After our mild winter and global-warming type spring, allergies have been worse than ever. Even patients who seldom have allergies, or who suffer only for a few weeks, are complaining. The pharmaceutical industry, ever ready for challenge and opportunity, is bombarding the airwaves, and our offices, with newer medications, each of which is easier to take, more effective, and less sedating. What to make of the wealth of information?
Antihistamines, as their name implies, counteract the effects of histamines released by the body. Histamine is one of many inflammatory substances that cells release to react to physical insult. The insult may be trauma, such a scratch to the skin, or contact with foreign substances, such as allergens. Histamine is contained in small packets, or granules, within some of our cells. When the cells release the granules, inflammation results—redness, swelling, and itching. One of the effects of histamine is to make blood vessels leaky. This allows blood cells and other blood products to move out of the vessels and to the area of inflammation to address the injury and deal with the invaders, whether pollen, poison ivy resin, or insect bite. This is all good. What is NOT good is the body’s inappropriate overreaction to benign bits of dust, pollen and your cat. This is allergy—the bane of millions of otherwise perfectly healthy people.
Antihistamines counteract inflammation by blocking the effect of histamines. This can be done at many different levels, beginning with the point of histamine release, to sedating the brain. Some medications stabilize the cell membranes that contain the packets of antihistamines, preventing their release. Sodium chromoglycate, found in some eye drops and nasal sprays, acts in this way. A new product, Clarinex, is touted as having some of this effect, in addition to the usual antihistamine properties. Sodium chromoglycate-containing products are not sedating, but they only work before histamine is released. They are preventive, not curative. Conventional antihistamines, on the other hand, counteract the effects of histamine after its release. This is the group that includes the usual suspects: Claritin, Allegra, Zyrtec, and the stronger ones such as Benadryl. Each one is a bit different, some stronger than others, and there’s the rub (actually, the rub also lies where the itch is, which is why you take this stuff in the first place!).
The main complaints I hear about antihistamines is that either they are too weak or too strong. Efficacy varies, however, not only by formulation, but also from patient to patient. One patient may say that Claritin is too strong, whereas another complains that Zyrtec (a more potent drug) doesn’t touch her symptoms. So, despite all the scientific data, trial and error is the ultimate test when choosing an antihistamine. Equally important are the side effects. These are known to all, and are (going from weaker to stronger drugs): sedation, drying, blurred vision, and difficulty urinating (for those of you blessed with a prostate).
For singers, the greatest problems are caused by drying of the vocal tract, which decreases control, particularly when singing softly and at the higher extremes of range.
For the general population, however, sedation is an important issue; patients experience difficulty driving, focusing, and staying alert on the job. Unfortunately, the more effective (i.e. strong) an antihistamine is, the greater the sedative side effects. The pharmaceutical industry responds to this by adding decongestants to the formulation, as seen in Allegra D, Claritin D, and over-the-counter multi-drug combinations, such as Tylenol Cold and Sinus.
Orally taken decongestants, (which for all practical purposes is the same as saying pseudephedrine or Sudafed), constrict the blood vessels and decrease the swelling of the tissues. While superficially this may resemble the effect of antihistamines, it is quite different and carries with it its own side effects. These include palpitations, increased blood pressure, and again, dryness. So, while this combination of antihistamines and decongestants is less sedating, it is potentially doubly drying for singers. Topical decongestants, found in Afrin-type nasal sprays, work quickly to shrink nasal membranes, but after a few days’ use are no longer effective.
How is a singer to navigate this vocally treacherous course? My suggestions are the following:
Find out what your allergens are, and minimize exposure to them.
If you have perennial (versus seasonal) allergies, consider desensitization shots.
If your allergies are localized (e.g. only nasal), consider using topical sprays rather than systemic medications.
Look at alternative anti-allergy medications, such as stinging nettle, recommended by Dr.
Andrew Weill and other alternative medicine experts.
Again, how you personally respond to a particular medication is unpredictable and idiosyncratic. You may do very well with a drug someone else finds intolerable. So do experiment (with your doctor’s blessing), especially if you need to take these medications long term.
