The War on (Allergy) Drugs

By Dr. Paul Ehrlich
I recently realized that I had reached a milestone in my 30 years plus of practice. I went more than a month without prescribing an oral antihistamine. This has implications for the way health care is bought and paid for in the United States.

Let’s review for a moment the old way of doing things. The first antihistamines, including diphenhydramine (Benadryl) and chlorpheniramine (Chlor-Trimeton) started out as prescription drugs. They had a side effect: they made you sleepy, so you couldn’t drive or operate heavy machinery after using them, as the labels still warn.

Drug companies had a medical incentive as well as a financial one to develop the next generation of antihistamines, which didn’t knock you out. And so we got the wave of drugs that included loratadine (Claritin) and cetirizine (Zyrtec), which stopped the sneezing and itching without making you long for the couch. As they approached the end of their patent protection, the drug companies that made them started to add a few bells and whistles at the molecular level so they could get premium prices again.

But things have changed. Insurance companies don’t want to pay for new drugs that don’t make a big difference from the old ones and have stopped paying for them. The OTC drugs cost about the same at retail as a standard co-payment. In the meantime, members’ health dollars go for urgent things, including asthma treatment, or cost-efficient measures like immunotherapy and asthma control medications, or so we hope. Regardless, those with chronic allergies should use the OTC drugs as part of a medication strategy, not as a substitute for monitoring and treatment. It’s not that I won’t prescribe the newer medications at all, but I will do so when indicated.

I must also point out that the OTC, self-medicating approach doesn’t work for every allergy or allergy-related condition. For example, as Dr. Chiaramonte describes so movingly in his postscript to our book, many inner-city kids rely dangerously on Primatene, the OTC inhaler, to keep their asthma in check. It gives them a dangerous jolt that’s even worse than the one they would get from prescription albuterol. Both are worse for them in the long run than inhaled therapies like Advair, which with regular conscientious use keeps them from having attacks, arrests inflammation, and halts the dangerous process of airway remodeling.

Those who rely on OTC Neo-Synephrine to keep their sinuses clear would be better off with the prescription drugs like Nasonex or Omnaris (both of which I prescribe regularly) if they have allergic rhinitis. Regular use of Neo-Synephrine can make the sinuses look like hamburger. But they would also be better off with a high-concentration 2-3% saline solution sinus rinse, such as those marketed as SaltAire and Ocean, which come in convenient plastic squeeze bottles. The bargain-minded parent can make this at home: 2 or 3 heaping teaspoons of Kosher or sea salt (no additives) and one level tablespoon of baking soda, mixed in a quart of tap water. You can buy a plastic squeeze bottle or a 30-cc bulb syringe for easy administration.

In the end, the answer to your allergic symptoms will probably lie in a combination of judicious use of drugs, both high-tech and low-tech, changing your behavior, keeping an eye on the weather, perhaps watching what you eat, and generally living right. The most important body part an allergist treats is the brain.

(To read about The Hows and Whys of Allergy Medication, turn to chapter 8, Asthma Allergies Children: a parent’s guide.)

(Note: Dr. Ehrlich has worked for the Claritin Council, sponsored by Claritin. His participation is for information purposes only and he does not, nor does this website, endorse one OTC drug over another. All have characteristics that make them more or less useful than others for certain individuals at different times.)

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