Highlights from the Allergy Seminar at the Submarine Base, New London, CT

George A. Sprecace M.D., J.D., F.A.C.P. and Allergy Associates of New London, P.C.
www.asthma-drsprecace.com

PRESENTATION: U.S.NAVAL SUBMARINE BASE GROTON, 3/03

ALLERGIES AND ANTI-HISTAMINES

Allergic disorders have both immunologic and inflamatory pathophysiologies.
Histamine itself is a pro-inflamatory agent.
Anti-histamines (H1, particularly 2nd generation) are both anti-allergic and anti-inflamatory. Thus, they have a role beyond classical allergies.
1st generation anti-histamines are effective, but have two serious short-comings:

they are sedative - and reduce reflex activity even when sedation is not recognized; thus, “Caution - may cause drowsiness” warning indicated on Rx;
they have atropine-like inspissating qualities, generally not desirable.

2nd generation anti-histamines have neither of the above short-comings, with the exception of Zyrtec, which is sedating in a significant percentage of patients: 15% of adults and 5% of children. In children, there is a 10-15% incidence of headaches reported.
The prevalence of allergic diseases is high (20% world-wide, higher in developed countries) and is increasing.
The prevalence of bronchial asthma in the world is also increasing, as is an epidemic of deaths from acute asthma. At least 80% of children with bronchial asthma have it on the basis of respiratory allergies.
The majority of patients with allergic disorders continue to be treated by primary care physicians and pediatricians rather than by specialists - which is OK, if they would only follow available clinical treatment parameters - which they do not in the majority of cases!
Major treatment options for allergic diseases, including bronchial asthma, after a comprehensive diagnosis: cf handout on “Medications”.
The non-sedating 2nd generation anti-histamines have variable effectiveness, in different patients and in the same patient at different times. Of these, Allegra has, in my experience, proven more useful than Claritin, especially in the 180mg dose form. The jury is still out on Clarinex. I reserve Zyrtec for use in the treatment of skin disorders with itching; there is still nothing that beats Atarax and Zyrtec for itching. There the somnolence can be a benefit. And in those cases I use also H2 anti-histamines (eg. Zantac) for greater effectiveness.
Allegra has the added advantage of having no drug interactions. In fact, the only agent that interacts with Allegra (increasing its concentration) is grapefruit! Zyrtec use is associated with a large number of drug interactions, especially with sedating or psychotropic agents.
In children 2 to 6 years of age, Claritin liquid is useful. For children 6 and above, I use Allegra.
In pregnant women, both Claritin and Zyrtec are Category B, while Allegra is Category C.
In the initial (and often exclusive) treatment of upper respiratory infections, the most important medicine - besides adequate hydration - is topical decongestion in the form of Neosynephrin 1/4% nose spray (mild, children’s type, even for adults) or Mild Afrin; either should be used three times daily for three days. Then stop! Oral decongestants should generally be avoided, as should 1st generation anti-histamines, which are inspissating. Of course, nearly all the OTC “cold remedies” contain these agents. They should be avoided in favor of the above approach. A 2nd generation anti-histamine should also be part of this regimen for any allergic individual.
While antibiotics are most often not indicated for the general population with URI, the threshold should be much lower for allergic patients and for patients with underlying chronic upper and/or lower respiratory diseases, including recurrent serous and/or acute otitis media. By the way, Zithromax is useless for respiratory tract infections in the currently recommended dosage regimen.
In the comprehensive treatment of moderate to severe and/or year-round or prolonged seasonal upper respiratory allergies as well as bronchial asthma, allergy immunotherapy should be an integral part of the treatment program: it works clinically; it is the only treatment that produces true desensitization in well over 80% of cases; and it seems to be the only form of treatment that can avoid or interrupt the development and progression of airway remodeling in asthma - which often appears to continue despite the proper use of inhalational steroids and leukotriene receptor inhibitors.

Thank you. George Sprecace, M.D., J.D.

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