NUR 602 Module 2 Class Comparison Example

One Family, Three Ages, One Allergy Season: Comparing Intranasal Corticosteroids and Oral Antihistamines Across the Life Span

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Southern New Hampshire University

NUR 602: Advanced Pharmacology Across the Life Span

Module Two Class Comparison

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[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

One Family, Three Ages, One Allergy Season: Comparing Intranasal Corticosteroids and Oral Antihistamines Across the Life Span

Allergic rhinitis is usually treated as a simple problem with an over-the-counter answer. The drugs in the pharmacy aisle, however, differ in ways that matter far more for some patients than for others. A nasal steroid that is ideal for a bus driver raises a growth question in a preschooler, and an antihistamine sold as a sleep aid is a real hazard for an 80-year-old man with a large prostate. This paper compares intranasal corticosteroids with first and second generation oral H1 antihistamines, using one composite family to show that a class comparison is only useful when it is organized around the features that decide a choice for a particular person.

The Family

Lily is 3 years old and weighs 15 kg. Each April she has a runny, blocked nose, sneezing and mouth breathing at night, and her parents have been giving her a children's diphenhydramine syrup that makes her drowsy and, some evenings, oddly agitated. Her mother, Dana, is 38 and drives a school bus; her symptoms are sneezing, itchy eyes and heavy congestion, and she avoids any tablet that says it may cause drowsiness because of her commercial license. Dana's father, Walter, is 80. He has benign prostatic hyperplasia treated with tamsulosin, an estimated glomerular filtration rate of 45 mL/min/1.73 m² and mild short-term memory complaints, and he takes 50 mg of diphenhydramine at bedtime because it helps both his nose and his sleep.

The Features That Decide

Most drug references list dozens of properties for these classes. For this family, five decide the choice: whether the drug relieves congestion, how much it sedates, how much anticholinergic effect it carries, the youngest approved age and whether the dose depends on kidney function. Table 1 sets out those five features for the main options.

Table 1. Deciding Features of Three Drug Classes for Allergic Rhinitis

Note. Summarized from Dykewicz et al. (2020), Church et al. (2010) and the 2023 AGS Beers Criteria. Labeled ages are for allergic rhinitis in the United States.

Intranasal Corticosteroids

Intranasal corticosteroids act on the late phase of the allergic response, reducing mucosal inflammation, and they are the only class in the table that reliably relieves congestion. For patients 12 and older with seasonal allergic rhinitis, the Joint Task Force recommends starting with an intranasal corticosteroid alone rather than combining it with an oral antihistamine, because the combination adds little (Wallace et al., 2017). The broader practice parameter supports the same class as first-line therapy for persistent or moderate symptoms at most ages (Dykewicz et al., 2020). Onset is within a day, but full effect may take several days of regular use, which patients need to hear.

The concern in children is growth. In a one-year randomized trial of prepubertal children aged 6 to 9, those using intranasal beclomethasone grew 5.0 cm compared with 5.9 cm with placebo (Skoner et al., 2000). A trial of the same length in children aged 3 to 9 found no growth suppression with once-daily mometasone at 100 mcg, a drug with very low systemic bioavailability (Schenkel et al., 2000). The difference supports choosing an agent with low bioavailability, using the lowest dose that controls symptoms and measuring height.

Oral Antihistamines, Old and New

First generation antihistamines cross the blood-brain barrier and bind central H1 and muscarinic receptors. A position paper from a European allergy network describes reduced REM sleep, impaired learning and work efficiency, involvement in transport accidents and deaths from overdose in young children, and argues that these drugs no longer belong on open sale (Church et al., 2010). The impairment is not always felt. In a driving simulator trial, 50 mg of diphenhydramine impaired driving more than alcohol at a concentration of about 0.1%, while 60 mg of fexofenadine did not differ from placebo, and self-rated drowsiness did not predict impairment (Weiler et al., 2000). For older adults, the 2023 Beers Criteria advise against this whole generation, citing their links to delirium, retained urine, constipation and falls (American Geriatrics Society Beers Criteria Update Expert Panel, 2023).

Second generation antihistamines relieve sneezing, itching and rhinorrhea with little or no sedation, although cetirizine sedates some patients at usual doses. They do little for congestion, so they suit patients whose main symptoms are itch and sneezing, or those who will not use a spray.

Applying the Comparison

For Lily, the diphenhydramine should stop. Her congestion and night mouth breathing point to a nasal steroid, and mometasone is labeled from age 2 at one spray in each nostril once daily. If itch and sneezing persist, loratadine 5 mg daily is labeled for children aged 2 to 5. Her height should be measured at each visit on the same stadiometer, and the spray used only during the season.

For Dana, a daily nasal steroid addresses her main complaint, congestion, with no impairment. If her eyes still itch, fexofenadine 180 mg is the least sedating oral choice; she should take it with water rather than fruit juice, which reduces absorption. She should avoid first generation products, including many night-time cold remedies, and know that feeling alert is not proof of being unimpaired.

Walter's diphenhydramine carries the most risk in the family. It adds anticholinergic load to a man with an enlarged prostate and memory complaints, and it accumulates with reduced kidney function. The plan is to taper it over one to two weeks while starting a nasal steroid. If an oral agent is still needed, fexofenadine at 60 mg once daily is appropriate for his kidney function. His sleep complaint needs its own assessment, beginning with sleep habits, rather than a replacement sedative.

Education, Monitoring and Limits of the Evidence

Spray technique is the most common reason nasal steroids fail. Each person should aim the nozzle away from the septum, toward the outer wall of the nostril, and use the spray daily rather than as needed. Nosebleeds or crusting are reasons to check technique and examine the septum. For Walter, the follow-up visit should ask about urinary stream, bowel habits, sleep and any change in memory once diphenhydramine has stopped.

The evidence is thinnest for the oldest family member. Guideline trials of rhinitis drugs mostly enrolled adolescents and adults of working age, and the Joint Task Force synopsis applies to patients 12 and older without an upper age analysis (Wallace et al., 2017). The advice for Walter therefore rests on pharmacology and on geriatric safety data rather than on rhinitis trials in adults over 75, and his chart should say so.

Conclusion

A useful class comparison does not rank drugs once for everyone. For this family, the same five features point to a low-bioavailability nasal steroid with height checks for a preschooler, a nasal steroid with a nonsedating antihistamine for a bus driver and the removal of a sedating antihistamine for an 80-year-old man. The diagnosis is the same in all three; the decision is not.

References

American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052-2081. https://doi.org/10.1111/jgs.18372

Church, M. K., Maurer, M., Simons, F. E. R., Bindslev-Jensen, C., van Cauwenberge, P., Bousquet, J., Holgate, S. T., & Zuberbier, T. (2010). Risk of first-generation H1-antihistamines: A GA2LEN position paper. Allergy, 65(4), 459-466. https://doi.org/10.1111/j.1398-9995.2009.02325.x

Dykewicz, M. S., Wallace, D. V., Amrol, D. J., Baroody, F. M., Bernstein, J. A., Craig, T. J., Dinakar, C., Ellis, A. K., Finegold, I., Golden, D. B., Greenhawt, M. J., Hagan, J. B., Horner, C. C., Khan, D. A., Lang, D. M., Larenas-Linnemann, D. E., Lieberman, J. A., Meltzer, E. O., Oppenheimer, J. J., . . . Steven, G. C. (2020). Rhinitis 2020: A practice parameter update. Journal of Allergy and Clinical Immunology, 146(4), 721-767. https://doi.org/10.1016/j.jaci.2020.07.007

Schenkel, E. J., Skoner, D. P., Bronsky, E. A., Miller, S. D., Pearlman, D. S., Rooklin, A., Rosen, J. P., Ruff, M. E., Vandewalker, M. L., Wanderer, A., Damaraju, C. V., Nolop, K. B., & Mesarina-Wicki, B. (2000). Absence of growth retardation in children with perennial allergic rhinitis after one year of treatment with mometasone furoate aqueous nasal spray. Pediatrics, 105(2), Article e22. https://doi.org/10.1542/peds.105.2.e22

Skoner, D. P., Rachelefsky, G. S., Meltzer, E. O., Chervinsky, P., Morris, R. M., Seltzer, J. M., Storms, W. W., & Wood, R. A. (2000). Detection of growth suppression in children during treatment with intranasal beclomethasone dipropionate. Pediatrics, 105(2), Article e23. https://doi.org/10.1542/peds.105.2.e23

Wallace, D. V., Dykewicz, M. S., Oppenheimer, J., Portnoy, J. M., & Lang, D. M. (2017). Pharmacologic treatment of seasonal allergic rhinitis: Synopsis of guidance from the 2017 Joint Task Force on Practice Parameters. Annals of Internal Medicine, 167(12), 876-881. https://doi.org/10.7326/M17-2203

Weiler, J. M., Bloomfield, J. R., Woodworth, G. G., Grant, A. R., Layton, T. A., Brown, T. L., McKenzie, D. R., Baker, T. W., & Watson, G. S. (2000). Effects of fexofenadine, diphenhydramine, and alcohol on driving performance: A randomized, placebo-controlled trial in the Iowa driving simulator. Annals of Internal Medicine, 132(5), 354-363. https://doi.org/10.7326/0003-4819-132-5-200003070-00004