Wednesday, April 30, 2008

Allergies: Yogurt or Singulair?

Given that it is the allergy season, two recent headlines suggested that I blog about allergies.
Allergies are nothing to sneeze at. Allergic Rhinitis (nasal allergies) affects about 40 million Americans, cause about 4 million missed days from work or school, and cost about 8 billion dollars a year.

The first headline was from ABC news, that discussed a Finnish study that gave probiotics (healthy bacteria that can be found in certain yogurts), to pregnant women who had allergies or whose husband had allergies, since their child would be genetically predisposed to developing allergies. The infants whose mothers got the priobiotics had 30% less chance of getting eczema, which is an allergic skin condition. The study is intriguing and goes along with they "hygiene hypothesis" which suggests that since we now live in a much cleaner environment, our immune system is not stimulated enough when we are infants and children, and this leads to allergies later in life. Probiotics are generally safe and have been found helpful in other conditions. Not sure I am ready to recommend this to all pregnant women with an allergy history.

A second story, that did not seem to get a lot of attention but to me was very interesting is the announcement that The Food and Drug Administration has turned down an application by Merck and Schering-Plough to combine the drugs they make, Singulair and Claritin respectively, into one pill. It is somewhat surprising to me that they would try this again since previous attempts to combine the pills have failed and since Claritin and Zyrtec are now over the counter (and Allegra is now generic), it would seem to me difficult for insurance companies to approve a combo pill, which would likely be expensive.

More on Allergic Rhinitis
There are several treatments for nasal allergies:
Non-sedating antihistamines: Claritin, Zyrtec, Allegra
Leukotriene modifiers: Singulair
Inhlaed nasal steroids: Flonase (fluticasone), Rhinocort, Nasacort, Veramyst
Inhaled nasal antihistamines: Asteline

There are muliple studies that show that fluticasone (Flonase) is better than Singulair, better than Claritin, and several studies that show that the combination of Singulair and Claritin is not better than either agent alone. However, in one study, though the combination of Singulair and Singulair was better than either agent alone, the individual agents were no better than placebo. In another study, Flonase was not only better than the combination of Singulair/Claritin or either alone, but for night time allergy symptoms both the combination Singulair/Claritin or Claritin alone was no better than placebo.

An excellent review by Dr. Robert Nathan showed that "leukotriene receptor antagonists (Singulair) are sometimes more effective than placebo, are no more effective than nonsedating antihistamines (Claritin) , and are less effective than intranasal corticosteroids in the treatment of allergic rhinitis." -my parenthesis and bolds

In other words, the non-sedating antihistamines do work some, Singulair is really no better than the non-sedating antihistamines , and the inhaled nasal steroids are clearly the best agents.

A recent guideline from World Health Organization suggests that for patients with mild, intermittent allergic rhinitis; treatment with non-sedating antihistamines and leukotriene modifiers were both acceptable forms of treatment, but patients with more chronic or bothersome symptoms, inhaled nasal steroids should be used.

Bottom Line: If you are an allergy sufferer, and you have symptoms that don't really bother you that much, and you don't get symptoms regularly, an as needed pill is a good option. Since prescription Singulair is really no better than over the counter Zyrtec or Claritin (and their generic equivalents), either of these non-sedating antihistamines should be fine. Patients with more chronic or bothersome symptoms should use an inhaled nasal steroid like fluticasone (generic for Flonase).

25 comments:

Freadom said...

I've fallen into the Clariton-Singulair crowd, and they seem to work pretty well for me. Except I still get itchy eyes and throat. What would you recommend for that?

You don't have to answer that, I was just curious.

Overall, though, even though this is a new regime, this sping has been much more enjoyable than the past few years, so it must be working. I never thought about trying the nasal steroids before, and my doctor never mentined it either. But usually the meds he prescribes are meds I ask for.

Great information. If you don't mind, I'm going to add you to my blogroll.

Dr. Matthew Mintz said...

For some people, Singulair and Claritin work great. The are just less likely to be effective than other products for the general public. So if it is working for you, you should stay on it.
For eye symptoms, Veramyst ( a new nasal steroid) has been approved to relieve ocular symptoms. If you try Veramyst (unless you are a Federal employee where it is the preferred drug), make sure you ask for a coupon to defer the cost of your co-pay, as it will likely be higher than generic fluticasone.

julesandcolinsmom said...

I would love your thoughts on treating seasonal hives(extreme)in a 3yr old boy w/FA's.(Tree Pollen) He is on daily Singulair-4mg. We are thinking Zyrtec, but he was cranky on it last year. Nothing helps, help! TIA-Monica

Dr. Matthew Mintz said...

julesandcolinsmom,
Hives respond best to antihistamines. If Zyrtec caused side effects, I would try another one:allegra, claritin, or even xyzal. For more detailed information please click on "Ask Dr. Mintz for Medical Advice."

jimholte@hotmail.com said...

i had been a seasonal allergy sufferer since one day in 1973 (age 10)when it hit me like a brick in idaho, took sleepy pills up until the non-sedating ones came out. (still suffering in AZ)zyrtec i believe made me homocidal. claritin pretty much "cured" me, taken daily. however i took it sporadically until my second surgury to clean up after sinus infections. i take it daily now and have not had a serious sinus issue in almost two years. even w/claritin sometimes i feel a little extra "stuffy" at times and have found that adding singulair to it for a week or so opens me up again. I am a true believer.

Dr. Matthew Mintz said...

It's not that Singulair doesn't work. It works quite well in a subset of patients. If non-sedating antihistamines or inhaled steroids are not working, then this is a good option to try. The problem is that there overall effect on the general population is limited and not as effective as other agents.

Anonymous said...

I love Singulair. I have gotten allergy injections since I was a kid, and have tried all of the nasal sprays and anti-histamines. The anti-H ALL make me sleepy--even the supposedly non-sleepy ones. And while they dry me up, I never had tons of mucus to begin with. What I did have was terrible, terrible swelling of the nasal and sinus passages leading to days and weeks of non-stop migraine-like pain. Nothing seemed to really help this except shots, but after a few years, they weren't as effective. Singulair went straight to this swelling and knocked it out, all without being sleepy. THANK GOD!!!

Anonymous said...

For chronic, 3 season allergic rhinitis. . .(severe mold allergy) Can you compare flonase to pulmicort added to a nasal saline rinse? Would you recommend one over the other, side effects, long term effects, effectiveness? Can singular be administered in a saline rinse? (local vs. systemic) Do you think using singulair in addition to corticosteroids would be useful?
thanks so much for your input

Dr. Matthew Mintz said...

pulmicort is for the lungs, not the nose. However, there doesn't seem to be much of a difference in terms of efficacy for allergic rhinitis with any of the newer inhaled corticosteroids (fluticasone=flonase, mometasone=nasonex, budesonide=rhinocort, ciclesonide=omnaris); however, there are few if any head to head comparisons. One thing to consider is the delivery system. Since Veramyst (fluticasone fumarate) is a mist as opposed to a spray, its delivery is slightly improved. Again, no head to head studies, but I have had some patient do better on Veramyst compared to the other nasal steroids.
Adding Singular to inhaled steroids may help, but there is no data to support this. Singular, to my knowledge, can not be applied topically.
An additional nasal spray you should consider in a nasal antihistamine such as azalastine (Astelin/Astepro). These work well in combination with an inhaled steroid (the company plans on coming out with a combo of astepro and flonase in one spray).
Nasal saline is also great. Do this before using the nose spray medications. You may also want to try a netti pot.

Lisa said...

i am getting sneezing continuously and wen i get affected by cold i get rashes around my nose and i have heard that getting rashes around nose is the Symptom of nasal allergy

Dr. Matthew Mintz said...

Lisa,
Ask your physician about nasal ipatropium (Atrovent nasal spray). Don't use a lot of this, but seems to work very well for vasomotor rhinitis.

Mark said...

Hi Dr. Mintz,

I've tried multiple times to use Flonase and this most recent attempt generic fluticasone, but everytime I use them I develop nose bleeds about a week or two into treatment. I tried stopping for a while, then returning, and the bleeds always go away, but nowadays I'll get bleeds as quickly as two days into use. It's basically made me discontinue them entirely, which is a shame because they really do help with the chronic allergic rhinitis (I'm also doing the twice weekly injections for my most severe allergens -- one year into treatment and very little change as far as I can tell). Is there any data to show that nose bleeds are a common side effect? Are there any nasal sprays that minimize this side effect? It's embarrassing enough that I'd rather suffer the chronic allergic rhinitis than be in a work meeting with a bloody nose.

Dr. Matthew Mintz said...

@Mark
Nose bleeds are a side effect of all nasal steroids. It is not that common and usually occurs with prolonged use, but certainly can happen. There are a few options to consider that I would discuss with your allergist or primary care physician.
1. Try nasal saline before each use. One of the reasons for nose bleeds is the drying of the nasal membranes. Nasal saline use before using the Flonase may help this.
2. Try a different formulation. Veramyst is fluticasone furoate, which is a similar inhaled steroid, but comes as a mist instead of a spray. It is possible that this may decrease the nose bleeds.
3. Try a puffer. Again, unclear the puffer would be any better, but you may be less sensistive to this. The one I am aware of that is currently available is called Qnasal, though others are or will soon be available.

Joshua R. Miller said...

Dr. Mintz:

Greetings! It is refreshing to read your blog content. Last week I went to my local urgent care for what was thought to be either strep throat or sinusitis, had a negative strep test. However, I do suffer from chronic sinusitis, allergies and hives. I was prescribed a Z-Pak…Who knows if it worked or not. I have not been taking any antihistamines for a while, because I have so many adverse reactions to the drugs. Benadryl works the BEST; however, it makes me sleep. Claritin stopped working. Zyrtec makes me CRAZY (anxiety etc.) and Allegra causes me to become depressed over using the drug for a prolonged period of time. Moreover, I was told by the doctor that I needed to try Singulair because I would not have these reactions. So the doctor placed me on Singulair and Flonase. It is too soon to tell if the combination is working. I almost want to try just the Singulair for a month, and then switch to just the Flonase, so I will have some kind of control. I am feeling better now. Do you have any recommendations for me in regarding my situation? Also, I had a doctor place me on Omnaris one time and it helped a great deal; however, the doctor told me she has never heard of the drug. Do you have any experience with Omnaris? And what are the long term effects of using these types of nasal sprays? Oh, and on a side note do you think that pharmaceutical companies should be able to advertise drugs that require a prescription to the general public?


Thanks!

Dr. Matthew Mintz said...

Josh,
Thanks for the comments.
Omnaris is one of the newer nasal steroids. No study shows that one is better than another. If you have chronic sinusitis than you should definitely be on an inhaled nasal steroid. There are many to choose from and no one is particularly better than the next. Main difference is preference (generic fluticasone has a smell that many don't like, some newer meds have come out as a puff instead of a spray). Not clear is singulair would add benefit to inhaled nasal steroid. Of the few studies I am aware of where this was tried, little benefit was seen.
Direct to Consumer (DTC) drug ads are a whole entire post. Part of the problem is that the current regulations make most of these ads useless. By the time you are done hearing about all the horrible things the medication can do, you probably won't want to take it.
I am not opposed in theory to DTC ads, but think they should be done in a different way so that they really inform patients about new treatments.

AwwRITE said...

What would you suggest for non-allergic rhinitis? I have been through 2 allergy tests and neither one showed that I had seasonal allergies but that doesn't stop my body from reacting as if I did! I get sinus issues (stuffy or runny nose), eye issues (they water or get itchy and dry), and it all makes my asthma worse.

Dr. Matthew Mintz said...

@AwwRITE
Not sure what kind of allergy testing you had, but the gold standard is skin testing done by an allergist.
If you had this, and it was negative, you could have non-allergic rhinits, which means you don't tecnhically have an allergy, but respond to other environmental factors. Best treatment for non-allergic rhinitis is inhaled nasal steroids.
If you have not seen an allergist, I would strongly suggest this.

Anonymous said...

Hi Doc, I have allergies with constant wet ear wax and itching.
ent wants me to try nasal steroids.
my problem is I had a steroid shot some years ago for pain relief after a hernia operation and had a bad allergic reaction. with my mental health condition I have an irrational fear of any steroid use.
any words of wisdom?
thanks

Dr. Matthew Mintz said...

I can not give specific medical advice over a blog, especially not knowing your history or specific conditions. However, if you do have nasal allergies, nasal steroids are a very good treatment. While you may have had a bad reaction to the shot, it is unlikely you would have a bad reaction to the nasal steroids. These are generally considered topical medications. In other words they go in your nose and stay there. Very little gets into your blood stream. Though some can get into the stomach, it is usually digested/inactivated so it really has no affect.

Anonymous said...

Is it ok to take singulair, zyrtec and flonase together? That is what the doctor prescribed for my son.
Thank you,
W.saito

Dr. Matthew Mintz said...

There is no contraindications to taking zyrtec, singulair and Flonase together.
Merk tried to come up out a combination singulair/Claritin pill, but that was not successful. However, no harm in combining these pills and/or taking them with Floanse.

Gavin said...

Hi Dr. Mintz,

I have had nasal polyps for the last 2 years, which only went away pretty consistently when I started a full no salicylate diet.

I'm trying to find other alternatives to a full non salicylate diet, as it is quite disruptive to my life.

Auto immune conditions (Crohns, asthma, IBS, etc.) run in the family and I've had allergies since I was a kid (dust, mold, trees, grass, hayfever).

I've been on Flonase which helps. The only other medicine which helps is Montelukast (singulair) which completely takes away the polyps and allows me to introduce some additional foods, but which gives me a chronic chesty cough.

Is there anything I can substitute the Singulair for, as an anti leukotrine treatment which seems to help the polyps, or is there anything I can take with the Singulair in order to control the cough? Finding the right balance could give me a big improvement in my lifestyle, which has been impacted by the polyps (when I have them) and the diet (when the polyps are not as disruptive).

Many Thanks
Gavin

Dr. Matthew Mintz said...

Gavin,
I can't give you specific medical advice over a blog, but can tell you a few general things.
1. Singulair/montelukast is the most popular of the anti-leukotriene medications because it is once a day and it has the fewest side effect. Zafirlukast is a receptor antagonist like montelukast. Zileuton works on the same pathway but is an enzyme inhibitor.
2. Monteukast does work well on nasal polyps, and usually doesn't cause a cough. For complex situations like the one you are having, I usually recommend (in case you are not doing this already)seeing a specialist. In this case it would be an allergist or ENT, preferably at an academic institution near you.

AATFRI said...

Hello Doctor Mintz,
I have been diagnosed with AR (seasonal as well as perennial due to working in a moldy old building (school). MY ENT prescribed Singulair and the continuing use of OTC Allegra. Since taking Singulair for a week now, I have has the following side effects: fatigue, sleepiness, and anxiety. Is this normal and will it lessen after continued use. Would you recommend that I alert my ENT.
Thank you for your advise.

Michael

Dr. Matthew Mintz said...

@AATFRI,
Singulair shouldn't cause those side effect, but any medication can cause any side effect in any given patient. Though I can't give specific medical advice over a blog, one approach to consider (I would recommend consulting with a physician that is taking care of you) would be to stop the Singulair temporarily. If your symptoms resolve, then it MIGHT be due to the Singulair. If you restart the Singulair, and the symptoms come back, then it is more likely than not related to Singulair, even though I wouldn't expect Singulair to cause those side effects.