Before You Reach for That Allergy Medicine, Read This

Allergy season can make anyone miserable with sneezing, coughing, stuffy nose, and itchy, watery eyes. For those with heart issues, getting through allergy season requires an extra measure of vigilance.

It’s not because allergies affect you any worse than someone without a heart issue. In fact, whether allergies worsen heart disease is a bit unclear, according to the American Heart Association. Two studies showed contradictory effects: One in the American Journal of Epidemiology found the risk of heart attack increased by 5.5% on days with high pollen counts, while another in the Annals of Allergy, Asthma & Immunology found those diagnosed with allergic rhinitis had a lower risk of coronary heart disease, cerebrovascular disease, and all-cause death.

The reason to be vigilant is because the heart health risk of allergy season comes from the medications used to keep allergies from making you miserable. They can have serious side effects for people with underlying heart conditions, which is why you shouldn’t just grab a box of over-the-counter allergy meds and call it a day. Here’s what you should know about finding relief safely.

Decongestants

Step Away From the Decongestants

When allergies cause a stuffy nose, the first thing many people want to take is a decongestant. However, these medications should be the biggest concern for those with heart disease and high blood pressure, says Paula Miller, M.D., director of cardiac rehabilitation and the women’s heart program at UNC Medical Center in Chapel Hill, NC.

Decongestants help relieve congestion in your nasal passages by constricting blood vessels in your nose and sinuses. “When you constrict peripheral blood vessels that affects your blood pressure, increasing it,” Dr. Miller says, as well as increasing your risk of aneurysm, heart attack, and stroke.

This doesn’t mean you have to banish decongestants from your allergy-relief toolkit if you have heart disease. You just need to be highly selective when choosing one. “Decongestants containing pseudoephedrine or phenylephrine can be an issue for some of those patients and cause elevated blood pressure and rapid heart rate,” says Christian Nageotte, M.D., an allergist and immunologist with the Henry Ford Health Center in Novi, MI.

Of these two active ingredients, pseudoephedrine, found in Sudafed and similar decongestants, is the bigger concern, as it is a stimulant, and something to be on the watch for if you have heart rhythm problems, such as atrial fibrillation, or if you have high blood pressure. Decongestants can sometimes cause your heart rate to go up slightly, Dr. Miller says. “If you [already] get palpitations, it can make the palpitations a little worse.” Nothing bad will happen to you, she says, but the feeling can be disconcerting.

If you are someone with heart issues but high blood pressure isn’t one of them, pseudoephedrine may not affect you as much, Dr. Miller says. “It’s not like if you take one pseudoephedrine your blood pressure is going to double or you’re going to have a stroke. There’s not really any correlation to that,” she says. “Even people who have high blood pressure can use it. They just have to use it sparingly.”

As always, check with your doctor before using a decongestant, and follow these tips:

• Choose one with a 24-hour time release. “That way you don’t get a big burst of pseudoephedrine in your system,” Dr. Miller says.

• Use it sparingly, for the shortest amount of time, according to label directions. Don’t take any decongestant longer than 7 days without checking with your doctor.

• Monitor your blood pressure using an at-home blood pressure cuff while taking the decongestant.

In general, however, if you have heart disease or high blood pressure it’s best to avoid decongestants and try safer alternatives first, Dr. Miller says.

Safer Options

Safer Options to Decongestants

Antihistamines are one of the oldest medications used to treat allergic rhinitis, your body’s inflammatory response to allergens. Antihistamines work by blocking histamine, the chemical your body releases when an allergic reaction takes place.

These medications are considered heart safe. “Most cardiac patients can take antihistamines that don’t contain decongestants without a problem,” Dr. Nageotte says.

Antihistamines come in syrups, eye drops, nasal sprays, and oral tablets. Older antihistamines, such as diphenhydramine, the active ingredient in Benadryl, can make you drowsy or cause physical impairment, which can lead to accidents or injury. It’s best to take these before bed. When possible, choose non-drowsy antihistamines, says Dr. Miller. These include Zyrtec (cetirizine) and Claritin (loratadine).

Nasal Sprays

Nasal Sprays Are Also on the Table

Going directly to the source of your allergy discomfort can help. That means treating your nasal passages directly with nasal sprays. But some nasal sprays are better than others for those with heart issues, Dr. Miller says. For instance, saline nasal sprays are a natural and effective way to wash out your sinuses of pollen and other allergens. If you’re concerned about the sodium in saline nasal sprays, don’t worry. There’s not enough of sodium to increase blood pressure, Dr. Miller says. “Your system doesn’t get a high absorption of it.”

However, you should use some caution when using nasal sprays containing oxymetazoline hydrochloride, the active ingredient in Afrin, Vicks Sinex 12-Hour Nasal Spray, and more, because it can be habit-forming, and worsen congestion if used too long. “It can shrink the capillaries in your nose. So, you should only use those for three days at most. Longer than that and you can get a rebound effect and sinus congestion,” Dr. Miller says. In addition, any restriction of blood flow affects your blood pressure by raising it.

There are non-habit-forming nasal spray options available. Steroid nasal sprays, known as intranasal corticosteroids, such as Flonase and Nasacort, are two. “These are available now, over-the-counter, without a prescription, and they are very, very safe when used as directed. And they’re not habit-forming,” Dr. Nageotte says. “In addition, those are usually not bioavailable to the bloodstream and usually wouldn’t cause any effects for heart patients.”

There are a few exceptions on who should use caution when using any nasal spray: people who are on blood thinners for an arrhythmia or other issue, and anyone prone to nosebleeds. “Any kind of nasal spray could cause a pretty serious nosebleed in those patients,” Dr. Nageotte says. “For a person who’s already on a blood thinner, a simple nosebleed could become a serious problem.”

Allergy Prevention

Try to Prevent Allergies in the First Place

Avoiding allergens is the key to decreasing symptoms, Dr. Nageotte says, and therefore the need for allergy medicines. Try these effective prevention measures to avoid allergen exposure:

• Wear a face mask when outdoors. A study published in the Journal of Allergy and Clinical Immunology found that nurses who wore face masks due to COVID-19 had reduced symptoms of allergic rhinitis. “Some form of face covering would decrease exposure to the allergen that’s causing your symptoms,” Dr. Nageotte says. “It’s a common-sense thing. If there’s a filter or barrier between the nose and mouth and the environment, you’re going to have less symptoms with your allergies.”

• Take a shower before bed. That helps to wash off the pollen and allergens from your body and hair.

• Stay well-hydrated. “You need to keep your body well hydrated to keep the mucus clear and thin,” Dr. Miller says. “Sometimes that doesn’t happen and that’s when you end up needing a decongestant.”

• Wearing glasses or sunglasses outdoors to keep pollen out of your eyes.

• Keeping windows closed during high pollen days. Use an air conditioner instead.

• Washing your hands after petting animals.

• Using dust mite covers for mattresses.

• Using a dehumidifier to control mold in your home.

One Last Thing to Know

Unless your medication label says otherwise, it’s okay to take allergy medications at the same time as your heart medications, Dr. Miller says. “They don’t really interact one on one with heart medications.” Make sure to discuss your allergies and how you treat them with your doctor so your heart keeps humming along unfazed.

Notes: This article was originally published November 9, 2021 and most recently updated November 15, 2021.

• Whether Allergies Worsen Heart Disease: American Heart Association. (2020.) “A Look at Allergies and Heart Health, With Tips to Endure Pollen Season Amid Coronavirus Fears.” https://www.heart.org/en/news/2020/03/18/a-look-at-allergies-and-heart-health-with-tips-to-endure-pollen-season-amid-coronavirus-fears

• Lower CVD Risk Study: Annals of Allergy, Asthma, & Immunology. (2016.) “Association of Allergic Rhinitis, Coronary Heart Disease, Cerebrovascular Disease, and All-Cause Mortality.” https://www.annallergy.org/article/S1081-1206(16)30576-2/fulltext

• What to Look for in a Decongestant: Harvard Medical School. (2021.) “Don’t Let Decongestants Squeeze Your Heart.” https://www.health.harvard.edu/heart-health/dont-let-decongestants-squeeze-your-heart

• Tips for Preventing Allergies: American College of Allergy, Asthma, and Immunology. (2020.) “Hay Fever.” https://acaai.org/allergies/allergic-conditions/hay-fever/

• Masking Outdoors: The Journal of Allergy and Clinical Immunology. (2020.) “Reduction Of Allergic Rhinitis Symptoms With Face Mask Usage During The COVID-19 Pandemic.” https://www.jaci-inpractice.org/article/S2213-2198(20)30867-9/fulltext

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Treatments to relieve allergy symptoms may impact blood glucose

Pamela Daniels, Michigan State University Extension -
May 15, 2020

Get relief and stay safe during allergy season.

Spring ushers in seasonal allergies. First, trees release pollen soon followed by summer grasses, rye and weeds generating hay fever. Allergens can be more intrusive for individuals with diabetes.

If you have diabetes, you know that being under the weather from seasonal allergies may affect how you manage your diabetes. Diabetes can alter the body’s immune system and reaction to both allergy symptoms and allergy medications. Even on a good day, keeping blood sugar levels where they should be, getting enough sleep, staying disciplined with medications or insulin along with exercising can be challenging. What about the days when we are not feeling well?

Diabetes self-management with allergies

Allergy season can be especially hard for people with diabetes. Allergies themselves may not affect blood glucose, but medications to treat allergies can. Almost all medications whether over the counter or prescribed may impact blood sugar. Medication side effects such as drowsiness, hyperactivity, nausea, diarrhea and dizziness impact blood sugar.

Common allergy medications

According to dLife, medications, whether over the counter or prescription, can affect blood sugar levels. Check with your pharmacist or healthcare provider before taking allergy medications. Here is a short list of allergy medications and possible side effects:

• Decongestants—common allergy medication containing decongestants may raise blood sugar, blood pressure and heart rate.
• Antihistamines—they tend to not affect blood sugar; however, antihistamines do tend to make you drowsy. Therefore, it is important to understand that long periods of drowsiness can also be associated with hypoglycemia and hyperglycemia. Drowsiness may make you less able to accurately monitor blood sugar.
• Steroids (Corticosteroids)—prescribed by providers but there are types that can be purchased over the counter. A side effect of steroids is they may make blood sugar go up. Monitoring for high blood sugar (hyperglycemia) is very important for people with diabetes who take steroids.

Follow these helpful tips if you take allergy medications

• Before starting any new treatment, always talk to your provider or asthma specialist about treatment options while managing your diabetes.
• Stay prepared for any diabetic health risk by monitoring your blood sugar frequently. If you are having unusually high or low blood sugar readings, contact your healthcare provider.
  • High blood sugar – Hyperglycemia
  • Low blood sugar – Hypoglycemia
• If you take allergy medication while on insulin, you may need to adjust your dose.
• Ask you provider or asthma specialist about treatment options and managing diabetes.
• Read labels. Medication labels contain important information for our health.
• Taking your medicine before peak allergy season can help alleviate symptoms.
• Pay attention to your local allergen report, which commonly includes mold, pollen and the breathing index. Use weather applications on your phone/tablet or check your local weather station’s web page for a daily or weekly forecasted allergy index.
• Plan on exercising indoors during peak allergy season.
• Keep your windows and basement doors closed to help avoid allergens from entering your home.
• If you need to do yard work during peak allergy season, wear a mask.

Food allergy medications impact blood glucose

Food allergy is in the group of disorders called food intolerance. Although much rarer than seasonal allergies, treatments administered to treat non-life-threatening allergic reactions such as hives, diarrhea, mild hand, lip or eye swelling may include seasonal allergy medications such as Zyrtec, Singular and Benadryl, for example. These medications like those mentioned above can have the same impact on blood glucose levels.

For more information on diabetes and chronic disease, Michigan State University Extension recommends the following resources:

• Standards of Medical Care Diabetes 2020
• Food Allergy Research & Education
• The American Diabetes Association

This article was published by Michigan State University Extension. For more information, visit https://extension.msu.edu. To have a digest of information delivered straight to your email inbox, visit https://extension.msu.edu/newsletters. To contact an expert in your area, visit https://extension.msu.edu/experts, or call 888-MSUE4MI (888-678-3464).

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Acute respiratory infections in allergic patients | #09/06

Acute respiratory infections (ARIs) are the most common in childhood, accounting for up to 90% of all registered diseases. Moreover, children prone to allergies get sick with ARI more often and more severely than their peers. But according to statistics, almost every third child belongs to this group.

It is known that acute respiratory viral infections (ARVI) (respiratory syncytial, rhinovirus, parainfluenza, influenza) have the ability to induce the synthesis of immunoglobulin E (IgE) and the formation of specific IgE antibodies. Therefore, upon contact with a viral infection in patients prone to allergic reactions, allergic symptoms may worsen, and in people with a predisposition to bronchial asthma, its attacks may develop.

At the same time, the results of numerous studies have shown that patients with allergies have a constant level of minimal inflammation in the body (it can be compared, for example, with the embers of a fire). Minimal persistent inflammation is one of the key concepts in allergology and can be defined as an inflammatory process that persists (even in the absence of symptoms) in allergic patients exposed to allergens. Minimal persistent inflammation is characterized by tissue infiltration by inflammatory cells (eosinophils and neutrophils) and expression (activation) of intercellular adhesion molecules (ICAM-1). Recent studies have shown that allergy symptoms can no longer be considered as the only marker of an allergic disease. Visible allergic symptoms are just the “peak of the allergic iceberg”. At the same time, inflammation and sensitization, playing a huge role in pathogenesis, do not manifest themselves in any way, but are always present in allergic diseases. Diseases such as bronchial asthma, atopic dermatitis and allergic rhinitis, even in the period of clinical remission, should be considered as chronic inflammatory diseases, and patients should receive anti-inflammatory therapy.

It is extremely important, including from the point of view of substantiating anti-inflammatory therapy in patients with allergic diseases, and the fact that ICAM-1 (an increase in which is associated with the presence of minimal persistent inflammation) is a receptor for 90% of rhinoviruses that use intercellular adhesion molecules to penetrate in human epithelial cells. This largely explains the propensity of allergic patients to frequent SARS. Of course, all these facts can play an important role in increasing the susceptibility of patients to rhinovirus infection, i.e., increase the likelihood of the disease.

Thus, minimal persistent inflammation in children prone to allergies does not have distinct clinical signs, but when allergens enter the body, the inflammatory process flares up with renewed vigor, manifesting itself in the form of severe allergic reactions. It should also be taken into account that not only allergens can cause such an effect, but also the ARI pathogens themselves.

It has now been established that patients prone to allergic reactions are characterized by features of the immune response that cause the frequent development of ARI. Firstly, this is a decrease in the synthesis of γ-interferon, the level of which largely determines the severity of the course of an atopic disease, as a result, antiviral and antimicrobial protection weakens.

Secondly, in patients with allergies, some viruses alter the activity of intercellular adhesion molecules and thereby increase their ability to penetrate respiratory epithelial cells. Thus, they not only increase the likelihood of infection, but also contribute to the manifestation of allergic reactions (for example, nasal congestion). These facts largely explain the propensity of allergic patients to frequent SARS.

Thirdly, in young children with a hereditary predisposition to allergies, frequent ARIs significantly increase the risk of developing allergic diseases, primarily bronchial asthma. It is known that in children of the first years of life, rhinovirus infection often precedes the onset of the first symptoms of bronchial asthma. It is possible that in these cases, even before the onset of symptoms of bronchial asthma, there was a minimal persistent allergic inflammation of the respiratory tract, which caused the expression of ICAM-1, which facilitated the development of rhinovirus infection. Rhinovirus infection, having accumulated, in turn, through the activation of cytological processes, leads to the manifestation of clinical manifestations of allergy.

Thus, a vicious circle is formed: the tendency to allergies provokes the introduction of respiratory viruses, and then the viruses contribute to the development of clinical symptoms of allergy.

Is there a way to break this vicious circle? Yes, if ARI is treated correctly and in a timely manner. There is an erroneous opinion that ARI can be left untreated: the disease will “pass” on its own. However, ARI in people prone to allergies, without adequate treatment, often takes a complicated or chronic course, mild rhinitis can result in severe pneumonia, sinusitis, or the development of an asthma attack. ARI can also cause exacerbation of chronic diseases, such as glomerulonephritis, heart disease, etc. Timely ARI therapy contributes to a faster recovery and prevents the development of complications. Undoubtedly, the treatment of ARI should be comprehensive and directed not only to the elimination of the symptoms of the disease. When choosing therapy, the inflammatory component of the disease must be taken into account. To this end, in patients with allergies, it is currently recommended to include the latest generation of antihistamines in the treatment regimen for ARI.

It is known that antihistamines are widely used in the treatment of acute respiratory viral infections and in children who do not have a burdened premorbid background, but this practice is not scientifically substantiated. At the same time, according to the National Scientific and Practical Program “Acute Respiratory Diseases in Children: Treatment and Prevention” (2002), it is recommended to prescribe antihistamines to all patients with ARVI if they have allergic diseases or are at high risk of developing them. However, it is clarified that it is undesirable to use first-generation antihistamines, for example, suprastin, tavegil, diphenhydramine, fenistil.

The fact is that these drugs, which effectively block H ₁ -histamine receptors, do not have an anti-inflammatory effect. In addition, they cause drowsiness, dizziness, disrupt coordination. To first-generation antihistamines, addiction quickly develops, and after a week another treatment has to be prescribed. It is important to remember that first-generation antihistamines also have an M-anticholinergic effect, therefore, they cause dryness of the mucous membranes and make it difficult for patients with ARVI to discharge already viscous sputum, so it is undesirable to prescribe them to patients with allergic rhinitis, hay fever, obstructive bronchitis. First generation antihistamines should not be used in patients with bronchial asthma. First, by increasing the viscosity of sputum, these drugs increase bronchial obstruction, thereby worsening the course of the disease. Secondly, patients with bronchial asthma primarily need to reduce allergic inflammation and reduce the number of receptors that help viruses invade the respiratory mucosa.

A significant event was the development of a new generation of H ₁ -histamine blockers. Their main advantages are very high efficiency, duration of action up to 24 hours, they do not cause drowsiness, addiction, do not dry mucous membranes and, what is very important, they have an anti-inflammatory effect.

Numerous studies have shown that one of the most effective and safe antihistamines of the latest generation is cetirizine (Zyrtec). Due to its dual action (antihistamine and anti-inflammatory), Zyrtec prevents the development and facilitates the course of allergic reactions, has antipruritic and anti-inflammatory effects, and reduces nasal congestion. The effect occurs within half an hour and persists for more than a day. Zyrtec can be used for a long time, if necessary – several months. The drug practically does not cause drowsiness, does not increase the viscosity of bronchial secretions. Its appointment is justified in all patients with acute respiratory viral infections, suffering from bronchial asthma, allergic rhinitis, atopic dermatitis, and also prone to the development of allergic reactions. A unique property of the drug is also the ability to significantly reduce the risk of developing bronchial asthma in individuals with a predisposition to this disease.

Zyrtec is safe, as proven by numerous studies. It is the only latest generation antihistamine approved for use in children from 6 months of age.

The possibility of long-term use of zirtek in children prone to allergies and often suffering from acute respiratory viral infections is especially important in the case of hyperplasia of adenoid vegetations (adenoids), since in 30–40% of young children it is allergic inflammation that stimulates their rapid increase by the age of two, which goes beyond physiological hyperplasia, characteristic of children under 5 years of age. Persistent infections of the nasopharynx and allergic inflammation contribute to an increase in adenoid vegetations in 70% of school-age children, delaying their age-related physiological involution.

To improve nasal breathing, such patients need a longer intake of the latest generation of antihistamines (for 2-3 months), with the help of which it is possible not only to control the symptoms of rhinitis (itching, sneezing, rhinorrhea), but also to globally reduce edematous-inflammatory reactions from the side of lymphoid tissue. It is allergic inflammation that is the cause of the continued growth of adenoid vegetations in children who have undergone removal of the adenoids (adenotomy). Therefore, if such interventions are undertaken in patients with allergies (according to strict indications), then in the postoperative period it is advisable to prescribe a 2–3-week treatment with the latest generation of antihistamines with a pronounced anti-edematous effect.

In children with allergic diseases and hyperplasia of adenoid vegetations, to improve nasal breathing, a longer intake of the latest generation antihistamines (for 2–3 months) is required, which makes it possible to significantly reduce the size of adenoids due to a positive effect on edematous-inflammatory reactions from the lymphoid tissue. , as well as to prevent the growth of adenoid vegetations in children who underwent adenotomy.

The feasibility of using antihistamines in bronchial asthma is widely discussed. An important conclusion was made by Van De Venne et al. (2001). Their studies have shown that the introduction of Zyrtec into the regimen of complex therapy for persistent bronchial asthma helps to reduce the need for β ₂ – adrenomimetics in both adults and children. In another study by the same authors, Zyrtec 10 or 15 mg twice daily was used in combination with inhaled corticosteroids (200–1000 mcg/day). There was an improvement in the clinical course of bronchial asthma and a decrease in the need for β ₂ -agonists compared with placebo (p < 0.05). Very important is the fact of the potential possibility of reducing the daily dosages of corticosteroids to the level of 50% of the initial level with the simultaneous administration of Zyrtec at a daily dose of 30 mg / day. The authors note that taking Zyrtec in patients with persistent bronchial asthma may, in some cases, contribute to the abolition of theophylline. It should be noted that cetirizine was well tolerated by all children who participated in the study.

Thus, the conducted studies indicate that the use of Zyrtec in the complex therapy of bronchial asthma significantly reduces the need for bronchodilators and makes it possible to significantly better control the symptoms of bronchial asthma. Moreover, Zyrtec can be used without the danger of reducing the pharmacological action of albuterol (salbutamol) or negatively affecting the course of bronchial asthma.

Analysis of the bronchodilatory effect of combination therapy with cetirizine and albuterol (β ₂ -short-acting agonist) in patients with mild and moderate atopic bronchial asthma was conducted by S. Spector and co-authors during a randomized, double-blind, placebo-controlled cross-over study. It was shown that combination therapy resulted in a significant increase in forced expiratory volume in the first second (FEV ₁ ) compared with placebo (p < 0. 02). Zyrtec did not potentiate or inhibit the bronchodilatory effect of albuterol, however, the combined use of these drugs is considered more effective, since they synergistically complement each other’s action. In none of the cases, when taking Zyrtec, there was a deterioration in pulmonary function, tolerability in all patients was good. The authors conclude that cetirizine potentiates the bronchodilatory effect in patients with mild to moderate allergic bronchial asthma and can be used without the risk of reducing the pharmacological action of albuterol or adversely affecting the course of bronchial asthma.

Studies by M. Miraglia del Giudice, F. Decimo, P. Paduano et al (1995) also reported the efficacy of cetirizine in controlling asthma symptoms. The purpose of this study was to evaluate the ability of cetirizine in children with bronchial asthma to control bronchospastic reactions induced by inhalation of a hyperosmolar saline solution. Children in the control group received inhalations with sodium cromoglycate. The results of the study indicate that the use of both drugs led to an inhibitory effect in hyperosmolar tests, however, the effectiveness of cetirizine was statistically significantly more pronounced (p < 0.05). At the same time, the efficiency when taking cetirizine averaged 73.4±12.5%, and when taking sodium cromoglycate - 68.7±18.4%.

Thus, the use of Zyrtec in complex therapy opens up new prospects for the therapeutic control of bronchial asthma symptoms, and especially against the background of an associated ARI, when the risk of developing bronchospasm significantly increases.

In addition, it was found that the use of the latest generation of antihistamines can be considered as the primary prevention of the onset of bronchial asthma in children from a high-risk group for the development of this disease. The most important property of the latest generation of antihistamines, and cetirizine in particular, in the complex therapy of bronchial asthma, of course, is the anti-inflammatory effect. It has been convincingly proven that zyrtec inhibits cellular, including eosinophilic infiltration in the lungs in the late phase of an allergic reaction in patients with atopic bronchial asthma. It is also important that zirtek has a bronchoprotective effect, this was shown in a study by T. Zimmermann.

A positive effect of Zyrtec therapy on the course of bronchial asthma was noted. In children with exacerbation of bronchial asthma, an improvement in bronchial patency was observed already on the 3rd day after the start of taking Zyrtec. The most significant was the increase in FEV ₁ , FVC (forced vital capacity), MOS50 (instantaneous volume velocity after exhalation 50% FVC), SOS75/85 (average expiratory volume velocity with a lung volume of 75 to 80% FVC). After 3 days of treatment with Zyrtec, children showed a decrease in the sensitivity of the bronchi to histamine. During therapy, there was a decrease in the number of attacks of bronchial asthma both during the day and at night, a decrease in the number of bronchospasmolytic drugs used. A four-week course of treatment contributed to the improvement of bronchial patency at the level of large, medium and small bronchi. A positive clinical effect and improvement in bronchial patency were noted in 35 (87.5%) of 40 children treated with Zyrtec. Under the influence of treatment in patients with bronchial asthma, there was a decrease in peripheral blood eosinophilia.

In connection with the significant prevalence of allergic diseases in children, the problem of preventing allergic pathology is becoming increasingly important. Primary and secondary prevention of allergic reactions is an important way to reduce allergic morbidity in children and adolescents. It is carried out in children at risk for the occurrence of allergic pathology.

Bronchial asthma, like atopic dermatitis and allergic rhinitis, is an inflammatory disease. In children of the first years of life, suffering from atopic dermatitis and not having symptoms of bronchial asthma, there are signs of nonspecific bronchial hyperreactivity, which is considered as a characteristic symptom of bronchial asthma. The progression of an allergic disease is associated with the specificity of the IgE antibody response. These changes over time lead to the development of allergy manifestations from other organs. The successive development of allergic reactions and diseases in individuals is referred to as the “atopic march”. In children, it is characterized by the initial development of food allergy, followed by the onset of atopic dermatitis, followed by allergic rhinitis and bronchial asthma. Subsequently, the development of recurrent urticaria, Quincke’s edema, pollinosis is possible.

The effectiveness of the prevention of bronchial asthma in children prone to allergic reactions, carried out in the form of early preventive therapy with Zyrtec, has been proven by studies conducted under the ETAC program (Early Treatment of the Atopic Child, The UCB Institute of Allergy, 2001). Zyrtec has been shown to reduce the risk of atopic asthma in high-risk children. The ETAC study also proved the high safety of Zyrtec even with long-term (18 months) administration: there were no clinically significant differences in the neurological status or the state of the cardiovascular system between the groups of children treated with cetirizine and placebo. There were no cases of QT interval prolongation in children treated with Zyrtec. Simultaneous administration of cetirizine with macrolides did not affect the values ​​of the QT interval and the level of activity of liver enzymes. Zyrtec-treated children had significantly fewer cases of urticaria (p < 0.001) compared with the placebo group. Timely appointment of antihistamines reduces the likelihood of developing an "allergic march".

Therefore, the latest generation of antihistamines can be an effective and safe means of primary and secondary prevention of allergic diseases, including in children with frequent ARI. Therefore, the appearance of a children’s form of zyrtec was timely. The drug is approved for use from 6 months of age, the recommended dose for children from 6 to 12 months is 2.5 mg (5 drops) 1 time per day; children from 1 to 2 years old – 2.5 mg (5 drops) up to 2 times a day; children from 2 to 6 years old – 2.5 mg (5 drops) 2 times a day or 5 mg (10 drops) 1 time per day. For adults, Zyrtec is available in the form of tablets that are taken once a day.

Thus, the observations and evaluation of the therapeutic efficacy of the drug cetirizine (Zyrtec) in a number of allergic diseases (atopic dermatitis, urticaria, dermatorespiratory syndrome, allergic rhinitis, bronchial asthma, etc.) allow us to recommend it to all patients prone to allergic reactions to use this antihistamine drug in the complex therapy of ARI.

O. V. Zaitseva , doctor of medical sciences, professor
MGMSU, Moscow

Cetirizine in pediatric practice | Kondyurina E.G., Elkina T.N., Gribanova O.A.

Atopy is one of the most common pathological conditions in childhood. The rapid growth of allergic diseases (AD), observed in recent decades, is a serious social, economic and medical problem. According to epidemiological studies, 10-40% of the population of European countries have their clinical manifestations, the most common of which are food allergies, atopic dermatitis, urticaria, allergic rhinitis and bronchial asthma. A high level of morbidity, the formation of severe forms of atopy, a decrease in the quality of life of children and parents, the development of life-threatening conditions dictate the need for the use of effective means of drug therapy and prevention [1].

In the development of allergic reactions, a significant role is played by mediators of various chemical structures – biogenic amines (histamine, serotonin), leukotrienes, prostaglandins, kinins, chemotactic factors, etc. In recent years, new drugs with antimediator effects – leukotriene receptor antagonists – have been synthesized and introduced into clinical practice. , 5-lipoxygenase inhibitors, antichemotactic agents. However, the main chemical mediator of allergic inflammation is histamine, so histamine type 1 receptor (h2R) blockers play an important role in the control of atopy [2].
Antihistamines were among the first drugs for the treatment of allergies, their effectiveness has long been well studied, although attitudes towards them have changed, as well as their place in therapy and rehabilitation programs [3]. The first agents of this group, available for use in clinical practice, were developed back in the 40s of the last century, since that time h2R blockers have become traditional in the treatment of atopic diseases [4].
There are currently many h2R antagonists with various properties in the physician’s arsenal. First-generation antihistamines (diphenhydramine, chloropyramine, clemastine, promethazine, mebhydroline, dimethindene, cyproheptadine, etc.) are competitive h2R blockers, their binding to the receptor occurs quickly and is reversible. Therefore, to achieve the main pharmacological action, high doses are required, which leads to an increase in the frequency of manifestations of side effects. The short duration of action of these drugs requires their repeated use during the day. Antihistamines of the first generation in therapeutic doses have a blocking effect on other receptors (cholinergic receptors, adrenergic receptors), which explains the undesirable side effects associated with their use, in particular the negative impact on the cardiovascular system, vision, urinary system, gastrointestinal tract, central nervous system [5]. First-generation h2R antagonists impair cognitive function, adversely affect learning ability, disturb sleep, have cardiotoxicity, and there is a risk of potentially fatal overdose when they are used [6]. High incidence of adverse reactions (drowsiness, dizziness, headache, impaired coordination of movements and concentration, lowering blood pressure, increased heart rate, stomach pain, constipation, nausea, vomiting, impaired urination, decreased visual acuity, weight gain), formation tachyphylaxis, the need to take several times a day significantly limit the use of antihistamines 1st generation in pediatric practice [7,8].
Antagonists h2R 2nd generation (acrivastine, astemizole, azelastine, cetirizine, ebastine, loratadine, etc.) selectively inhibit histamine receptors, inhibit the early and late phases of the allergic reaction, combine antihistamine, antiallergic and anti-inflammatory activity [9,10]. They do not cross the blood-brain barrier, do not have a sedative effect, and have a higher safety profile. The drugs have a rapid onset of action, a prolonged therapeutic effect, have a longer half-life, and are prescribed 1 time / day. They do not cause the development of tachyphylaxis, their therapeutic activity does not decrease with long-term use, and therefore a change in the drug is not required [11]. It is assumed that they may be useful and improve the quality of life of patients with bronchial asthma and associated allergic rhinitis, although further research is needed [12].
A special place among antihistamines of the 2nd generation is occupied by cetirizine hydrochloride (Zyrtec®), synthesized in 1987. It is a metabolite of hydroxyzine, a representative of the first generation of piperazine antihistamines. Three important characteristics characterize Zyrtec®: high specificity for h2R, low metabolic rate, and the existence of an effect independent of h2R blockade on cells involved in the immune response. This substance binds to a small extent with serotonin, dopamine and α-adrenergic receptors. Cetirizine (Zyrtec®) is considered the standard antihistamine and antiallergic drug because it has the ability to inhibit the release of histamine from mast cells and basophils, inhibit the activation of eosinophils and airway epithelial cells by suppressing the expression of intercellular adhesion molecules (ICAM-1), slow down platelet aggregation and the release of leukotrienes different cell types under the action of allergenic and non-allergenic stimuli. The effect of reducing the level of leukotrienes when using cetirizine is due to a decrease in the movement of leukotriene-producing cells (eosinophils, basophils and macrophages) to the site of an allergic response. Cetirizine penetrates the blood-brain barrier to a small extent, does not have a pronounced sedative effect. The drug is characterized by renal elimination: 70% is excreted unchanged in the urine within 72 hours. The half-life is 10 hours in adults and 7 hours in children. Cetirizine does not inhibit the system of cytochrome P450 CYR3A4-oxygenases of mixed function, which reduces its metabolic conversion in the liver. Characterized by a low volume of distribution (0.56 l / kg) and a high ability to penetrate the skin. After a single application, the effect of the drug appears after 20 minutes. in half of the patients, after 24 hours, the concentration of cetirizine in the skin is equal to or even slightly higher than the concentration in the blood. With course admission up to 8 weeks. a constant level in the blood is achieved within 3 days, then there is no accumulation of the drug and the rate of elimination does not change.
Currently, out of 40 h2R blockers, pharmacokinetics have been described in children only in 11 [13], especially few studies in young children. Zyrtec® is one of the most studied drugs in young patients, including infants, so its use is possible from 6 months of age. As part of the ETAC™ (Early Treatment of the Atopic Child) study on a large group of children (343 children aged 14–46 months weighing 8.2–20.5 kg), it was shown that the pharmacokinetics of cetirizine are not affected by eosinophilia, sensitization to allergens, AZ, gastroenteritis and diarrhea, taking other medications. The drug does not have a toxic effect, it is safe when used in childhood. Acts for 24 hours, this allows you to prescribe cetirizine 1 time / day. in children older than 2–6 years, which is very convenient, especially at an outpatient appointment.
Cetirizine has some properties that are unique to other antihistamines. For him, a steroid-sparing effect is described: with the simultaneous administration of cetirizine and inhaled corticosteroids in patients with bronchial asthma, the dose of corticosteroids may be reduced or not increased, despite contact with the allergen. Cetirizine, in addition to h2R blockade, suppresses the skin response to platelet-activating factor, which gives it advantages over other drugs in skin manifestations of allergies [15,16]. This has been confirmed in numerous clinical comparative studies: the ability to accumulate in the skin allows the drug to stop itching and flushing more effectively than such drugs as ebastine, epinastine, terfenadine, fexofenadine and loratadine [17-19].
Cetirizine has traditionally been used in the treatment of urticaria [17,20]; recent studies have shown that twice the dose of cetirizine may be effective in patients with urticaria refractory to the usual dose [21]. In most cases, urticaria associated with the use of non-steroidal anti-inflammatory drugs can be prevented by cetirizine, which opens up new possibilities for the treatment of pain and rheumatic disorders [22].
Cetirizine (Zyrtec®) is the only antihistamine drug with a proven ability to prevent the formation of AD, which was shown in a large, long-term, prospective, randomized, double-blind, placebo-controlled ETAC™ study. [23]. It involved more than 800 children from 13 countries (56 clinical centers) aged 1 to 2 years who had symptoms of atopic dermatitis, which for 18 months. took the drug and the next 18 months. were under observation. Placebo or Zyrtec® (10 mg/ml) at a dose of 0.25 mg per 1 kg of the child’s body weight was prescribed 2 times a day. in the form of an oral solution. The results of this study made it possible to clarify the place of the drug in the treatment and prevention of AD. First, good control of allergic skin lesions has been shown. In particular, according to the SCORAD index, the severity of atopic dermatitis decreased after 18 months. in both groups (p<0.001). But placebo-treated children were more likely to require additional use of other antihistamines (24.9% versus 18.6%, p=0.03). In the subgroup of patients with a SCORAD score ≥25, there was a statistically significant corticosteroid-sparing effect (in the placebo group 35.1 versus 25.8 in the Zyrtec® group; p=0.014). Taking the drug had a preventive effect on urticaria - the number of children who developed it during the study was significantly less in the main group (in the placebo group - 16.2%, in the Zyrtec® group - 5.8%; p<0.001) [24].
The preventive effect in relation to bronchial asthma was expressed in the fact that treatment with cetirizine, started in the first and second years of life in patients with atopic dermatitis who had hypersensitivity to inhaled allergens, significantly reduced the number of cases of subsequent bronchial asthma – by 50% in pollen-sensitized grasses and by 40% – in those sensitized to house dust. Follow-up results for 18 months. showed that in children treated with cetirizine, the reduction in the risk of developing bronchial asthma persisted.
Thus, the use of cetirizine prevents or delays the development of bronchial asthma in every second child from the high-risk group (with atopic dermatitis, aggravated heredity and sensitization to plant pollen and house dust mites) [25].
An important place is occupied by the drug in the treatment of allergic rhinitis, including in young children [26]. The prescription of Zyrtec® for seasonal allergic rhinitis in children aged 2–6 years contributed to the reduction of clinical symptoms and the restoration of nasal patency. When using the drug Zyrtec® for the treatment of seasonal allergic rhinoconjunctivitis in children aged 6 to 12 years, there was a regression of the symptoms of rhinitis and conjunctivitis. In allergic rhinitis, cetirizine is more effective than other antihistamines. A randomized, double-blind, comparative study evaluated the duration of effect of cetirizine (10 mg 1 time/day) and fexofenadine (180 mg 1 time/day) after exposure to ragweed pollen in patients with seasonal allergic rhinitis [27]. The drugs demonstrated the same rate of onset of action and control of rhinitis symptoms within 5 hours after the first dose compared with placebo. However, after 21-24 hours, the effectiveness of cetirizine was 33% higher, as well as after 40 minutes. after the second dose compared with fexofenadine.
The expediency of taking cetirizine in acute allergic reactions to food has been proven. It begins to relieve symptoms as quickly and effectively as diphenylhydramine, but has a longer duration of action [28]. Compared to other new antihistamines, the drug begins to work faster in other types of acute allergic reactions, up to anaphylactic ones [20].
The use of drugs in young children always requires a thorough study of their safety and effects on cognitive activity. In adult patients, it has been shown that Zyrtec® can affect the speed of information processes in the central nervous system, but these effects are not essential for the onset of cognitive deficits [29]. The effect of long-term high-dose Zyrtec (0. 25 mg/kg 2 times/day for 18 months) on behavior and cognition was assessed in the already mentioned ETAC™ study, which used well-validated and standardized behavioral questionnaires (Behavior Screening Questionnaire) and cognitive activity (McCarthy Scales of Children’s Abilities), the age of acquisition of psychomotor skills was recorded. The analysis of the results did not reveal significant differences in behavior and cognitive performance between children treated with placebo and Zyrtec® during treatment and during the follow-up period, which confirms the absence of adverse effects on behavior and learning processes associated with prolonged use of Zyrtec® in younger children. age with atopic dermatitis [30]. Between the groups of children who received Zirtek® and placebo, there were no clinically significant differences in neurological status, the state of the cardiovascular system; in patients taking Zyrtec®, no cases of QT interval prolongation were identified. Simultaneous administration of the drug Zyrtec with macrolides did not affect the value of the QT interval and the level of activity of liver enzymes.
The possibility of using cetirizine was studied in pregnant women in the first trimester of pregnancy: in a prospective observational cohort study, compared with the control group, the drug did not increase the number of congenital malformations (OR 1.07; CI 0.21-3.59), the frequency of spontaneous abortions ( OR 0.97; CI 0.54–1.65), preterm birth (OR 0.76; CI 0.35–1.5), and the weight of newborns did not differ (p = 0.13), which allows us to consider drug the drug is relatively safe in the first trimester of pregnancy [31].
Cetirizine (Zyrtec®) is on the list of vital and essential drugs [32], approved by the FDA [33].
The original preparation of cetirizine hydrochloride – Zirtek® (UCB Pharma) has a form of release convenient for use in children – drops for oral administration. Designed for children aged 6 to 12 months. 5 drops 1 time / day, from 1 year to 2 years – 5 drops 2 times / day, from 2 to 6 years – 5 drops 2 times / day. or 10 drops 1 time / day. Children over 6 years old – 20 drops or 1 tablet (10 mg) 1 time / day.
Thus, Zyrtec® is indicated for allergic rhinitis, allergic conjunctivitis, urticaria, Quincke’s edema and dermatoses, manifested by itching and rashes. The possibility of long-term use allows us to recommend the drug for the secondary prevention of AD, with comorbidity. The high efficacy and safety of cetirizine (Zyrtec®), confirmed by scientific studies, allow it to be widely used in pediatric practice, including in younger patients from an increased risk of developing bronchial asthma.

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