222 SECTION 3 • MEDICAL PROBLEMS IN THE ATHLETE
sedation (see Table 37-1). Antihistamines can decrease
heat dissipation by their anticholinergic effects on sweat
glands and should be used with caution in athletes.
•Topical nasal antihistamines can be beneficial in both
allergic and nonallergic rhinitis. Side effects include
drowsiness and an unpleasant aftertaste. While
intranasal steroids provide greater relief of nasal
symptoms, nasal antihistamines can be considered as
an alternative when the response to an oral antihista-
mine and a nasal steroid is inadequate (Yanez and
Rodrigo, 2002).
- Cromolyn, a topical mast cell stabilizer, provides
modest improvement in the sneezing, itching, and rhi-
norrhea associated with allergic rhinitis and has a low
potential for toxicity. It is useful when given prior to
allergen exposure, but often requires dosing up to 4 to
6 times daily to be effective. - Nasal steroids are the most effective therapy for per-
sistent or severe symptoms (Pullerits et al, 2002).
Several days of treatment are usually necessary for
maximal effectiveness. They can be used periodically
for an athlete’s allergy season, but once initiated, the
steroid needs regular administration for efficacy (see
Table 37-2). Side effects are low and include irrita-
tion, burning, sneezing, and bloody nasal discharge. - Chronic nasal steroids, when used properly, are not
associated with significant adrenal suppression, nasal
or pharyngeal candidiasis, cataracts, or glaucoma
(Boner; Krahnke and Skoner, 2002). Studies using the
newer agents mometasone furoate and fluticasone in
children showed no difference in growth compared to
placebo (Skoner et al, 2000; Schenkel et al, 2000;
Allen et al, 2002).- Leukotriene receptor antagonists (LRAs) provide mild
improvement in allergic rhinitis with efficacy similar
to second-generation antihistamines (Nathan, 2003).
Their side effect profile is no different than placebo.
They should be considered when nasal steroids and/or
antihistamines fail or have intolerable side effects and
when concomitant asthma may benefit from LRA
therapy. - Ipratropium bromide 0.03% nasal spray is effective for
treating rhinorrhea, particularly vasomotor-induced
rhinorrhea triggered by cold air or exercise. It has no
effect on pruritus or congestion. Side effects include
occasional epistaxis and nasal dryness, but no systemic
anticholinergic or rebound effects. It is effective when
dosed 30 min prior to exercise or exposure.
•When treatments fail, consider medication inade-
quacy and noncompliance, as well as the possibility of
other diagnoses such as anatomical or physical
obstruction and/or chronic sinusitis.
ATHLETE-SPECIFIC
MEDICATION ISSUES- As restrictions on over-the-counter and prescription
medications can change, an athlete should discuss a
medication’s status with the governing body for their
particular sport or level of competition prior to its use.
This would include the National Collegiate Athletic
Association (NCAA) and U. S. Olympic Committee
(USOC). - The NCAA has no restrictions on any allergy-related
products with the exception that any products con-
taining ephedrine are banned.
TABLE 37-1 Second Generation Oral Antihistamines
2ND GENERATION
ORAL ANTIHISTAMINE DOSE SEDATION
Fexofenadine (Allegra) Age ≥12: 180 mg qd or 60 mg bid No different than placebo
Age 6–11: 30 mg bid
Cetirizine (Zyrtec) Age ≥6: 5–10 mg qd Slightly higher than placebo,
Age 2–5: 2.5–5 mg qd (syrup) but less than 1st generation
Loratadine (Claritin) Age >6: 10 mg qd No different that placebo at
Age 2–6: 5 mg qd 10 mg, sedating at higher doses
Desloratadine (Clarinex) Age ≥12: 5 mg qd No different than placebo*
*7% of population may have sedation because of decreased metabolism of the drug.
TABLE 37-2 Topical Nasal Corticosteroids
TOPICAL NASAL
CORTICOSTEROID DOSE: SPRAYS PER NOSTRIL
Flonase (fluticasone) Age ≥12: 1 bid or 2 qd; Age 4–11:
same but start at 1 qd
Nasonex (mometasone furoate) Age ≥12: 2 qd; Age 3–11: 1 qd
Rhinocort Aqua (budesonide) Age ≥12: 1–4 qd; Age 6–11: 1–2 qd
Nasarel (flunisolide) Age >14: 2 bid to qid; Age 6–14:
1 tid
Nasacort AQ (triamcinolone) Age ≥12: 2 qd; Age 6–11: 1–2 qd
Beconase AQ (beclomethasone) Age ≥12: 1–2 bid; Age 6–11: 1 bid
Vancenase AQ DS Age ≥6: 1–2 qd
(beclomethasone)