One of the most common problems in Internal Medicine, hardly a day goes by where I don’t see at least one patient suffering with allergies. I am a fellow sufferer, so I’m right there next to you…sneezing and snuffling!
So what’s the big deal, right? Runny nose, congestion…you pop over to the drug store and buy any one of the many allergy drugs available. Case solved, right? Elementary my dear Watson!
Not so fast there, Basil!
Allergic Rhinitis, Vasomotor Rhinitis, Perennial Rhinitis, Seasonal Allergic Rhinitis, Rhinosinusitis, Nasal Polyps, Purulent Rhinitis, Sinusitis, Atrophic Rhinitis…Ack!!!
How can you tell the difference? I’m glad I asked!
Well, actually, the easiest way is to see your doctor. That’s what he is there for! But for the sake of argument, let’s talk about The Usual Suspects (loves me some Kevin Spacey).
Allergic Rhinitis – the most common cause of the usual symptoms of runny nose, sneezing, congestion and often sinus pressure. Sometimes also associated with itching of the nose, eyes or palate. This is the body’s immune system responding (vehemently!) to an allergen in the area. Molds, Mites, Dusts, Pollens, Grasses and Animal Dander are the most common causes (by far). When symptoms occur seasonally (usually spring and fall), we call this Seasonal Allergic Rhinitis, and are much more likely to be caused Pollens and Grasses. When symptoms are year-round, we call this Perennial Allergic Rhinitis and the cause is much more likely to be Molds, Dusts or Mites. Often, people have Perennial Allergic Rhinitis with Seasonal Exacerbations. This means you likely have a mix of the two and get your worst symptoms during the spring and fall.
So what do we do about it?
First line treatment for allergies is….avoidance of the allergen. Duh. Sounds simple, but in reality almost no one succeeds in treating their allergies by avoiding the allergen. I have a terrible cat allergy, but I took allergy shots for 3 years before I would consider getting rid of my pets. Most people think the same way, so being the practical doc that I am, I usually start with step two therapy. I will list my usual “steps” below:
Long-acting, Non-Sedating Oral Antihistamines – These include Allegra (by prescription only), Claritin and Clarinex (by Prescription only). These 3 medications are truly non-sedating. They are, however, weaker than their sedating counterparts. Of the three, Allegra has the most anti-histamine activity and works very well for me. Claritin is probably the weakest antihistamine ever created by man (sorry, Merck!) but it does have the advantage of being non-sedating. Clarinex is possibly slightly more effective than Claritin. For many people, this alone will suffice to control their symptoms and they are practically side-effect free.
Long-acting Sedating Oral Antihistamines – Let’s be clear here. Not everyone gets sedated with these drugs. As a matter of fact, it’s the minority who do. Zyrtec and Xyzal (by prescription only) are sedating, but only about 1 in 6 people gets drowsy with Zyrtec and even fewer with Xyzal. These are more potent anti-histamines, are only minimally sedating and last all day. Good meds, Maynard!
Nasal Steroids – No, these will not make your noses stronger! Nasal steroids are excellent medications, especially for people who have symptoms which are predominantly nasal. A couple of snorts of this stuff every morning is a preventative. That’s right. These sprays do not treat the symptoms of allergies, they actually prevent the allergic reaction from occurring in the first place. The only problem with nasal steroids is that you have to take them all the time or they don’t work. They take about a full week to get to full effectiveness, so they are useless for treating symptoms NOW! They can also cause nose bleeds in people who use them for a long time and some people just don’t like shooting liquid in their nose. There is good medical evidence to even use these drugs as first line therapy.
Leukotriene Inhibitors – The allergic response has two phases, the Early Phase and the Late Phase. The early phase is predominated by the Histamine response and occurs minutes after exposure to the allergen. If this early response is not completely blocked, the resulting immunological reaction occurs about 6-12 hours later and is called the Late Phase Allergic Response and is predominated by the release of leukotrienes. This Late Response can be even more potent than the early response, in some people. There is a drug called Singulair and another called Accolate (both by prescription only) which block this late phase response. Only the former is actually FDA approved for Allergic Rhinitis, but there is no biological reason why the latter would not help. These drugs are much weaker than the ones listed above, when treating allergies, but happen to also be potent drugs for the prevention of Asthma (which many people with allergies tend to have).
Nasal Antihistamines – There is a spray called Astelin (by prescription only) which causes an antihistamine reaction within the nose. A good therapy for some people with Allergic Rhinitis, but also works for people with Vasomotor Rhinitis (see below). This spray can cause drowsiness (if i take the maximum dose, it puts me out like a light!), but most people can tolerate the lower doses.
Immunotherapy – A fancy term for “Allergy Shots”. These inoculations are a steady and ever-increasing dose of the very allergens you are allergic to. Over time, your body creates antibodies to these allergens, which bind the allergens before they can bind to Mast Cells (found in the blood and in in tissues) and cause them to release histamine, which begins the allergic response. The downside is you have to get shots 1-2 times weekly, sometimes for years. The upside is that apart from the pain of the shot, and the possibility of having a shot reaction, these shots are side effect free and leave you much better off at the end of the road! You will need to see an Allergist to get these, and he will have to test you for which specific things you are allergic to (a blood or skin test).
Steroids – Yes, sometimes the allergic response gets into hyperdrive and once it starts rolling downhill, there is nothing you can do to stop it. Steroids (by pills or injection) potently block all aspects of the allergic cascade. This will allow your doctor to sorta “reset” your allergies back to square one, so that the other medications can begin to do their job by blocking the allergic response. Steroids are fairly safe when used for a short time, but they have a dramatic long list of horrible side effects when used for more than a couple weeks. This is usually the very last thing your doctor will try.
Other Medications – There are a multitude of medications available to help treat the symptoms of allergies. They do nothing to treat either the cause or the allergic reaction itself, but they can make you feel better!
- Nasal Decongestants – Pseudoephedrine and Phenylephrine (both available over-the-counter) work to decrease nasal congestion by constricting the blood vessels in the nose, making them less “leaky”. These drugs work pretty well, but they can cause jitteriness, insomnia, hypertension and can make symptoms of an enlarged prostate much worse. Pseudoephedrine works better, but you may have to ask the pharmacist for it, and he may only allow you to purchase a small amount, as it is used to make Methamphetamine, a drug of abuse.
- Nasal Decongestant Sprays – Sprays such as Afrin, Dristan and Neo-Synephrine. These also cause constriction of the blood vessels in the nose, but with far fewer of the side effects noted for the pills. The problem is that your body will quickly habituate to the sprays, usually within a few days, and you will get rebound nasal congestion when you stop taking the sprays. Some people, who take them for too long, get “addicted” to them, and cannot have an unstuffy nose without them. These work in a pinch, but don’t use them for longer than 3 days.
- Atrovent Nasal Spray (by prescription only) – a potent anticholinergic spray (google that word, I dare ya), which leads to drying of the nose for about 4 hours. Can cause a fast heart beat, dry mouth, difficulty urinating and sometimes dizziness to the point of passing out when you stand up. These side effects generally only affect the elderly, but you never know.
The Great Pretenders
There is a very long list of medical problems which can easily mimic Allergic Rhinits. I call these the Great Pretenders. If you have symptoms which do not quickly clear up with over-the-counter medications, you should quickly consult your physician to make sure one of these is not the cause for your symptoms:
Vasomotor Rhinitis – When the blood vessels in the nose dilate, they get “leaky” and can cause a stuffy nose, and sometimes profuse nasal drip. It is possible to have this and Allergic Rhinits. Symptoms of Vasomotor Rhinitis may be worse at night.
Nasal Polyps – Ewwwwww! Yes, you can get polyps in your nose, and obviously they can plug things up! The most common cause of these polyps (which can become cancerous over time) is uncontrolled Allergic Rhinitis, so getting your your allergies under control is not just for your comfort, but to avoid getting these icky things. Treatment of polyps is dependent on the size of them. Small ones can sometimes be treated with nasal steroid sprays, but once they get any larger, they have to be removed surgically.
Sinusitis and Purulent Rhinitis – A bacterial infection of the nasal passage or sinuses, these are often associated with a nasal discharge which can be green, grey or bloody. Sometimes there is a foul odor or fever. Antibiotics can usually clear this up. Often, an allergic reaction which causes a lot of nasal inflammation causes the sinuses to be unable to drain properly…and they get infection, leaving you with both the infection AND the allergy. Nice.
Atrophic Rhinitis – When the nasal mucosa becomes overly dry, it can mimic all the symptoms of Allergic Rhinitis. Some people describe a bad odor, probably associated with a specific bacteria which becomes colonized in the noses of people who have this ailment for a long time. This is most common in the elderly, but there are other systemic illnesses which can cause it. Merely using moisturizing sprays can cure this.
Medication Side Effects – A variety of medications can cause nasal congestion, which can be mistaken for allergies. The most common ones are the vasodilating blood pressure medications (drugs that dilate blood vessels, which makes them leaky). The various drugs we use for enlargement of the prostate can cause this as well, as they are also vasodilators. Stopping the medication is usually the best solution.
Nasal Cancer – Yes, you can get cancer in your nose. The #1 risk factor is smoking, by far, but uncontrolled allergies can lead to polyps which can become cancerous.
Having allergies is much more troublesome that merely a runny nose. Many studies have shown a direct correlation with reduced ability to enjoy their lives and be productive in all aspects of their life, perhaps due to the uncontrolled inflammation and sleep issues inherent in those symptoms. It has even been associated with a higher incidence of depression. Regardless, it is more important that it would seem to get your allergies under control. Take it from a fellow sufferer, it is worth the effort to get your symptoms under control!