Table 1.
Pharmacologic treatment of allergic diseases related to mental health
| Drug | Mode of action | Uses | Comments | Suicide risk considerations |
|---|---|---|---|---|
| Antihistamines | Histamine antagonist at HI receptor site | Allergic rhinitis and conjunctivitis, urticaria, allergic asthma | First-line therapy for mild or intermittent symptoms | 1st generation: somnolence, cognitive dysfunction |
| Oral, 1st generation | Often combined with oral decongestant | 2nd generation: less prominent, although sedation possible | ||
| Oral, 2nd generation | For symptoms rhinorrhea, sneezing, nasal and ocular itch | Attention to combinations; propensity to potentiation of ethanol and other sedating medications | ||
| Intranasal | 2nd generation: less significant CNS side effects | |||
| Topical (optical) | Not very effective for congestion (may require addition of decongestant); minimal effect on cytokine production | |||
| Corticosteroids | Anti-inflammatory | Treatment of many allergic diseases: allergic rhinitis and conjunctivitis, asthma, urticaria | First-line therapy for moderate/severe and persistent symptoms | Systemic: may cause depression, mania, psychosis |
| Oral | Potent anti-inflammatory; reduces cytokine production and effects | Local (eg, intranasal): compliance often is not very good; some mild systemic effects with local administration | ||
| Inhaled | Intranasal first-line therapy for moderate to severe symptoms of rhinitis | |||
| Intranasal | Oral: severe exacerbations of asthma, urticaria | |||
| Topical (skin) | ||||
| Decongestants | Alpha adrenergic agonist causes nasal vasoconstriction | Rhinitis | Reduce nasal congestion | Phenylephrine, phenylpropanolamine, pseudoephedrine, and synephrine may cause agitation, restlessness, insomnia, anxiety |
| Oral | Intranasal may cause rebound nasal congestion (rhinitis medicamentosa) | |||
| Intranasal | ||||
| Cromolyn/nedocromil sodium | Mast cell stabilizer; inhibits degranulation | Asthma, allergic rhinitis | Nonsteroidal anti-inflammatory | Few, if any, CNS effects |
| Oral | Minimal side effects | |||
| Inhaled | Mild efficacy | |||
| Intranasal | Requires frequent administration (daily dosing, poor compliance) | |||
| Anticholinergics | Muscarinic receptor antagonist | Asthma, rhinitis | Effectively reduces rhinorrhea | May add to anticholinergic effects of psychiatric medications |
| Inhaled | Role in acute bronchospasm | |||
| Intranasal | ||||
| Leukotriene inhibitors | Phospholipid metabolism inhibition | Asthma | Effective for daytime symptoms | Depression, anxiety, suicidal ideation |
| Oral (montelukast, zafirlukast, zileuton) | Steroid-sparing | Ongoing investigation of possibility of increased suicide risk with montelukast (check FDA website) | ||
| Adjust for liver impairment, monitor liver enzymes | ||||
| Zafirlukast and zileuton inhibit metabolism of warfarin | ||||
| Allergen immunotherapy | Th2 response suppression, Th1 response stimulation | Allergic rhinitis and conjunctivitis, asthma | Clinical efficacy confirmed in allergic rhinitis and allergic asthma (SCIT) | Unknown, caution recommended considering possible immune connections |
| Subcutaneous (SCIT) | Emerging evidence efficacy in allergic rhinitis (SLIT) | |||
| Sublingual (SLIT) | ||||
| Anti-IgE antibody | Reduces serum IgE | Severe asthma, possibly chronic urticaria and other IgE-mediated diseases | Approved for severe asthma | Unknown |
| IM injection | Requires multiple IM injections | |||
| Expensive |
CNS—central nervous system; FDA—US Food and Drug Administration; IM—intramuscular; Th1—T helper cell type 1; Th2—T helper cell type 2.
(Modified from Komarow HD, Postolache TT: Seasonal allergy and seasonal decrements in athletic performance. Clin Sports Med 2005, 24:e35—e50, and Postolache et al.: Allergy, depression, and suicide. Directions of Psychiatry 2005, 25:59−70.)