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Australian Journal of Pharmacy : September 2005
pharmacy practice foundation research of regular use. INCS are also effective when used on an ‘as needed’ basis. Sore throat, dry mouth and cough may occur. In higher doses they have been shown to decrease the severity of ocular symptoms. They may do this by reducing allergen- induced increases in reflex nerve activity, so that ocular irritation is reduced as nasal symptoms are reduced. Oral antihistamines Older antihistamines are still available and used extensively in combination products with oral decongestants. The earlier antihistamines commonly cause CNS effects such a somnolence, sedation, drowsiness, fatigue, loss of attention and impaired psychomotor performance, as well as anticholinergic effects including difficulty in micturition, impotence, con- stipation and other gastrointestinal symp- toms. These ‘drugs’ are contraindicated in patients wishing to drive. Second gen- eration antihistamines have a more favourable side effect profile. With regard to the newer (less sedating) antihistamines, these is no evidence that one agent is more effective than any other. They are not as effective as INCS for nasal itching, sneezing and running, and have little or no effect on nasal blockage. This is because histamine is not a significant mediator of the late-phase allergic response. There is, however, an increased risk of sedation and other side effects such as dry mouth and constipation in the eld- erly because the elderly are more sensitive to the effects of drugs in general. The eld- erly are also at increased risk of sedation. The newer antihistamines are not usually used in children under two years. They are safe to use in lactation. In pregnancy, Zyrtec and Telfast are B2 and Claratyne is B1. In some patients they may cause drowsiness and fatigue. Loratadine is also available in combination preparations with pseudoephedrine (Clarinase and Sinease Repetabs). The Australian Medi- cines Handbook 2004 (AMH) stated that there is little sense for these preparations and that they should be avoided.19 With regards to the older (sedating) antihistamines, individual response may vary widely with respect to effectiveness and tolerance. Further, they have many issues associated with their use. They may have additive sedative effects with alcohol and other sedating drugs like medications prescribed for sleep. The patient should always be asked if they are taking any other medication. They may have additive side effects (called anticholinergic side effects) with many other drugs, such as some antide- pressants and antipsychotics, to cause effects such as dry mouth, constipation and hesitancy of urine in males. They may also cause sedation, dizziness, blurred vision, nausea, altered bowel habit and anxiety. Driving (concentration and co-ordination) may be affected. They are used extensively in combina- tion with oral decongestants (and anal- gesics). The AMH stated that there is little rationale for these preparations and that they should be avoided.19 They are not usually used in infants and children younger than two because of the risk of SIDS and near miss SIDS. Many can safely be used in pregnancy. In lactation, their use in the short-term is probably safe. Oral decongestants Oral decongestants are helpful in certain circumstances, such as when patients need to travel by plane. Less effective than top- ical (spray) decongestants without causing rebound nasal congestion, they are con- traindicated in some groups of patients including people with hypertension or coronary artery disease. They should be used with care in patients with heart dis- ease, hyperthyroidism, elevated intraocu- lar pressure, prostatic enlargement or bladder dysfunction. Common adverse effects include CNS stimulation, such as nervousness, excitability and insomnia. Oral decongestants may affect blood glucose control in diabetes because the adrenergic nervous system is involved in control of glucose. People with overactive thyroid glands are more sensitive to these medications. This is because many of the symptoms of hyperthyroidism are those of the adrenergic nervous system. The elderly are particularly susceptible 710 ? THE AUSTRALIAN JOURNAL OF PHARMACY VOL. 86 SEPTEMBER 2005 to their adverse affects. They are not usu- ally used in children younger than two years nor in pregnancy. They are included in many OTC prepa- rations for the relief of nasal obstruction in AR and also for the common cold. They may interact with monoamine oxidase inhibitors (selective and nonselec- tive) because pseudoephedrine and these antidepressants both act to increase nora- drenaline. Blood pressure may then rise markedly. They may also be misused by people dependent on stimulants, or wanting to reformulate them for illegal sale. Intranasal decongestants Topical decongestants act to constrict nasal blood vessels to reduce tissue swelling and nasal congestion. Maximal effects of these agents can be obtained by steam inhalations before use. Very little is absorbed into the body and they rarely cause systemic side effects. Even so, you will find warnings on the container about heart disease, high blood pressure, thyroid disease, diabetes or difficulty in urination due to prostate enlargement. They may cause transient burning or stinging. If this happens, a saline nasal spray can be used to dilute and reduce this irritation initially, and another type of topical decongestant can be tried. After four or five days of continuous use, they may actually begin to cause rebound congestion. Therefore, a com- mon recommendation is to use these preparations for four to five days, then cease for two days. Rebound congestion may take several weeks to reverse. Saline nasal drops and sprays loosen and liquefy mucous secretions and are the medications of choice in children and infants. Topical nasal decongestants are not used in infants younger than six months. The AMH stated that the use of saline nasal sprays or drops should be encouraged in preference to topical nasal decongestants.19 Intranasal anithistamines They are as effective as oral antihista- mines, which are less effective than INCS,