Allergy Medications As Deprescribing Targets

Allergic rhinitis is a very common condition. I’ve encountered numerous patients throughout my career who take more than one medication to help keep their symptoms at bay. When reviewing polypharmacy cases, I do consider allergy medications as deprescribing targets because oftentimes allergy medications are added and the original success of the first agent is not reassessed. Here’s a common situation where allergy medications can accumulate.

JS is a 58-year-old female who has started taking cetirizine 10 mg daily for allergic rhinitis. The predominant symptoms reported are runny nose and itchy eyes. Following two weeks of symptoms despite the use of OTC cetirizine, she visits her primary provider and is prescribed fluticasone nasal spray.

Another month goes by and her symptoms improve mildly but are not under good enough control for the patient. The primary provider now prescribes montelukast 10 mg daily. Within a period of a couple of months, JS is now taking three medications to manage her allergy symptoms.

Cetirizine (podcast) 10 mg daily
Fluticasone (podcast) 1 spray each nostril daily
Montelukast (podcast) 10 mg daily

When symptoms become under control, which medication would be appropriate to deprescribe first? If you have enough information available to determine which medication was started first, that is usually the one I consider for deprescribing. In this case, it is reasonable to question the efficacy of cetirizine because we had to add two more medications following the use of this medication.

Adverse effects are important to consider as well when deprescribing. For instance, if the patient complains of feeling sleepy during the day, I would be much more likely to consider a trial reduction or discontinuation of the cetirizine. If the patient has concerns about nasal irritation and nose bleeds, it would be reasonable to look toward fluticasone. If psychiatric changes have been noted, montelukast would be a strong candidate to be reassessed for discontinuation.

One thing that is nice about considering allergy medications as deprescribing targets is that if a medication is discontinued, the worst thing that will happen is the symptoms will return and the medication can be restarted. This isn’t typically a life-threatening situation if the patient has an increase in allergic rhinitis symptoms.

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