet another disappointment.

BOTTOM LINES

  1. Spring has sprung in Cleveland.  Soon pollen will fill the air.  The pollen from all the lawns and all the trees are the source of most spring allergy miseries.
  2. Very fortunately, the suffering caused by spring allergies, although it can be intense, is not dangerous to vast, vast majority of us who have spring allergies.   Allergies tend to be dangerous in only two domains:  breathing and blood pressure.  No matter how itchy our eyes get, or runny our noses, if our breathing can continue and our blood pressure remain unaffected, we are safe.
  3. Also very fortunately, the array of allergy medications available, mostly over-the-counter, work very well, and very safely, even when used daily for months.
  4. There are three key strategies for allergy medications:  block the action of allergy chemicals like histamines, kill the cells that make these chemicals, and block the antibodies that are needed to release the allergy chemicals.
  5. To block the action of allergy chemicals like histamine, use antihistamine- orally and/or in the eye.  To block leukotrienes, use anti-leukotrienes like Singulair.
  6. To kill the cells that make allergy chemicals- use topical steroids, such as nasal spray or inhaled steroids.
  7. If all else fails, or if the allergy suffering is intense enough, consider blocking the allergy antibodies, by using allergy shots.

Winter is nearing its final gasp, the Earth is singing spring, we hope everyone can enjoy the sunshine, warm air, the  great outdoors.  Pollen allergies are manageable, and we are here to help you manage them.

To your health,
Dr. Arthur Lavin

 

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