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Suggest an alternative medication for Cetirizine

Answered by
Dr.
Dr. Parin N. Parmar

Allergist and Immunologist

Practicing since :2006

Answered : 870 Questions

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Posted on Tue, 11 Oct 2016 in Asthma and Allergy
Question: Hi Doctor. I have been having allergic rhinitis. I have been taking cetrizine/levo cetrizine (both work equally good on me) for almost 10 years now (the last few years i took it for almost 1 tab every alternate day). This continued till end of year 2014, post which i did a 6 month course of mometasone nasal spray (July'14 to Dec'14) as advised by a doctor friend who himself had this problem and was using it and had positive results. I used it intermittently post the 6 month course and the results were amazing. I stopped using it from January'15. Now since 1 month I am having cold and same symptoms to begin with itching, sneezing and then running nose (same as before). I have been having 1 cetrizine every alternate day since 1 month and since last 10 days using mometasone spray but both don't seem to work now. Also, to bring to your notice I had viral cold and fever a month back. Can you guide me on the following 1. What should I currently do as of now to control this cold problem? 2. Should i replace cetrizine with loratadine (i havnt used this earlier but just read about it on the internet and spoke to a GP once)? 3. Is there any other alternate form of medicine other than these modern drugs to cure or prevent/control this form of cold? 4. Is there a permanent cure to this problem? Kindly guide, thanks!
doctor
Answered by Dr. Parin N. Parmar 3 hours later
Brief Answer:
The questions answered, more details desirable

Detailed Answer:
Hello XXXXXXX

Thank you for asking at HCM.

I went through your query and would like to know more about your symptoms as follows:

a. Apart from nasal itching, running nose, and sneezing, do you have nose congestion/feeling of nose obstruction? Do you need to breath through mouth?

b. Do you have accompanying eye symptoms - excessive tears from eyes, redness in eyes, itching in eyes, etc?

c. Have you had experienced ear symptoms anytime - fullness in ear, ear pain, ear discharge, itching in ear, etc?

d. Do you have symptoms like fullness/heaviness over face or headache?

e. Do you smoke? Or are you exposed to passive smoke? Are you exposed to other air-pollutants or irritants like perfumes, sprays, etc?

f. What is the best season for you? What is the worst season for you? What is the most common time in the day when you have maximum symptoms (midnight, early morning, evening, etc)Have you observed any environmental/food triggers for your symptoms? (will give clue towards air-born allergens)

g. How is your digestion? Do you have any symptoms like constipation, acidity, diarrhea, pain in abdomen, etc? (for possible food allergy)

i. Do you have/have had in past any skin symptoms like itching, rash, dermatitis, urticaria, etc? (for possible skin allergy)

j. Have you ever had any allergy test? You have mentioned allergies to dust, mites, and smoke. How were they diagnosed?

k. Does anyone in your family have any allergic problem? (allergy often runs in family)

As an Allergist-Immunologist, above details will help me to understand your problem and to make better suggestions for you.

At present, based on your details, I would like to reply to your four question as follows:

1. What should I currently do as of now to control this cold problem?

Ans: As you had a viral cold with fever one month back, I would suggest my such patient a combination of montelukast and fexofenadine once daily for at least 14 days. Montelukast has additional beneficial effect in allergic cause.

Mometasone spray can take 10-14 days to get its best effect, so I would suggest my such patient to continue it for one more week or so.

As symptoms would improve, I would gradually reduce the medications.

2. Should i replace cetrizine with loratadine (i havnt used this earlier but just read about it on the internet and spoke to a GP once)?

Ans - Both cetirizine and loratidine are antihistamines, so as levocetirizine and fexofenadine. So, as long as effect on symptoms, no one has special advantage over the other.

Important aspect is sedation as side effect - usually, among the above four, sedation is more with cetirizine. Fexofenadine and loratadine have least sedation. Levocetirizine is in between.

Hence, if my patient is comfortable with cetirizine, and is not experiencing any side effect, I usually do not suggest him/her to change antihistamine. If one experiences any side effect, the drug can be changed.

3. Is there any other alternate form of medicine other than these modern drugs to cure or prevent/control this form of cold?

Ans - All the drugs - antihistamines, montelukast, and nasal steroid sprays - are used to control symptoms and do not work on immunity level. Allergy is an immunological abnormality. Hence, symptoms return after stopping drugs.

However, to my patients, I suggest following measures to reduce requirement of drugs:

Steam inhalation (with caution to avoid possible burns over face due to spillage of hot water) helps to reduce congestion, especially those who have symptoms that aggravate in cold environment. So I suggest my such patients daily steam inhalation before going to bed.

Nasal breathing exercises or pranayama like anuloma-viloma help to improve allergic rhinitis symptoms on a long run. But they do not work immediately.

I also suggest my patients to stay away from aggravating factors - dust, air-pollution, smoke, sprays, perfumes, stress, cold wind, physical and mental stress, etc.

4. Is there a permanent cure to this problem?

Ans - As I mentioned above, allergy lies in immunity. It is important to consult an allergist-immunologist. He will perform allergy skin prick testing for specific air-borne and food-born allergens (particles) and identify the allergens that are causing symptoms to you.

One an air-borne allergen (such as house dust mite) is identified, he will suggest to you allergen specific immunotherapy, which, in simple language, gradually retrains your immune system towards normal response. Immunotherapy is a long process, it takes a few months to be effective, and then has to be continued for minimum of 3 years. As immunotherapy shows its effect, your medicine requirement reduces significantly.

Based on allergy testing, an allergist-immunologist will also suggest you specific avoidance measures for the allergens that you are allergic to.

For long-lasting relief, I suggest my such patients combination of appropriate use of medications, immunotherapy, allergen avoidance, steam inhalation, stress reduction and lifestyle management (better diet, regular exercise, yoga, pranayama, etc). This is important as our immune system is affected adversely by inappropriate diet and stress & worries.

Hope above answers help you.

If you have further queries, please feel free to ask on follow-up and please give the details that I have asked.

Wish you the best of the recovery and a complete health and well-being ahead.

Thank you very much & regards,

Dr Parin N Parmar
Consultant Allergist-Immunologist
Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Parin N. Parmar 18 hours later
Thank you Dr for your valuable advise, this is really helpful. Answering your questions one by one;

a. Apart from nasal itching, running nose, and sneezing, do you have nose congestion/feeling of nose obstruction? Do you need to breath through mouth?
Ans. I usually donot have congestion in my nose, it usually starts with sneezing 5-10 times followed by running nose which continues untill i take an antihistamine.

b. Do you have accompanying eye symptoms - excessive tears from eyes, redness in eyes, itching in eyes, etc?
Ans. While i have cold i do have itching in my eye, eyes become photosensitive, also redness at times.

c. Have you had experienced ear symptoms anytime - fullness in ear, ear pain, ear discharge, itching in ear, etc?
Ans. No.

d. Do you have symptoms like fullness/heaviness over face or headache?
Ans. No.

e. Do you smoke? Or are you exposed to passive smoke? Are you exposed to other air-pollutants or irritants like perfumes, sprays, etc?
Ans. I smoke occasionall, although i havent smoked for last 1 year now. I do use deodrants and perfumes but very cautiously since i know it triggers my cold.

f. What is the best season for you? What is the worst season for you? What is the most common time in the day when you have maximum symptoms (midnight, early morning, evening, etc)Have you observed any environmental/food triggers for your symptoms? (will give clue towards air-born allergens)
Ans. I am in XXXXXXX right now and looks like the current season is worse for me. Mostly its the same for entire year. I was in Europe for a month last year in december and to my XXXXXXX I had no cold for a single day there (might be because of less dust and mites there or may be the cold climate.
My cold usually begins when i wakeup in the morning and it aggrevates post taking bath which might be because of the soap and rubbing my nose while taking bath (i avoid rubbing to hard). Although i havent undergone any allergen test, i believe dust and mites are the major reason for my problem followed by smoke.

g. How is your digestion? Do you have any symptoms like constipation, acidity, diarrhea, pain in abdomen, etc? (for possible food allergy)
Ans. I used to have constipation earlier, but no such problem since last 5-7 years. Although i do have acidity issue at times which is mostly when i have stress related to work or any other form.

i. Do you have/have had in past any skin symptoms like itching, rash, dermatitis, urticaria, etc? (for possible skin allergy)
Ans. No.

j. Have you ever had any allergy test? You have mentioned allergies to dust, mites, and smoke. How were they diagnosed?
Ans. No.

k. Does anyone in your family have any allergic problem? (allergy often runs in family)
Ans. My dad used to have cold issue long back. It remained for some years but later subsided. He has such issue now. This is the reason why i think it might be a heredity problem.

If my answers are not satisfactory kindly do let me know, i can decipher it further.

A few more questions if I may ask;
1. Will smoking aggravate my cold problem?
2. How to get rid of mites on my bed,sofa, etc (although not a question to be asked to a Dr, still if you may guide basis your experience with such patients)

An important info which i forgot to share it earlier is that my nose has become very sensitive and if i touch it or itch it the cold begins with sneezing and so on. Thanks.
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Follow up: Dr. Parin N. Parmar 8 minutes later
A few more things to share;
a. My cold begins with lot of itch inside my nose just below where the nose bone starts because of which the sneezing begins followed by running nose (it is the most sensitive area in my nose now, even if i just insert my finger there and touch it the cold begins). Although the itch begins while i wake up in the morning, it can happen any time of the day at some instances and then the story begins.

b. Since my dad is a GP and he brings home generic cetrizine or avil home from his clinic which i use it while i have cold. Do you think i should shift to branded medicines rather than using these generic medicines for better results?

c. Cetrizine/levocetrizine and avil, both of them give me sedation which hinders my work most of the times. Is it recommended for me to try the other antihistamine you suggested?
doctor
Answered by Dr. Parin N. Parmar 50 minutes later
Brief Answer:
Answers to your questions

Detailed Answer:
Hello Mr XXXXXXX

Thank you for your follow-up and the valuable information that is helpful for reaching closer to diagnosis.

a. It's good that you don't have congestion, probably because you have used medications, including intranasal spray regularly. Otherwise, in longstanding cases of allergic rhinitis, congestion and sinusitis become problematic. You don't have developed these issues because you have been taking medications regularly.

b. Eye symptoms often co-exist with allergic rhinitis, known as allergic rhinoconjunctivitis. This suggests allergy to air-born inhalants. Eye symptoms are less common with food allergies.

c & d. You haven't developed ear or sinus-related complications of allergic rhinitis, again, because you have used medications appropriately.

e. I should appreciate that you haven't smoked for last 1 year. Smoking is not advised to those with respiratory allergies. It does not cause, but definitely aggravates allergies, just like other irritants (not allergens) like deos, perfumes, sprays, etc.

f. Early morning symptoms suggest allergy to indoor allergens - such as house dust mites, molds, insect allergens, and pets (if any). House dust mite flourish in wet and cold season. Hence, I would test my such patient for allergy to house dust mites, mold, and insect allergens, by skin prick test, of course. I believe you don't have a pet in home.

House dust mites flourish in closed, over-crowded, humid and cold environments. That could be the reason you were symptom-free in Europe - although cold may be there but there wouldn't be over-crowding and humidity.

Of course, allergy to inhalants (unlike allergy to foods) can only be confirmed after performing allergy testing and getting it interpreted by a qualified allergist.

g & i. You don't seem to have long-standing gastrointestinal or skin problem, so that reduces possibility of a food allergy and skin allergy.

Now, coming to your questions:

1. Please read "e" above.

2. Don't worry, this is the exact question to be asked to an allergist, because they only know scientific measures to control dust mites better.

First important thing to know is, it is products of dust mites, not live dust mites, that cause allergies. Second, they thrive on our dead skin cells and perspiration, so they are most abundant in bedsheets and pillow covers; from here they spread to all other areas due to air-currents.

I suggest my patients following measures to reduce exposure to house dust mites:

--> To wash bedsheeets, pillow covers, mattress-covers, etc every week in hot water (>50 C) and to dry them in sunlight. As house dust mites grow at temperature < 30 and they need humidity for their growth.

--> To make sure that the residence, especially bedroom (because we are exposed to house dust mites maximally in bedroom), gets enough sunlight and is well-ventilated. This is important to minimize growth of dust mites indoors.

--> Avoid curtains, carpets, furry furniture, and upholstered furniture, as much as possible, especially in bedroom. This might not be practical for many.

--> There are house dust mite proof bedsheets available in market, but I do not recommend them to my patients as they alone cannot remove dust mite entirely and are expensive. You could give them a try, if you wish.

Many patients with allergic rhinitis have sensitive nose, because the inner lining of nose is inflamed. So any touch, pressure, environmental change, temperature change, irritants or allergens could trigger symptoms upon exposure.

Your next queries:

a. Itching and sneezing are main symptoms of allergic rhinitis. You start itching when the triggering air-particles enter the nose. This follows the whole cascade of symptoms.

b. There is no problem with generic or branded medicines. What is important is the molecule used in treatment. I don't suggest my patients to shift to branded medicines if generic medicines are working for them.

c. As mentioned in last answer, sedation is more with avil > cetirizine > levocetirizine > fexofenadine > loratadine. So if cetirizine, levocetirizine, and avil are causing sedation and hinder your work, I would suggest consider change to a lesser sedating antihistamine.

As combination of fexofenadine and montelukast is readily available in market (montelukast is a molecule with beneficial effects in allergic disorders), I suggest my such patients combination of fexofenadine and montelukast, if they are experiencing side effects with cetirizine/levocetirizine.

Please note that, on healthcaremagic, I can give you only an expert opinion and give information. I cannot suggest change/prescribe medications, which is best done by your consulting physician.

Hope above answer will be helpful to you.

If you have any further query, please feel free to ask on follow-up.

Wish you best of the health ahead.

Thank you & regards,

Dr Parin N Parmar
Above answer was peer-reviewed by : Dr. Veerisetty Shyamkumar
doctor
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Follow up: Dr. Parin N. Parmar 46 hours later
Thank you for your extended support Dr. A few more questions;

a. I use the mometasone nasal spray just before sleeping everyday - 2 sprays in each nostril (so that i donot get cold while i wake up in the morning). Best relief from the nasal spray is that the irritation in the nose stops because of which i donot get cold.
a.1. Using the spray once a day is enough?
a.2. Is there any other way to control this irritation and sensitivity inside my nose (eg: smelling camphor, operational procedure to remove the sensitive part of the sikn inside my nose or any other method)

* Nose sensitivit/irritation is my biggest enemy as of now!! Kindly guide!!
doctor
Answered by Dr. Parin N. Parmar 1 hour later
Brief Answer:
Can use the spray once, other options discussed

Detailed Answer:
Hello Mr XXXXXXX

Thank you for your follow-up.

Mometasone nasal spray can be used once a day.

During a "bad season", if symptoms worsen despite using nasal spray, one can use it twice a day. After around 2 weeks of gaining good control of symptoms, I would suggest my such patients to reduce frequency back to once a day.

As you have asked for other ways to control nasal irritation, I suggest my patients application of sesame oil or cow ghee inside nose using finger. When properly done, this process forms an oily layer over nasal mucosa, prevents direct contact between mucosa and irritants.

In Ayurveda, this procedure is known as Nasya, where a qualified Ayurveda specialist uses medicated oil for instillation into nose.

Please note that above two ways are not part of allopathy medicine and are not evidence based.

I am not sure about smelling camphor, as camphor can act as an irritant for those with inflamed nasal mucosa, so it could worsen symptoms for some patients.

I am not aware of any evidence-based operational procedure for reducing sensitivity of nasal mucosa. A few experimental procedures may be there and are performed at specialized centers only. Pros and cons of such procedures are best known to ENT surgeons only.

Till date, in modern medicine, best way to improve allergy symptoms on long term basis is allergen specific immunotherapy only.

Hope this helps you.

Wish you best of the health ahead.

Regards,

Dr Parin N Parmar
Above answer was peer-reviewed by : Dr. Priyanka G Raj
doctor
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Follow up: Dr. Parin N. Parmar 2 days later
it was good to seek guidance from you. thank you.
doctor
Answered by Dr. Parin N. Parmar 6 minutes later
Brief Answer:
Thank you, understand allergy & stay healthy with minimum medicines

Detailed Answer:
Hello XXXXXXX

Thank you for your appreciation.

I am happy that my knowledge and experience were helpful to you.

If you don't have any further query, you can close the question. You also can give your feedback and review about your experience if you wish to do so.

By understanding allergy (allergy is an abnormality in immune system, not in nose as what many patients with allergic rhinitis believe), you will be able to control your symptoms with minimum medicines.

Also, by use of immunotherapy and non-pharmacological measures, there is always a possibility of decreased requirement of medicines and have a healthy, better life.

Wish you best of the health ahead.

Thank you very much & best regards,

Dr Parin N Parmar
Consultant Allergist-Immunologist
Above answer was peer-reviewed by : Dr. Priyanka G Raj
doctor
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Follow up: Dr. Parin N. Parmar 8 minutes later
i am really happy to have seeked guidance from you in a thorough professional manner. i feel the way you explained me things and a holistic list of advises shall help me control and manage my problem in a better way. infact my approach will be in the right direction while i try to implement the suggestions you have given. thanks.
doctor
Answered by Dr. Parin N. Parmar 1 hour later
Brief Answer:
Thanks again and please close the question if no further query to ask

Detailed Answer:
Hello XXXXXXX

I am really happy to have your positive feedback.

At this moment, I would like to inform you that you haven't closed your query.

Please do not reply to my this answer if you do not have any further question to ask. Answering to this answer will again be considered a follow-up query by you. After certain limit, follow-ups may not be free for you and you might have to pay.

If you want to know how to close a query, feel free to contact HCM support team. They will definitely help you.

I am happy that you would like to adopt holistic approach towards allergic rhinitis, which makes reduction of medications possible on a long run and also reduces suffering.

Thank you very much for your feedback again.

Best regards,

Dr Parin N Parmar
Consultant Allergist-Immunologist
Above answer was peer-reviewed by : Dr. Nagamani Ng
doctor
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