Allergic Conjunctivitis: what eyedrops to use

Patients often ask what to use for allergic conjunctivitis.
OTC antihistamine and decongestant eyedrops (Naphcon-A, etc) are good for short-term or intermittent symptoms. They're inexpensive and work fast...but have to be used QID.
Rx antihistamines (Emadine, Livostin) cost more. But they can be used for longer periods because they don't contain a decongestant.
Mast cell stabilizers (Alocril, Alamast, cromolyn, etc) are for CHRONIC use during allergy season to help prevent symptoms.
These drugs inhibit histamine release...but they don't block histamine that has already been released.
Tell patients it may take several days to see a benefit.
Some of the newer drugs have a dual mechanism of action and work as both antihistamines and mast cell stabilizers.
Elestat (epinastine) is the newest. It's a "me-too"... similar to Patanol, Optivar, and Zaditor.
These are for treatment AND prevention...but they're expensive.
Use an ORAL antihistamine (Claritin, Allegra, etc) for patients with additional allergy symptoms...nasal discharge, etc.
We've created a chart of eyedrops that are useful for allergic conjunctivitis...plus you can get a good patient handout on how to instill eyedrops correctly. For a copy, go to www.prescribersletter.com.

Ophthalmic Medications for Allergic Conjunctivitis

Lead author: Ellen Whipple Guthrie, Pharm.D.

―See Detail-Document #140904 for the patient handout, "How to use Eyedrops".―

Drug Name	Administration	AWP	Comments
*ANTIHISTAMINE / DECONGESTANT*
Naphazoline/ pheniramine *(Naphcon-A, Opcon-A, Visine-A OTC, etc)*	Instill one to two drops in affected eye(s) up to four times a day.	Less than $10.00 (15 mL)	Available OTC. Many of these products contain the preservative benzalkonium chloride, which can accumulate in soft contact lenses and cause irritation.⁴ Advise patients to remove contact lenses before administering these products.¹⁵ Should not be used >3 days.^8,15 Contraindicated with heart disease, enlarged prostate, high blood pressure, & glaucoma.^8,15 *Multiple (generic) decongestant products are currently available on the market.
*ANTIHISTAMINE*
*Emedastine 0.05% (Emadine)⁵*	Instill one drop in the affected eye(s) up to 4 times a day.	$56.88 (5 mL)	Avoid wearing contact lenses if eyes are red. Remove soft contacts prior to using this product; contacts may be reinserted after 10 minutes if eyes are not red.
*Levocarbastine 0.05% (Livostin)¹⁰*	Instill one drop each eye 2 times a day (may increase to 3 to 4 times per day).	$53.23 (5 mL)	Remove contact lenses prior to using this product; contacts may be reinserted after 15 minutes if eyes are not red. Shake product before each application. *This product is scheduled to be discontinued by the manufacturer in 2004.
*ANTI-INFLAMMATORY*
Ketorolac 0.5% (Acular)⁷	Instill one drop in eye(s) 4 times a day.	$66.85 (5 mL)	Remove contact lenses prior to using this product; contacts may be reinserted after 15 minutes if eyes are not red. Do not use if allergic to aspirin or NSAIDs. *If stored in the refrigerator, the product will sting less during application.⁸
*MAST CELL STABILIZER*
Cromolyn 4% *(Crolom)²*	Instill one to two drops in each eye 4 to 6 times a day.	$44.56 (10 mL)	Available generically. Avoid wearing contact lenses during treatment with this product.
*Lodoxamine 0.1% (Alomide)¹¹*	Instill one to two drops in affected eye(s) 4 times a day for up to 3 months.	$72.00 (10 mL)	*Avoid wearing soft contact lenses during treatment with this product.
Nedocromil 2% *(Alocril)¹⁶*	Instill one or two drops in each eye 2 times a day.	$76.05 (5 mL)	*Remove contact lenses prior to using this product; contacts may be reinserted after 15 minutes if eyes are not red.
Pemirolast 0.1% *(Alamast)¹⁸*	Instill one to two drops in affected eye(s) 4 times a day.	$60.70 (10 mL)	Avoid wearing contact lenses if eyes are red. Remove soft contact lenses prior to using this product; contacts may be reinserted after 10 minutes if eyes are not red.
*ANTIHISTAMINE / MAST CELL STABILIZER*
Azelastine 0.05% *(Optivar)¹*	Instill one drop into affected eye(s) 2 times a day.	$70.46 (6 mL)	Avoid wearing contacts if eyes are red. Remove soft contacts prior to using this product; contacts may be reinserted after ten minutes if eyes are not red.
Epinastine 0.05% *(Elestat)⁶*	Instill one drop in eye(s) 2 times a day.	$73.76 (5 mL)	Avoid wearing contact lenses if eyes are red. Remove soft contact lenses prior to using this product; contacts may be reinserted after 10 minutes if eyes are not red.
Ketotifen 0.025% *(Zaditor)⁹*	Instill one drop 2 times a day, every 8 to 12 hours.	$56.28 (5 mL)	Avoid wearing contact lenses if eyes are red. Remove soft contact lenses prior to using this product; contacts may be reinserted after 10 minutes if eyes are not red.
*Olopatadine 0.1% (Patanol)¹⁷*	Instill one drop in affected eye(s) 2 times a day (every 6 to 8 hours).	$73.44 (5 mL)	Avoid wearing contact lenses if eyes are red. Remove soft contact lenses prior to using this product; contacts may be reinserted after 10 minutes if eyes are not red.
*CORTICOSTEROID*
Dexamethasone sodium phosphate 0.1% (various)³	Instill one drop 3 to 4 times a day.	$17.31 (5 mL)	Available generically. Only recommended for short-term. Not first line therapy.⁴ Remove soft contact lenses prior to using this product; contacts may be reinserted after 15 minutes if eyes are not red. *Monitor intraocular pressure if this drug is used for ten days or more.
Loteprednol 0.2% *(Alrex)¹²*	Instill one drop in affected eye(s) 4 times a day.	$40.31 (5 mL)	Only recommended for short-term use. Not first line therapy.⁴ Avoid wearing contact lenses if eyes are red. Remove soft contact lenses prior to using this product; contacts may be reinserted after 10 minutes if eyes are not red. Patient should be re-evaluated if eye(s) do not improve in two days. Monitor intraocular pressure if this drug is used for ten days or more. *Shake product well before using.
Loteprednol 0.5% *(Lotemax)¹³*	Instill one to two drops in affected eye(s) 4 times a day.	$32.05 (5 mL)	Only recommended for short-term use. Not first line therapy.⁴ Remove soft contact lenses prior to using this product; contacts may be reinserted after 15 minutes if eyes are not red. Patient should be re-evaluated if eye(s) do not improve in two days. Monitor intraocular pressure if this drug is used for ten days or more. Shake product well before using.
Medrysone *(HMS Liquifilm)¹⁴*	Instill one drop in the eye(s) up to every 4 hours.	$21.63 (5 mL)	Only recommended for short-term use. Not first line therapy.⁴ Remove contact lenses prior to using this product; contacts may be reinserted after 15 minutes if eyes are not red. Monitor intraocular pressure if this drug is used for ten days or more. *Shake product before each application.
Prednisolone acetate 1% (various)¹⁹	Instill two drops in eye(s) 2 to 4 times a day.	$12.60 (5 mL)	Available generically. Only recommended for short-term use. Not first line therapy.⁴ Remove contact lenses prior to using this product; contacts may be reinserted after 15 minutes if eyes are not red. Patient should be re-evaluated if eye(s) do not improve in two days. Monitor intraocular pressure if this drug is used for ten days or more.
Prednisolone sodium phosphate 1% (various)²⁰	Instill one drop in eye(s) 3 to 4 times a day.	$16.00 (5 mL)	Available generically. Only recommended for short-term use. Not first line therapy.⁴ This product contains the preservative benzalkonium chloride, which can accumulate in soft contact lenses and cause irritation.⁴ No data exists from manufacturer on concurrently using this medicine and wearing contact lenses. *Monitor intraocular pressure frequently while on this medication.

*This chart is based on U.S. labeling.