Allergy Update
ALLERGY UPDATE
The latest news on identifying, treating and understanding this common condition.

About 40 million Americans suffer from allergies, according to the American Optometric Association. Probably many of these people show up in your office at one time or another.

Here, we'll offer you updated information on managing complex allergy cases, treating athletes with allergies, and more.

Moving Toward OTC Drugs and Managing Complex Allergy Cases
BY TERRI B. GOSHKO, Senior Associate Editor

As you may know, there's a movement afoot to change the rules and make prescription oral anti-allergy medications available over the counter (OTC). We asked a panel of experts for their reactions to this issue, and also for their advice on how to treat complex allergy patients. Our panel includes the optometrists pictured below.

	J. James Thimons, O.D., F.A.A.O., is from Ophthalmic Consultants, a multi-specialty surgical practice, and TLC Laser Center in Fairfield, Conn. He's also Optometric Management's clinical director.
	Chris Quinn, O.D., F.A.A.O., of Iselin, N.J., is center director of Omni Eye Services of New Jersey, a multi-specialty ophthalmology/optometry referral-based practice.
	Jimmy D. Bartlett, O.D., F.A.A.O., is interim chair at the University of Alabama at Birmingham (UAB) Department of Optometry. He's also a professor of optometry at UAB School of Optometry and is a professor of pharmacology at the UAB School of Medicine.
	Daryl Mann, O.D., is center director of SouthEast Eye Specialists in Chattanooga.
	Bobby Christensen, O.D., F.A.A.O., has a partnership practice in Midwest City, Okla. He's a diplomate in the Cornea and Contact Lens Section of the American Academy of Optometry. He's also a member of National Academies of Practice.

QUESTION: How do you feel about the move to deregulate prescription oral anti-allergy agents and make them available OTC?

Dr. Thimons: A change would would be both a blessing and a curse. Typically, allergy drugs we prescribe (for example, loratadine [Claritin], fexofenadine [Allegra] and cetirazine [Zyrtec]) are expensive and many patients fill their prescriptions because the drugs are covered by insurance plans. OTC medications, of course, wouldn't be covered. The patient would have to decide whether to spend the money. The self-managing patient is more challenging because of compliance. Also, a change in relationship with the patient is possible when the drugs are available OTC. On the good side, in states without oral prescribing privileges, O.D.s will have access to oral therapies that were previously unavailable for allergy patients.

Dr. Quinn: I think the change would be positive. OTC drugs would become more accessible and cheaper for patients. In fact, I don't think a change in the status of oral allergy medications will impact optometric care of allergy patients much because orals aren't often used for ocular allergies. I would, however, caution patients not to overuse oral OTC allergy drugs, which can dry the ocular surface and exacerbate symptoms.

Dr Mann: I endorse the change. These medications are safe and have fewer side effects than those currently available OTC. However, with the medications available today, I seldom find it necessary to use oral medications to treat ocular allergy.

Dr. Christensen: The newer prescription antihistamines are safer than many existing OTC antihistamine/decongestants. The most notable side effect of OTC allergy meds is drowsiness. For patients who need to drive, the risks of falling asleep at the wheel are considerably reduced with the prescription drugs.

If prescription medications go OTC, they'll cost substantially less. So patients will get the benefits of fewer side effects plus lower cost. I'd rather have these choices available to patients.

Dr. Bartlett: I think it's a good idea to make these drugs available OTC. Their safety has been demonstrated. Older, nonsedating drugs had safety issues, so they needed to stay prescription only. But new drugs such as loratadine, fexofenadine and cetirazine have no major drug interaction potential and good safety profiles. They're also non-sedating.

Furthermore, they have less of a drying effect on mucous membranes and cause fewer dry eye and contact lens wear problems. And as OTC agents, they'd be less expensive.

QUESTION: How do you manage the complex patient who's already taking a topical ocular anti-allergy drug but is still having problems?

Dr. Thimons: Patients who are taking ketotifen fumarate (Zaditor), olopatadine HCl (Patanol), ketorolac tromethamine (Acular), levocabastine HCl (Livostin) and using oral agents, but still have rhinitis or esophagitis, benefit if I co-manage with an allergist who can prescribe additional medications.

Some patients may be candidates for allergy shots that simulate their immune systems and limit their need for medication. Others are allergic to uncommon stimuli, and the allergist's tests can determine what those stimuli are and help the patient avoid or remove them from his environment. If I'm unsuccessful with topical and oral drugs, I refer my patients to an allergist group I work with for consultation.

Dr. Quinn: Most topical drugs work well, and there's a vast selection to choose from. No one drug works for all patients. So if one treatment isn't working, try something else. But I wouldn't add a second medication if the patient isn't responding at all to the first.

For example, adding a topical steroid to a regimen of olopatadine probably wouldn't help much but would introduce the potential for complications. I'd discontinue the first medication and substitute a second from a different class. For complicated patients at this point, it's best to refer to an allergist for sensitivity testing or desensitization therapy.

Dr. Mann: First, I review the clinical findings that led to my original diagnosis to make certain I didn't misdiagnose the problem. Try this whenever a condition doesn't respond to your initial therapy.

For allergic rhinitis that hasn't responded to drugs like ketotifen or olopatadine, I'd add a topical steroid, providing no contraindications to its use exist, to control the inflammatory response. Typically, a topical steroid is only necessary for a short time to treat ocular allergy now that we have effective nonsteroidal medications. I prefer loteprednol etabonate (Lotemax) because of its good safety profile.

I seldom find it necessary to involve an allergist. I'll recommend an allergist to patients who suffer from symptoms that go beyond eye problems, but often these patients have already been down that road.

While allergists can desensitize patients to particular allergens, treatment requires constant maintenance and many patients eventually become noncompliant. Most seasonal allergy sufferers survive their allergy seasons and aren't motivated to seek desensitizing therapy.

Dr. Christensen: The secondary treatment plan depends on the type of tissue reaction. Adding a steroid would be the most likely treatment for viral or allergic keratoconjunctivitis. Adding loratadine or fexofenadine might relieve chronic seasonal allergic conjunctivitis. If this combination therapy were unsuccessful, referral to an allergist for sensitivity testing would be in order.

Dr. Bartlett: For sporadic, mild symptoms of seasonal allergic conjunctivitis, I first use artificial tears to dilute the antigen, such as pollen, that's in the tear film. I've found that this treatment can be almost as successful as using a therapeutic agent. The benefits of artificial tears are that they have no side effects, they're readily available and they're inexpensive.

For constant or annoying signs or symptoms, I recommend an OTC topical such as naphazoline HCl and pheniramine maleate (Opcon-A). If that doesn't work, I try oral or topical prescription drugs. Chlorpheniramine maleate (Chlor-Trimeton) is a good OTC oral antihistamine for patients who have systemic problems. Chlorpheniramine is safe for pregnant patients as well.

I prescribe topicals such as olopatadine for moderate-to-severe ocular allergy symptoms. I start off with prescription medications immediately, not because they necessarily work best, but because patients have more faith in them. Olopatadine is my agent of choice for pediatric allergies.

If olopatadine doesn't work, I try another agent such as ketotifen or nedocromil sodium (Alocril), or even a topical steroid. I try each of the many topical anti-allergy drugs that are available until I find the right one for the patient.

I see no reason to send a patient with ocular allergies to an allergist unless the patient has significant systemic allergies, such as atopy. We can handle most ocular allergy problems ourselves.