Many options exist for the treatment of seasonal allergies (“hay fever”), and year-round allergies. Treatment often depends on which symptoms a person is having (such as stuffy nose, sneezing, itchy/watery eyes, etc.), and whether related conditions such as asthma are present. Sometimes, especially when allergy problems are more severe, a combination of treatments becomes necessary.

Most people are familiar with antihistamine medications. These most commonly come in pill form (although antihistamine eye drops and nasal sprays do exist, discussed below). Antihistamines work by keeping histamine from binding to histamine receptors on our bodies’ cells. Because histamines can lead to many of the problems we see with allergy, such as itching, swelling, congestion, increased mucous production, and so on, blocking the effect of histamine is often quite helpful.

There are many antihistamine medications available- over-the-counter and prescriptions. They tend to be quite safe and well-tolerated when/if used correctly. Some antihistamines, especially some of the older medications, can cause sedation (sleepiness or fatigue) in people who have more tendencies or are more sensitive to this effect. Surprisingly, these same antihistamines will sometimes lead to hyperactivity or insomnia. The newer antihistamines tend to be better tolerated.

The effectiveness of antihistamines can be limited, however. For people with more mild symptoms, antihistamines are often adequately effective. Unfortunately, in people with severe allergy problems, a simple antihistamine pill often is not adequate enough to control allergy. Fortunately, there are other treatment options available in these situations.

Leukotriene Blockers:
Another common allergy medication is Montelukast (Singulair). This medication is frequently confused with antihistamines, but it works by blocking a different pro-inflammatory molecule called Leukotriene D4. Leukotrienes are a class of inflammatory molecules that tend to be involved in allergic inflammatory processes, such as allergies and asthma. There are a handful of medications that can limit the production and/or the effect of leukotrienes; these tend to be helpful in allergic inflammation. For allergies, one of the Leukotrienes- Leukotriene D4- has many pro-inflammatory effects similar to those of histamine. Because of this, the Leukotriene D4 blocking medication, Montelukast (Singulair) is often used. This medication works by blocking the interaction of Leukotriene D4 with its receptors on our cells, very much like the antihistamine medications that keep histamine from interacting with histamine receptors.

Montelukast (Singulair) is only available by prescription, but because it is available in generic form, it is often affordable. Montelukast (Singulair) tends to well-tolerated when used correctly, although if used in high doses it can cause sedation.

For most people, Montelukast (Singulair) is about as effective as one of the newer antihistamine pills. One advantage is that it can also be helpful in people who have difficulties with asthma. But, once again, when dealing with antihistamines, the effects often times are not adequate enough to have any effect if allergies are more severe.

Steroid Nasal Sprays:
Steroid medications are very effective at controlling many types of inflammation, including allergic inflammation. Because of this, steroid medications are very effective for the treatment of nasal and eye allergy problems, even when severe. Unfortunately, these anti-inflammatory steroids can cause numerous body-wide side effects when used in the form of pills or injections. To obtain the anti-inflammatory benefit of the steroid medications without the body-wide side effects, there are different very low-dose nasal spray preparations that have been formulated. Rather than blocking the effect of a single chemical, steroid medications are much more broadly anti-inflammatory. Because of this, nasal steroid sprays are one of the most effective (if not the most effective) of the daily medications used for allergy symptoms.

Even though most of the nasal steroid spray medications are available by prescription only, a few of them are available over the counter. Insurance coverage and cost for the older nasal steroid spray are often affordable. The side-effects include dryness, irritation inside the nose, bloody nose or sores that can develop within the nose. If nasal sprays are used properly, they are very well-tolerated and can be used long-term.

As a class, nasal steroid sprays are probably the most effective of the daily allergy medications. They are typically more effective than antihistamine pills or Montelukast. Interestingly enough, most patients experience significant improvement in eye-allergy symptoms with nasal steroid sprays.

Antihistamine Nasal Sprays:
Antihistamine nasal sprays are antihistamine medications that are sprayed directed within the nose. This is beneficial because the medication is placed directly where it is needed without having to circulate throughout the entire body. As such, much lower doses are needed. Unlike most typical antihistamine medications, those that are available in spray form (Azelastine and Olapatadine) tend to have additional anti-inflammatory effects that make them somewhat more effective than most antihistamine medications. These medications exhibit some ability to stabilize allergy cells to keep them from releasing histamine and other inflammatory molecules. The combination of this double mechanism-of-action and availability in nasal spray form make this small group of medications very useful.

The nasal antihistamine sprays (Azelastine [Astelin, Astepro] and Olapatadine [Patanase]) are now available in generic form, but are still prescription-only medications. Like any nasal spray, they can lead to some dryness and irritation within the nose and even bloody nose, but overall, these medications tend to be well-tolerated. Even though Azelastine is potentially sedating because the administered dose is very low, the likelihood of sedation is low and can be easily tolerated. These medications are also available in eye drop form for people with eye allergy symptoms.

For most people, the nasal antihistamine sprays are not as effective as regular use of nasal steroid sprays. They do offer the advantage of rapid onset of action unlike the steroid nasal sprays, which require regular use for maximal benefit. The antihistamine nasal sprays are more effective when used either consistently or intermittently. These medications can often be used in people that do not tolerate steroid nasal sprays well. They can also be used in combination with the steroid nasal sprays, which can be helpful particularly in people with very severe allergy symptoms.

Decongestant Medications:
Decongestant medications are available in pill-form or as a variety of nasal sprays. They work by constricting the muscles that surround blood vessels in the nose, resulting in less vascular congestion and hence less stuffy nose. Decongestant medications taken in pill form (Pseudoephedrine (Sudafed) or Phenylephrine (Sudafed PE)) are not limited in there effect to blood vessels in the nose, but rather can have effect on the whole body. This limits the use of decongestants in people with certain health conditions, such as high blood pressure. The decongestant nasal sprays, such as Oxymetazoline (Afrin, etc.) offer the advantage of placing the spray directly within the nasal passages; this allows more immediate onset of action, lower dose, with less impact on the rest of the body. Unfortunately, the decongestant nasal sprays can lead to very rapid development of tolerance leading to a need for increasing doses. For this reason, the decongestant nasal sprays are often described as being “addicting.” Use for more than even a few days can lead to tolerance.