How to Pick an OTC Medication for Allergic Rhinitis

Allergic rhinitis, also known as hay fever, is a type of inflammation in the nose which occurs when the immune system overreacts to allergens in the air. Symptoms include sneezing, itchy nose, eyes or throat, watery eyes, rhinorrhea (runny nose), nasal congestion, and postnasal drip. Allergic rhinitis symptoms are similar to cold symptoms, however, the common cold is caused by a virus, and allergic rhinitis is caused by allergens. Keep reading to learn how to pick an OTC medication, supplement or nutraceutical, and non-drug treatments for allergic rhinitis.

Oral antihistamines

Antihistamines work by blocking histamine at the histamine-1 (H1) receptor site. They are effective in reducing symptoms of itching, sneezing, and runny nose, but have little effect on nasal congestion.


Oral antihistamines are separated into three generations. First generation antihistamines are very effective at reducing symptoms, however, they are known to cause many side effects. The most common side effect is sedation, but you may also experience dizziness, tinnitus, blurred vision, anxiety, nausea, vomiting, and dry mouth. Examples of first generation antihistamines include diphenhydramine (Benadryl) and chlorpheniramine (Chlor-Trimeton). First generation antihistamines are not recommended for older adults who are a fall risk.

Second generation antihistamines are much more selective for peripheral H1 receptors. They do not cross the blood brain barrier like the first generation agents, which means less sedation and cognitive impairment. Examples of second generation antihistamines include cetirizine (Zyrtec) and loratadine (Claritin). Cetirizine (Zyrtec) is considered the most potent of all the second generation antihistamines.

Third generation antihistamines are derivatives of second generation agents and are intended to have increased efficacy with fewer adverse drug reactions. Examples of third generation antihistamines include levocetirizine (Xyzal) and fexofenadine (Allegra). The second and third generation agents are generally preferred since they cause less side effects than first generation antihistamines.


Decongestants

Decongestants are alpha-adrenergic agonists that work by causing vasoconstriction. To put this in simpler terms, decongestants shrink swollen nasal mucous membranes, which helps to reduce sinus and nasal congestion. Phenylephrine and pseudoephedrine are two examples of common decongestants.


Side effects of decongestants include cardiovascular stimulation (increased heart rate, palpitations, and increased blood pressure), CNS stimulation (anxiety, tremors, insomnia, restlessness), dizziness, and headache. Due to the risk of cardiovascular stimulation, you should avoid decongestants if you have high blood pressure or other heart conditions.  You should also avoid decongestants if you have an enlarged prostate, thyroid disease, or anxiety.

While phenylephrine is available in products on a drug store’s shelf, pseudoephedrine products are kept behind the pharmacy counter. This regulation was put into place in 2005 as part of the Combat Methamphetamine Epidemic Act (CMEA), under the Patriot Act. The act applies to pseudoephedrine, phenylpropanolamine, and ephedrine, all of which can be easily converted into methamphetamine. Methamphetamine, commonly called crystal meth, is a potent CNS stimulant that is highly addictive. In order to sell products with these decongestants, pharmacies must keep a logbook of sales and the customer must show photo ID. The pharmacy staff must record what the person received, and the customer must sign the logbook. The maximum that can be sold is 3.6 grams per calendar day or 9 grams in a thirty day period.



Intranasal corticosteroids

Intranasal corticosteroids are sprayed into the nostrils and work by decreasing inflammation. Examples of common OTC intranasal corticosteroids include fluticasone (Flonase), mometasone (Nasonex), triamcinolone (Nasacort), and budesonide (Rhinocort). Adverse effects that may occur with intranasal corticosteroids include nasal dryness, burning, stinging, sneezing, and headache.


Fluticasone is available in two OTC formulations: fluticasone propionate (Flonase) and fluticasone furoate (Flonase Sensimist). While the active ingredient (fluticasone) is the same, the salt form used in each formulation is different. Studies conducted among patients have demonstrated advantages of intranasal fluticasone furoate (Flonase Sensimist) in those who find the taste and smell of fluticasone propionate formulations bothersome and in those who complain that the product drips into their throat or runs out of their nose. Steroids can increase blood sugar levels and may not be the best option for diabetics.

Intranasal antihistamines

Intranasal antihistamines are sprayed into the nostrils and work by blocking histamine release. They relieve congestion, itchy and runny nose, and sneezing. The only intranasal antihistamine that is available OTC is cromolyn sodium (NasalCrom). This drug prevents the release of histamine from mast cells (a type of immune system cell). The other intranasal antihistamines are available by prescription only and include azelastine (Astelin, Astepro) and olopatadine (Patanase). Intranasal antihistamines usually cause less drowsiness than oral antihistamines, but they still may make some people sleepy.  This may not be the best option for older adults who are at risk of falling.

Intranasal decongestants

Intranasal decongestants are sprayed into the nostrils and work by stimulating the alpha-adrenergic receptors to constrict dilated arteries within the nasal mucosa. This alleviates sinus and nasal congestion. Common examples of OTC intranasal decongestants include oxymetazoline (Afrin), levmetamfetamine (Vicks Vapo Inhaler), naphazoline (Privine), phenylephrine (Neo-Synephrine), propylhexedrine (Benzedrex Inhaler), and xylometazoline (Triaminic).


Intranasal decongestants are supposed to be used for a maximum of three days. If you use them longer than that, they can cause rebound congestion. You can also develop a tolerance to intranasal decongestants, which means you will need to take increasingly larger amounts to achieve the desired effect. In order to avoid this, it is recommended to stop using the intranasal decongestant after three days and switch to an intranasal corticosteroid if you still have symptoms.

You should not use an intranasal decongestant if you have high blood pressure that is not under control. Even though intranasal decongestants are applied to the nose, they can still have systemic effects, including potential elevation of blood pressure. Other conditions that warrant special consideration for intranasal decongestant use include benign prostate hyperplasia (BPH), diabetes, narrow-angle glaucoma, and pregnancy.



Supplements and Nutraceuticals

If you suffer from chronic allergic rhinitis, taking a daily supplement is an option to help prevent your symptoms. Below are a few examples of supplements and nutraceuticals that have been studied for prevention and treatment of allergic rhinitis.

  • Butterbur: Butterbur contains the active ingredient petasin, which exhibits antileukotriene and antihistamine activity. By inhibiting these inflammatory mediators, butterbur may improve the symptoms of allergic rhinitis. Only purchase the product if it is labeled hepatotoxic PA-free.  

  • Beta-glucans: Beta-glucans are soluble fibers derived from the cell wall of bacteria, yeast, algae, and fungi and found in plants such as oat and barley.  Clinical research shows that patients allergic to ragweed experienced 28% less allergic symptoms, and 52% reported that their symptoms were not as severe when compared to placebo.  The patients in the study used a beta-glucan derived from yeast Wellmune WGP.

  • Turmeric: Studies have shown that using a type of curcumin turmeric by Organika Health for two months significantly reduces nasal symptoms including sneezing, itching, runny nose, and congestion compared with placebo.

  • Vitamin C with bioflavonoids: Vitamin C is thought to help reduce symptoms of allergic rhinitis by preventing the formation of histamine. To maximize effectiveness, vitamin C is best taken with bioflavonoids. Bioflavonoids also help to stabilize mast cells, which are the cells that secrete histamine.

  • EPA/DHA: Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are omega-3 fatty acids that are essential to our health, particularly brain, eye, and heart health. Both EPA and DHA must be obtained either through our diet (i.e. fatty fish) or supplementation. Numerous studies investigating the effect of fish intake or omega-3 fatty acid supplementation during pregnancy, lactation, infancy, childhood, and adulthood on asthmatic and allergic outcomes have been conducted. These studies indicate protective effects and suggest a causal relationship between decreased intake of fish oil in modernized diets and an increasing number of individuals with asthma or other allergic diseases. Thus, it is theorized that supplementing with EPA and DHA may reduce the risk of developing allergic rhinitis.

  • Quercetin: Quercetin is a flavonoid found in many types of plants and foods, such as onions, green tea, apples, berries, and red wine. Supplementing with quercetin can be helpful for those with allergic rhinitis because it is known to inhibit histamine release and decrease proinflammatory cytokines.




Non-Drug Treatments

In addition to using an OTC medication, supplement, or nutraceutical for allergic rhinitis, you can also treat your symptoms with non-pharmacologic measures. Examples include saline nasal sprays, nasal strips, the neti pot, steam vaporizer, and ClearUP™.

Saline nasal sprays help to flush out irritating substances that may have entered the nose and can also flush out excess mucus. Additionally, if your nose is irritated by dry winter air, saline sprays can add healing moisture.

Nasal strips are another non-pharmacologic option for allergic rhinitis, especially when the primary symptom is congestion. Nasal strips physically open the nostrils and allow you the breathe more easily and quietly.


Another popular treatment option is the neti pot. A neti pot is a small vessel with a spout that you fill it with a mixture of warm water and salt. The salt solution flows into one nostril, through the nasal passages, and out the other nostril, which loosens mucus to relieve congestion and clear out allergens.


A steam vaporizer can be used to alleviate the effects of dry air on the sinuses. Vaporizers convert water into a warm mist that you can inhale deeply, which helps to moisturize and clear the airway. However, there is a danger of over-humidifying with steam vaporizers that can actually increase mold, bacteria, and other harmful allergens. Therefore, it is recommended to keep the humidity level between 45% to 55%.


A new non-drug treatment option to relieve sinus pressure and pain is a device by Tivic Health called ClearUP™. You glide the device along the cheek, nose, and brow bone in order for it to locate treatment points. At these treatment points, the device emits low-current electrical stimulation, called Microcurrent, to stimulate underlying nerve fibers. According to Tivic Health, electrical stimulation of nerves helps reduce the sensory perception of pain. Research has also shown that electrical stimulation can activate sympathetic nerve fibers and promote constriction of blood vessels, which shrinks swollen tissue. This device is an excellent option if you do not want to use decongestants due to high blood pressure or if you get palpitations from using decongestants.



What is the best OTC medication for allergic rhinitis?

After discussing all of the options above, you may be wondering what is the best treatment for allergic rhinitis. As a pharmacist, I can say from experience that there’s no clear cut answer to this question. What works for one person may not work for another.

To help you with your selection, I am including the following product reviews by real customers from Drugs.com.

Zyrtec (cetirizine) reviews:

  • "Works alright on getting rid of allergies I guess but every time I’ve taken it it’s made my throat extremely sore and my voice hurts. It gets so bad it hurts to talk while taking it so I’m finding something else."

  • "After a week using it all symptoms were gone. If I miss it 3 to 5 days , symptoms returned. No drowsiness is the best part."


Flonase (fluticasone) reviews:

  • "I have severe chronic sinusitis and trust me at first this did not - work it took a couple days I had to remember to take it everyday and now I have zero breathing issues and can go to sleep amazing every night"

  • "Do NOT buy this!!!!! Like other nose sprays, this does NOTHING to help your allergies. Unlike pills that actually work and cure all your allergy symptoms. Flonase does NOTHING but burn your nose and leave you with a very harsh aftertaste. Their ads are very misleading, and Flonase needs to be taken off the market for good. "


NasalCrom (cromolyn sodium) review:

  • “It is my drug of choice by far over all others (even Nasacort). I still use a saline spray to clean out the nostrils when my allergies are acting up, and then use a Nasalcrom spray in each nostril. I believe it is so much healthier for my body than all that other stuff I have taken over the years. If it works for you at all - stay with it.”


Afrin (azelastine) reviews:

  • “I used this stuff for the first time last night and it is amazing! I could not breath AT ALL, and within a minute I could breathe clearly like nothing was wrong. It REALLY works! It’s a fantastic product and I regret not using it for past common cold congestion issues while trying to sleep.”

  • "NEVER NEVER TAKE THIS MEDICATION. I repeat NEVER. This medication put me in a worse position than I was before. I decided to take this because all of the pills weren’t working, but it does not help. Afrin says to put 2 squirts in each nostril every 10-12 hours. However, when doing that, it creates a horrible BURNING sensation in your nose and specifically your throat that lasts for hours. If you want to be congested and burning for hours, take this."


Sudafed (pseudoephedrine) reviews:

  • "One of the best and most effective decongestants around."

  • "I've had plugged ears from sinus congestion for two weeks. I took two doses every four hours of two tablets each and the congestion has finally cleared but I didn't realize that it would make for a sleepless jittery night and now a jittery morning with no appetite and mild nausea. Next time I would start with one tablet and see if that helps and make sure I had plenty of time before going to sleep."


To sum it up

As you can see, there are many different ways to treat  allergic rhinitis. In order to choose the best method of treatment for yourself, I would recommend taking into consideration your lifestyle factors. For instance, do you feel wary about using a nasal spray? If so, avoid the intranasal inhalers and try an oral antihistamine instead. Do you have anxiety, trouble sleeping at night, a heart condition, enlarged prostate, or thyroid disease? If so, it might be best to avoid oral decongestants.


If you have any further questions regarding anything that you have read here, or if you would like to share what has worked for you, please comment below.


References:

Wikipedia, “H1 Antagonist”

Healthline, “Can You Become Addicted to Nasal Spray?”

WebMD, “Nasal Sprays for Allergies”

Pharmacy Times, “Special Considerations for Nasal Decongestants in Certain Populations”

Ann Allergy Asthma Immunol. 2004 Jul;93(1):56-60

Chatelaine.com, “Six supplements to help you beat allergy season”, 2014

Allergology International, “Role of omega-3 fatty acids and their metabolites in asthma and allergic diseases” 2015 Jan;64(1):27-34

Molecules. 2016 May 12;21(5)

TivicHealth.com/research

Drugs.com, “User Reviews for Zyrtec”

Drugs.com, “User Reviews for Fluticasone nasal”

Drugs.com, “User Reviews for NasalCrom”

Drugs.com, “User Reviews for Afrin”

Drugs.com, “User Reviews for Sudafed Congestion”

Pharmacotherapy. 2002 Nov;22(11):1458-67.

Naturalmedicines.therapeuticresearch.com