New York City
- I recently realized that I had reached a milestone in my 30 years plus of practice. I went more than a month without prescribing an antihistamine. This has implications for the way health care is bought and paid for in the United States.
Let's review for a moment the old way of doing things. The first antihistamines, including diphenhydramine (Benadryl) and chlorpheniramine (Chlor-Trimeton) started out as prescription drugs. They had a side effect; they made you sleepy, so you couldn't drive or operate heavy machinery after using them, as the labels still warn.
Drug companies had a medical incentive as well as a financial one to develop the next generation of antihistamines, which didn't knock you out. And so we got the wave of drugs that included loratadine (Claritin), cetirizine (Zyrtec), and fexofenadine (Allegra), which stopped the sneezing and itching without making you long for the couch. Allegra was the last of these medications to go OTC, just a couple of month ago.
As they approached the end of their patent protection, the drug companies that made them started to add a few bells and whistles at the molecular level so they could get premium prices again. But things have changed. Insurance companies don't want to pay for new drugs that don't make a big difference from the old ones. Many allergy patients are self-medicating with older, over-the-counter medications, and for plenty of them that is fine. The OTC drugs cost about the same at retail as a standard co-payment.
However, the OTC, self-medicating approach doesn't work for every allergy or allergy-related condition. Take the example of Primatene. This is the oldest asthma inhaler. It has been advertised on television and the radio for decades, and has been a prominent sponsor of after-midnight programming, complete with celebrity endorsers. Did these athletes actually use the stuff, assuming they have asthma? Not if their team physicians have anything to do with it, because the active ingredients don't just affect the lungs, they stimulate the heart. They have both beta-2, which works on the lungs, and beta-1, which works on the heart, whereas the most common rescue inhaler we use, Albuterol, is specific for the lungs.
This medication will pass into history at the end of the year for an odd reason: it utilizes chlorofluorocarbons (CFCs) as a propellant, and CFCs were fazed out because of their effects on the ozone layer. Replacing it with an acceptable propellant would mean re-certifying the whole drug from scratch, and frankly, I'm not sure it would make it because of that lung-heart action. As an allergist I am not sorry to see it go. However, as a New Yorker, I know it will create a problem for many working poor families that relied on it as a cheap way to function well enough to go to school and work. I hope that public health policy will be wise enough to extend real asthma control to this population.
Just a month ago, the FDA took away more OTC choices when it banned the sale of some 500 over-the-counter drugs for treating symptoms of colds and allergies. These drugs were essentially survivors of a bygone era, the early 1960s, when the FDA was less robust. They had gone all these years without evaluation for safety and effectiveness, and may be riskier than approved drugs.
In the end, the answer to your allergic symptoms will probably lie in a combination of judicious use of drugs, both high-tech and low-tech, changing your behavior, keeping an eye on the weather, perhaps watching what you eat, and generally living right. The most important body part an allergist treats is the brain.