MEDICATIONS & ALLERGY-ASTHMA

This is a short section on the best and worst of medications commonly encountered by allergy/asthma patients.

THE GOOD

Antihistamines - The newer antihistamines (ReactineTM-ceterizine,ClaritinTM-loratadine, AllegraTM-terfenadine, AeriusTM-desloratadine)are clearly superior to the older H1 antihistamines (diphenhydramine (BenadrylTM,AllerdrylTM,others),chlorpheniramine). The older antihistamines have repeatedly been shown to cause sedation and poor motor performance. What is particularly important is the individual taking these older antihistamines is often not aware of these reductions in performance capability. A recent study showed these older antihistamines can cause the equivalence of being mildly alcohol intoxicated when it comes to a variety of performance abilities. There seems to be some individual preference for one antihistamine over another, and I tell patients to use whichever newer antihistamine seems to work best for them. While it has not been shown that these medications lose effect over time (tachyphylaxis), I have had some patients state that after using a newer antihistamine for a period months to years continuously it seemed to lose it's effectiveness. Switching to another antihistamine would be appropriate. If there is no change on switching, it may be that your allergies are getting worse. I have no particular preference regarding the newer antihistamines. AllegraTM (60mg) acts for approximately 12 hours, whereas ReactineTM, ClaritinTM, and AeriusTM act for 24. Taking this into account, they all cost close to $1 per day. This is very expensive compared to the older antihistamines. Generic ceterizine and generic loratadine are now available for approximately half the cost of the trade name brands. ReactineTM has a small incidence of sedation (5-8%) compared to the others, should not be taken if it does cause drowsiness, and is likely slightly more effective in hives (urticaria). Rarely, any antihistamine can cause irritability, depressed mood, or dry eyes, and that specific antihistamine should not be used if this occurs. These newer antihistamines are safe, have no significant drug interactions, and can be used on a regular basis for years. I like to avoid all antihistamines during the first 4 months of pregnancy and preferably throughout the entire pregnancy, although there has never been evidence that they cause any fetal problems. I have no concerns about mom using antihistamines during breast feeding. Occasionally patients have found that doubling the standard daily dose provides improved results (with no side effects) and I safely use up to four times the standard dose for patients with chronic urticaria (hives). A word of caution: The above comments are for pure antihistamines. Many antihistamines are combined with other medications (particularly decongestants or analgesics) and the above comments do not apply to these combination medicines.

Nasal Sprays (anti-inflammatory, steroids) - All things being taken into account, I think the best nasal spray on the market is Nasonex TM (mometasone). Mometasone has been approved for treating associated sinusitis and approved in children as young as 2 years old, and is at least as effective as any of the other nasal anti-inflammatory sprays on the market. If the nose spray is being used short term and intermittently, I have no significant preference. However, if an individual is using their nose spray regularly long term or taking inhaled corticosteroids for asthma at the same time (or pregnant-breast feeding), I usually use Nasonex TM. You have to remember that all of these sprays have proven to be safe when used at normal dosage. All individuals who are using nasal steroids on a fairly regular basis should consider adding in a nasal saline rinse once or twice daily. The saline rinses are safe, can improve symptoms significantly, in some cases allow a significant reduction in the use of the nasal steroid, but are messy to use with some patients not able to tolerate a saline flush. Beconase TM (and generic beclomethasone) and Flonase TM (and generic fluticasone) use a carrier agent that has a significant flowery odour. Some allergy patients who have significant problems with perfumes and odours cannot stand the smell of these particular nasal sprays. In these odour sensitive individuals, I use NasacortAQ TM, Rhinocort aqua TM (and generic budesonide), or Nasonex TM as these sprays are odourless. The newest nasal corticosteroid is AvamysTM (a different type of fluticasone) which has a very nice press/click mechanism to deliver each spray, may be slightly better in helping associated allergy eye symptoms, but is more difficult to aim properly (small nasal tip). Omnaris TM (ciclesonide) is useful for individuals who have local problems with topical steroids (sore throat, thrush, etc.). All of the above sprays are wet-aqueous sprays. Some patients cannot stand a wet spray in their nose (some adults and particularly some young children). In these cases, I use Rhinocort Turbuhaler TM, a dry powder nasal inhaler that you can sniff into your nose. You have to be old enough to master this technique, but the powder is odourless and so fine patients rarely even sense the powder in their nose. However, the aqueous nasal sprays have a decided advantage when used according to my instructions (see nasal spray instructions-Contents page) as they will treat both nasal congestion-inflammation and also treat the sinus and eustachian tube openings. All patients on nasal steroids should be told to blow their nose very gently, as there is a slight increase in nosebleeds with these medications. Usually stopping the nasal spray for two weeks allows the nose to heal, but for those with persistent nosebleeds I will avoid topical steroids in the nose. Very rarely, a patient will get an immediate severe headache when they use these nasal sprays. I try to switch these persons to a different preparation (both different steroid and carrier agent, as I'm not sure which causes this rare problem). All patients must spray using proper technique (see nasal spray instructions-Contents page). Rarely, patients using the sprays regularly can develop atrophy of the nasal lining and if they are using improper technique can cause a perforation (hole) in the septum of the nose. There is a small chance that steroid nasal sprays can increase intraocular pressure, so these sprays should not be used in individuals with glaucoma and used very cautiously in individuals with a strong family history of glaucoma. Please review the subsection “Nasal Spray Instructions” for details on how to use nasal steroid sprays properly and the use of saline nasal rinses.

Asthma-Inhaled steroids - These medications form the base treatment for asthma. Please refer to my section in Respiratory Allergic Diseases, Asthma for a detailed discussion. What is important to keep in mind, is that asthma is a disease of chronic inflammation of the lining of the smaller airway tubes in the lungs, and the treatment of asthma revolves around avoiding allergens (that drive the inflammatory process) and taking appropriate anti-inflammatory medication. Virtually all asthmatics should be on anti-inflammatory medication. The inhaled steroids when used at low dosage, have proved to be exceedingly safe. Low dose means the following total ug of inhaled steriod per day: Pulmicort TM (budesonide) -400 ; QvarTM, Beclovent TM, Vanceril TM, (beclomethasone) generic-500 ; Flovent TM (fluticasone)-250 , Asmanex TM (mometasone) 200ug, Alvesco TM (ciclesonide) 200 ug. Alvesco TM is useful for individuals who have local problems with steroids (hoarse voice, sore throat, thrush) as this steroid is not activated until it lands on true respiratory lining. If higher doses than these are required to maintain control, other agents should be added in to lower the total steroid dose as much as possible and obtain maximum improvement in control and eliminate symptoms. The LRBs,leukotriene receptor blockers = LTRAs (Singulair TM, Accolate TM), which are anti-inflammatories and bronchodilators, should be the first added on medication, as they have an additive effect on the inhaled steroids, good compliance (oral pills), are very safe, can improve upper airway allergies (nose & sinuses) at the same time, but are expensive and often cannot be afforded unless the patient has a drug plan. These medications only work in 50 to 60% of asthmatics. If the LRBs don't help or adequate control has not been obtained, the long acting beta agonists (LABAs) should be added in, as they improve symptom control and lung function, but are not anti-inflammatories. LABAs are now available in combined inhalers (Symbicort TM (budesonide + formoterol, dry powder); Advair (fluticasone + salmeterol, dry powder and puffer-MDI: Zenhale TM (mometasone + formoterol, puffer). These combination inhalers are also expensive. Additionally, antimuscarinic (anticholinergic) inhalers are being used in some asthmatics who do not come under satisfactory control with the above medications. The antimuscarinics were developed for use with COPD patients. The original antimuscarinic was AtroventTM (ipratropium) which still proves useful in some individuals with cough. A newer antimuscarinic SpirivaTM (tiotroprium) 18 µg inhaled once daily has proved useful in a subset of these difficult to control asthmatics. A group of newer long-acting beta agonists(LABA) and long-acting antimuscarinics(LAMA) are now entering the market for COPD (some are being combined with inhaled steroids) and may eventually be useful for a subset of asthmatics, but there are no published studies with these medications in asthmatics at this time. A multitude of studies have shown that inhaled steroids are the primary treatment of choice for asthmatics as they consistently control symptoms, reduce inflammation, and reduce asthma flares better than any other single medication. The low doses of steroids mentioned above are exceedingly safe, and only in the very rare child can they possibly reduce growth velocity. Remember, that uncontrolled asthma significantly decreases growth and has a huge negative impact on quality of life. As long as periodic attempts are made to reduce total steroid dose to the lowest effective controlling dose, the asthmatic process is being properly treated. Dry powder inhalers can be used by most patients over the age of five to six years old (the patient has to generate a high airflow rate through the device). Pulmicort TM (budesonide) has had the very best studies on long term control of asthma in children and adults, and has demonstrated clear long term safety. For young children who cannot use dry powder inhalers, I use Flovent (fluticasone) puffer with spacer. If the combination of inhaled steroid plus LABA is required, I usually the go with Symbicort Turbuhaler or Zenhale TM puffer as the long acting beta agonist –formoterol -is fast acting, so this medication can be used both for maintenance asthma treatment and acute asthma flares. I usually use Advair when high dosage steroids are required (fluticasone is a more potent steroid than budesonide) or for the very young or very old, as Advair comes in both puffer (MDI) and dry powder (Diskus) forms. Remember, after using ANY inhaled steroid, you must gargle deeply and rinse the mouth with water, then spit the water out (you only want the steroid in your airways). Residual steroid in the back of your throat can cause hoarseness, a sore throat, or thrush (yeast overgrowth) in some individuals. You should add the dose of nasal steroid onto the daily dose of inhaled steroid if you are taking both to determine total daily steroid dose.

Leukotriene receptor antagonists (LTRA) / blockers (LRB) - by far the most common LRB used is SingulairTM (montelukast) with AccolateTM (zafirlukast) occasionally used. Montelukast was initially developed as an asthma medication. It acts to open the airways, decrease mucus production, has a mild anti-inflammatory effect, and is orally administered once a day in both adults and children. Importantly, in individuals that respond to montelukast/zafirlukast there is a beneficial effect on the upper airway (nose, sinuses), so this is the only medication that actually treats upper and lower airways at the same time. For any allergic individual that has both upper airway allergy symptoms and asthma this medication should seriously be considered as a primary medication as it can reduce all other allergy/asthma medications used. Montelukast has a very small percentage of side effects (approximately 3%) including headache, abdominal cramps, and more rarely anxiety or nightmares. It is nonsedating and has no significant drug interactions. The major drawback to montelukast is only 50% of individuals respond to this medication (the response is genetically predetermined) so it is often overlooked. Montelukast must be tried for several days to see if an individual responds. It should not be used in individuals who do not respond (no one should be placed on a medication regularly where the medication is not effective).

Short Term Oral Steroids - This refers to oral steroids (usually prednisone, prednisolone, or dexamethasone) that are used for 10 days or less. Many individuals are aware of the risk of long term oral steroids. Very few individuals are aware that short term oral steroids are exceedingly safe. These medications are used in millions of patients yearly to treat acute asthmatic attacks or acute allergic episodes (other uses are beyond the scope of this talk). I try to use the minimum amount of steroid that will treat the specific asthma attack or allergic reaction adequately. Mild reactions often can be treated with three to five days of 15 mg of prednisone twice daily. Moderate reactions are treated with 20 mg of prednisone twice daily for 1 week. More severe reactions may require higher doses of prednisone for longer periods of time. It is to be noted that splitting the prednisone into twice daily half doses is more effective than a single daily dose. No tapering of the dose is required if it is taken for 14 days or less. As prednisone can irritate the stomach it is best to taken with food or drink. There are possible side effects that every patient should be aware of. Most individuals note a significant increase in appetite and you should eat normal amounts of food. Prednisone increases blood sugars in diabetics, so careful attention to blood sugars is required. Many individuals note a significant increase in energy and rarely this can be to the point where they cannot sleep. Occasionally prednisone can cause irritability (bad tempered, “ bitchy”) and very rarely psychosis. Many individuals have no side effects at all except feeling radically better within 24 hours of starting prednisone. Individuals who have mild side effects have to weigh this against the severity of their symptoms. Any patient who experiences major side effects should stop short term prednisone immediately and contact their physician for advice and follow-up.

THE BAD

Long term oral steroids (prednisone, etc.) should be avoided unless no other safer medication works. For asthmatics this means that all aspects of asthma control have been properly done and inadequate control of asthma still occurs. All allergen avoidance measures should be in place, triggers should be avoided, proper inhaler technique and equipment is required, inhaled steroids have been used along with all other controlling medications, all other medical problems that can adversely affect asthma have been properly dealt with (i.e. sinusitis, reflux, etc.), and the asthmatic has been totally complaint with all of these measures. Only the rare very severe asthmatic falls into this category. In this situation it is a simple risk-benefit ratio. The long term adverse effects of oral steroids (osteoporosis, weight gain, thin skin, cardiovascular disease, thromboembolism, adrenal suppression, osteonecrosis, increased blood sugars, etc.) must outweigh the risk of a fatal asthma attack and quality of life issues. This requires extremely good communication between the physician and patient on all aspects of this difficult problem. Osteonecrosis is a rare but frightening complication (the blood supply to the hip joint is lost, resulting in the collapse of the bone, and requiring a replacement artificial hip). It is estimated to occur in approximately 1:300,000 patients who take oral steroids. It is usually associated with high dosage long-term oral steroid use, but occasionally has been reported in high dose short term use (never less than one week). Inhaled steroids (approximately 2000 ug per day) are still safer than regular oral prednisone. Please do not confuse short term prednisone use (for two weeks or less) with long term prednisone use (months to years), as short term use is safe, and very appropriate for asthma flares or other acute allergic problems.

THE UGLY

Types of medication individuals with allergy or asthma should avoid if possible.

Beta Blockers - this group of medication (atenolol,propanolol,pindolol,metoprolol,others) is strongly contraindicated in asthmatics and patients who are at risk for anaphylaxis or severe angioedema. Beta blockers are used to reduce blood pressure, pulse rate, and are commonly used to treat heart patients (particularly after an acute myocardial infarction) and high blood pressure. This group of drugs commonly makes asthma more severe, more difficult to treat, and can make most other allergy problems worse. The biggest problem is that beta blockers specifically block the sympathetic nervous system and the drugs used to treat acute asthma and anaphylaxis are sympathomimetics - beta agonists (openers), adrenalin-epinephrine (stimulate the sympathetic nervous system). In essence, beta blockers specifically neutralize the medication used for these life threatening situations. An individual who has asthma, angioedema, or is anaphylactic and is actively taking a beta blocker should understand that this is exceedingly hazardous. This should only be done if the patient clearly understands the risks involved and decides the risk-benefit ratio is acceptable (for example: does the risk of heart disease outweigh the risk of acute asthma attack/allergic reaction?).

ACE inhibitors - avoiding this group of medication is not as clear cut. ACE inhibitors are used to treat blood pressure, diabetics, kidney failure, and heart patients (captopril,enalapril, ramipril, others). These medications can cause coughing (usually persistent, dry) in over 15% of patients. Interestingly, some of these patients that cough have undiagnosed asthma. In some asthmatics, ACE inhibitors seem to make the asthma worse. A small number of people taking ACE inhibitors develop episodic angioedema (swelling with no itching) which can occur months to years after starting the medication. This angioedema usually involves the face and neck areas. These individuals must avoid ACE inhibitors as there have been deaths reported because of this adverse reaction. Patients on ACE inhibitors and undergoing immunotherapy (allergy shots) have an increased risk of fatal allergic reactions. I never give immunotherapy to a patient taking ACE inhibitors or beta blockers without extensive discussion with the patient regarding risks and benefits. There is a newer group of medications-ARBs-that can usually be substituted for ACE inhibitors that do not have an adverse effect on asthma-allergies.

Types of medication that individuals with allergy or asthma should be cautious with.

ASA , NSAIs - this large group of medications (non steroidal anti-inflammatories) are use to treat pain, fever, and inflammation-arthritis. There are dozens of medications in this group. ASA in particular has become very important in treating heart and stroke patients. These medications can cause the following problems: acute asthma attack, hives, angioedema, anaphylaxis. Any individual who has had one of these reactions from any medication in this group, can have a similar reaction from other members of this group. What is misleading and difficult is often an individual will take these medications for years before having a reaction. When they react to one NSAI, they will switch to another and often will not have problems with the other NSAI for a further period of time (but eventually often react to other medications in the NSAI family). The severity of initial reaction is important, because a severe asthma attack or anaphylactic episode should result in an absolute avoidance of all of these medicines. Should you have a significant reaction to one of these medications, the subsequent trial of another should be done under appropriate medical supervision and monitoring. Remember the triad of asthma, ASA sensitivity, and nasal polyps (see Asthma section). Individuals with the triad tend to have severe ASA-NSAI sensitivity and their asthma usually responds to the LRBs.

DECONGESTANTS - there are 2 types of decongestants available, topically applied nasal sprays and oral. Both of these types of decongestants can have problems associated with them. Topical decongestants such as DristanTM, OtrivinTM, ClaritnTM, and others, rapidly decrease nasal swelling within a matter of minutes. If they are used twice-daily they can only be used for 2 or 3 days regularly. When used regularly beyond this point they cause rebound congestion (the inside of the nose swells up as the medication wears off and the swelling becomes worse than the original problem) with these individuals using the medication more and more frequently. This group of medications MUST NOT be taken regularly. Topical nasal decongestants rarely cause systemic symptoms and can be useful for occasional use, particularly for severe nasal blockage at night or pre-flight for individuals with eustachian tube dysfunction. The oral decongestants found in many cold and sinus preparations (primarily pseudoephedrine, occasionally phenylephrine) can be useful as add-on medications to improve nasal air entry and decrease postnasal drip. However, oral decongestants act as a stimulant, can counter fatigue caused by allergy, and can significantly interfere with sleep in many individuals, so oral decongestants should never be in your system as you approach bedtime. A few individuals are very sensitive to oral decongestants and experience anxiety type symptoms (nervousness, irritability, increased heart rate, tremor, etc.) and must avoid all decongestants. Oral decongestants are contraindicated in individuals with uncontrolled hyperthyroidism. Oral decongestants can mildly increase blood pressure in some individuals so should be used very cautiously or not at all in the elderly and individuals with hypertension.

HERBALS, "NATURALS" - this represents a huge group of products that have rapidly evolved into a multi billion-dollar industry. Every individual should be aware of the facts surrounding these products. In Canada there is no effective legislative/legal control on these products to ensure: 1- they contain what they say they do, 2- quality control (one batch contains the same amount of product as other batches), 3- the safety of the product, 4- interactions of these products with medications/other preparations is reported/listed. (To look at it another way, when you buy a prescribed drug from a pharmacy you are guaranteed that drug contains exactly what it says it contains, that it is pure, that it has been tested for safety of use in humans, and that known interactions and adverse effects are listed.) Several studies have shown that well over half of certain herbal preparations contain none of the claimed ingredients, while others contain insignificant amounts of claimed ingredients. Many herbals have shown to be "cut" with known unlisted drugs (steroids) or to contain toxic substances (heavy metals). It is also becoming very clear that many herbal preparations have significant and possibly dangerous interactions with prescribed drugs or other herbals. Many surgeons and hospitals require that any patient undergoing surgery stop all herbal preparations two to four weeks prior to surgery. Most herbals are derived from plant products and the type of soil, nutrients available, type of growing conditions (weather, plant diseases, moulds), and variable processing practices can all cause huge variations in any specific plant derived product. The fact that a huge amount of money can be made in this area with absolutely no controls (the maker is under no risk no matter what they do) opens the door for the unscrupulous and dangerous/ineffective products.

Keeping these points in mind, the fact remains that many individuals take herbal/natural preparations on a daily basis. FROM AN ALLERGY POINT OF VIEW, several things must be kept in mind. All herbals should be stopped 3 days prior to skin testing as the effect is usually unknown (a few herbals definitely adversely affect test results). Many allergic individuals are severely allergic to plant products. Examples are: pollen allergy (very common), contact allergy (poison ivy). These individuals must be extremely cautious when eating any herbal preparation as they may eat a specific plant product that they are allergic to or a plant product that cross reacts (molecular structure is very similar) with something they are allergic to. There are well documented cases of severe/fatal allergy/anaphylactic reactions to bee products, honey products (pollen contaminated), other herbals containing pollens, etc. I strongly recommend allergic persons keep their herbal intake to a minimum, that they only take single herbal products (i.e. not a mixture of 30 different plant products in one capsule), that they only add in one new herbal product at a time (paying careful attention to how they feel when taking the first dose by itself), and that they stop herbals periodically for several days and then take a test dose of each individually to ensure they are not becoming allergic to these preparations. Remember, these products will vary tremendously in content, from one batch to another, and they do not necessarily contain what they say they do.

Dr. Bruce Sweet, 2016