A patient presents to your clinic looking for treatment of his seasonal allergic rhinitis (SAR) secondary to the blooming mountain cedar.  The patient was previously well controlled on loratadine [Claritin ®]. He's perplexed now because Claritin® is OTC and his insurance plan doesn't cover OTC medications.

What can you do for him?

It's true - most (if not all) civilian health plans do NOT cover over-the-counter (OTC) drugs. TRICARE is the same - not covering OTC drugs except insulin and insulin syringes. Neither the National Mail Order Pharmacy (NMOP) nor the retail network will cover prescriptions for over the counter prescriptions except as listed above. Remember through all of this, the patient can STILL get his Claritin® ........ but will have to purchase the OTC product.

Within the DoD system, the non-sedating antihistamine closed class contract is for fexofenadine [Allegra®], a Basic Core Formulary (BCF) agent. All new starts must be started on Allegra®. Patients previously controlled on another non-sedating antihistamine MAY (not must) be continued or "grand fathered" without violating the contract. The contract does NOT allow other non-sedating antihistamines to be added to your formulary. Despite it's new OTC status, Claritin® cannot be added to your formulary. MTFs may decide to continue to supply patient currently stabilized and doing well on loratadine. The patent on Claritin® has expired but, to date, no approved FDA generic, packaged for bulk dispensing, has come to market. For the military folks - Both Claritin® AND Allegra® are waiverable in aircrew members.

Other first generation antihistamines can be tried. The trade off for a significantly lower price will likely be increased sedation. Chlorpheniramine, diphenhydramine, cetirizine may be therapeutic options if sedation with these agents is not a problem.

Aqueous nasal steroids are effective agents and work very well for SAR. Nasal steroids are as effective for all SAR symptoms except eye symptoms when compared to the non-sedating antihistamines. They also have a better decongestant effect than the non-sedating antihistamines. Aqueous nasal steroids are also waiverable in aircrew members.

Aqueous nasal steroids are more cost effective when used for a longer term (usually > 3 weeks) when compared to the non-sedating antihistamines. Nasal steroids usually require chronic use/dosing but some patients will experience benefit from PRN use. Fluticasone [Flonase®] is the BCF agent in this class.

Another option may be the leukotriene antagonists such as montelukast [Singulair®]. This agent has recently received the FAD indication for SAR. Singulair® is the BCF agent in this class. This will probably be used as an adjunct and shouldn't replace non-sedating antihistamines nor aqueous nasal steroids.

Other therapeutic options may include allergy shots and desensitization.