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How to counsel patients on OTC allergy medications

Allergic rhinitis can bring on symptoms like sneezing, congestion, and itching. These treatments can help.
Patricia Weiser
By | Mar. 8, 2023

Sneezing. Itchy eyes and throat. Stuffy nose. The arrival of spring means the start of these annoying allergy symptoms for approximately 50 million Americans. Many allergy sufferers will turn to their pharmacists for advice and assistance in finding the right over-the-counter (OTC) remedies for relief. 

Over the past 10-15 years, almost all allergy medications have switched from Rx to OTC status. This ever-growing number of OTC treatment options for allergies can make product selection overwhelming, even for pharmacists. Today’s article will help refresh your knowledge in order to help your patients make informed decisions about OTC allergy medicine.

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Understanding allergic rhinitis

Allergic rhinitis (aka hay fever) is an inflammatory condition that results from exposure to one or more allergens. If people are constantly exposed to an allergen (such as pet hair within the home), they may experience chronic symptoms. However, if their exposure occurs intermittently (such as pollen exposure during the spring and summer), their symptoms will only happen seasonally.

Symptoms vary, but the most common symptoms of allergic rhinitis include itching, nasal congestion, sneezing, and runny nose. The challenge is that these symptoms are not exclusive to allergic rhinitis. So, before considering medication options for a patient, it is essential to rule out other possible medical conditions.

If a patient reports having or recently had any of the following conditions, referring them to a healthcare practitioner before recommending OTC allergy medicine is best.

  • Uncontrolled asthma
  • COPD
  • Bronchitis
  • Pneumonia
  • Ear or sinus infection

Next, you must consider the patient’s age, pregnancy or lactation status, other medications, and severity of allergic rhinitis symptoms to guide OTC product selection and/or healthcare practitioner referrals.

Treatment goals and trigger avoidance

There are several treatment options you can recommend for seasonal allergies. The goals of allergy treatment should be to relieve symptoms, prevent symptom recurrence, and reduce the risk of side effects. 

While recommending OTC allergy medications, pharmacists should counsel on allergen avoidance as a primary method for limiting exposure. While complete allergen avoidance may not be possible, people can take some steps to proactively reduce exposure, such as minimizing time outdoors on high-pollen days and using a filtered dehumidifier to reduce allergens within the home.

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Treatment options and counseling points

The following OTC medications are available for managing allergic rhinitis.

Antihistamines

Antihistamines are a first-line therapy option for allergic rhinitis in adults and children (ages vary with individual products, so be sure to check labels). They are effective for easing sneezing, itching, and runny nose. Second-generation antihistamines are preferred over first-generation agents due to less sedation and a reduced side effect profile. While oral antihistamines do not treat nasal congestion, combining them with nasal steroids or decongestants usually provides better congestion relief than either nasal option alone. 

Common OTC antihistamines include: 

Counseling notes: Antihistamines work best if taken before allergen exposures. For best results, counsel patients to begin taking antihistamines several hours or days before anticipated exposure and continue taking them daily throughout the allergy season. Side effects may include pharyngitis, dry mouth, and fatigue, but they aren’t common with second-generation agents. Avoid first-generation antihistamines in older adults due to the risk of sedation and falls. Drug interactions are generally not clinically significant with loratadine.

Nasal steroids

Nasal steroids are a first-line therapy option for adults and some children with allergic rhinitis symptoms, especially nasal congestion. (As with antihistamines, pediatric age ranges vary for nasal steroids; check individual product labels.) They can be recommended alone or in combination with antihistamines. 

Common OTC steroid nasal sprays include: 

Counseling notes: Advise patients that nasal steroids do not take effect immediately; it may take several days of daily use before they experience symptom relief. Side effects are not common when used properly but may include headache, pharyngitis, nausea, vomiting, epistaxis, cough, and increased infection risk. Go over proper head positioning to minimize the drug running down the back of the throat. Drug interactions may occur with strong CYP3A4 inhibitors, such as ritonavir or ketoconazole, causing elevated corticosteroid levels.

Nasal decongestants

Nasal decongestants are generally not recommended for allergic rhinitis due to their unfavorable side effect profile. However, combination oral antihistamine-decongestant products (such as Claritin-D or Zyrtec-D) can be recommended in adults and older children when other treatments haven’t helped enough. Nasal decongestant sprays are effective for rapidly relieving a stuffy nose, but they should not be used for more than three consecutive days due to the risk of rebound congestion.

Common OTC nasal decongestants include: 

Counseling notes: Avoid nasal decongestants in patients taking antihypertensives or MAOIs, as well as those with a history of glaucoma, stroke, heart disease, hyperthyroidism, or bladder obstruction. Common side effects include high blood pressure, increased heart rate, insomnia, and irritability.

Other options and considerations for specific populations

Sometimes, patients may feel that first-line treatment options aren’t helping enough. Other OTC options, although less commonly used, are available, such as Nasalcrom (cromolyn sodium). Nasal cromolyn spray is an option for allergic rhinitis that works in a unique way to prevent immune mediator release during allergen exposure. This medication is less effective than other options for allergic rhinitis. However, it is safe for pregnant or breastfeeding patients and is the first-line agent in these groups. Note that nasal cromolyn must be used three to four times a day and may take one to two weeks to reach its full benefit.

Additionally, saline nasal spray or irrigation kits may also be beneficial for relieving nasal congestion. Since they contain no active drug, they can be used as often as desired and have no contraindications or drug interactions. 

With allergy season approaching, pharmacists must be prepared to assist patients looking for OTC allergy remedies. By recommending the proper medications and counseling on how to use them properly, you can help your patients enjoy a healthier, happier allergy season.