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Alomide: Long-term relief of chronic allergy
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This series spotlights specific ophthalmic medications, covering when to prescribe them, possible side effects and treatment plans based on a specific diagnosis. Bobby Christensen, OD, is in private practice and lectures widely on therapeutic pharmaceutical agents. He can be reached at Heritage Park Medical Center, 6912 E. Reno, Suite 101, Midwest City, OK 73110; (405) 732-1177; fax: (405) 737-4776.
Alomide is a mast-cell stabilizer and ophthalmic therapeutic drop designed to help patients remain relatively comfortable during allergy season. Depending on where you practice, the allergy season may last for a few weeks to 3 months in the spring and fall. Patients appreciate any relief from chronic irritation and itching that accompanies these eye-inflaming allergies. Alomide offers a partial solution for these patients.
Alomide 0.1% is supplied in a 10-mL bottle. It is preserved with benzalkonium chloride (0.007%) and, thus, should not be instilled while the patient is wearing contact lenses. Lodoxamide is approved for treating vernal conjunctivitis, vernal keratoconjunctivitis and vernal keratitis for up to 90 days. It inhibits the breakdown of the mast cells, which release histamine and other inflammatory mediators. These mast cells include prostaglandins and leukotrienes, which cause inflammation of the conjunctiva. Also, by inhibiting the breakdown of the mast cells, the inflammatory response by the white blood cells is reduced.
Mast-cell stabilizers work by inhibiting the degranulation of preformed mediators and the conversion of membrane arachidonic acid to prostaglandins and mixtures of leukotrienes.
No immediate relief provided
If you can't remember the scientific definition, remember that Alomide helps prevent these mast cells full of irritating chemicals from being released into the eye. For this reason, Alomide does not offer immediate relief. The chemicals that have already been released will still cause irritation for up to 1 week after you prescribe the Alomide. It is, therefore, beneficial to prescribe an antihistamine or decongestant in conjunction with the mast-cell stabilizer for the first week. This helps relieve the immediate itch and irritation.
Vernal conjunctivitis is defined as a chronic allergic reaction most often found in teenage male patients. The tarsal conjunctiva is inflamed, and usually large papilla are present with stringy matter. I have found that vernal conjunctivitis is a fairly rare condition and Alomide would have very limited use if this were all it is used for in our practices.
I use Alomide most often for adults between the ages of 30 and 55. This group of patients seems to develop vernal-like signs and symptoms later in life. They complain of chronic itch and small amounts of matter in the nasal canthus when they get up in the morning. Sometimes the matter accumulates and is removed two to four times per day. Usually little injection is noted on the palpebral conjunctiva, and small globs of mucin are noted in the tears after fluorescein instillation.
The diagnosis is made by inverting the upper lid and examining the tarsal conjunctiva. This tissue exhibits small papilla across the tarsal conjunctiva with moderate mucin around the base of the papilla. It is similar in appearance to soft contact lens patients with grade 1 giant papillary conjunctivitis (GPC). The papilla are usually smaller and more evenly distributed across the tarsal conjunctiva than with contact lens-induced GPC.
Diagnosis and treatment plans
Teenage vernal conjunctivitis (large papilla, chronic itch and eye rubbing, stringy matter) — Therapy plan 1 (severe case): Saline rinse before drops two times per day for 2 weeks. Cold compresses four times per day for 10 minutes after drops. Flarex (fluorometholone acetate, Alcon) drop (pulse dose), one drop every 2 hours while awake for 3 days, then taper to four times daily for 11 days. Alomide drop four times daily for 2 weeks. Have the patient wait 5 minutes between instillation of Flarex and Alomide drops. Examine the patient in 2 weeks and determine a maintenance dose if initial treatment has calmed the inflammatory process.
Therapy Plan 2 (mild to moderate): Saline rinse before drops, two times per day and cold compresses two times per day for 2 weeks after drops. Naphcon A (pheniramine maleate, naphazoline HCl, Alcon), one drop four times daily for 1 week and then twice daily for the second week. Alomide, one drop four times daily for 2 weeks. Have the patients wait 5 minutes between drops. Examine the patient in 2 weeks and determine a maintenance dose if the initial treatment helped calm the vernal conjunctivitis.
Alomide may be continued twice or four times daily for up to 90 days. Patients with vernal conjunctivitis requiring continuing medication should be followed monthly during their allergy season. The treatment plan may need to be altered often, as the disease waxes and wanes. Flarex is an additional treatment that is useful to accompany Alomide when the severity of symptoms increases.
Adult vernal-like conjunctivitis (small papilla, chronic itch, mild to moderate matter, dryness) - Therapy plan: Saline rinse twice daily before the drops for 2 weeks. Cold compresses for 10 minutes two times per day after the drops. Livostin, one drop four times daily for 1 week, then twice daily for 1 week. Alomide, one drop four times daily for 2 weeks. Check the patient in 2 weeks and decide if a maintenance dose of Alomide is needed. If an allergic response remains present, I continue treatment with Alomide twice daily for 6 weeks beyond the 2-week visit. Alomide can be used for up to 90 days.
When using Alomide, consider the following:
- Safety established for children age 2 years and older.
- Comfortable to use; transient stinging 15% of the patients.
- Patients must remove contact lenses before use and leave them out for 5 minutes.
- Avoid side effects common with steroids.
- Can be used with other drops, such as steroids, antihistamines and decongestants.
- Approved for continuous use for up to 90 days.
- Does not provide immediate relief.
Alomide is a mast cell stabilizer that provides the doctor and patient with a safe medication to treat chronic eye allergy. In most cases, patients with tarsal conjunctival papilla state that Alomide makes their eyes more comfortable and reduces the matter and itch that accompanies these vernal-like allergies. Combine its use initially with Livostin, saline rinses, cold compresses and patient education regarding eye rubbing and exposure to allergens. Alomide is my choice for long-term treatment.
For Your Information:
- Dr. Christensen has no financial interest in any products mentioned in this story nor is he a paid consultant for any of the companies mentioned above.