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Contents
2: OurRecommendations
3: Welcome
6: WhatAreAntihistaminesandWhoNeedsThem?
9: ChoosinganAntihistamine—OurBest BuyPicks
14: TheEvidence
17: 5TipstoTalkingWithYourDoctor
18: HowWePickedtheBest BuyAntihistamines
19: SharingthisReport
19: AboutUs
20: References
UsingtheAntihistaminestoTreat:
Allergies,HayFever,&HivesCOMPARINGEFFECTIVENESS,SAFETY,ANDPRICE
USINGTHEANTIHISTAMINESTOTREAT:ALLERGIES,HAYFEVER,ANDHIVESCONSUMERREPORTSBESTBUYDRUGS 2
Thisreportevaluatessevenneweror“second-generation”antihistaminemedicationsthatarewidelyusedtorelievethesymptomsofhayfever(atypeofallergicrhinitis),hives(urticaria),andotherallergies.Studieshavefoundthesedrugstobeequallyeffectiveandgenerallysafe,buttheycanbemisused.
Somepeoplewhotakeallergy
medicinesdonothaveallergies,soyou
shouldseeyourdoctorforadiagnosis
beforetakingantihistaminesona
regularbasis.
Thenewerantihistaminescauselessdrowsinessthantheolderones,whichincludenonprescriptiondrugssuchasBenadrylAllergy,Chlor-TrimetonAllergy,andDimetappAllergy.Butthenewerdrugsarenomoreeffectivethantheolderonesatrelievingsymptoms.
Themonthlycostforthenewermedicinesvariesfromabout$8tomorethan$200,sopricemightbeanimportantfactorinyourchoice.Thisreportshowshowyoucouldsavehundredsofdollarsayearormoreifyoucurrentlytakeanexpensivebrand-nameantihistamine.Takingdosingconvenience,cost,andeffectivenessandsafetyintoaccount,wehaveselectedthefollowingasConsumer Reports Best Buy Drugs:
■■ Cetirizine10mgtablets
■■ Loratadine10mgtablets
■■ Loratadinedissolving10mgtablets
■■ Loratadineliquid10mg
■■ Alavertdissolving10mgtablets
Allarelow-costgenericsavailablewithoutaprescriptioninpharmaciesandotherstoresthatsell
medications.Theyhavebeenshowntoeffectivelyrelievesymptomsofhayfever,hives,andotherallergies.Cetirizineisalsoavailableover-the-counterinsoftgelcapsuleandliquidformulationsforpeoplewhoneedthose.Youshouldalsobeawarethatsomepeoplemayrespondwelltooneantihistaminewhilegettingnobenefitfromanother.SoifourBest Buypicksdonotworkforyou,thentryoneoftheotherantihistamines.
Yourinsurancemightnotfullycoverantihistaminesormightchargeyouahigherthanusualco-payment.Checkwithyourinsurerorhealth-planadministratoraboutitspolicyonantihistamines.
OurRecommendations
USINGTHEANTIHISTAMINESTOTREAT:ALLERGIES,HAYFEVER,ANDHIVESCONSUMERREPORTSBESTBUYDRUGS 3
Thisreportonaclassofdrugstotreathayfever(atypeofallergicrhinitis),hives(urticaria),andotherupper-respiratorysymptomstriggeredbyallergiesispartofaConsumerReportsprojecttohelpyoufindsafe,effectivemedicinesthatgiveyouthemostvalueforyourhealth-caredollar.Tolearnmoreabouttheprojectandotherdrugswe’veevaluated,gotowww.CRBestBuyDrugs.org.
Hivesareredweltsonthesurfaceoftheskinthatareoftenitchy.Theyareusuallyanallergicreactiontofoodormedicine,butothersubstancesandfactors,includingstress,cantriggerthemtoo.About20percentofpeoplewillgethivesatsomepointintheirlives,accordingtoUpToDate,aphysicianwebsite.Hivesareusuallyharmlessanddisappearontheirown,butiftheybecomesevere,anantihistaminemightbeappropriate.
Hayfeverisatypeofallergicrhinitis,anallergicreactiontriggeredwhenapersonbreathesinsomethingtheyareallergicto,suchasdust,dander,orinthecaseofhayfever,pollen.About20percentofpeopleofallagessufferfromhayfever,accordingtoUpToDate.
Themostcommonsymptomsincludenasalcongestion,arunnynose,sneezing,anditchyandwateryeyes.Nonprescriptionallergymedicineisavailableindrugandgrocerystores.Thesecomeinavarietyofforms,includingpills,liquidsolutions,nasalsprays,andskincreams.Mostofthepillscontaintheactiveingredientschlorpheniramine(e.g.Chlor-TrimetonAllergy);clemastine(Tavist);brompheniramine(Dimetapp);ordiphenhydramine(BenadrylAllergy).Thosedrugsareconsidered“first-generation”antihistaminesandhavebeenavailablefordecades.
Thisreportfocuseson“second-generation”antihistamines,whichincludefiveoralmedicinesand
twonasalsprays.Alloftheoraldrugsareavailableasgenerics,andthreeareavailableasnonprescriptionover-the-counter(OTC)drugs.Thenasalspraysareavailableasbrand-nameandgenericprescriptionmedicines.Thedrugscoveredinthisreportare:
Youmightrecognizethebrandnamesoftheoralmedicines—Allegra,Claritin,Clarinex,Zyrtec,andXyzal.Allhavebeenwidelyadvertised.Andtheirusehasbecomewidespread,exceeding(thoughnoteliminating)theuseoffirst-generationantihistamines.
Themainreasonfortheirpopularityisthattheycauselesssedationanddrowsiness.Butthoseproblemscanstilloccurwhentakingthenewermedications,especiallyathigherdoses.Thesedativeeffectoffirst-generationantihistaminesisn’tjustannoyingorinconvenient;itcanbedangerous.Studieshaveconsistentlyfoundthatpeopletakingtheolderantihistaminesareatahigherriskforautoaccidentsandotherincidentsathomeandwork.Labelsonthese
Welcome
GenericName
BrandName(s)
AvailableasaPrescriptionGenericDrug?
AvailableasanOTCDrug?
Azelastinenasalspray/pump
Astelin,Astepro
Yes No
Cetirizine Zyrtec Yes Yes
Desloratadine Clarinex Yes No
Fexofenadine Allegra Yes Yes
Levocetirizine Xyzal Yes No
Loratadine Claritin,Alavert
Yes Yes
Olopatadinenasalspray
Patanase No No
USINGTHEANTIHISTAMINESTOTREAT:ALLERGIES,HAYFEVER,ANDHIVESCONSUMERREPORTSBESTBUYDRUGS 4
drugswarnpeoplenottodriveoroperatemachinerywhileusingthem.Inaddition,mostofthenewerantihistaminesneedtobetakenjustonceadaywhiletheolderonesmustbetakentwoormoretimesadaybecausetheireffectwearsoffmorequickly.
Evenso,there’sbeenalong-standingdebateaboutjusthowmuchbetterthenewerdrugsareandwhetherthey’reworththeextracost.There’snoeasyanswer.Mostdoctorsadvisetheirpatientstousethenewerpills,whileothersthinktheirpatientsdojustaswelltakingtheolder,nonprescriptiondrugs.Somepeoplerespondbettertotheolderantihistaminesthanthenewerones.Inaddition,apatientmightgetrelieffromanolderdrugwithoutmuchsedation,especiallyifhisorhersymptomsaremild.Beaware,however,thatstudieshavefoundaslowedreactiontimeamongsomepeopletakingtheolderantihistaminesevenwhentheydeniedfeelingdrowsy.
You,too,mightbesusceptibletothesedativeeffectofolderantihistaminesandrespondbettertothenewerdrugs.Youmightalsogetbettersymptomrelieffromanewerantihistamine,thoughouranalysisfoundtheyaren’tanymoreeffectivethanolderantihistamines.Andaswehavepreviouslynoted,thenewermedicinescanstillcausesomedrowsiness,especiallywhenhigherdosesaretaken.
Theavailabilityofloratadine(Alavert,Claritin,andgenerics),cetirizine(Zyrtecandgenerics),andfexofenadine(Allegraandgenerics)inlow-cost,nonprescriptionformulationschangesthecostandrisk/benefitdecision,aswediscusslaterinthisreport.Inaddition,someofthosemedicationsmaycostaslittleas$4foramonth’ssupplythroughgenericdrugprogramsrunbymajorchainstores,suchasKroger,Sam’sClub,Target,andWalmart.Foranevenbetterbargainifyouaregoingtobeonthosedrugslong-term,youmaybeabletogetathree-monthsupplyfor
aslittleas$10throughtheseprograms.Wenoteinthepricechartstartingonpage12whichantihistaminesareavailablethroughtheseprograms.Somestores,suchasCVSandWalgreens,requireamembershipfeetoparticipateandmightchargehigherprices.Theremightbeotherrestrictionstoo,socheckthedetailscarefullytomakesureyourdruganddosearecovered.
Mostantihistamines,newandold,arealsoavailableincombinationwithadecongestant,suchaspseudoephedrine.ThesecombinationproductswerenotincludedintheanalysisconductedbytheOregonHealth&ScienceUniversity’sDrugEffectivenessReviewProject,whichformsthebasisofthisreport,sowedonotincludetheminourreview.
Decongestantproductsshouldbeused
withcautionbypeoplewithhighblood
pressure,heartconditions,diabetes,
glaucoma,orprostatedisease.Consult
adoctorifyouarenotsurewhether
youshoulduseacombinationproduct.
Ifyoursymptomsaremild,anantihistaminemightbeallyouneed.Adoctorcanalsoevaluatewhetheryouneedothermedicines,includingprescriptiondrugs,torelieveyoursymptoms.Theyinclude:
■■ Asteroidoranantihistaminenasalspray
■■ Anewkindofallergydrugcalledaleukotrieneblocker.Therearethree:montelukast(Singulairandgeneric);zafirlukast(Accolate);andzileuton(Zyflo)
■■ Anothertypeofimmune-modifyingdrugcalledomalizumab(Xolair)
■■ Allergyshots(alsoknownasimmunotherapy)
Welcome
USINGTHEANTIHISTAMINESTOTREAT:ALLERGIES,HAYFEVER,ANDHIVESCONSUMERREPORTSBESTBUYDRUGS 5
Thisreportdoesnotdiscussthosemedications.Ifyouaretakingthemorhavequestions,consultyourdoctor.
Havingsevereallergysymptomscouldbeasignofasthma.Mostpeople—butnotall—whohaveasthmaalsohaveunderlyingallergies.Technicallyspeaking,asthmaisaseparateconditionwhereinflammationandconstrictionofthebronchialtubesmakesitdifficulttobreathe.Butthetwoconditionscangohandinhand,especiallyinchildrenandteenagers.Asthmaismorecommonamongtheyoungandusuallydevelopsinchildhood.Butitcanalsostrikeadults.SeeTable2onpage8foraquickguideonhowtotellthedifference.Antihistaminesarenotacommontreatmentforchronicasthma.
Someantihistaminesareoccasionallyusedtotreatotherconditions,suchasmotionsicknessorvertigo.Inthisreportwefocusontheuseofsecond-generationantihistaminesonlyfortreatinghayfever,chronicallergysymptoms,andhives.
This report was updated in July 2013.
Welcome
USINGTHEANTIHISTAMINESTOTREAT:ALLERGIES,HAYFEVER,ANDHIVESCONSUMERREPORTSBESTBUYDRUGS 6
Antihistaminesworkbyblockingthechemicalmessengerhistamine,themaintriggerofallergysymptomsinthenose,airways,andskin.Histamineisapartofthebody’snaturaldefensemechanisms.Itworksinpartbywideningbloodvessels.Thatactioncausescongestionandsneezing,andisalsowhatcausesred,itchyhivesonyourskinafter,say,abugbite.
Inpeoplewhohaveallergiesandallergy-inducedasthma(forreasonsstillnotentirelyclear),thebody’simmunesystemoverreactswhenexposedtootherwiseharmlesssubstancessuchaspollen,dustmites,moldspores,andanimaldander—it’stheirskinprimarily,butalsosalivaandurine,thattriggerstheallergicreaction.Excessiveamountsofhistaminearereleased,causingthesymptomsofanallergicreaction(seeTable1onpage7).Fortunately,mostallergicreactionsaremild,eveninpeoplewhosufferthemseasonallyorhavechronicallergies.
Butsevereallergicreactionsdooccurandcanbelife-threatening.Theyaremostlyreactionstoinsectstings,drugs,orfoods—nottomold,pollen,orotherhay-fevertriggers.Youmighthaveheardtheterm“anaphylacticshock.”Thisisatypeofallergicreactioninwhichalargeamountofhistamineisreleased,causingtheairwaysandbloodvesselstoconstrict,whichcanmakebreathingdifficultandcauseasignificantdropinbloodpressure.Suchreactionsaremedicalemergenciesthatgenerallyrequiretreatmentwithadrenalineinjectionsandintravenouscorticosteroids.
Thebestwaytopreventallergysymptoms,bothmildandsevere,istoavoidtheoffendingsubstance.Skintestscanhelpidentifywhatyouareallergicto.Butcompletelyavoidingthemisnotalwayspossible.Therealityisthatmostallergysufferersneedtotakemedicine,includingantihistamines.A2010ConsumerReportssurveyfoundthatpeoplewhosufferfromallergiesuseavarietyofmeasurestogetrelief,
includingavoidingthesubstancethey’reallergicto,andtakingbothnonprescriptionandprescriptionmedications.Youcanreadmoreaboutthesurveyresultsandthestrategiesthatpeoplesaidweremosthelpfulat:http://www.consumerreports.org/cro/2012/08/relief-from-springtime-allergies/index.htm.
Studieshavefoundthatsomepeoplewhogetprescriptionsforallergymedicinedonotactuallyhaveallergies.Ifyouaretakingantihistaminesorotherallergymedicineregularly,youshouldconsultadoctortomakesurethatyoudohaveallergies,andthatthemedicationisappropriateforyourcondition.
Ifadoctordeterminesthatyouhaveanallergy,treatmentisimportant.Mountingevidencehasfoundthatpeoplewithallergiesareatmuchhigherriskofdevelopingasthmaandsinusinfections(sinusitis).Andtheinflammationthataccompanies(andtosomedegreefosters)theallergicresponsecandamagetherespiratorysystemandmakeyoumoresusceptibletolunginfectionslikepneumonia.
So,onewaytothinkabout
antihistamines,andotherallergy
medicine,isthatthey’renotjustfor
symptomreliefbutmighthelpprevent
theprogressiontomoresevereand
potentiallylife-threateningproblems.
Ifyouknowyouhaveallergies,you’reastrongcandidateforantihistamines,andareprobablyalreadytakingone.Yourchoicesareabitmorecomplexifyouarenotsurewhetheryoursymptomsareduetoanallergy.Tables1and2onpages7and8willhelpyousortoutwhatcouldbecausingyoursymptoms.
WhatAreAntihistaminesandWhoNeedsThem?
USINGTHEANTIHISTAMINESTOTREAT:ALLERGIES,HAYFEVER,ANDHIVESCONSUMERREPORTSBESTBUYDRUGS 7
Themostcommonmistakeisthinkingyouhaveallergieswhenyouactuallyhaveacold,bronchitis,acough,ormildflu.
Ifyouhaveoneofthoseconditions,youmightneedmorethananantihistamineforrelief.Manynonprescriptioncoldandflumedicinescontainanantihistaminealongwithotherdrugs.Theyincludefeverreducersandpainrelieverssuchasaspirin,acetaminophen,andibuprofen.
Youcouldalsohaveamoreseriouscondition.Someolderpeoplewhohaveapersistentcough,troublebreathing,orboth,mightbeintheearlystagesofheartfailureoremphysema,forexample.
Youshouldseeadoctorifyoursymptomscontinue.Allergy-inducedasthmaorsevereallergicreactionsdon’trespondwelltoantihistaminesaloneandshouldbetreatedwithother,morepotentmedicines.Inparticular,youshouldseeaphysicianimmediatelyifyouhaveseriousbreathingproblemsassociatedwithanallergicreaction.
WhatAreAntihistaminesandWhoNeedsThem?
Table1.DoYouHaveAllergiesorSomethingElse?
Location ProbablyAllergies ProbablyNOTAllergies
NoseandEyes ■■ Sneezing
■■ Tearyeyes
■■ Itchynoseandthroat
■■ Congestion,runnynose
■■ Clearnasaldischarge
■■ Cough(sometimes)
■■ Headache(sometimes)
■■ Facialpain(sometimes)
■■ Sorethroat
■■ Runnynosewithcolored,sometimesthick,mucusdischarge
■■ Fever(slightifacold;higheriftheflu)
■■ Cough,chestcongestion
■■ Muscleaches,feelingachyallover
Skin ■■ Itchy,red,scalingpatches,oftenontheface,elbowsorknees(eczema)
■■ Itchy,red,largemap-likepatchesonthebody(hives)
■■ Painful,redblistersbutnotitchyrashesappearingsoonaftercontactwithoffendingsubstance(e.g.poisonoakorivy,orcausticsubstance)andonlywherecontactoccurred
■■ Itchy,redrashingroin,underarms,onfeetorunderbreastinwomen(likelyfungal)
■■ Silveryscalypatchesthatsometimesitch(maybepsoriasis)
■■ Itchyskinwithoutrash(simpledryskin)
Source:Adaptedfrom“IsitJustanAllergy?”Consumer Reports on Healthnewsletter,May2005(Vol.15,No.5),page4.
USINGTHEANTIHISTAMINESTOTREAT:ALLERGIES,HAYFEVER,ANDHIVESCONSUMERREPORTSBESTBUYDRUGS 8
WhatAreAntihistaminesandWhoNeedsThem?
Table2.IsitanAllergyorAsthma?
HayFeverorAllergies Asthma
Whatisit? ■■ Abodilyreactiontousuallyharmlesssubstancesintheenvironment—mostoftenpollen,mold,andanimaldander.
■■ Aconditioninwhichtheairwaysinthelungsbecomeswollenandnarrow,makingitdifficulttobreatheandgetenoughoxygeninandoutofyourlungs.Canbetriggeredbypollen,mold,dander,smokeandairpollution,exercise,otherillness,stress,andsomedrugs.
Whydosomepeoplegetit?
■■ Geneticpredisposition
■■ Canstrikepeopleofallages,butoftenshowsupinchildhoodandteenyears
■■ Geneticpredisposition
■■ Infectioncantriggerasthma
■■ Usuallyshowsupinchildhood;lesscommonlystrikesoverage25
MainSymptoms
■■ Sneezing
■■ Tearyeyes
■■ Itchynoseandthroat
■■ Congestion,runnynose
■■ Clearnasaldischarge
■■ Cough(sometimes)
■■ Difficultybreathing(sometimes)
■■ Headache(sometimes)
■■ Itchyredpatchesonskin(hives)
Mildattacks:
■■ Feelingoutofbreath
■■ Tightnessinchest
■■ Wheezing
■■ Coughing
Severeattacks:
■■ Verydifficulttobreath
■■ Difficultytalking
■■ Skinfeelsasifit’spulledtightlyaroundribsandneck
■■ Rapidheartbeat
■■ Mustsitdown,can’twalkeasily
MainTreatmentOptions
■■ Nasalsprays
■■ Antihistamines
■■ Decongestants
■■ Allergyshots
■■ Inhalersandnebulizerscontainingshort-actingbronchodilators
■■ Inhalerscontainingsteroids
■■ Leukotriene-blockerpills
■■ Steroidpillsorshots
■■ Immune-systemmodifiers
Source:Adaptedfrom“IsitJustanAllergy?”Consumer Reports on Healthnewsletter,May2005(Vol.15,No.5),page4.
USINGTHEANTIHISTAMINESTOTREAT:ALLERGIES,HAYFEVER,ANDHIVESCONSUMERREPORTSBESTBUYDRUGS 9
Antihistaminesareeffectiveandgenerallysafe.Theylessenthesymptomsofhayfever,hives,andotherallergiesinamajorityofpeople,thoughtheydon’tusuallyrelievesymptomsentirely.Andsomepeoplegetmorereliefthanothers.Antihistaminescanalsobecomelesseffectivewithlong-termuse.
Ouranalysisindicatesthatthetabletandliquidformsofsecond-generationantihistamines—cetirizine,desloratadine,fexofenadine,levocetirizine,andloratadine—don’tdifferinanyconsistentwayintermsofeffectiveness,safety,orthesideeffectstheycause.
Theyallgenerallybringsomereliefinonetothreehours.Andalthoughresponsesvary,thedrugscontinuetoworkfor12to24hoursinmostpeople.Butthenasalsprays—azelastineandolopatadine—havebeenlinkedtochangesintastesensations,includingbitternessandnasaldiscomfort.Olopatadinenasalsprayhasbeenlinkedtonosebleeding,soresinthenose,andholesinthenasalseptum.Thoughhumanstudieshavenotbeenperformedinpregnantwomen,animalstudieshavefoundthatbothnasalsprayscancausebirthdefects,sotheyshouldnotbeusedbywomenwhoarepregnantorbreast-feeding.
ChoosinganAntihistamine—OurBestBuyPicks
Table3.SummaryofEvidenceonAntihistamines
GenericName(Brandnames)
UsualAdultDose
ProvenEffectiveAgainstHayFeverandSeasonalAllergies?
ProvenEffectiveAgainstChronicorPerennialAllergies?
ProvenEffectiveAgainstHives?(Urticaria)
Azelastinenasalspray/pump(Astelin,Astepro)
Oneortwosprayspernostriltwicedaily
Yes Yes NA2
Cetirizine(Zyrtec) 10mgoncedaily Yes Yes Yes
Desloratadine(Clarinex) 5mgoncedaily Yes Yes Yes
Fexofenadine(Allegra) 60mgonceortwicedaily,or180mgoncedaily
Yes No1 Yes
Levocetirizine(Xyzal) 5mgoncedaily Yes Yes Yes
Loratadine(Alavert,Claritin)
10mgoncedaily Yes Yes Yes
Olopatadinenasalspray(Patanase)
Twosprayspernostriltwicedaily
Yes No NA2
1.Sufficientevidencewasnotavailableforfexofenadine,althoughitislikelyeffectiveintreatingperennialallergysymptoms.
2.NA=Notapplicable;thenasalspraysarenotusedfortreatinghives.
USINGTHEANTIHISTAMINESTOTREAT:ALLERGIES,HAYFEVER,ANDHIVESCONSUMERREPORTSBESTBUYDRUGS 10
Thereisonlylimitedresearchthathaslookedattheuseoftheseantihistaminesfortreatinghives.Loratadineappearsbetteratreducingsymptomsthancertirizineintwostudies.Cetirizinewasmoreeffectivethanfexofenadineinonestudy.Andlevocetirizineprovidedbettersymptomreliefthandesloratadine,buttherewasnodifferenceinimprovementsinquality-of-life.
Allofthenewerantihistaminescauselesssedationanddrowsinessthanolderantihistamines.Studiesindicatethatcetirizineandlevocetirizinearemoresedatingthanloratadineanddesloratadine,andthatcetirizinemightbemoresedatingthanfexofenadine.Cetirizinewasassociatedwithanincreasedriskofabnormalheartrhythminonestudy,butotheranalyses,includingalargesafetyanalysisbytheFDA,foundnoincreasedrisk.
Instudiescomparingthenewermedications,15to25percentofpeoplereportedatleastonesideeffect,includingdrowsiness.(SeeTable4totheright.)Butthreepercentorfewerstoppedtreatmentbecauseofsideeffects.Thus,aspresentedinTable3onpage9,thenewerantihistaminesarequitecomparable,withnoneofferingadistinctadvantageovertheothers.Buttheircostdifferssignificantly.AsTable5startingonpage12shows,theyrangefrom$8permonthtomorethan$200permonth.
Takingeffectiveness,safety,cost,anddosingconvenienceintoaccount,wehaveselectedthefollowingantihistaminesasConsumerReports Best Buy Drugs:
■■ Cetirizine10mgtablets
■■ Loratadine10mgtablets
■■ Loratadinedissolving10mgtablets
■■ Loratadineliquid10mg
■■ Alavertdissolving10mgtablets
Allarelow-costgenericdrugsavailablewithoutaprescriptionindrugandfoodstores,andmanysmallconveniencestores.Andallareaseffectiveandsafeastheothersecond-generationantihistamines.
Loratadineandcetirizinearemadebyseveralcompanies,andsomepharmacychainshavetheirownversionofit.Alavertisa“brandedgeneric”formofloratadine.Abrandedgenericisacopyofanoriginaldrug(inthiscaseClaritin)givenaspecialnamebyitsmanufacturerformarketingpurposes.
Cetirizineisalsoavailableover-the-counterinsoftgelcapsuleandliquidformulationsforpeoplewhoneedthose.
ChoosinganAntihistamine—OurBestBuyPicks
Table4.AntihistamineSideEffects
RelativelyMinor(usuallygoawayintime)
■■ Drowsiness
■■ Drymouth,nose,orthroat
■■ Hoarseness
■■ Headache
■■ Dizziness
■■ Nausea
Moreserious(canbeannoyingordangerousandshouldbereportedtoahealth-careprofessional)
■■ Rapidorpoundingheartbeat
■■ Unusualweakness
■■ Nervousness
■■ Stomachpain
■■ Yellowingoftheskin
■■ Difficultyurinating
■■ Visionproblems
USINGTHEANTIHISTAMINESTOTREAT:ALLERGIES,HAYFEVER,ANDHIVESCONSUMERREPORTSBESTBUYDRUGS 11
Youshouldalsobeawarethatsomepeoplemayrespondwelltooneantihistaminewhilegettingnobenefitfromanother.Soifloratadineorcetirizinedoesnotworkforyou,thentryoneoftheotherantihistamines.
AsyoucanseefromTable5startingonpage12,themonthlycostsforourBest Buysvaryconsiderably.That’scommonfornonprescriptiondrugs,soweurgeyoutoshoparoundforthebestprice,especiallyifyouneedtotakeanantihistamineonaregularbasis.YoumightwanttocheckonlineaswelltoseewhichpharmacychainsofferthebestpricesonourBest Buys.
Thereislittleresearchofgoodquality
ontheuseofsecond-generation
antihistaminesbychildren.Because
ofthis,thereisinsufficientevidence
todetermineifanyofthesecond-
generationantihistaminesaremore
effectiveatrelievingsymptomsor
posegreatersafetyconcernsthanthe
others.Butoverall,themedicationsare
well-toleratedbythem,withlowrates
ofwithdrawalduetoadverseevents.
Ifyourchildneedsanantihistaminetotreathayfeverorotherrespiratorysymptomsduetoallergiesorhives,weadvisetryingoneofourBest Buyloratadinepicksfirst.Theavailableevidenceindicatesloratadineisjustaseffectiveastheotherover-the-counteroption,cetirizine,butitislesslikelytocausesedation.Onestudyinchildrenfoundcetirizineandloratadinetobejustaseffectiveasfirst-generationantihistaminesforrelievingallergicrhinitissymptoms,andloratadinehasbeenfoundtoprovidesymptomreliefat5mgto10mgdaily.
OurBest Buynonprescriptionmedicinesareavailablein10mgdoses.Shouldyouneedtotakealargerdosetogetsymptomrelief,trytaking20mgofourBest Buys(twopillsorportions).(Notethatthisincreasesyourchancesofhavingsideeffects,includingfeelingdrowsy.)Ifthatdoesnotwork,consultyourdoctor.Youmightneedtotryanotherclassofmedicine.
Ifyouhaveinsurancecoverageformedicine,youshouldcheckyourplan’spolicyonantihistaminestofindoutwhetherantihistaminesarecoveredandhowmuchyouwillhavetopayout-of-pocket.
ChoosinganAntihistamine—OurBestBuyPicks
USINGTHEANTIHISTAMINESTOTREAT:ALLERGIES,HAYFEVER,ANDHIVESCONSUMERREPORTSBESTBUYDRUGS 12
ChoosinganAntihistamine—OurBestBuyPicks
Table5.AntihistamineCostComparison
Note:Ifthepriceboxcontainsa ,thatindicatesthedoseofthatdrugmaybeavailableforalowmonthlycostthroughprogramsofferedbylargechainstores.Forexample,Kroger,Sam’sClub,Target,andWalmartofferamonth’ssupplyofselectedgenericdrugsfor$4orathree-monthsupplyfor$10.Otherchainstores,suchasCostco,CVS,Kmart,andWalgreens,offersimilarprograms.Someprogramshaverestrictionsormembershipfees,socheckthedetailscarefullyforrestrictionsandtomakesureyourdrugiscovered.
GenericNameandDose BrandName1
DrugisaGeneric?2
DrugisOTC?3
UsualAdultDose4 AverageMonthlyCost5
Azelastinenasalspray/pump137mcg
Azelastine Yes NoTwosprayspernostril,twicedaily
$100
Azelastinenasalspray/pump137mcg
Astelin No NoTwosprayspernostril,twicedaily
$203
Azelastinenasalspray/pump205.5mcg
Astepro No NoTwosprayspernostril,twicedaily
$180
Cetirizinetablet10mg Zyrtec No Yes One $19
Cetirizinetablet10mg Generic Yes Yes One $11
Cetirizineliqui-gelcapsule10mg Zyrtec No Yes One $23
Desloratadinedissolvingtablet2.5mg
ClarinexReditabs
No No One $237
Desloratadinedissolvingtablet5mg
ClarinexReditabs
No No One $239
Desloratadinetablet5mg Clarinex No No One $201
Desloratadinetablet5mg Generic Yes No One $97
Desloratadineliquid2.5mg/5mL Clarinex No No 2.5mgperday $117
Fexofenadinetablet60mg Allegra No Yes Two $56
Fexofenadinetablet180mg Allegra No Yes One $24
Fexofenadinetablet60mg Generic Yes Yes Two $36
Fexofenadinetablet180mg Generic Yes Yes One $18
Fexofenadinedissolvingtablet30mg
AllegraODT No No Two $128
Fexofenadineliquid30mg/5mL Allegra No Yes 30mgtwiceperday $14
Levocetirizinetablet5mg Xyzal No No One $119
Levocetirizineliquid2.5mg/5mL Xyzal No No 5mgperday $116
USINGTHEANTIHISTAMINESTOTREAT:ALLERGIES,HAYFEVER,ANDHIVESCONSUMERREPORTSBESTBUYDRUGS 13
ChoosinganAntihistamine—OurBestBuyPicks
Table5.AntihistamineCostComparison(continued)
GenericNameandDose BrandName1
DrugisaGeneric?2
DrugisOTC?3
UsualAdultDose4 AverageMonthlyCost5
Levocetirizinetablet5mg Generic Yes No One $59
Levocetirizineliquid2.5mg/5mL Generic Yes No 5mgperday $87
Loratadinedissolvingtablet10mg
Alavert BG Yes One $12
Loratadinedissolvingtablet10mg
ClaritinReditabs
No Yes One $25
Loratadinedissolvingtablet10mg
Generic Yes Yes One $13
Loratadinetablet10mg Claritin No Yes One $22
Loratadinetablet10mg Generic Yes Yes One $8
Loratadineliqui-gelcapsules10mg
Claritin No Yes One $26
Loratadineliquid1mg/5mL Claritin No Yes 5mgperday $15
Loratadineliquid1mg/5mL Generic Yes Yes 5mgperday $8
Olopatadinenasalspray Patanase No NoTwosprayspernostril,twicedaily
$153
1. “Generic”indicatesthatthedrugissoldasageneric.
2. “Yes”meansitisageneric,soldunderthechemicalorscientificname.“BG”meansitisabrandedgeneric,whichisagenericcopyofanoriginaldruggivenaspecialnamebyitsmanufacturer.Inthistable,forexample,Alavertisabrandedgeneric.“No”meansitisabrand-namedrug.
3. OTCstandsforover-the-counter;“yes”meansitisanonprescriptionOTCdrug.
4. Frequencyofusereflectsrecommendationsonthepackageinsert;someproductscanbeusedmoreorlessfrequently.
5. Fordrugsavailablebyprescriptiononly,monthlycostsreflectnationwideretailaveragepricesforFebruary2013,roundedtothenearestdollar.DataisprovidedbySourceHealthcareAnalytics,Inc.,whichisnotinvolvedinouranalysisorrecommendations.FordrugsavailableOTC,priceswereobtainedbyConsumerReportssecretshoppersfromfivemajorchainpharmacies(CVS,RiteAid,Target,Walgreens,andWalmart)andlocalsupermarketsacrosstheU.S.inJanuary2013,andinsomecases,priceswereobtainedbyConsumerReportsinJune2013attheonlinesitesofthosechainpharmacies.Thepricesfromthevariousstoreswereaveragedtoyieldperpillprices,whichwerethenconvertedintoamonthlypricebasedonthemaximumrecommendednumberofpillsperday.
USINGTHEANTIHISTAMINESTOTREAT:ALLERGIES,HAYFEVER,ANDHIVESCONSUMERREPORTSBESTBUYDRUGS 14
Thissectionpresentsmoreinformationontheeffectivenessandsafetyofantihistamines.
Thisreportisbasedonananalysisofthescientificevidenceonsecond-generationantihistamines.Overall,3,121studiesandresearcharticleswereidentifiedandscreened.Fromthese,theanalysisfocusedon18studiesthatprovideddirectevidenceofcomparativeeffectivenessorsafety.
HowEffectiveAreAntihistamines?
Thescientificliteraturecomparingantihistamineswitheachotherisnotextensive.Mostofthestudiesareshort-term,andonlyafewincludelargenumbersofpeople.Takenasawhole,theevidenceindicatesthattheavailabledrugsdonotdiffersubstantiallyineffectiveness.Withall,reliefofsymptomsusuallybeginsinonetothreehoursandlasts12to24hoursformostpeople.
Theevidenceisparticularlyweakcomparingantihistaminesinpeoplewhohavechronicallergiesandneedtotakethedrugsfromtime-to-timeallyearlongandovermanyyears.Andthere’snoevidence—becausethestudieshavenotbeendone—thatfexofenadine(Allegraandgeneric)iseffectiveinsuchpeople,thoughtheassumptionfromotherevidenceandwideclinicaluseisthatitis.
Allthenewertabletantihistamineshavebeenfoundtobeeffectiveagainsthives,butthereisverylittleevidencecomparingonenewerantihistaminewithanother.Inonestudy,loratadineproducedaslowerbutslightlymorecompletereliefofsymptomscomparedwithcetirizine(Zyrtec)intheearlystages.Butattheendofthestudy,peopletreatedwithbothdrugsdidnotreportsignificantdifferencesintheirresponses.Inanotherstudy,levocetirizinewasbetterforrelievingsymptomsthandesloratadine,butpatientsreported
thatbothdrugsimprovedtheirqualityoflifetoasimilardegree.
HowSafeAreAntihistamines?
Thenewerantihistaminesappeartobequitesafe.Theycauselessdrowsinessthanolderfirst-generationantihistamines.But15to25percentofthepeopletakinganantihistaminewillexperienceasideeffect,includingdrowsiness.Alcoholcanexacerbatedrowsiness,soyoushouldn’tdrinkwhiletakingantihistamines.Andyoushouldusecautionifdrivingoroperatingheavyordangerousmachinerywhiletakinganantihistamine.
Inaverysmallnumberofpeople,antihistaminescancausemoreseriousreactions,suchasrapidheartbeatorheartpalpitations.Seeadoctorifyouexperiencesuchsymptoms.
Thenewerantihistaminescause
drowsiness,butstudiesindicatethey
causelessdrowsinessthantwoolder
antihistamines,diphenhydramineand
chlorpheniramine.
Otherresearchfoundthatcetirizineandlevocetirizineweremoresedatingthanloratadineanddesloratadine.Thereissomeevidencethatcetirizineisalsomoresedatingthanfexofenadine.Oneobservationalstudyfoundnodifferenceinsedationbetweenloratadineandfexofenadine.
Twosecond-generationantihistamines(terfenadineandastemizole)wereremovedfromthemarketbecausetheyledtoahigherriskofpotentiallyseriousheartproblems.Someevidencesuggeststhattheremightbeaverysmallriskofheartproblemswith
TheEvidence
USINGTHEANTIHISTAMINESTOTREAT:ALLERGIES,HAYFEVER,ANDHIVESCONSUMERREPORTSBESTBUYDRUGS 15
currentlyavailableantihistamines.Alargestudyfoundthatcetirizinewasassociatedwithanincreasedriskofheartarrhythmias.Otherresearch,however,indicatedthatcetirizine,desloratadine,fexofenadine,andloratadinedonotposeanincreasedriskofarrhythmias.
Antihistaminescaninteractwithothermedicineordietarysupplementsinwaysthatcanbedangerous.Besuretotellyourdoctoraboutallothermedicationyoutake,evenifyouthinkitmightnotbeimportant.Themaindrugstobeconcernedaboutare:
■■ Antifungalmedications,suchasketoconazole.Theycanincreasetheeffectofsomeantihistamines.
■■ Aspirin,whichinlargedosescancauseringingintheears(tinnitus),adangersignsometimesmaskedbyantihistamines.
■■ Certaintypesoffruitjuice,suchasgrapefruitjuice,applejuice,andorangejuice.Theymightmakesomesecond-generationantihistamineslesseffective.
■■ Anydrugsknowntochangethewaytheheartbeats,suchasdroperidol.Theyshouldbeusedcautiouslyifyouaretakingantihistamines.
■■ Medicationsusedtoimprovebreathing,suchastheophylline.Theymayraisetheriskofantihistaminessideeffects.
■■ Certainantibiotics,suchaserythromycin.Theycanincreasetheeffectsofantihistamines.
■■ Antacidsthatcontainaluminumormagnesium.Whentakenwithin15minutesoffexofenadine,theseantacidssignificantlydecreasedtheeffectofthatantihistamine.
■■ Thestomachacidreducercimetidine,whichincreasestheeffectofazelastinenasalspray.
Ifyoutakeanantihistamine
combinedwithadecongestantcalled
pseudoephedrine(lookonthepackage
wheretheactiveingredientsarelisted),
beawarethatsuchproductsshould
beusedwithcautionbypeoplewith
highbloodpressure,heartconditions,
diabetes,glaucoma,orprostate
disease.
Peoplewhotakeproductsthatcombinethesedrugsaremorelikelytohavesideeffects,suchasheadachesandtroublesleeping.
Age,Race,andGenderDifferences
Peopleolderthan65andmembersofvariousethnicgroupshavebeenunder-representedinstudiesofantihistamines.Theevidenceisinsufficienttodetermineifanyofthenewerantihistaminesaresaferorbetterthantheothersatrelievingallergysymptomsamongpeopleofanyparticularracialgrouporage.There’salsoinsufficientevidencetodetermineifmenandwomenrespondtothedrugsdifferently.
Butsafetyandsideeffectsareaconcernindifferentagegroups.Desloratadine(Clarinex),levocetirizine(Xyzal),andcetirizine(Zyrtec)havebeenfoundtobesafeandeffectiveinchildrenasyoungassixmonthsold;evidenceonthesafetyandefficacyofloratadineislimitedtochildrentwoyearsorolder.Evidenceonfexofenadine,azelastinenasalspray,andolopatadinenasalsprayislimitedtochildrensixyearsorolder.
TheEvidence
USINGTHEANTIHISTAMINESTOTREAT:ALLERGIES,HAYFEVER,ANDHIVESCONSUMERREPORTSBESTBUYDRUGS 16
Childrenmightexperiencedrowsiness
tovaryingdegreeswhentaking
antihistamines,andtheadults
responsibleforthemshouldbealert
tothis.Thisisespeciallyimportant
whenitcomestoteenagerswhodrive,
becausedrowsinesscanimpedethe
abilitytooperateanautomobilesafely.
Peopleage60andolderaremoresusceptibletothesideeffectsofantihistamines,especiallydrowsiness.Peopleolderthan70orsoareatgreaterriskoffallsingeneral,andantihistamine-induceddrowsinesscanraisethatrisk.Thedosageofsomesecond-generationantihistamines(primarilyZyrtec)shouldbereducedinolderageandforpeoplewithkidneyorliverproblems.
Pregnantornursingwomenshouldonlyusethesecond-generationantihistaminesiftheirdoctoragreesit’sabsolutelynecessary.Andeventhen,itshouldbelimitedtotheoralandliquidformulations—cetirizine,desloratadine,fexofenadine,levocetirizine,andloratadine.Animalstudiesindicatethatthosesecond-generationantihistaminesdon’tincreasetheriskofbirthdefects.Noclinicaltrialshavebeendoneinpregnantwomentoascertainthebirthdefectrisk.Azelastinenasalspraycausedbirthdefectsinmouse,rabbit,andratstudies,andolopatadinenasalsprayhasbeenassociatedwithadverseeffectsonfetusesinanimalstudies.
TheEvidence
USINGTHEANTIHISTAMINESTOTREAT:ALLERGIES,HAYFEVER,ANDHIVESCONSUMERREPORTSBESTBUYDRUGS 17
It’simportantforyoutoknowthatthe
informationwepresenthereisnotmeantto
substituteforadoctor’sjudgment.Butwe
hopeitwillhelpyouandyourdoctorarrive
atadecisionaboutwhichantihistamineand
doseisbestforyou,ifoneiswarrantedatall,
andwhichgivesyouthemostvalueforyour
health-caredollar.
1.Mentioncosttoyourdoctor.Bearinmindthatmanypeoplearereluctantto
discussthecostofmedicineswiththeirdoctor,andthatstudieshavefoundthatdoctorsdonotroutinelytakepriceintoaccountwhenprescribingmedicines.Unlessyoubringitup,yourdoctormayassumethatcostisnotafactorforyou.
2.Askaboutoldermedications.Manypeople(includingphysicians)think
thatnewerdrugsarebetter.Whilethat’sanaturalassumptiontomake,it’snotalwaystrue.Studiesconsistentlyfindthatmanyoldermedicinesareasgoodas,andinsomecasesbetterthan,newermedicines.Thinkofthemas“triedandtrue,”particularlywhenitcomestotheirsafetyrecord.Newerdrugshavenotyetmetthetestoftime,andunexpectedproblemscananddocropuponcetheyhitthemarket.Ofcourse,somenewerprescriptiondrugsareindeedmoreeffectiveandsafer.Talkwithyourdoctoraboutnewervs.oldermedicines,includinggenericdrugs.
3.Considergenericdrugs.Prescriptionmedicinesgo“generic”whena
company’spatentsonthemhavelapsed,usuallyafterabout12to15years.Atthatpoint,othercompaniescanmakeandsellthedrugs.Genericsaremuchless
expensivethannewerbrand-namemedicines,buttheyarenotlesserqualitydrugs.Indeed,mostgenericsremainusefulmedicinesevenmanyyearsafterfirstbeingmarketed.Thatiswhymorethan75percentofallprescriptionsintheU.S.todayarewrittenforgenerics.
4.Keepup-to-daterecords.Anotherimportantissuetotalkwithyour
doctoraboutiskeepingarecordofthedrugsyoutake.Thereareseveralreasonsforthis:
■■ First,ifyouseeseveraldoctors,eachmaynotbeawareofmedicinestheothershaveprescribed.
■■ Second,sincepeopledifferintheirresponsetomedications,it’scommonfordoctorstodaytoprescribeseveralmedicinesbeforefindingonethatworkswellorbest.
■■ Third,manypeopletakeseveralprescriptionmedications,nonprescriptiondrugs,anddietarysupplementsatthesametime.Theycaninteractinwaysthatcaneitherreducethebenefityougetfromthedrugorbedangerous.
■■ Fourth,thenamesofprescriptiondrugs—bothgenericandbrand—areoftenhardtopronounceandremember.
Forallthesereasons,it’simportanttokeepawrittenlistofallthedrugsandsupplementsyoutakeandperiodicallyreviewitwithyourdoctors.
5.Knowthefacts.Finally,alwaysbesurethatyouunderstand
thedoseofthemedicinebeingprescribedandhowmanypillsyouareexpectedtotakeeachday.Yourdoctorshouldtellyouthisinformation.Whenyoufillaprescriptionatapharmacy,orifyougetitbymail,checktoseethatthedoseandthenumberofpillsperdayonthebottlematchtheamountsyourdoctortoldyou.
5 TipstoTalkingWithYourDoctor
USINGTHEANTIHISTAMINESTOTREAT:ALLERGIES,HAYFEVER,ANDHIVESCONSUMERREPORTSBESTBUYDRUGS 18
Ourevaluationisprimarilybasedonanindependentscientificreviewoftheevidenceontheeffectiveness,safety,andadverseeffectsofsecond-generationantihistamines.PhysiciansandresearchersattheOregonHealth&ScienceUniversityEvidence-BasedPracticeCenterdidtheanalysisaspartoftheDrugEffectivenessReviewProject,orDERP.
DERPisafirst-of-its-kind,multi-stateinitiativetoevaluatethecomparativeeffectivenessandsafetyofhundredsofprescriptiondrugs.AsynopsisofDERP’sanalysisoftheantihistaminesformsthebasisforthisreport.AconsultanttoConsumer Reports Best Buy DrugsisalsoamemberoftheOregon-basedresearchteam,whichhasnofinancialinterestinanypharmaceuticalcompanyorproduct.
ThefullDERPreviewofantihistaminesisavailableathttp://derp.ohsu.edu/about/final-document-display.cfm(Thisisalongandtechnicaldocumentwrittenforphysicians.)
Additionalinformationwasextractedfromwww.ConsumerReports.org,Consumer Reports,andanarticleinConsumer Reports on Health.Consumer Reports on HealthisasubscriptionmonthlynewsletterpublishedbyConsumersUnion.
Theprescriptiondrugcostswecitewereobtainedfromahealth-careinformationcompanythattracksthesalesofprescriptiondrugsintheU.S.Pricesforadrugcanvaryquitewidely,evenwithinasinglecityortown.Thepricesforprescriptiondrugsinthisreportarenationalaveragesbasedonsalesofthedrugsinretailoutlets.Theyreflecttheretailcashpricethatwouldbepaidforamonth’ssupplyofeachdruginFebruary2013.Pricesfornonprescriptiondrugswereobtainedfromseverallargedrugstorechains.TheyreflectaveragepricesinJanuary2013.
ConsumerReportsselectedtheBest Buy Drugsusingthefollowingcriteria.Thedrug(anddose)hadto:
■■ BeapprovedbytheFDAfortreatingallergicrhinitis
■■ Beaseffectiveasanyothersecond-generationantihistamine
■■ Haveasafetyrecordequaltoorbetterthanothersecond-generationantihistamines
■■ Haveanaveragepricefora30-daysupplythatissubstantiallylowerthanthemostcostlysecond-generationantihistaminemeetingthefirsttwocriteria
TheConsumers Reports Best Buy DrugsmethodologyisdescribedinmoredetailintheMethodssectionatwww.CRBestBuyDrugs.org.
HowWePickedtheBestBuyAntihistamines
USING THE ANTIHISTAMINES TO TREAT: ALLERGIES, HAY FEVER, AND HIVESCONSUMER REPORTS BEST BUY DRUGS 19
This copyrighted report can be freely downloaded, reprinted, and disseminated for individual noncommercial use without permission from Consumers Union as long as it clearly attributed to Consumer Reports Best Buy Drugs™. We encourage its wide dissemination as well for the purpose of informing consumers. However, Consumer Reports does not authorize the use of its name or materials
for commercial, marketing, or promotional purposes. Any organization interested in broader distribution of this report should contact us at [email protected]. Consumer Reports Best Buy Drugs™ is a trademark of Consumers Reports. All quotes from the material should cite Consumer Reports Best Buy Drugs™ as the source.
©2013 Consumers Reports of United States, Inc.
Consumer Reports is an independent and nonprofit organization whose mission since 1936 has been to provide consumers with unbiased information on goods and services and to create a fair marketplace. Its website is www.consumerreports.org.
Consumer Reports Best Buy Drugs is a public-education project administered by Consumers Union. These materials were made possible by the states Attorney General Consumer and Prescriber Education Grant Program, which is funded by a multistate settlement of consumer-fraud claims regarding the marketing of the prescription drug Neurontin.
The Engelberg Foundation provided a major grant to fund the creation of the project from 2004 to 2007. Additional initial funding came from the National Library of Medicine, part of the National Institutes of Health. A more detailed explanation of the project is available at www.CRBestBuyDrugs.org.
We followed a rigorous editorial process to ensure that the information in this report and on the Consumer Reports Best Buy Drugs website is accurate and describes generally accepted clinical practices. If we find, or are alerted to, an error, we will correct it as quickly as possible. But Consumer Reports and its authors, editors, publishers, licensers, and suppliers cannot be responsible for medical errors or omissions, or any consequences from the use of the information on this site. Please refer to our user agreement at www.CRBestBuyDrugs.org for further information.
Consumer Reports Best Buy Drugs should not be viewed as a substitute for a consultation with a medical or health professional. This report and the information on www.CRBestBuyDrugs.org are provided to enhance your communication with your doctor rather than to replace it.
Sharing this Report
About Us
USINGTHEANTIHISTAMINESTOTREAT:ALLERGIES,HAYFEVER,ANDHIVESCONSUMERREPORTSBESTBUYDRUGS 20
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References