“Decisions, decisions,” said the gentleman standing in the aisle of allergy meds, pondering his purchase. “I never know which one to get.”
As a pharmacist, I see this very often – the allergy aisle is one of the most confusing to navigate. Many of the boxes look alike, and patients need our assistance picking the best product for their symptoms. I thought a quick lesson in navigating over-the-counter allergy meds would be helpful. Luckily, pharmacists are always ready and willing to help patients choose the right products to get them on their way to feeling better.
The most common class of allergy meds is antihistamines. Histamines cause allergy symptoms, so antihistamines block histamines, thereby decreasing symptoms. When I think of antihistamines, I think of “drying,” if a patient has a runny nose, sneezing, watery eyes, drippy cough – they need to dry up. Antihistamines are also great for itching, for example, treating an itchy reaction to a bug bite.
Diphenhydramine (Benadryl) is a popular antihistamine which is very sedating. In fact, it is often used as a sleep aid. I would only recommend taking diphenhydramine at night, right before bed, and when you have at least 8 hours to sleep/rest. Also, diphenhydramine should not be used in patients with certain medical conditions such as thyroid problems, glaucoma, or enlarged prostate due to its anticholinergic effect (https://www.peoplespharmacy.com/2018/04/26/commonly-prescribed-anticholinergic-drugs-linked-to-dementia/). These effects typically include bothersome symptoms such as dry mouth and blurred vision. Because of these issues, I rarely recommend this medication.
The newer, non-sedating antihistamines include loratadine (Claritin), cetirizine (Zyrtec), fexofenadine (Allegra), and the newest one, levocetirizine (Xyzal). All of these medications used to be available only by prescription, but now are available over the counter.
I think of all of these as just like diphenhydramine with the drying effect, but these newer antihistamines are non-drowsy, and can be taken any time of day. They are also to be taken once a day, as opposed to diphenhydramine which is dosed every 6 hours. People’s Pharmacy has reported on a troubling effect of Zyrtec (https://www.peoplespharmacy.com/2010/05/05/itching-from-cetirizine-withdrawal/) and Xyzal (https://www.peoplespharmacy.com/2017/03/30/stopping-xyzal-triggers-horrible-itching/), where upon abruptly stopping these medications, patients have experienced very bothersome itching.
I would recommend stopping these medications after allergy season (not only Zyrtec or Xyzal, but Allegra or Claritin as well, since they are all in the same category). Instead of stopping suddenly, slowly discontinue these medications over a period of a few weeks. For example, instead of taking one tablet daily and then stopping, I would recommend taking one tablet every other day for a week or two, then every third day for another week or two, etc. Consult your allergist for more information.
Antihistamine + Decongestant:
When you see the placards for allergy meds such as Claritin-D or Allegra-D, the D stands for decongestant and contains pseudoephedrine. These medications are kept behind the pharmacy counter (but do not require a prescription). You must show ID to purchase them, and the amounts purchased are logged. This is because pseudoephedrine is used illegally to make methamphetamine. If you also feel stuffed up, or “clogged,” I would recommend one of these medications with the decongestant. If you have high blood pressure, though, you do not want to take a decongestant unless your doctor says you can, because decongestants can raise your blood pressure.
Of note, decongestants are also available on their own, both in the OTC aisle and behind the pharmacy (pseudoephedrine). They have their place in helping relieve a stuffy nose, but for allergies, we usually recommend the antihistamines with or without decongestants, as opposed to the decongestant alone.
I spoke with allergist Jessica W. Blume, MD. She explains that OTC antihistamines differ based on the patient. She recommends generic Zyrtec or Xyzal be taken at night due to possible sedation. She notes that her patients do well on a variety of antihistamines, so sometimes patients may need to try a few different antihistamines to see which is most effective with the least side effects.
Next, we come to the nasal sprays. Nasal steroids decrease inflammation and help relieve nasal symptoms. Fluticasone (Flonase) is a steroid nasal spray and is usually the most prominent nasal spray on a pharmacy shelf. There is also a newer Flonase Sensimist, which is just a lower dose of fluticasone (27.5 mcg per spray) than the regular Flonase (50 mcg per spray). Flonase by far is the most popular of these. At the pharmacy, not only do we sell a lot of it over the counter, but doctors still prescribe generic fluticasone spray. Other available OTC steroid nasal sprays include triamcinolone (Nasacort) and budesonide (Rhinocort).
Often, these nasal steroids have a drying effect, and you can always use a nasal saline spray as needed to combat feelings of nasal dryness.
Be careful to not mix up saline with oxymetazoline (Afrin) nasal sprays, which are often placed next to the saline sprays – Afrin sprays are to unclog a stuffy nose and can only be used for a maximum of 3 days. Otherwise, you may experience something called rebound congestion (https://www.verywellhealth.com/everything-you-need-to-know-about-rebound-congestion-1192177), where you feel even stuffier than before.
Another nasal spray that is not as popular, but seems to be quite effective, is cromolyn (Nasalcrom), which is steroid-free and works as a mast-cell stabilizer (http://www.nasalcrom.com/allergy-info/nasalcromr-nasal-allergy-spray-different-good-kind-different), and is used more to prevent nasal allergy symptoms than to treat them. Here is some more information about cromolyn (https://www.peoplespharmacy.com/2017/10/23/nasalcrom-is-a-forgotten-allergy-treatment-that-works/)
Many of my patients in the pharmacy love nasal rinses. Dr Blume prefers the NeilMed sinus rinse but says that it is very important for patients to use only distilled water, so that bacteria is not introduced into the sinuses. If distilled water is not available, bottled or tap water must be boiled before using.
OTC Eye Drops:
Ketotifen (Zaditor) eye drops have been flying off our shelves this season. Patients seem to really gravitate toward this OTC eye drop, which used to be available only by prescription. It is a great eye drop for relieving itchy, red, watery eyes that allergies bring.
I also recommend lubricating eyedrops such as generic Systane or Refresh, between doses of Zaditor, to be used as needed when eyes feel irritated or itchy.
Opcon-A and Naphcon-A are antihistamine/decongestant eye drops that also may be effective for allergies.
Dr Blume finds skin allergy testing very helpful to identify exactly what patients will react to, and she sometimes recommends allergy shots if no other therapy works. She also finds a combination of OTC and prescription medications is often necessary and more effective for symptom relief than just trial and error with OTC allergy meds.
Dr Blume also notes that during pollen season, allergic patients should be sure to keep windows closed (in both the house and car). Patients should also shower and wash their hair before bed and stay inside as much as possible during a high pollen count day. This article (https://www.mayoclinic.org/diseases-conditions/hay-fever/in-depth/seasonal-allergies/art-20048343) has some more great tips for avoiding allergy triggers during peak season.
Information in this article is intended to be general. Consult your physician for personalized medical advice.
Karen Berger, PharmD, RPh, graduated from the University of Pittsburgh School of Pharmacy in 2001. She has worked in community pharmacies for 17 years, first, as a pharmacist/pharmacy manager for a large chain, and currently, as a pharmacist at an independent pharmacy in Northern New Jersey. Karen is a contributing writer. She can be reached at firstname.lastname@example.org