What are the treatment options for allergies?

Treatment Options for Allergies

The primary treatment options for allergies include allergen avoidance, pharmacotherapy, and allergen immunotherapy, with the specific approach depending on the type of allergy, severity of symptoms, and impact on quality of life. 1

First-Line Treatments

Pharmacotherapy

1. Antihistamines

   • First-generation (older) antihistamines: Effective for non-histamine-mediated upper airway cough syndrome and allergic rhinitis due to their anticholinergic properties 1
   • Second-generation (newer) antihistamines: Preferred for allergic rhinitis with less sedation 1
   • Often combined with decongestants for better symptom control

2. Nasal Corticosteroids

   • First-line treatment for allergic rhinitis
   • Highly effective at reducing inflammation and controlling symptoms 1

3. Leukotriene Inhibitors

   • Effective for allergic rhinitis symptoms 1
   • May be used as an alternative or adjunct to antihistamines

4. Nasal Cromolyn

   • Preventive medication for allergic rhinitis
   • Safe option for long-term use 1

5. Epinephrine

   • Emergency treatment for severe allergic reactions (anaphylaxis)
   • Indicated for Type I allergic reactions to foods, drugs, insect stings, and other allergens 2

Allergen Avoidance

• Fundamental approach for all allergies
• Particularly important for food allergies where strict avoidance is currently the primary management strategy 1
• For inhalant allergies, environmental control measures should be implemented as part of a holistic approach 3, 4

Second-Line/Advanced Treatments

Allergen Immunotherapy (AIT)

• Indications: Should be offered to patients whose symptoms are inadequately controlled with medical therapy and allergen avoidance, or who prefer immunomodulation 1

• Types:

  1. Subcutaneous Immunotherapy (SCIT): Traditional allergy shots
  2. Sublingual Immunotherapy (SLIT): Tablets or drops under the tongue

• Benefits:

  • Reduces allergic symptoms and induces immunologic tolerance 1
  • Can maintain reduction in allergy symptoms after treatment discontinuation 1
  • May prevent new allergen sensitizations and reduce risk of developing allergic asthma 1
  • Can alter the natural history of allergic disease 1

• Duration: Minimum of 3 years for patients experiencing symptomatic control 1

• Contraindications:

  • Pregnancy
  • Uncontrolled asthma
  • Inability to tolerate injectable epinephrine 1

Experimental Treatments for Food Allergies

• Oral Immunotherapy (OIT) and Sublingual Immunotherapy (SLIT)

  • Currently in experimental phase 1/2a trials for food allergies
  • Not FDA approved for food allergies in the US 1

• Chinese Herbal Medicine

  • Food Allergy Herbal Formula (FAHF-2) shows promise in early trials
  • Currently undergoing phase 3 study 1

Treatment Selection Algorithm

1. Assess allergy type and severity:

   • Mild intermittent symptoms → Antihistamines as needed
   • Moderate to severe or persistent symptoms → Add nasal corticosteroids
   • Symptoms unresponsive to medications → Consider immunotherapy

2. For allergic rhinitis/conjunctivitis:

   • Start with second-generation antihistamines and/or nasal corticosteroids
   • If inadequate control: Add leukotriene inhibitors or nasal cromolyn
   • If still inadequate: Consider immunotherapy evaluation

3. For food allergies:

   • Strict allergen avoidance
   • Emergency epinephrine prescription for those at risk of anaphylaxis
   • Consider referral for clinical trials of immunotherapy if appropriate

4. For insect sting allergies:

   • Venom immunotherapy for those at risk of anaphylaxis 1

Important Considerations

• Immunotherapy should only target clinically relevant allergens confirmed by testing that correlate with the patient's history 1
• The clinician performing allergy testing or administering immunotherapy must be able to diagnose and manage anaphylaxis 1
• For seasonal allergic rhinitis treated with SLIT, pre- and co-seasonal immunotherapy should be offered 1
• Local reactions to immunotherapy are common and generally not a reason to discontinue treatment 1

Remember that while allergen avoidance is often recommended as a first-line approach, evidence supporting its efficacy as a standalone intervention is still limited and subject to controversy 4. A comprehensive approach combining appropriate pharmacotherapy with targeted allergen avoidance measures is most likely to provide optimal symptom control.