Is Claritin (loratadine) or Zyrtec (cetirizine) better during pregnancy?

Claritin (Loratadine) and Zyrtec (Cetirizine) Are Equally Safe and Effective During Pregnancy

Both loratadine (Claritin) and cetirizine (Zyrtec) are the recommended first-line antihistamines during pregnancy, including the first trimester, with no clinically meaningful difference in safety between them. 1, 2, 3

Why These Two Are Preferred

• Both are FDA Pregnancy Category B drugs, meaning no evidence of fetal harm exists in available human data 4, 2
• Multiple guidelines consistently recommend loratadine and cetirizine as the antihistamines of choice during pregnancy, with the NAEPP Expert Panel, European Respiratory Society, and Journal of Allergy and Clinical Immunology all naming these two specifically 1, 2, 3
• Large birth registries, case-control studies, and cohort studies confirm safety of both agents during the first trimester with no increased risk of major malformations 3, 5

Evidence Supporting Equal Safety

• Cetirizine has been studied in 196 first-trimester exposures with no increased risk of major birth defects (OR 1.07; CI 0.21-3.59), spontaneous abortions, preterm deliveries, or differences in birth weight 6
• A prospective controlled study of 39 cetirizine exposures during organogenesis found no significant differences in pregnancy outcomes, rates of major or minor anomalies, birth weight, or neonatal distress compared to controls 7
• Both medications have been used extensively for many years with accumulated safety data making them preferable to newer antihistamines with limited pregnancy data 2, 3

Practical Decision-Making Algorithm

Choose based on these factors:

1. Prior response: If the patient has already been using one successfully before pregnancy, continue that same medication 1, 3
2. Side effect profile: Cetirizine may cause mild drowsiness in 13.7% of patients (vs 6.3% placebo), while loratadine is generally less sedating 1
3. Cost and availability: Both are available over-the-counter; choose whichever is more accessible or affordable 8, 9

What to Avoid

• Do NOT use oral decongestants during the first trimester due to associations with cardiac, ear, gut, and limb abnormalities including gastroschisis and small intestinal atresia 4, 2, 10
• Avoid levocetirizine (the active enantiomer of cetirizine) due to limited pregnancy safety data 4, 2, 3
• Avoid hydroxyzine specifically during early pregnancy based on animal data showing potential risks 4, 2
• Avoid first-generation antihistamines like diphenhydramine due to sedative/anticholinergic properties and lingering concerns about cleft palate association 3, 5

Additional Treatment Considerations

• Start with non-pharmacologic measures first: saline nasal rinses, positioning, exercise, and nasal valve dilators are safe and can reduce medication needs 3, 10
• For moderate-severe symptoms, combine with intranasal corticosteroids: budesonide has the strongest safety data and is preferred over other intranasal steroids 1, 4, 10
• Intranasal cromolyn (sodium cromoglycate) is considered safe during pregnancy and can be used as first-line therapy, though it requires frequent dosing 4, 11

Common Pitfalls to Avoid

• Do not assume all antihistamines have equivalent safety profiles - they do not, and specific agents must be avoided 4, 2
• Do not combine decongestants with acetaminophen or salicylates as this may increase risk of malformations 4
• Do not switch medications unnecessarily if a patient is already well-controlled on either loratadine or cetirizine before pregnancy 1, 3