What kind of allergy medicine is safe during pregnancy

What kind of allergy medicine is safe during pregnancy

This article is based on a personal collection of the relevant English language literature, dating from the s, and on publications traced through the PubMed database, searched using the term antiepileptic drug, in combination with, individually, the terms: epilepsy, foetus, malformation, neonate, neurodevelopment, pregnancy, seizure, and teratogenesis. Some material drawn from the Australian Register of Antiepileptic Drugs in Pregnancy is also included. Since this register includes pregnancies in women with epilepsy who did not take antiepileptic drugs in at least the earlier half of pregnancy, its data can be used to assist discriminate between the effects of antiepileptic drug exposure itself and the combined effects of the drugs plus having epilepsy.



As of [update] brands included: Actalor, Actidin, Aerotina, Alaspan, Alavert, Albatrina, Alerdina, Alerfast, Alergan, Alergiano, Alergiatadina, Alergin Ariston, Alergipan, Alergit, Alergitrat L, Aleric Lora, Alermuc, Alernitis, Alerpriv, Alertadin, Alertine, Aleze, Algac, Algecare, Algistop, Alledryl, Aller-Tab, Allerfre, Allerget, Allergex Non Drowsy, Allergyx, Allerhis, Allernon, Allerta, Allertyn, Allohex, Allor, Allorat, Alloris, Alor, Analor, Anhissen, Anti-Sneeze, Antial, Antil, Antimin, Ao Hui Feng, Ao Mi Xin, Ao Shu, Ardin, Atinac, Avotyne, Axcel Loratadine, Bai Wei Le, Bang Nuo, Bedix, Belodin, Benadryl, Besumin, Bi Sai Ning, Bi Yan Tong, Biliranin, Biloina, Biolorat, Bollinol, Boots Hayfever Relief, Boots Hooikoortstabletten, Boots Once-a-Day Allergy Relief, Carin, Carinose, Chang Ke, Civeran, Clara, Claratyne, Clarid, Clarihis, Clarihist, Clarilerg, Clarinese, Claritin, Claritine, Clarityne, Clarityne SP, Clarotadine, Clatatin, Clatine, Clear-Atadine, Clear-Atadine Children’s, Clistin, Contral, Cronitin, Da Sheng Rui Li, Dao Min Qi, Dayhist, Debimin, Desa, Devedryl, Dexitis, Dimegan, Dimens, Dimetapp Children’s ND Non-Drowsy Allergy, Doliallérgie Loratadine, Effectine, Eladin, Elo, Emilora, Encilor, Eradex, Erolin, Ezede, Fei Ge Man, Finska, Flonidan, Flonidan Control, Florgan, Folerin, Frenaler, Fristamin, Fu Lai Xi, Fucole Minlife, Genadine, Glodin, Gradine, Halodin, Helporigin, Hisplex, Histaclar, Histafax, Histalor, Horestyl, Hua Chang, Hysticlar, Igir, Immunix, Immunex, Inclarin, Inversyn, Jin Su Rui, Jing Wei, Ke Mi, Klarihist, Klinset, Klodin, Kui Yin, Lallergy, Larotin, Latoren, Laura, LD, Lei Ning, Lesidas, Liberec, Lisaler, Logadine, Logista, Lohist, Lolergi, Lolergy, Lomidine, Lomilan, Loptame, Lora, Lora-Lich, Lora-Mepha Allergie, Loracare, Loracil, Loraclear, Loradad, Loraderm, Loradin, Loradine, Lorado Pollen, Loradon, Lorafix, Lorahexal, Lorahist, Lorakids, Loralab-D, Loralerg, Loralivio, Loramax, Loramin, Loramine, Loran, Lorange, Loranil, Lorano, Loranox, Lorantis, LoraPaed, Lorastad, Lorastamin, Lorastine, Lorastyne, Lorat, Loratab, Loratadim, Loratadin, Loratadina, Loratadine, Loratadinum, Loratadyna, Loratan, Loratin, Loraton, Loratrim, Loratyne, Lorchimin, Lordamin, Lordinex, Loremex, Loremix, Lorfast, Lorid, Loridin, Lorihis, Lorimox, Lorin, Lorine, Loristal, Lorita, Loritex, Loritin, Lorly, Lormeg, Lorsedin, Lortadine, Losta, Lostop, Lotadin, Lotadine, Lotarin, Lotin, Megalorat, Mildin, Min Li Ke, Minlife, Mintapp, Mosedin, Mudantil L, Nasaler, Neoday, Niltro, Non-Drowsy Allergy Relief, Nosedin, Noseling, Novacloxab, NT-Alergi, Nufalora, Nularef, Numark Allergy, Omega, Oradin, Oradine, Oramine, Orin, Orinil, Pollentyme, Pressing, Pretin, Primorix, Profadine, Pulmosan Aller, Pylor, Rahistin, Ralinet, Ramitin, Refenax, Restamine, Rhinigine, Rihest, Rinalor, Rinconad, Rinityn, Rinolan, Riprazo, Rityne, Roletra, Rotadin, Rui Fu, Run Lai, Rupton, Sensibit, She Tai, Shi Nuo Min, Shi Tai Shu, Shu Rui, Shun Ta Xin, Silora, Sinaler, Sohotin, Soneryl, Sunadine, Symphoral, Tabcin, Tai Ming Ke, Ticevis, Tidilor, Tinnic, Tirlor, Toral, Triaminic, Tricel, Tuulix, Urtilar, Utel, Vagran, Winatin, Xanidine, Xepalodin, Xian Ning, Xin Da Yue, Xing Yuan Jia, XSM, Xue Fei, Yi Fei, Yi Shu Chang, Yibang, Zhengshu, Zhi Min, Zifar, Zoratadine, and Zylohist.[26]

As of [update], in a combination drug with pseudoephedrine, it was available under the brands: Airet, Alavert D, Aldisa SR, Alerfast D, Alergical LP, Alergin Plus Ariston, Alerpriv D, Alledryl-D, Allerpid, Aseptobron Descongestivo, Bai Wei Qing, Benadryl 24 D, Ciprocort D, Claridex, Claridon, Clarinase, Clarinase Repetab, Claritine Athletic, Claritin Allergy + Sinus, Clarityne, Clarityne D, Clarityne-D, Clear-Atadine, Coderin, Cronase, De-Cold, Decidex Plus, Decongess I, Defonase, Demazin NS, Dimegan-D, Effectine D, Ephedrol, Fedyclar, Finska-LP, Frenaler-D, Hui Fei Shun, Ke Shuai, Claritin-D, Larotin D, Lertamine, Lohist-Extra, Lora Plus, Loralerg D, Loranil-D, Loratin D, Loratin Plus, Lordinex D, Loremix D, Lorexin-D, Lorfast-D, Loridin-D, Lorinase, Minlife -P, Mosedin plus sr, Narine Repetabs, Nasaler Plus, Nularef-D, Oradin Plus, Pretin-D, Primorix-D, Rhinos SR, QiKe, Rinomex, Sinaler D, Sudamin, Sudolor, Tricel-D, Zhuang Qi, Zoman-D, and Zoratadine-P.[26]

As of [update], in a combination drug with paracetamol, it was available as Sensibit D and in combination with paracetamol and pseudoephedrine, it was available as: Atshi, Clariflu, and Trimed Flu.[26]

As of [update], in a combination drug with betamethasone, it was available as Celestamincort, Celestamine NF, Celestamine NS, Celestamine* L, Ciprocort L, Claricort, Clarityne cort, Corticas L, Cortistamin-L, Histafax Compuesto, Histamino Corteroid L, Labsalerg-B, Lisaler Beta, and Sinaler B, and in combination with betamethadol with available as Nularef Cort.[26]

As of [update], in a combination drug with ambroxol, it was available as Aliviatos, Ambroclar, Antitusivo L Labsa, Bronar, Broncovital, Broquixol, Clarixol, Ideobron, Lorabrox, Lorfast-AM, Sensibit XP, and Toraxan, and in a combination drug with ambroxol and salbutamol as Sibilex.[26]

As of [update], in a combination drug with phenylephrine, it was available as Bramin-Flu, Clarityne D, Clarityne Plus, Clarityne-D, Histafax D, Brafelix, Loramine R, Loraped, Maxiclear Freezing & Nasal, Maxiclear Hayfever & Sinus Relief, and Rinavent, and in combination with phenylephrine and paracetamol it was available as Sensibit D NF.[26]

As of [update], in a combination drug with dexamethasone it was available as Alerfast Forte and Frenaler Forte.[26]

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  • Asthma During Pregnancy

    Asthma is one of the most common medical problems that occurs during pregnancy.

    It can be potentially serious. Some studies own suggested that asthma complicates up to 7% of every pregnancies.About 30% of every womenwith asthma report their asthmaworsened while pregnant. Butwith the correct treatment and care, you and your baby can own a goodoutcome.

    How Does Uncontrolled Asthma Affect the Fetus?

    Uncontrolled asthma cuts the oxygen content of the mother's blood. Since the fetus gets its oxygen from the mother's blood, this can lead to decreased oxygen in the fetal blood.

    The result may impair fetal growth and survival. The fetus requires a constant supply of oxygen for normal growth and development. There is evidence that adequate control of asthma during pregnancy reduces the chances of fetal or newborn death and improves fetal growth inside the uterus. There are no indications that a mother’s asthma contributes to either spontaneous abortion or congenital malformation of the fetus.

    What Should I Do to Avoid Asthma Attacks During Pregnancy?

    Avoid Your Asthma Triggers

    Avoiding asthma triggers is always significant, but is particularly significant during pregnancy. Pregnant women with asthma should increase avoidance measures to acquire greatest comfort with the least medication.

    1. Stay away frompeople who are ill with respiratory infections.
    2. Avoidallergens love dust mites, animal dander, pollen, mold and cockroach.

    Stop Smoking Cigarettes/Tobacco

    Giving up cigarette smoking isimportant for any pregnant lady.

    Smoking may worsenasthma and harmsthe health of the growing fetus as well.

    Exercise

    Regular exercise is significant to health.

    What helpful of allergy medicine is safe during pregnancy

    Talk to yourobstetrician for the best adviceabout exercising during pregnancy. Swimming isa particularly excellent exercise for people with asthma. Using quick-relief medicine10 minutes before exercise may assist you tolerate recommended exercise.

    Are Allergy Shots Safe During Pregnancy?

    Pregnant lady with asthma already receiving allergy shot therapycan generally continueif they are not having reactions.

    As an additional precaution, though, the allergist may cut thedosage of the allergy extractto reducethe chance that a severe allergic reactionoccurs or at a minimum hold the dose the same but the dose should not be increased during pregnancy since that increases the chance of a reaction.

    Is It Safe to Breastfeed?

    Doctors do not believe asthma medicines are harmful to a nursing baby when used in usual amounts.

    The transfer of asthma medicines into breast milk has not been fully studied.

    When breastfeeding, drinking additional liquids to avoid dehydration is also significant (as it is for every people with asthma). Discuss with your baby’s pediatrician.

    Will I Pass On Asthma to My Baby?

    Genetics plays a role in whether a baby will develop asthma. In other words, asthma tends to be more likely in a baby if their relatives own it. The environment also plays an significant role.

    Changes in Asthma Severity

    About one-third of pregnant women with asthma will see their asthma symptoms get worse.

    Another third will stay the same. The lastthird will see their asthma symptoms improve.

    Most women with asthmawhose symptoms changed in any way during pregnancy will return to their pre-pregnancy condition within three months after giving birth.

    There is a tendency for women whose asthma symptoms increased or decreased during one pregnancy to experience the same thingin laterpregnancies. It is hard to predict how asthma will change during pregnancy.

    Because of this uncertainty,asthma should be followed closely.

    This way,any change can be promptly matched with an appropriate change in treatment. This calls for goodteamwork between the obstetrician, primary care physician and asthma specialist.

    Are Asthma Medicines Safe to Use During Pregnancy?

    Is It Safe to Use Asthma Inhalers or Corticosteroids While Pregnant

    Ensuring asthma is well-controlled is key. It is recommended that mothers seek regular check-ups to ensure their asthma remains controlled. Working with an asthma provider is essential. The asthma regimen that is best suited for the mom is the best approach.

    Some asthma medicines are considered "safer" during pregnancy because their risks appear to be less than the risks of uncontrolled asthma.

    These include:

    1. Short-actinginhaled bronchodilators
    2. Anti-leukotriene agents love montelukast (SINGULAIR®)
    3. Some inhaled corticosteroids, love budesonide

    Based on the severity of the mother’s asthma, a doctor may consider switching her treatment to an inhaled corticosteroid alone.

    Long-acting beta agonists (like SEREVENT®, Symbicort® and ADVAIR®) and theophylline are not considered first-line treatments for pregnant asthma patients. But doctors may consider them if the mother’s asthma is not adequately controlled by the above medicines.

    If asthma is extremely severe, oral steroids such as prednisone, may be necessary for the health of the mom and baby.

    Remember: It is better for mom and baby if the mom maintains asthma control (using any approved asthma drugs).

    Does Asthma Cause Complications During Pregnancy?

    Potential Complications

    Pregnant women with asthma may havea bit greater risk of delivering early.

    Or the baby may own alow birth weight. High blood pressure and a related condition known as pre-eclampsiaare also more common in pregnant women with more severe asthma.

    It is not known if uncontrolled asthma causes these problems directly or if other reasonsare to blame.

    However, optimal control of asthma during pregnancy is the best way to cutthe risk of these complications.

    Asthma Attacks During Labor

    When asthma is under control, asthma attacks almost never happen during labor and delivery.

    Also, mostwomen with well-controlled asthma are capable to act out breathing techniques during their labor without difficulty.

    Are Flu Shots Safe to Get During Pregnancy?

    People with asthma should get flu shots. Pregnancy does not change that recommendation. In fact, influenza may be particularly severe in pregnant women.

    Can I Do Anything to Prevent Asthma in My Baby?

    One major prenatal risk factor for the development of asthma is maternal smoking. Giving up cigarette smoking is extremely significant.

    Other prenatal factors that may influence the development of asthma are:

    1. Diet
    2. Maternal stress
    3. Vitamin D levels
    4. Antibiotic use
    5. Method of delivery

    Talk to your doctors about identifying your risk factors and making safe changes in preparation for your new baby.

    Medical Review November .

    References

    Subbarao, P., Mandhane, P.J., Sears, M. R. (). “Asthma: epidemiology, etiology and risk factors.” CMAJ. +html

    Willemsen, G., van Beijsterveldt, T.C.; van Baal, C.G.; et al.

    (). “Heritability of self-reported asthma and allergy: a study in adult Dutch twins, siblings and parents.” Twin Research and Human Genetics.

    Holberg, C.J., Elston, R.C., Halonen, M., et al. (). “Segregation analysis of physician-diagnosed asthma in Hispanic and non-Hispanic white families. A recessive component?” American Journal of Respiratory and Critical Care Medicine.

    ;– [PubMed]

    Lawrence, S., Beasley, R., Doull, I., et al. (). “Genetic analysis of atopy and asthma as quantitative traits and ordered polychotomies.” Annals of Human Genetics. ;– [PubMed]

    Fraga, M.F., Ballestar, E., Paz, M.F., et al. (). “Epigenetic differences arise during the lifetime of monozygotic twins.” Proceedings of the National Academy of Sciences of the United States of America. [PMC free article]

    Qiu, Jane.

    (). “Epigenetics: unfinished symphony.” Nature.

    Camargo Jr, C.A., Rifas-Shiman, S.L.,Litonjua, A.A., et al. (). “Maternal intake of vitamin D during pregnancy and risk of recurrent wheeze in children at 3 y of age.” The American Journal of Clinical Nutrition.

    Allergic rhinitis is an immunoglobulin E&#x;mediated disease that occurs after exposure to indoor or outdoor allergens, such as dust mites, insects, animal dander, molds, and pollen.

    Symptoms include rhinorrhea, sneezing, and nasal congestion, obstruction, and pruritus.1

    Optimal treatment includes allergen avoidance and pharmacotherapy. Targeted symptom control with immunotherapy and asthma evaluation should be considered when appropriate.2,3

    Symptoms of allergic rhinitis are classified based on the temporal pattern (seasonal, perennial, or episodic), frequency, and severity. Frequency can be divided into intermittent or persistent (more than four days per week and more than four weeks per year, respectively).

    Severity can be divided into mild (symptoms do not interfere with quality of life) or severe (symptoms impact asthma control, sleep, sports participation, or school or work performance).3


    Environmental Control and Prevention

    Patients with allergic rhinitis should avoid exposure to cigarette smoke, pets, and allergens that are known to trigger their symptoms.3 Nasal saline irrigation alone or combined with traditional treatments for allergic rhinitis has been shown to improve symptoms and quality of life while decreasing overall allergy medication use.

    Additional studies are needed to determine the optimal method and frequency of nasal irrigation and the preferred type of saline solution.5

    Prevention has been a main focus in studies of allergic rhinitis, but few interventions own been proven effective. Although evidence does not support measures to avoid dust mites, such as mite-proof impermeable mattresses and pillow covers, numerous guidelines continue to recommend them.2,3,6 Other examples of proposed interventions without documented effectiveness include breastfeeding, air filtration systems, and delayed exposure to solid foods in infancy or to pets in childhood.7&#x;11


    Pharmacotherapy

    Pharmacologic options for the treatment of allergic rhinitis include intranasal corticosteroids, oral and intranasal antihistamines, decongestants, intranasal cromolyn, intranasal anticholinergics, and leukotriene receptor antagonists,13 Decongestants and intranasal cromolyn are not recommended for children

    The International Primary Care Respiratory Group; British Society for Allergy and Clinical Immunology; and American Academy of Allergy, Asthma, and Immunology recommend intranasal corticosteroids alone for the initial treatment of persistent symptoms affecting quality of life and second-generation nonsedating antihistamines for mild intermittent disease.3,12,13,15,16 Patients with more severe disease not responding to intranasal corticosteroids with or without second-line therapies should be referred for consideration of immunotherapy.2,3,14,17Table 1 lists treatments based on symptom type.4Table 2 summarizes the treatment options.4

    INTRANASAL ANTIHISTAMINES

    Compared with oral antihistamines, intranasal antihistamines own the advantage of delivering a higher concentration of medication to a targeted area, resulting in fewer adverse effects and an onset of action within 15 minutes.2 Intranasal antihistamines FDA-approved for the treatment of allergic rhinitis are azelastine (Astelin; for patients five years and older) and olopatadine (Patanol; for patients six years and older).

    They own been shown to be similar or superior to oral antihistamines in treating symptoms of conjunctivitis and rhinitis, and may improve congestion Adverse effects include a bitter aftertaste, headache, nasal irritation, epistaxis, and sedation. Although intranasal antihistamines are an option if symptoms do not improve with nonsedating oral antihistamines, their use as first- or second-line therapy is limited by adverse effects, twice daily dosing, cost, and decreased effectiveness compared with intranasal corticosteroids&#x;33

    DECONGESTANTS

    Oral and intranasal decongestants improve nasal congestion associated with allergic rhinitis by acting on adrenergic receptors, which causes vasoconstriction in the nasal mucosa, decreasing inflammation.2,12,13 The most common decongestants are phenylephrine, oxymetazoline (Afrin), and pseudoephedrine.

    The abuse potential for pseudoephedrine should be weighed against its benefits.

    Common adverse effects of intranasal decongestants are sneezing and nasal dryness. Use for more than three to five days is generally not recommended because patients may develop rhinitis medicamentosa, or may own rebound or recurring congestion.2,3 Oral decongestants may cause headache, elevated blood pressure and intraocular pressure, tremor, urinary retention, dizziness, tachycardia, and insomnia; therefore, these medications should be used with caution in patients with underlying cardiovascular conditions, glaucoma, or hyperthyroidism.2,12,13 Decongestants may be considered for short-term use in patients without improvement in congestion with intranasal corticosteroids.2,3

    INTRANASAL CROMOLYN

    Intranasal cromolyn is available over the counter and is thought to inhibit the degranulation of mast cells.1 Although safe for general use, it is not considered first-line therapy for allergic rhinitis because it is less effective than antihistamines and intranasal corticosteroids and is given three or four times daily.1,2,34

    COMBINATION THERAPY

    Although most patients should be treated with just one medication at a time, combination therapy is an option for patients with severe or persistent symptoms.

    Numerous studies own looked at the combination of an intranasal corticosteroid and an oral antihistamine or leukotriene receptor antagonist, but most own concluded that combination therapy is no more effective than an intranasal corticosteroid alone.3,20,37&#x;39 However, recent studies own found the combination of azelastine/fluticasone (Dymista) to be superior (better effectiveness and faster symptom relief) to either treatment alone in patients with more severe allergic rhinitis&#x;42

    LEUKOTRIENE RECEPTOR ANTAGONISTS

    The leukotriene D4 receptor antagonist montelukast (Singulair) is comparable to oral antihistamines but is less effective than intranasal corticosteroids.2,16,36 It may be particularly useful in patients with coexistent asthma because it reduces bronchospasm and attenuates the inflammatory response.2

    INTRANASAL CORTICOSTEROIDS

    Intranasal corticosteroids are the mainstay of treatment for allergic rhinitis.

    They act by decreasing the influx of inflammatory cells and inhibiting the release of cytokines, thereby reducing inflammation of the nasal mucosa.2 Their onset of action can be less than 30 minutes, although peak effect may take several hours to days, with maximum effectiveness generally noted after two to four weeks of use Numerous studies own demonstrated that intranasal corticosteroids are more effective than oral and intranasal antihistamines in the treatment of persistent or more severe allergic rhinitis.2,3,12,13,19&#x;21

    There is no evidence that one intranasal corticosteroid is superior.

    However, numerous of the products own diverse age indications from the U.S. Food and Drug istration (FDA), only budesonide (Rhinocort Aqua) has an FDA pregnancy category B safety rating, and only fluticasone furoate (Flonase) and triamcinolone acetonide are available over the counter.

    The most common adverse effects of intranasal corticosteroids are throat irritation, epistaxis, stinging, burning, and nasal dryness.2,22 Although there has been concern about potential systemic adverse effects, including the suppression of the hypothalamic-pituitary axis, these effects own not been shown with currently available intranasal corticosteroids,24 The studies that specifically looked at the effects of the drugs on skeletal growth and adrenal activity did not protest a decrease in growth of children over the course of one to three years,26 Despite these data, every intranasal corticosteroids carry a warning that long-term use may restrict growth in children.

    ORAL ANTIHISTAMINES

    Histamine is the most studied mediator in early allergic response.

    It causes smooth muscle constriction, mucus secretion, vascular permeability, and sensory nerve stimulation, resulting in the symptoms of allergic rhinitis.

    First-generation antihistamines, including brompheniramine, chlorpheniramine, clemastine, and diphenhydramine (Benadryl), may cause sedation, fatigue, and impaired mental status. These adverse effects happen because the older antihistamines are more lipid soluble and more readily cross the blood-brain barrier than second-generation antihistamines. The use of first-generation sedating antihistamines has been associated with poor school performance, impaired driving, and increased automobile collisions and work injuries&#x;30

    Compared with first-generation antihistamines, second-generation drugs own a better adverse effect profile and cause less sedation, with the exception of cetirizine (Zyrtec) Second-generation nonsedating oral antihistamines include loratadine (Claritin), desloratadine (Clarinex), levocetirizine (Xyzal), and fexofenadine (Allegra).

    Second-generation antihistamines own more complicated chemical structures that decrease their movement across the blood-brain barrier, reducing central nervous system adverse effects such as sedation. Although cetirizine is generally classified as a second-generation antihistamine and a more potent histamine antagonist, it does not own the benefit of decreased sedation.

    In general, oral antihistamines own been shown to effectively relieve the histamine-mediated symptoms associated with allergic rhinitis (e.g., sneezing, pruritus, rhinorrhea), but they are less effective than intranasal corticosteroids at treating nasal congestion and ocular symptoms.

    Because their onset of action is typically within 15 to 30 minutes and they are considered safe for children older than two years, second-generation antihistamines are useful for numerous patients with mild symptoms requiring as-needed treatment.2,3,14

    INTRANASAL ANTICHOLINERGICS

    Although evidence supports the use of intranasal ipratropium (Atrovent) for severe rhinorrhea, one study showed that it may also improve congestion and sneezing in children, but to a lesser extent than intranasal corticosteroids Adverse effects include dryness of the nasal mucosa, epistaxis, and headache, and the recommended istration is two to three times daily.1

    IMMUNOTHERAPY

    Immunotherapy should be considered for moderate or severe persistent allergic rhinitis that is not responsive to usual treatments, in patients who cannot tolerate standard therapies or who desire to avoid long-term medication use, and in patients with allergic asthma.2,3,13,16,17,31,43&#x;46 Targeted immunotherapy, the only treatment that changes the natural course of allergic rhinitis, consists of istering a little quantity of allergen extract subcutaneously or sublingually

    Subcutaneous injections are istered in the physician’s office at regular intervals, typically three times per week during a buildup phase, then every two to four weeks during a maintenance phase.

    The first dose of sublingual immunotherapy is istered in the physician’s office so that the patient can be observed for adverse effects, and then it is istered at home daily. The optimal length of therapy has not been sure, but three to five years is thought to be the best duration.3 The effects of immunotherapy can final up to seven to 12 years after the treatment is discontinued.3,45

    Subcutaneous immunotherapy has been proven effective in the treatment of adults and children with allergic rhinitis from exposure to dust mites, birch, Parietaria

    Enlarge Print

    Table 1.

    Pharmacotherapy

    Pharmacologic options for the treatment of allergic rhinitis include intranasal corticosteroids, oral and intranasal antihistamines, decongestants, intranasal cromolyn, intranasal anticholinergics, and leukotriene receptor antagonists,13 Decongestants and intranasal cromolyn are not recommended for children

    The International Primary Care Respiratory Group; British Society for Allergy and Clinical Immunology; and American Academy of Allergy, Asthma, and Immunology recommend intranasal corticosteroids alone for the initial treatment of persistent symptoms affecting quality of life and second-generation nonsedating antihistamines for mild intermittent disease.3,12,13,15,16 Patients with more severe disease not responding to intranasal corticosteroids with or without second-line therapies should be referred for consideration of immunotherapy.2,3,14,17Table 1 lists treatments based on symptom type.4Table 2 summarizes the treatment options.4

    INTRANASAL ANTIHISTAMINES

    Compared with oral antihistamines, intranasal antihistamines own the advantage of delivering a higher concentration of medication to a targeted area, resulting in fewer adverse effects and an onset of action within 15 minutes.2 Intranasal antihistamines FDA-approved for the treatment of allergic rhinitis are azelastine (Astelin; for patients five years and older) and olopatadine (Patanol; for patients six years and older).

    They own been shown to be similar or superior to oral antihistamines in treating symptoms of conjunctivitis and rhinitis, and may improve congestion Adverse effects include a bitter aftertaste, headache, nasal irritation, epistaxis, and sedation. Although intranasal antihistamines are an option if symptoms do not improve with nonsedating oral antihistamines, their use as first- or second-line therapy is limited by adverse effects, twice daily dosing, cost, and decreased effectiveness compared with intranasal corticosteroids&#x;33

    DECONGESTANTS

    Oral and intranasal decongestants improve nasal congestion associated with allergic rhinitis by acting on adrenergic receptors, which causes vasoconstriction in the nasal mucosa, decreasing inflammation.2,12,13 The most common decongestants are phenylephrine, oxymetazoline (Afrin), and pseudoephedrine.

    The abuse potential for pseudoephedrine should be weighed against its benefits.

    Common adverse effects of intranasal decongestants are sneezing and nasal dryness. Use for more than three to five days is generally not recommended because patients may develop rhinitis medicamentosa, or may own rebound or recurring congestion.2,3 Oral decongestants may cause headache, elevated blood pressure and intraocular pressure, tremor, urinary retention, dizziness, tachycardia, and insomnia; therefore, these medications should be used with caution in patients with underlying cardiovascular conditions, glaucoma, or hyperthyroidism.2,12,13 Decongestants may be considered for short-term use in patients without improvement in congestion with intranasal corticosteroids.2,3

    INTRANASAL CROMOLYN

    Intranasal cromolyn is available over the counter and is thought to inhibit the degranulation of mast cells.1 Although safe for general use, it is not considered first-line therapy for allergic rhinitis because it is less effective than antihistamines and intranasal corticosteroids and is given three or four times daily.1,2,34

    COMBINATION THERAPY

    Although most patients should be treated with just one medication at a time, combination therapy is an option for patients with severe or persistent symptoms.

    Numerous studies own looked at the combination of an intranasal corticosteroid and an oral antihistamine or leukotriene receptor antagonist, but most own concluded that combination therapy is no more effective than an intranasal corticosteroid alone.3,20,37&#x;39 However, recent studies own found the combination of azelastine/fluticasone (Dymista) to be superior (better effectiveness and faster symptom relief) to either treatment alone in patients with more severe allergic rhinitis&#x;42

    LEUKOTRIENE RECEPTOR ANTAGONISTS

    The leukotriene D4 receptor antagonist montelukast (Singulair) is comparable to oral antihistamines but is less effective than intranasal corticosteroids.2,16,36 It may be particularly useful in patients with coexistent asthma because it reduces bronchospasm and attenuates the inflammatory response.2

    INTRANASAL CORTICOSTEROIDS

    Intranasal corticosteroids are the mainstay of treatment for allergic rhinitis.

    They act by decreasing the influx of inflammatory cells and inhibiting the release of cytokines, thereby reducing inflammation of the nasal mucosa.2 Their onset of action can be less than 30 minutes, although peak effect may take several hours to days, with maximum effectiveness generally noted after two to four weeks of use Numerous studies own demonstrated that intranasal corticosteroids are more effective than oral and intranasal antihistamines in the treatment of persistent or more severe allergic rhinitis.2,3,12,13,19&#x;21

    There is no evidence that one intranasal corticosteroid is superior.

    However, numerous of the products own diverse age indications from the U.S. Food and Drug istration (FDA), only budesonide (Rhinocort Aqua) has an FDA pregnancy category B safety rating, and only fluticasone furoate (Flonase) and triamcinolone acetonide are available over the counter.

    The most common adverse effects of intranasal corticosteroids are throat irritation, epistaxis, stinging, burning, and nasal dryness.2,22 Although there has been concern about potential systemic adverse effects, including the suppression of the hypothalamic-pituitary axis, these effects own not been shown with currently available intranasal corticosteroids,24 The studies that specifically looked at the effects of the drugs on skeletal growth and adrenal activity did not protest a decrease in growth of children over the course of one to three years,26 Despite these data, every intranasal corticosteroids carry a warning that long-term use may restrict growth in children.

    ORAL ANTIHISTAMINES

    Histamine is the most studied mediator in early allergic response.

    It causes smooth muscle constriction, mucus secretion, vascular permeability, and sensory nerve stimulation, resulting in the symptoms of allergic rhinitis.

    First-generation antihistamines, including brompheniramine, chlorpheniramine, clemastine, and diphenhydramine (Benadryl), may cause sedation, fatigue, and impaired mental status. These adverse effects happen because the older antihistamines are more lipid soluble and more readily cross the blood-brain barrier than second-generation antihistamines. The use of first-generation sedating antihistamines has been associated with poor school performance, impaired driving, and increased automobile collisions and work injuries&#x;30

    Compared with first-generation antihistamines, second-generation drugs own a better adverse effect profile and cause less sedation, with the exception of cetirizine (Zyrtec) Second-generation nonsedating oral antihistamines include loratadine (Claritin), desloratadine (Clarinex), levocetirizine (Xyzal), and fexofenadine (Allegra).

    Second-generation antihistamines own more complicated chemical structures that decrease their movement across the blood-brain barrier, reducing central nervous system adverse effects such as sedation. Although cetirizine is generally classified as a second-generation antihistamine and a more potent histamine antagonist, it does not own the benefit of decreased sedation.

    In general, oral antihistamines own been shown to effectively relieve the histamine-mediated symptoms associated with allergic rhinitis (e.g., sneezing, pruritus, rhinorrhea), but they are less effective than intranasal corticosteroids at treating nasal congestion and ocular symptoms.

    Because their onset of action is typically within 15 to 30 minutes and they are considered safe for children older than two years, second-generation antihistamines are useful for numerous patients with mild symptoms requiring as-needed treatment.2,3,14

    INTRANASAL ANTICHOLINERGICS

    Although evidence supports the use of intranasal ipratropium (Atrovent) for severe rhinorrhea, one study showed that it may also improve congestion and sneezing in children, but to a lesser extent than intranasal corticosteroids Adverse effects include dryness of the nasal mucosa, epistaxis, and headache, and the recommended istration is two to three times daily.1

    IMMUNOTHERAPY

    Immunotherapy should be considered for moderate or severe persistent allergic rhinitis that is not responsive to usual treatments, in patients who cannot tolerate standard therapies or who desire to avoid long-term medication use, and in patients with allergic asthma.2,3,13,16,17,31,43&#x;46 Targeted immunotherapy, the only treatment that changes the natural course of allergic rhinitis, consists of istering a little quantity of allergen extract subcutaneously or sublingually

    Subcutaneous injections are istered in the physician’s office at regular intervals, typically three times per week during a buildup phase, then every two to four weeks during a maintenance phase.

    The first dose of sublingual immunotherapy is istered in the physician’s office so that the patient can be observed for adverse effects, and then it is istered at home daily. The optimal length of therapy has not been sure, but three to five years is thought to be the best duration.3 The effects of immunotherapy can final up to seven to 12 years after the treatment is discontinued.3,45

    Subcutaneous immunotherapy has been proven effective in the treatment of adults and children with allergic rhinitis from exposure to dust mites, birch, Parietaria

    Enlarge Print

    Table 1.

    Symptom-Based Treatments for Allergic Rhinitis

    Treatment Symptoms


    Ocular Nasopharyngeal itching Sneezing Rhinorrhea

    Intranasal corticosteroids

    &#x;

    &#x;

    &#x;

    &#x;

    Oral and intranasal antihistamines

    &#x;

    &#x;

    &#x;

    Combination intranasal corticosteroid and antihistamine

    &#x;

    &#x;

    &#x;

    &#x;

    Oral and intranasal decongestants

    &#x;

    Intranasal cromolyn

    &#x;

    &#x;

    &#x;

    Intranasal anticholinergics

    &#x;

    Leukotriene receptor antagonists

    &#x;

    &#x;

    &#x;

    Immunotherapy

    &#x;

    &#x;

    &#x;

    &#x;

    Table 1.

    Symptom-Based Treatments for Allergic Rhinitis

    Treatment Symptoms


    Ocular Nasopharyngeal itching Sneezing Rhinorrhea

    Intranasal corticosteroids

    &#x;

    &#x;

    &#x;

    &#x;

    Oral and intranasal antihistamines

    &#x;

    &#x;

    &#x;

    Combination intranasal corticosteroid and antihistamine

    &#x;

    &#x;

    &#x;

    &#x;

    Oral and intranasal decongestants

    &#x;

    Intranasal cromolyn

    &#x;

    &#x;

    &#x;

    Intranasal anticholinergics

    &#x;

    Leukotriene receptor antagonists

    &#x;

    &#x;

    &#x;

    Immunotherapy

    &#x;

    &#x;

    &#x;

    &#x;

    Enlarge Print

    Table 2.

    Summary of Treatments for Allergic Rhinitis

    Type of therapy FDA pregnancy category Minimum age for use Mechanism/onset of action Adverse effects Cost*

    Intranasal corticosteroids

    Decrease the influx of inflammatory cells and inhibit the release of cytokines; onset of action is less than 30 minutes

    Bitter aftertaste, burning, epistaxis, headache, nasal dryness; possible systemic absorption, rhinitis medicamentosa, stinging, throat irritation

    Beclomethasone

    C

    4 years

    NA ($) for 1 inhaler

    Budesonide (Rhinocort Aqua)

    B

    6 years

    $ ($) for 1 nasal spray

    Ciclesonide (Omnaris)

    C

    6 years

    NA ($) for 1 nasal spray

    Flunisolide

    C

    6 years

    $55 (NA) for 1 nasal spray

    Fluticasone furoate (Veramyst)

    C

    2 years

    NA ($) for 1 nasal spray

    Fluticasone propionate (Flonase)

    C

    4 years

    $15 ($15) for 1 nasal spray

    Mometasone (Nasonex)

    C

    2 years

    NA ($) for 1 nasal spray

    Triamcinolone acetonide

    C

    2 years

    $70 ($) for 1 nasal spray

    Oral antihistamines

    Block histamine H1 receptors; onset of action is 15 to 30 minutes

    Dry mouth, sedation at higher than recommended doses

    Cetirizine (Zyrtec)

    B

    6 months

    $10 ($20) for 30 tablets

    Desloratadine (Clarinex)

    C

    6 months

    $40 ($) for 30 tablets

    Fexofenadine (Allegra)

    C

    2 years (allergic rhinitis)

    $15 ($20) for 30 tablets

    Loratadine (Claritin)

    B

    2 years

    $13 ($25) for 30 tablets

    Combination intranasal corticosteroid and antihistamine

    See intranasal corticosteroids and intranasal antihistamines

    See intranasal corticosteroids and intranasal antihistamines

    Azelastine/fluticasone (Dymista)

    C

    6 years

    NA ($) for 1 nasal spray

    Intranasal antihistamines

    Azelastine (Astelin)

    C

    5 years

    Block H1 receptors; onset of action is 15 minutes

    Bitter aftertaste, epistaxis, headache, nasal irritation, sedation

    $50 ($) for 1 nasal spray

    Olopatadine (Patanol) [corrected]

    C

    6 years

    Block H1 receptors; onset of action is 30 minutes

    Bitter aftertaste, epistaxis, headache, nasal irritation, sedation

    $50 ($) for 1 nasal sprays

    Oral decongestants

    Pseudoephedrine

    C

    2 years (usually not started until 4 years)

    Vasoconstriction; onset of action is 15 to 30 minutes

    Headache, elevated blood pressure and intraocular pressure, tremor, urinary retention, dizziness, tachycardia, and insomnia

    $5 ($10) for 24 tablets

    Intranasal cromolyns

    Cromolyn

    B

    2 years

    Inhibits histamine release

    Epistaxis, nasal irritation, sneezing

    NA ($18) for 1 nasal spray

    Intranasal anticholinergics

    Ipratropium (Atrovent)

    B

    5 years

    Block acetylcholine receptors; onset of action is 15 minutes

    Epistaxis, headache, nasal dryness

    $30 ($) for 1 nasal spray

    Leukotriene receptor antagonists

    Montelukast (Singulair)

    B

    6 months

    Block leukotriene receptors; onset of action is 2 hours

    Elevated levels of alanine transaminase, aspartate transaminase, and bilirubin

    $15 ($) for 30 tablets

    Immunotherapy

    Not well understood, believed to shift immune response from immunoglobulin E mediated to immunoglobulin G mediated

    Minor local mouth irritation, diarrhea, vomiting; rare anaphylaxis

    Sublingual Grastek (timothy grass pollen extract, cross reactive with 6 other grass pollens)

    B

    5 years

    NA ($) for 30 tablets

    Sublingual Oralair (5-grass pollen extract)

    B

    10 years

    NA ($) for 30 tablets

    Sublingual Ragwitek (short ragweed pollen extract)

    C

    18 years

    NA ($) for 30 tablets

    Subcutaneous allergen extracts: several tree, grass, weed pollens; cat and dog dander; dust mites; certain molds; and cockroaches; istered by a physician

    Should not be initiated during pregnancy; maintenance therapy is considered safe

    Has not been established; generally 5 years so that the kid is ancient enough to cooperate

    Local injection site reactions and, less commonly, systemic allergic reactions

    Varies

    Table 2.

    Summary of Treatments for Allergic Rhinitis

    Type of therapy FDA pregnancy category Minimum age for use Mechanism/onset of action Adverse effects Cost*

    Intranasal corticosteroids

    Decrease the influx of inflammatory cells and inhibit the release of cytokines; onset of action is less than 30 minutes

    Bitter aftertaste, burning, epistaxis, headache, nasal dryness; possible systemic absorption, rhinitis medicamentosa, stinging, throat irritation

    Beclomethasone

    C

    4 years

    NA ($) for 1 inhaler

    Budesonide (Rhinocort Aqua)

    B

    6 years

    $ ($) for 1 nasal spray

    Ciclesonide (Omnaris)

    C

    6 years

    NA ($) for 1 nasal spray

    Flunisolide

    C

    6 years

    $55 (NA) for 1 nasal spray

    Fluticasone furoate (Veramyst)

    C

    2 years

    NA ($) for 1 nasal spray

    Fluticasone propionate (Flonase)

    C

    4 years

    $15 ($15) for 1 nasal spray

    Mometasone (Nasonex)

    C

    2 years

    NA ($) for 1 nasal spray

    Triamcinolone acetonide

    C

    2 years

    $70 ($) for 1 nasal spray

    Oral antihistamines

    Block histamine H1 receptors; onset of action is 15 to 30 minutes

    Dry mouth, sedation at higher than recommended doses

    Cetirizine (Zyrtec)

    B

    6 months

    $10 ($20) for 30 tablets

    Desloratadine (Clarinex)

    C

    6 months

    $40 ($) for 30 tablets

    Fexofenadine (Allegra)

    C

    2 years (allergic rhinitis)

    $15 ($20) for 30 tablets

    Loratadine (Claritin)

    B

    2 years

    $13 ($25) for 30 tablets

    Combination intranasal corticosteroid and antihistamine

    See intranasal corticosteroids and intranasal antihistamines

    See intranasal corticosteroids and intranasal antihistamines

    Azelastine/fluticasone (Dymista)

    C

    6 years

    NA ($) for 1 nasal spray

    Intranasal antihistamines

    Azelastine (Astelin)

    C

    5 years

    Block H1 receptors; onset of action is 15 minutes

    Bitter aftertaste, epistaxis, headache, nasal irritation, sedation

    $50 ($) for 1 nasal spray

    Olopatadine (Patanol) [corrected]

    C

    6 years

    Block H1 receptors; onset of action is 30 minutes

    Bitter aftertaste, epistaxis, headache, nasal irritation, sedation

    $50 ($) for 1 nasal sprays

    Oral decongestants

    Pseudoephedrine

    C

    2 years (usually not started until 4 years)

    Vasoconstriction; onset of action is 15 to 30 minutes

    Headache, elevated blood pressure and intraocular pressure, tremor, urinary retention, dizziness, tachycardia, and insomnia

    $5 ($10) for 24 tablets

    Intranasal cromolyns

    Cromolyn

    B

    2 years

    Inhibits histamine release

    Epistaxis, nasal irritation, sneezing

    NA ($18) for 1 nasal spray

    Intranasal anticholinergics

    Ipratropium (Atrovent)

    B

    5 years

    Block acetylcholine receptors; onset of action is 15 minutes

    Epistaxis, headache, nasal dryness

    $30 ($) for 1 nasal spray

    Leukotriene receptor antagonists

    Montelukast (Singulair)

    B

    6 months

    Block leukotriene receptors; onset of action is 2 hours

    Elevated levels of alanine transaminase, aspartate transaminase, and bilirubin

    $15 ($) for 30 tablets

    Immunotherapy

    Not well understood, believed to shift immune response from immunoglobulin E mediated to immunoglobulin G mediated

    Minor local mouth irritation, diarrhea, vomiting; rare anaphylaxis

    Sublingual Grastek (timothy grass pollen extract, cross reactive with 6 other grass pollens)

    B

    5 years

    NA ($) for 30 tablets

    Sublingual Oralair (5-grass pollen extract)

    B

    10 years

    NA ($) for 30 tablets

    Sublingual Ragwitek (short ragweed pollen extract)

    C

    18 years

    NA ($) for 30 tablets

    Subcutaneous allergen extracts: several tree, grass, weed pollens; cat and dog dander; dust mites; certain molds; and cockroaches; istered by a physician

    Should not be initiated during pregnancy; maintenance therapy is considered safe

    Has not been established; generally 5 years so that the kid is ancient enough to cooperate

    Local injection site reactions and, less commonly, systemic allergic reactions

    Varies

    Abstract

    Original submitted: 12 September ; Revised submitted: 11 October ; Accepted for publication: 24 October ; Published online: 15 January

    Source: AJ Photo / Science Photo Library

    With appropriate dosage adjustment, there is little evidence of safety concerns for a lady taking antiepileptic drugs during pregnancy, but the foetus may be at risk of malformations and neurodevelopmental shortcomings


    Key points

    1. Increased drug clearances during pregnancy may lower circulating antiepileptic drug concentrations, resulting in loss of seizure control.
    2. Intrauterine valproate exposure is also associated with lower IQ values, neurodevelopment delay and autism.
    3. Intrauterine exposure to certain antiepileptic drugs, particularly valproate, may be associated with the development of foetal malformations.
    4. As far as possible, prescription of valproate in women capable of pregnancy is better avoided.


    Introduction

    The safety of antiepileptic drug use in pregnancy involves: the pregnant lady in her own right; the foetus while in her womb; and during its subsequent extra-uterine existence as a neonate and baby.

    The safety of antiepileptic drugs during pregnancy is not significantly diverse from the safety of these drugs in women in general, except in relation to consequences of pregnancy affecting the female body’s handling of the drugs, and the drugs’ effects on the foetus in utero and afterwards. This article focuses on these additional pregnancy-related safety aspects, and not with more extensive matters of antiepileptic drug safety in general.

    In recent years, antiepileptic drugs own been increasingly used in treating disorders other than epilepsy. So much so that Bobo et al. reported that, in the United States, these drugs were more often prescribed for psychiatric disorders than for their original indication of epileptic seizure control[1].

    In that study, antiepileptic drugs had been taken in % of more than , pregnancies, in % being indicated for various psychiatric disorders, % for pain management and % for epilepsy. Therefore, antiepileptic drugs were taken for epilepsy by –% of pregnant women, consistent with the % prevalence figure for athletic epilepsy that seems to apply in Western societies. Despite this considerable use for disorders other than epilepsy, almost every the available scientific information relating to the clinical pharmacology of these drugs in pregnancy has been derived from studies on their use in women with epilepsy, and their employment in other disorders has depended on application of this experience.

    Consequently, this article is mainly concerned with the use of these drugs in pregnant women who own epileptic seizure disorders.


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