Consider this deck OTC treatments 101 for allergic conditions such as rhinitis, conjunctivitis and dermatitis.

1. Allergies
Rhinitis – Conjunctivitis – Dermatitis
Over-The-Counter Treatment Options,
Information & Counsel for the Consumer
John W. Probst, MPH
USC School of Pharmacy
Community Rotation
April 14, 2009

2. Overview of Presentation
Present scope, objectives and brief intro
Discuss topics including:
Allergic rhinitis
Allergic conjunctivitis
Allergic contact dermatitis
Key talking points include: 1) when to treat (i.e.
when to use OTC product vs. refer pt to see MD);
2) how to treat/tx options; and 3) duration of tx
Summary and Q & A

3. Topics Not Covered
This talk WILL NOT focus on mold, food, animal/insect
or chemical (e.g. latex) allergies, especially those causing
anaphylaxis, and their treatments. Commercially
available OTC products focus primarily on the three
conditions to be covered in this presentation.

4. Objectives
Outline criteria for self-treatment and
when it is advisable to refer a patient to a
physician for further care and treatment
Describe condition-centric OTC treatment
options/regimens for those suffering from
common seasonal or chronic allergies
Provide useful counseling points that aid
in the safe and effective use of the OTC
products that are available to treat allergies

5. Introduction
Up to 50 million
Americans suffer
from seasonal and
chronic allergies
Roughly $4 billion
in direct healthcare
costs annually due to
allergy related illness
OTC allergy drugs
account for 58% of
non-rx purchases

6. Allergic Rhinitis

7. Etiology & Symptoms
Outdoor aeroallergens: pollen, mold spores and
pollutants (e.g. ozone & exhaust particles)
Indoor aeroallergens: dust mites, cockroaches,
mold spores, cigarette smoke and pet dander
Primary symptoms: “more than a runny nose”
Watery eyes
Itchy eyes, nose and/or throat
Nasal congestion
Watery rhinorrhea
Red, irritated eyes w/ conjunctival injection

8. Self-Treatment or Refer?
Exclusions for self-treatment
Symptoms of sinusitis, otitis media (w/ effusion) and/or a
lower respiratory infection (e.g. pneumonia, bronchitis, etc)
Exacerbation or recent-onset of asthma
History of non-allergic rhinitis
Seasonal vs. Perennial – slightly different
algorithms, but same objective = ↑ QOL!
Seasonal – Six (6) different tx approaches based on s/sxs
Perennial – Three (3) different tx approaches based on s/sxs
FYI…algorithms are found on p. 218-220 of HNPD 15th Ed.

9. Treatment Options
Antihistamines (AH) Nonpharmacologic
Systemic Allergen avoidance
1st and 2nd generation HEPA filters
Decongestants (DC) Allergen-free products
Phenylephrine Nasal rinses (e.g. saline)
Pseudoephedrine
Alternative therapy
Nasal sprays/drops
Immunotherapy
Combo products
Herbal treatments
Cromolyn Sodium Ephedra & Feverfew

10. AH & Dosages

11. Systemic AH Products
Chlorpheniramine Cetirizine
1st generation 2nd generation
Clemastine Loratadine
1st generation 2nd generation
Diphenhydramine Loratadine ODT
1st generation 2nd generation

12. Nasal DC & Dosages

13. Nasal DC Products
Saline Nephazoline
Rx only
Ephedrine Xylometazoline
in the USA
Phenylephrine Oxymetazoline

14. Systemic DC & Dosages

15. Select OTC Products

16. Cromolyn Sodium
Unique MOA
Mast cell stabilizer
Ideal for prophylaxis
Strengths
Well tolerated
Low systemic absorption
Weaknesses
Approx. 3-7 days for results
2-4 weeks = max benefit
CI for kids ≤5 years old

17. Tx Approach - AH & DC
Decongestants
Antihistamines
2nd line after AH
1st line
Systemic preferred
2nd gen. preferred
Non-drowsy Nasal products
tend to be overused
Peripherally selective
No anticholinergic SE Combo products
are popular, but
No photosensitivity
avoid ones w/ pain
Well tolerated
relievers if possible

18. Duration of Treatment
Algorithms point to short-term
treatment intervals of 3-4 days per step
NMT 3 days if using long-acting non-saline nasal sprays
Max for DC use is 5 days (risk for rhinitis medicamentosa)
Assessment should occur after each 3-4 day period
Dependent upon severity of symptoms
and medication-related side effects
Other factors include exposure to
allergen, need for prophylaxis and QOL

19. Key Counseling Points
Encourage pt to assess allergen exposure and
remove if possible – best method for “cure”
Stress compliance and proper administration
strategies (i.e. prophylaxis & multiple meds)
Confirm that pt is able to take AH and/or DC
CI in newborns and premature infants
CI in pregnant and nursing ♀
CI in pts w/ HTN, DM, LRT disease, narrow angle glaucoma,
stenosing peptic ulcer, BPH, bladder-neck obstruction,
esophogeal narrowing, abnormal esophogeal peristalsis and
pylorduodenal
Ask pt about other meds – screen for DDI
EtOH, sedatives, MAOI and CNS depressants are CI

20. Allergic
Conjunctivitis

21. Etiology & Symptoms
Multiple allergens can cause conjunctivitis –
1o are pollen, animal dander and topical eye
products (i.e. makeup)
Very common comorbid condition
with seasonal allergic rhinitis
Primary symptoms: “I’m not crying…”
Itching and irritation
Excessive tearing (can cause blurring of vision)
Watery discharge from the eye

22. Self-Treatment or Refer?
Majority of cases seen in community
pharmacy are self-treatment
Commonly associated with allergic rhinitis
Serious eye conditions usually prompt MD visit
Pain is usually tolerable – pt seeks sx control
If pharmacist suspects damage to eye’s
surface refer to MD immediately!
When in doubt, and if sxs become worse
or don’t resolve…refer to MD

23. Treatment Options
Decongestants (DC) Nonpharmacologic
Nephazoline Allergen avoidance
Phenylephrine HEPA filters
Tetrahydrozoline Allergen-free products
Oxymetazoline
Eye lubricants/tears
Antihistamines (AH) Cold compress
Pheniramine maleate
Alternative therapy
Antazoline phosphate
Homeopathic product
Combo products Similasan Eye Drops #2

24. DC and AH + Dosages
1st line is artificial tears
HNPD 15th Ed. p. 580-81 Table 28.1
2nd line is DC/AH combo
3rd line is DC/AH + oral AH

25. Select DC
Products

26. Ocular Combo Products
Pheniramine 0.3% Naphazoline 0.012%
Naphazoline 0.025% Zinc Sulfate 0.25%
Pheniramine 0.3% Tetrahydrozoline 0.05%
Naphazoline 0.0267% Zinc Sulfate 0.25%
Antazoline 0.5% Phenylephrine 0.12%
Naphazoline 0.05% Zinc Sulfate 0.25%

27. Duration of Treatment
Decongestants (e.g. phenylephrine)
should be limited to NMT 3 days of use
Rebound conjunctival hyperemia, allergic
conjunctivitis and allergic blepharitis can result if
ocular decongestants are abused or used long-term
Antihistamines are shown to aid in
rapid relief of sxs DC+AH = shorter tx
Combo products should be limited to
NMT 3 days of regular use (1-2 gtts QID)

28. Key Counseling Points
Stress adherence to regimen and 72 hr
duration to avoid SEs and rebound problem
DC CI in pregnant ♀ and pts w/ angle-
closure glaucoma, HTN, arteriosclerosis,
CV disease and DM (CI ↑thyroid w/ CV dx)
Suggest pts try the DC naphazoline or
tetrahydrozoline less rebound congestion
Avoid if taking TCA, MAOI, & atropine
Store meds at proper temperatures (i.e.
avoid heat)

29. Allergic Contact
Dermatitis

30. Etiology & Symptoms
Hypersensitivity reaction type 4 (cell mediated
response – delayed = 24-72 hours for sxs)
Main causative agents
Chemical allergens: latex, neomycin, rubber, fragrances etc.
Environmental allergens: toxicodendron plants
Poison ivy – T. radicans and T. rydbergii
Poison sumac – T. vernix
Poison oak – West (T. diversilobum); East (T. toxicarium)
Easy Dx? – main s/sxs include red rash, blisters or
wheals, itching and/or burning skin

31. Self-Treatment or Refer?
Exclusions for self- Exclusions for self-
treatment treatment (cont’)
Swollen eyes/eyelids
<2 years old
Genitalia involvement
ACD > 2 weeks
Itching of mouth, eyes,
>25% of body surface
nose or anus
Presence of ↑ # of bullae
Low tolerance of pain
Extreme s/sxs and associated itching
Swelling of body/extrem Impairment of ADL

32. Treatment Options
Hydrocortisone (1%) Nonpharmacologic
1st line treatment
Cold showers
Anesthetics
Avoidance of further
Antihistamines
exposure
Diphenhydramine
Wash or dispose of
Benzocaine (20%)
contaminated clothing
Pramoxine (1%)
Alternative therapy
Antipruritics
Jewel weed
Phenol, camphor and
menthol

33. Hydrocortisone Options

34. Select OTC Products

35. Duration of Treatment
Resolution of symptoms is key driver for how
long tx should last – limited to 1 week w/ tx
Some treatments have NMT limits
Hydrocortisone, TID-QID/day, should not be used >7 days
or if symptoms clear then re-appear after a few days –
ointment is preferred formulation
Astringents, used for oozing and wet sores, can be used for 5
to 7 days – don’t used anything too harsh on skin
Anesthetics (CI if open sores) & antipruritics
should be limited to 3 to 4 applications/day

36. Key Counseling Points
Avoidance of allergens and locations that
harbor them is the BEST strategy
If contact is made, take cold shower but don’t
scrub too hard – avoid wounds
Self-limiting (NMT 21 days), but tx options
should be used to avoid infection and limit
duration of sxs to 7 days – discuss options
See MD if sxs become worse, last >2 wks,
involve genitalia, face, eyes, or cover large area

37. Summary

38. Treatment Toolbox
Drug categories covered
Antihistamines (systemic, topical, nasal & ocular)
Decongestants (systemic, topical, nasal & ocular)
Cromolyn sodium and saline (nasal)
Artificial tears, lubricants, and astringents (ocular)
Hydrocortisone (topical)
Antipruritics and anesthetics (topical)
Immunotherapy (systemic)
Alternative/Homeopathic and herbal

39. Take Home Points
#1 – Know your exclusion #3 – Discuss how to use
criteria & when to refer med and for how long
Should/can not treat all Frequency and duration
pts seeking care are important to state and
repeat – pt safety issue!!
Dictates whether or not a
non-rx suggestion is Acute vs. chronic use needs
appropriate and safe to be stressed due to
potential rebound issues
#2 – Know all your first-
#4 – If possible, follow-up
line non-rx tx options
and answer pt questions
Most pts want YOU to
make the choice for them PCP usually isn’t involved
Fast recall of BEST option Try to finish the treatment
adds to your credibility that you started for the pt

40. References
American Academy of Allergy Asthma and Immunology website
www.aaaai.org/patients/resources/medication_guide.asp
Epocrates Rx
Fiscella RG, Jensen MK. “Allergic Conjunctivitis” Handbook of
Nonprescription Drugs: An Interactive Approach to Self-Care,
15th ed. 2006:585-588.
Keefner KR. “Contact Dermatitis” Handbook of Nonprescription
Drugs: An Interactive Approach to Self-Care, 15th ed. 2006:746-
758.
Scolaro KL. “Allergic Rhinitis” Handbook of Nonprescription
Drugs: An Interactive Approach to Self-Care, 15th ed. 2006:213-
227.
Product photos – www.walgreens.com