Over the counter medication
Over the counter treatment has become quite popular as most allergy medications are now available without a prescription. Therefore, standing on the allergy aisle at your local pharmacy or grocery store can be absolutely overwhelming since there are more options than ever. It can be confusing to figure out what medicine to pick for your symptoms, so I will break them into classes to make it easier next time you go pick up your allergy meds.
Oral Antihistamines – Antihistamines are typically used for itching, sneezing, and runny nose symptoms, but are not as effective for nasal congestion.
First generation antihistamines like diphenhydramine (Benadryl), chlorpheniramine, brompheniramine, and doxylamine are commonly found over the counter. You can find these antihistamines as single agents and in combination with other medications (frequently used in cold medications). First generation antihistamines are troublesome in children because they can produce significant sedation and somnolence . Also, young children may experience paradoxical agitation characterized by fussiness, excessive movement, hyperactivity, and crying spells after taking it. The use of over the counter cold medications containing this class of antihistamines has been linked to several deaths in children younger than 2 years of age. In general, dosing is more frequent than the newer antihistamines, about every 6 hours. Children’s Benadryl Allergy– dosing is 2.5 ml every 6 hours for children 2-5 years old; 5-10 ml every 6 hours for children 6-11 years old; 10-15 ml every 6 hours for children older than 12 years of age.
Some examples of first generation antihistamine that you can find over the counter:
- brompheniramine (Childrén’s Dimetapp Cold)
- chlorpheniramina (Chlor-Trimeton y Actifed Cold)
- dimenhydrinate (Dramamine)
- diphenhydramine (Benadryl, Nytol o Sominex)
- doxylamine (Vicks NyQuil, Tylenol Cold and Cough Nighttime)
Second and third generation antihistamines like cetirizine (Zyrtec), loratadine (Claritin), levocetirizine (Xyzal), fexofenadine (Allegra) are long acting, thus they are dosed once or twice a day. Overall, these have less side effects than first generation antihistamines and are non-sedating.
- Cetirizine (Zyrtec) is available as tablets and liquid gels ( 10 mg), orally disintegrating tablets(10 mg) and liquid formulation. It is dosed once a day.
6 to 11 months old: dose is 1.25 ml (1/4 tsp) to 2.5 ml (1/2 tsp) of the liquid once a day; max dose is 2.5 ml in 24 hours
12 to 23 months old: dose is 2.5 ml ( 1/2 tsp) of the liquid once a day; could use 2.5 ml twice a day if needed; max is be 5 ml (1 tsp) per 24 hours
2 to 5 years old: dose is 5 mg (1/2 of a disintegrating tablet), or 5 ml (1 tsp) of the liquid once a day
6 years and older: dose is one 10 mg tablet or 10 ml (2 tsp) of the liquid once a day
- Loratadine (Claritin) is available as tablets and liquid gels (10 mg), orally disintegrating tablets (5 mg and 10 mg), and liquid formulations. It is dosed once a day.
2 to 5 years old: dose is one 5 mg orally disintegrating tablet or 5 ml (1 tsp) of the liquid once a day
6 years and older: dose is one 10 mg tablet or 10 ml (2 tsp) of the liquid once a day
- Levocetirizine (Xyzal) is available as tablets (5 mg) and liquid formulation ( 2.5 mg per 5 ml). It is dosed once daily.
2 to 5 years: dose is 1.25 mg , which would be 2.5 ml (1/2 tsp) of the liquid once a day
6 to 11 years old: dose is 2.5 mg, which would be 1/2 a tablet or 5 ml (1 tsp) of the liquid once a day
12 years and older: one 5 mg tablet or 10 ml (2 tsp) of the liquid once a day
- Fexofenadine (Allegra) is available in tablets (30, 60, 180 mg) and liquid formulation
6 months to 2 years old: dose is 2.5 ml (1/2 tsp) twice daily of the liquid
2 to 11 years old: dose is one 30 mg tablet twice a day or 5 ml (1 tsp) twice a day of the liquid
12 years and older: dose is one 60 mg tablet twice a day or 10 ml (2 tsp) twice daily; alternatively you can use one 180 mg tablet once a day
Oral Antihistamine-Decongestant Combinations- The use of non sedating, second generation antihistamines in combination with the decongestant pseudoephedrine has become popular since it results in better symptom relief than antihistamines alone. Some common formulations are loratadine-pseudoephedrine (Claritin-D, Alavert Allergy and Sinus), fexofenadine- pseudoephedrine (Allegra D), and cetirizine-pseudoephedrine (Zyrtec D). All are approved for children 12 years of age and older. Side effects include high blood pressure, difficulty falling asleep, and headaches.
- Loratadine 5 mg/Pseudoephedrine 120 mg: dose is one tablet every 12 hours
- Loratadine 10 mg/Pseudoephedrine 240 mg: dose is one tablet daily
- Fexofenadine 60 mg/Pseudoephedrine 120 mg: dose is one tablet every 12 hours
- Fexofenadine 180 mg/Pseudoephedrine 240 mg: dose is one tablet daily
- Cetirizine 5 mg/Pseudoephedrine 120 mg: dose is one tablet every 12 hours or two tablets daily
Glucocorticoid nasal sprays are the most effective single therapy for patients with persistent nasal congestion due to it’s anti inflammatory properties. They are superior to oral antihistamines for symptoms such as nasal blockage, post nasal drip and nasal discharge. Some available over the counter are fluticasone (Flonase), budesonide (Rhinocort), triamcinolone (Nasacort).
The proper technique is important when using a nasal spray. I always tell my patients to look at their toes when spraying their nose, then to insert the spray pump tip in the nostril aiming towards that side’s eye and spray, lastly sniff gently to move the medication to the higher parts of their nose. Repeat on the other nostril. Make sure not to spray your nasal septum. Side effects include nasal burning and discomfort, sore throat, and nose bleeds. Usually young kids don’t like the taste of the medicine as it trickles down their throats
- Fluticasone (Flonase, ClariSpray) & triamcinolone (Nasacort) nasal sprays are approved for use in children age 2 and older. The dose for each of these medications is one spray per nostril once a day, but two sprays per nostril can be tried for a limited period (about two weeks ). Fluticasone is considered safer than the other over the counter nasal sprays.
- Budesonide (Rhinocort) nasal spray is approved for patients 6 years and older. The dose is 1-2 sprays per nostril once daily for ages 6 to 11 years of age and up to 4 sprays per nostril for patients older than 12 years of age.
Cromolyn Sodium nasal spray is available over the counter as NasalCrom. It prevents allergy symptoms by maintaining the nasal mast cell’s integrity, minimizing the release of histamines and avoiding the nasal allergy symptoms even before they start. It is recommended for runny, itchy nose and sneezing. It is safe to use and non-sedating, but requires frequent dosing. Dose is one spray per nostril up to four times per day. Approved for use in children 2 years of age and older.
Nasal decongestant sprays– Also known as topical nasal vasoconstrictors, are typically recommended only for short-term treatment of nasal congestion since their use past three to seven days has been associated with rebound nasal congestion. I would not recommend its use for more than 3 days. These are not approved for kids younger than 2 years of age.
Common over the counter formulations are:
- Phenylephrine (Afrin Children’s, Neo-synephrine, Little Noses Decongestant Drops)
2 to 6 years: Find the pediatric formulation (0.125% solution) dose is 1 drop in each nostril every 4 hours as needed. *Little Noses Decongestant- may use 1-3 drops in each nostril every 4 hours as needed
6 to 12 years: can use the 0.25% solution, dose is 1 to 3 sprays every 4 hours as needed
12 years and older: may use the 0.25%-1% solution, dose is 1 to 3 sprays every 4 hours as needed
- Oxymetazoline (different Afrin and Mucinex formulations available, Vicks Sinex, Neo-Synephrine 12 hr)– mostly available as a 0.05% solution. Not recommended for children younger than 6 years old.
6 year and older: dose is 1 to 3 sprays into each nostril twice daily
Antihistamine/vasoconstrictor eye drops like Naphcon-A and Visine-A are available for red, itchy eye symptoms. Not for use beyond two weeks. For kids older than 6 years of age. Dosing is 1 drop up to 4 times a day.
Antihistamine eye drops like Zaditor and Alaway are approved for children 3 years and up. Dose is 1 drop in eyes twice daily. May use for prolonged periods of time
Just a little bit more on treatment…
Oral decongestants – phenylephrine and pseudoephedrine are the most commonly used oral decongestants. There are serious side effects associated with the improper use of these agents including excessive sweating, agitation, high blood pressure, seizures, and cardiac rhythm abnormalities . Therefore, oral decongestants are not approved for use in children younger than 4 years of age. For children ages 4 to 6 years, they should be used exclusively if recommended by your child’s doctor. After the age of six, it is safe to use but make sure you are following the package instructions carefully. Always ask your pediatrician if your not sure what dose to use.
Other-Supportive therapy with nasal saline irrigation could be used alone for mild symptoms or prior to the use of medicated nasal sprays. Nasal irrigation has been shown to be beneficial and carries insignificant risks if performed properly. There are a variety of over the counter devices to be used for nasal irrigation. I recommended using a commercially prepared saline solution , but if you decide to make your own, please use distilled, sterilized, or previously boiled water. The use of tap water for nasal irrigation is not advised because of the risk of contracting an amebic infection. Although extremely rare, infection with the amoeba Naegleria Fowleri is usually fatal.
If your child’s symptoms are not improving despite the correct use of over the counter medication, it is time for a visit to the pediatrician. There are a vast array of prescription medications that can be extremely useful for controlling allergic rhinitis symptoms.
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