Do you agree with this choice or not? Why or why not?

***THANKS to Dr Eugene Moore for his help with this Pearl. ***

Both agents would be effective in treating symptoms of seasonal allergic rhinitis. Both have advantages and disadvantages.

Non-sedating antihistamines (NSAs) are effective for the symptoms of sneezing, itching, rhinorrhea, and eye symptoms. They are marginally effective against nasal congestion. The NSA/decongestant combinations products may be more effective in this subset of patients. Their onset of action is relatively quick, probably within 1-3 hours. NSAs (and any antihistamine) are best taken BEFORE the exposure instead of afterward. They are better at preventing an allergic reaction than relieving it once it's occurred. These agents are well tolerated with the most common side effects being headache.

Nasal corticosteroids are also effective against sneezing, itching, rhinorrhea, and eye symptoms. They are probably less effective than the NSAs for eye symptoms but they are effective. The nasal corticosteroids are better for nasal congestion and other nasal symptoms than the NSAs. Their onset of action is slower than the NSAs, generally requiring several days for maximal effect. Some patients claim benefit as soon as 6-12 hours after the first dose. Nasal corticosteroids are also well tolerated with the most common side effects being nasal dryness and epistaxis. These agents are also best used before the exposure. The nasal corticosteroids are best started several days to a week before the allergy season starts and continued daily throughout the season. For additional info see The Allergy Report published by the American Academy of Allergy, Asthma, and Immunology at www.theallergyreport.org.

You may ask which agent is the most cost effective in this patient? Both are effective for seasonal allergic rhinitis. A British Medical Journal meta analysis (BMJ 1998;317:1624-9) shows that nasal corticosteroids are more effective than NSAs for nasal symptoms. How does one choose which to use? See the following:

Factors favoring nasal corticosteroids:

- longer duration of therapy

- more severe disease

- presence of a non-allergic component

Factors favoring NSAs:

- Shorter duration of therapy

- mild to moderate disease

- presence of an allergic component (increases likelihood of beneficial response)

For chronic therapy, the nasal corticosteroids are less expensive on a cost per day basis compared with the NSAs. Using the Basic Core Formulary (BCF) agents fexofenadine and fluticasone nasal spray the costs per day are $ 0.60/day for fexofenadine 180mg and $ 0.37/day for fluticasone nasal spray. For less severe disease (short duration, seasonal flare-ups) the NSAs appears to be less expensive. For example, for 10 days therapy fexofenadine 180mg = $ 6.00/10 days. Fluticasone nasal spray works out to $12.56 (1 inhaler)/10 days = $ 1.25/day. This assumes that a new nasal spray canister is dispensed every season. Using these figures, the 'breakeven point' works out to be about 3 weeks. Thus, if a patient requires less than 3 weeks of therapy a NSA is more cost effective. If a patient requires more than 3 weeks of therapy, a nasal corticosteroid is more cost effective. Other factors that may enter into the prescribing decision include: disease severity, duration of treatment, presence of a non-allergic component, likelihood of a non-allergic component, patient preferences, prior adverse drug effects for one or the other therapy, and drug acquisition costs.

In this patient, barring any past problems, treatment failures, or contraindications, a NSA would likely be the most cost effective therapy because of the presence of an allergic component, short duration of symptoms, drug costs, and the assumption that the efficacy of both agents is equal.

Fexofenadine 60mg ($ 0.37/tablet) and 180mg tablets ($ 0.60/tablet) are BCF agents. The NSA contract is a joint DoD/VA contract and the NSA class is a closed class. Fluticasone nasal spray ($ 12.56/bottle) is also a BCF item.