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Often, a drug belongs to a class of drugs with similar characteristics. In these cases, we include information that pertains to all the drugs in a particular category. We may also include information about a particular disease or condition that is commonly treated with the drug you select. In the case of ADVAIR, we’ve included information about two sets of conditions frequently treated with this medication:


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If you suffer from an itchy and runny nose, watery eyes, sneezing, and a tickle in the back of your throat, then you probably have an allergy. An allergy means a hypersensitivity to a particular substance called an allergen. Hypersensitivity means that the body’s immune system, which defends against infection, disease, and foreign bodies, reacts inappropriately to the allergen. Examples of common allergens are pollen, mold, ragweed, dust, feathers, cat hair, makeup, walnuts, aspirin, shellfish, poison ivy, and chocolate.

There are four common types of allergic responses, although many substances can cause more than one type of response in a given person:

  • Itchy and runny nose, watery eyes, sneezing, and a tickle in the back of your throat. This type of allergy is sometimes called allergic rhinitis and is commonly caused by exposure to allergens in the air, such as pollen, dust, and animal feathers or hair. It is called hay fever when it occurs seasonally, in response to ragweed in the fall.
  • Hives or other skin reactions. These commonly result from something you eat or from skin exposure to an allergenic substance, such as poison ivy or chemicals. Allergic skin reactions may also follow insect bites or an emotional disturbance.
  • Asthma.
  • Sudden, generalized itching, rapidly followed by difficulty breathing, and possible shock (extremely low blood pressure) or death. This rare and serious allergic response, called anaphylaxis, usually occurs as a response to certain injections (including allergy shots), drugs (including antibiotics such as penicillin and many arthritis drugs such as celecoxib [CELEBREX]), and insect bites as from a bee or wasp. This reaction may become increasingly severe with repeated exposures. Anaphylaxis is a medical emergency requiring an immediate trip to an emergency room, clinic, or doctor’s office. If you are likely to have an anaphylactic response to an allergen, such as a bee sting, in a locale where medical attention may be out of reach, you should obtain a prescription from a doctor for an emergency kit containing injectable epinephrine to keep with you, and learn how to use it.

How to Treat Allergic Symptoms

The best way to treat an allergy is to discover its cause and, if possible, to avoid the substance. Sometimes this is easy, but in many cases it is not. If, for example, your eyes swell, your nose runs, and you break out in hives each time you are around cats, avoid cats and you have solved your problem.

If, however, you sneeze during one particular season (typically, late spring, summer, or fall) each year or all year round, there is not too much you can do to avoid the pollens, dust, or grass particles in the air. Some people find relief in an indoor retreat where it is cooler, closed, and less dusty, but this is not always possible.

If you can’t seem to figure out the cause of your allergy, have tried eliminating most of the common allergens from your environment, and are still suffering significant discomfort, you may have to see your doctor or another health professional. It is possible that you may be an appropriate candidate for skin testing and may be referred to a doctor specializing in allergies.

Beware of the allergist who sends you home with a long list of substances to avoid because they gave positive patch tests. Even if you avoid all of them, you may be left with your allergy if none of the substances on the list is the particular one responsible for your symptoms.

When identifying the cause of your allergy is not possible, you may choose to treat the symptoms. Allergy symptoms are caused primarily by the release of a chemical in your body called histamine, and a class of drugs known as the antihistamines is the most effective initial treatment available. We recommend that you use antihistamines in a single-ingredient preparation to treat your symptoms. Another choice are the steroid-containing nasal sprays.

Allergic rhinitis should not be treated with topical nasal decongestants (drops, sprays, and inhalers) that are recommended for treating the temporary stuffy nose of a cold. Allergies are long-term conditions, lasting for weeks, months, or years, and use of these topical decongestants for more than a few days can lead to rebound congestion (an increase in nasal stuffiness after the medication wears off) and sometimes permanent damage to the membranes lining the nose. If you think your congestion is caused by allergies, don’t use an OTC nasal spray, or you may eventually find that you cannot breathe through your nose without it.

Drugs for Allergy

Antihistamines: Of all the products sold for allergy, we recommend that you use a single-ingredient product containing only an antihistamine. Antihistamines are the most effective ingredients you can buy for treating an allergy, and you will minimize the adverse effects by buying the single-ingredient formulation.

A major adverse effect of antihistamines is drowsiness. If they make you drowsy, you should avoid driving a motor vehicle or operating heavy machinery while taking these drugs. Even if they don’t make you drowsy, they may still slow your reaction time. Additionally, keep in mind that drowsiness is increased dramatically by adding other sedatives, including alcoholic beverages.

The amount of drowsiness produced by an antihistamine differs depending on the person who takes it and the antihistamine that is used. Of antihistamines classified by the FDA as safe and effective for OTC use, those causing the least drowsiness are chlorpheniramine maleate, brompheniramine maleate, pheniramine maleate, and clemastine. For daytime use, we urge you to use one of these.

Other FDA-approved antihistamines causing a great deal of drowsiness include diphenhydramine hydrochloride and doxylamine succinate, which are the ingredients in some currently available OTC sleep aids.

The advent of the less sedating but dangerous prescription antihistamines, the first of which were astemizole and terfenadine, now banned, has lessened the tendency of physicians and patients to use the lowest possible dose of the older, less expensive, and safer antihistamines such as chlorpheniramine maleate, the active ingredient in Chlor-Trimeton and dozens of other prescription and over-the-counter allergy medicines. By trying a lower dose, you may find that you significantly reduce the sedating effects. There are now other, less dangerous nonsedating antihistamines on the market.

Another common adverse effect of antihistamines is dryness of the mouth, nose, and throat. Other less common adverse effects include blurred vision, dizziness, loss of appetite, nausea, upset stomach, low blood pressure, headache, and loss of coordination. Difficulty in urinating is often a problem in older men with enlarged prostate glands. Antihistamines occasionally cause nervousness, restlessness, or insomnia, especially in children.

For antihistamine treatment of allergies, your first choice should be a low dose of chlorpheniramine in an OTC single-ingredient product such as Chlor-Trimeton. Check the label and be sure that nothing else is in the product. Chlor-Trimeton Decongestant and Dimetapp both contain an additional ingredient that is not necessary for the treatment of allergy. Less expensive store brand or generic equivalents are often available and should be purchased if possible. If you can’t find them, ask the pharmacist.

You should not use antihistamines for self-medication if you have asthma, glaucoma, or difficulty urinating due to enlargement of the prostate gland.

Nasal decongestants: Many over-the-counter products sold for allergies contain amphetamine-like nasal decongestants, such as pseudoephedrine hydrochloride or ingredients found in many oral cold preparations (see earlier discussion on oral decongestants for colds). Some of these adverse effects and adverse reactions (such as jitteriness, sleeplessness, and potential heart problems) occur even more frequently when they are used to treat allergies, because allergy medication is usually taken for a longer period of time than a cold remedy is.

More to the point, nasal decongestants do not treat the symptoms most frequently experienced by allergy sufferers: the runny nose, itchy and watery eyes, sneezing, cough, and the tickle in the back of the throat. They treat only a stuffy nose, which is not the major problem for most allergy sufferers.

Examples of OTC nasal decongestants that are labeled to treat symptoms “without drowsiness” (since they do not contain antihistamines) include Afrinol and Sudafed. We do not recommend the use of these products for allergies.

Combination allergy products: As usual in the OTC market (particularly in the cold and allergy area), most products available are fixed-combination products using a “shotgun” approach to your ailment. The majority of allergy combination products contain antihistamines and nasal decongestants; some also contain pain relievers. We do not recommend any of these for self-treatment.

It is our opinion that nasal decongestants should not be used for allergy symptoms that are appropriate for self-treatment. The likelihood of adverse effects is increased by taking a combination product, and decongestants are seldom useful for allergy symptoms.

Examples of OTC combination drugs for allergy, which we cannot recommend, are Actifed Cold & Allergy Tablets, Chlor-Trimeton Allergy-D 12 Hour Tablets, and Drixoral Cold & Allergy Tablets. Many of the combination cold products that we urge you not to use are also marketed for allergic symptoms and hay fever. We do not recommend using any of these products for allergies either.

 

Asthma, Chronic Bronchitis and Emphysema

Asthma, chronic bronchitis, and emphysema all occur commonly, may occur together, and may have similar treatments.

Asthma is a disease in which the smaller air passages in the lungs are hyperirritable. Attacks, which may be initiated by various influences, lead to narrowing of the airways and difficulty breathing. Wheezing, chest tightness, and an unproductive cough usually accompany the sensation of shortness of breath. Most asthmatics have only occasional trouble breathing.

Asthma attacks are commonly caused by exposure to specific allergens, air pollutants, industrial chemicals, or infection. They can be caused by exercise (especially in cold air). Asthma can be worsened by emotional factors, and the disease often runs in families. Other ailments common to many asthma sufferers, or their family members, are hay fever and an allergic skin condition called eczema.

Chronic bronchitis is a disease in which the cells lining the lungs secrete excess mucus, leading to a chronic cough, usually accompanied by phlegm.

Emphysema is due to destruction of the walls of lung air sacs and is characterized by shortness of breath, with or without a cough. There is a fair degree of overlap between chronic bronchitis and emphysema, and the two are sometimes lumped together into “chronic obstructive pulmonary disease,” or COPD. Wheezing may occur with chronic bronchitis or emphysema.

Chronic bronchitis or emphysema is most commonly the end result of many years of cigarette smoking. Other causes include occupational or environmental air pollution, chronic lung infections, and hereditary factors.

Asthma, chronic bronchitis, and emphysema may be occupational illnesses (a problem related to the workplace). Asthma frequently occurs among meat wrappers, bakers, woodworkers, and farmers, and among workers exposed to specific chemicals. Chronic bronchitis frequently is the result of exposure to dusts and noxious gases.

Asthma, bronchitis, and emphysema may be mild. For some people, however, these diseases can become life-threatening or can cause restriction in lifestyle. For all people afflicted with these problems, the types of drugs prescribed to treat or prevent the attacks are quite strong. If used incorrectly, they may have an immediate and dangerous effect on the health of the user.

Do not try to diagnose or treat yourself. Asthma, chronic bronchitis, and emphysema must be diagnosed and treated by a doctor or other health professional. Two other common conditions that cause breathing difficulties, congestive heart failure and pneumonia, have similar symptoms, and many of the drugs used to treat asthma or COPD may worsen these conditions. Therefore, it is extremely important that you have your condition properly diagnosed before starting any medication.

Treatment

Like its diagnosis, the treatment of asthma or COPD should be determined by a doctor. Attacks of asthma can be very frightening, and sufferers often overtreat themselves, especially when the desired relief has not been provided by the recommended dosage. Do not use more or less than the prescribed dose of any asthma or bronchitis medication without first consulting your doctor.

All medications for the treatment of these disorders, including those available without a prescription, should be chosen by you and your doctor together. A doctor is likely to prescribe one or more prescription drugs for the asthmatic. The currently available nonprescription (over-the-counter) drugs should not be used even for the treatment of minor or infrequent asthmatic episodes. The drug of choice for treatment of occasional acute symptoms of asthma is an inhaled short-acting beta2-agonist, such as albuterol (PROVENTIL, VENTOLIN), or pirbuterol (MAXAIR).1 These drugs are also commonly used for chronic bronchitis or emphysema.

Corticosteroids such as oral prednisone (DELTASONE, METICORTEN), or inhaled beclomethasone (BECLOVENT, VANCERIL), flunisolide (AEROBID), and triamcinolone (AZMACORT) are commonly used when severe acute symptoms of asthma do not improve after treatment with inhaled albuterol.1 These are not used in COPD unless there is a component of asthma on top of the COPD.

Theophylline and aminophylline are commonly used for suppressing the symptoms of chronic asthma, bronchitis, or emphysema. Aminophylline is identical to theophylline except that aminophylline contains a salt called ethylenediamine, which has caused rashes and hives in some people. Oxtriphylline (CHOLEDYL) is not recommended because it is no more effective than theophylline and costs more. These drugs must be taken exactly as prescribed, and the level of drug in the bloodstream must be monitored by a doctor. These measures will prevent adverse effects and ensure the optimal dose.

Montelukast (SINGULAIR) and zafirlukast (ACCOLATE) are members of a family of asthma drugs called leukotriene antagonists. Both of these drugs are approved only to prevent asthma attacks in people with chronic asthma, not to treat acute attacks of asthma. Montelukast is also approved for seasonal allergy.2 Montelukast is associated with liver toxicity. Production of the third leukotriene antagonist zileutin (ZYFLOW) was halted in December 2003. The manufacturer cited poor sales as the reasons; however, zileutin was also associated with liver toxicity.

The National Institutes of Health’s 1997 Guidelines for the Diagnosis and Management of Asthma said of the leukotriene inhibitors that “further clinical experience and study are needed to establish their roles in therapy.” At this time, the role of the leukotriene inhibitors in the management of asthma is still far from established.3

The leukotriene inhibitors are promoted as useful in helping patients reduce their dosages of steroid drugs, for example triamcinolone (AZMACORT). The Cochrane Database of Systematic Reviews published in 2002 found, in comparing leukotriene inhibitors to placebo in people also using steroids, that the dosage of inhaled steroids can be safely reduced without requiring the use of leukotriene inhibitors. Furthermore, the dose of leukotriene inhibitors required to achieve a significant reduction in steroid dosage is several times the currently approved maximum dosage.

Proper Use of Inhalers

To receive the most benefit from your inhaler, follow the directions below,4 even though they may not agree with the directions on the drug manufacturer’s packaging. Always shake well before taking each dose. Remove the plastic cap that covers the mouthpiece. Hold the inhaler upright, approximately 1 to 11DA2 inches from your lips. Open your mouth widely. Breathe out as fully as you comfortably can. Breathe in deeply as you press down on the can with your index finger. When you have finished breathing in, hold your breath as long as you comfortably can (try to hold it for 10 seconds). This allows time for the medication to treat your lungs before you breathe it out. If you have difficulty with hand-breath coordination, as many people do, ask your doctor for an “add-on” device that attaches to your inhaler. It allows you to close your lips around the inhaler, yet still receive the full therapeutic benefit from that dose.

If your doctor has told you to take more than one puff at each treatment, wait one minute, shake the can again, and repeat. If you also take a bronchodilator in addition to the corticosteroids, you should inhale the bronchodilator first. Wait 15 minutes before inhaling the corticosteroids. This allows more corticosteroid to be absorbed into the lungs.

Your inhaler should be cleaned every day. To do this properly, remove the can from the plastic case. Rinse the plastic case and cap under warm running water. Dry thoroughly. Using a gentle, twisting motion, replace the metal can into the case. Put the cap on the mouthpiece.


1   Drugs for asthma. Medical Letter on Drugs and Therapeutics Jan 30, 1987; 29: 11 - 16.
2   Physicians' Desk Reference. 58th ed. Montvale, NJ: Thomson PDR, 2004: 2076 - 2081.
3   National Heart LaBI. National Asthma Education and Prevention Program Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma, Jul 1, 1997. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. Accessed 2004 Apr 27.
4   Newhouse MT, Dolovich MB. Control of asthma by aerosols. New England Journal of Medicine Oct 2, 1986; 315: 870 - 874.

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