Clinicians favor Livostin, Patanol among newer anti-allergy agents

Issue: March 1998

CHICAGO - Newer drugs are definitely blunting the effects of allergic diseases. Livostin (levocabastine HCl, Ciba Vision) has rapidly become a standard for many practitioners. When Livostin fails or when cost is not a factor, Patanol (olopatadine, Alcon) is a big favorite.

Timothy T. McMahon, OD, FAAO, an associate professor in the department of ophthalmology and vision sciences at the University of Illinois, said, "Livostin is a potent antihistamine, used in the dermatologic area for some time before being approved for ocular use. It is an excellent, fast-acting drug for acute allergic problems, particularly seasonal allergic conjunctivitis. It is relatively inexpensive.

"Patanol is much newer and has the combined effect of an antihistamine as well as a mast-cell stabilizer," he continued. The potency of the antihistamine is similar to Livostin. The mast-cell stabilizer effect is similar to that of Alomide (lodoxamide tromethamine, Alcon). It has proved to be fantastic for patients who have more chronic allergic responses, and it has been great for us with our giant papillary conjunctivitis (GPC) patients. We use it concurrently with lens wear for those with mild to moderate GPC. We think it is better than Crolom alone (cromolyn sodium, Bausch & Lomb)."

Adding orals

Dr. McMahon added, "Although in Illinois optometrists cannot prescribe orals, I favor Claritin (loratadine, Schering) for chronic GPC. It is excellent with patients who you must keep in contacts. It can reduce the signs and symptoms remarkably."

Michael Bloom, OD, said, "We're doing a lot with mast-cell inhibitors in Atlanta. I use Alomide. I think it's very well tolerated. I add Livostin if there is a topical allergic response. However, with Patanol available, we are able to have a combination drop with twice-a-day dosing.

"Allegra (fexofenadine, Hoechst Marion Roussel) and Claritin seem to work pretty well, but there's a problem with dry eye, especially for contact lens wearers," he continued. "Most of these patients have already had these drugs prescribed by their regular physician. Sometimes, I'll use a mast-cell stabilizer with Acular (ketorolac tromethamine, Allergan) added to help the first few days. I warn patients about the stinging and suggest they keep it in the refrigerator. The nonsteroidal anti-inflammatory drugs (NSAIDs) solve so many problems. Sometimes, they're more efficacious for the itch than the antihistamines. I think the drug's effect lasts a little longer."

Another fairly new, commonly used oral agent is Zyrtec (cetirizine, Pfizer).

Staging allergy before treatment

An important part of allergy treatment is staging the severity of the individual case. For minor allergic symptoms, cold compresses and irrigation are helpful. Cold is also a way of stabilizing mast cells.

"Chronic allergy should be approached differently from acute allergy," Dr. McMahon said. "For acute seasonal allergic conjunctivitis, the fast-acting antihistamines, such as over-the-counter Opcon A (naphazoline HCl and pheniramine maleate, Bausch & Lomb) and Vasocon A (antazoline phosphate and naphazoline HCl, Ciba Vision), are my first lines of defense followed by Livostin. The next after that is Patanol.

"For chronic allergy, we tend to emphasize prevention with mast-cell stabilizers: Alomide and Crolom," Dr. McMahon said. "Antihistamines themselves are often not tolerated well by these patients. We consider NSAIDs in this group. Voltaren (diclofenac sodium, Ciba Vision) or Acular are equally effective."

"There do seem to be some theoretical advantages to Patanol, but studies have shown that considering the way people actually use the drops, levocabastine (Livostin) seems to work on a twice-a-day basis, as well," said Michael B. Raizman, MD, assistant professor of ophthalmology at Tufts University School of Medicine in Boston. "Differences are not nearly as great as you would expect based on the laboratory work," he said, in reference to clinical use studies on the two different drops. He believes the most refinements have been made in the area of antihistamines.

"There has been some interesting work showing that blocking histamine does more than just stop the itching," Dr. Raizman said. "We usually think of histamine causing itching, but histamine can actually trigger the release of cytokines, which set up the whole inflammatory cascade." He believes Livostin and Patanol are "far superior to their predecessors." Emadine (emodastine, Alcon), which recently received Food and Drug Administration (FDA) approval, blocks both histamine and cytokine production.

New steroids

Two newer steroids are now available. Alcon's Vexol (rimexolone) is said to be less likely to increase intraocular pressure. Alrex (loteprednol, Bausch & Lomb), another steroid to be used four times a day for acute allergic conjunctivitis, received FDA approval in March. It is said not to raise intraocular pressure while having the effect of prednisolone.

Homeopathic agent brings relief

Robert Owens, OD, from New Holland, Pa., works with Amish and Mennonite farmers. His patients like a more natural approach, so they were very pleased when he began offering Similasan Eye Drops 2 (Similasan Corp., Kent, Wash.), a homeopathic remedy for ocular allergy.

"It's a nice middle ground," he said. "You can use it as often as you want. It's a better price than Patanol, unless the patient is on a prescription plan. I prescribe Similasan 2 four to six times per day for allergy. We've been using Similasan for about 4 years, and although there's no perfect drop for everybody, it has had the best track record of any agent aside from prescription allergy drugs. It offers some relief on acute allergic reactions.

"I didn't expect this, because I was told that it was similar to mast-cell stabilizers in needing some time to have an effect," Dr. Owens continued. "Some patients have had immediate results using Similasan 2 and cold compresses. It's done a good job in curbing early papillary hypertrophy in contact lens patients, too."

Dr. Owens added that he uses Similasan 2, which is preserved with silver sodium chloride, as a rewetting drop with both soft and gas-permeable contact lenses. "I tried it first on my dry eyes," he said. "It had a petroleum feel. When I asked about it, the company thought it was the silver sodium chloride. The problem with a lot of drops is the caustic preservatives."

Homeopaths look more at a patient's unique symptoms, regarding them as the organism's way of adapting or responding to stress. Then, they "look for a substance in nature that would cause the same symptoms a sick person is having as a way of mimicking and thus augmenting the body's own defenses. Immunizations and allergy treatments are based on this principle," said Dana Ullman, MPH, who is president of the Homeopathic Educational Services and a consultant to Harvard Medical School's Center to Assess Alternative Therapy for Chronic Illness.

Similasan 2 performed better than placebo in studies at Harvard. "Initially, it didn't seem to have any effect," he said. "This was because they were putting Similasan 2 in one eye and placebo in the other. But when it was retested by placing Similasan in one person's eyes and the placebo in a different person's eyes, they saw a difference. When you put a homeopathic substance in one eye, it affects both eyes," he said.

Vernal keratoconjunctivitis

Brian Den Beste, OD, FAAO, of Orlando, Fla., said, "When I was at Bascom Palmer, we used baby aspirin for children with vernal keratoconjunctivitis. It was not the mainstay of therapy, but sometimes it seemed to help." Dr. Den Beste uses steroids to calm the storm of vernal.

"The cases I see are often cases that have failed elsewhere," he continued. "The clinicians have tried drugs that are good for maintenance, but the kids can't sit still. The teachers think they have pink eye and send them home. Even the mild steroids will quiet them, and then maintenance will work. You have a disease that is typically seasonal and episodic. I start them on steroids, get them comfortable and then explain that they have to go the more expensive mast-cell stabilizers and antihistamines."

Dr. Den Beste has not used Vexol on vernal keratoconjunctivitis because he tends to stick with inexpensive drugs he knows will work. "You have to consider the economics just a little bit," he said.

Atopic keratoconjunctivitis

Dr. Den Beste sees a similarity between atopic disease and vernal. "If you ask about atopy, you find a lot of patients have some sort of dermatitis or rhinitis. Many times, the eyes are not the only thing involved," he said. "Even if it's just ocular, an air purifier in the bedroom helps the patient avoid the antigen."

Dr. Bloom agrees that atopy can be a systemic issue. "I pulse them with a steroid ointment and have them use Benadryl (diphenhydramine HCl, Warner Lambert) at night. However, if the problem is recurring and other areas are affected, I consider it more of a dermatologic problem and will refer to a dermatologist for a consult," he said.

Dr. Raizman has done recent work with topical cyclosporine on atopic patients, and he is very enthusiastic about it for severe, recalcitrant disease. Cyclosporine is currently approved for immunosuppression to combat corneal transplant rejection. "I think there is enough literature regarding cyclosporine's use in ocular allergy, so I don't think there is any major legal threat," Dr. Raizman said.

"If this product is approved for treating dry eye, then we will have a commercially available cyclosporine product for topical use," he continued. "I think that will be a very exciting development, because it is becoming increasingly clear that it is an excellent drug for fighting allergy."

For Your Information:
Timothy T. McMahon, OD, FAAO, may be reached at 1855 W. Taylor Street, Chicago, IL 60612; (312) 996-5410; fax: (312) 996-4098; e-mail: timomcma@uic.edu. Dr. McMahon is a paid consultant with the contact lens division of Bausch & Lomb.

Brian Den Beste, OD, FAAO, may be reached at 121 West Underwood, Orlando, FL 32806; (407) 843-1471; fax: (407) 872-7939; e-mail: besteyedoc@AOL.com. Dr. Den Beste has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Dana Ullman, MPH, is an elected board member of the National Center for Homeopathy and directs Homeopathic Educational Services. He has co-taught a course on homeopathy at the University of California San Francisco School of Medicine and is a member of the Advisory Council of the Alternative Medicine Center at Columbia University's College of Physicians and Surgeons. He has authored several books on homeopathic medicine, including a consumer's guide to homeopathic medicine. He may be reached at 2124 Kittredge Street, Berkeley, CA 94704; (510) 649-0294; fax: (510) 649-1955; e-mail: mail@homeopathic.com.

Robert Owens, OD, practices at 654 Main Street, New Holland, PA 17557; (717) 354-2251; fax: (717) 354-2262; e-mail: ROwens@Epix.net. Dr. Owens has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Michael B. Raizman, MD, may be reached at 750 Washington Street, Box 450, Boston, MA 02111; (617) 636-7625; fax: (617) 636-4866. Dr. Raizman has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Michael Bloom, OD, is in practice at Ross Eyecare Group, 2625 Piedmont Rd., Atlanta, GA 30324; (404) 233-3513; fax: (404) 814-0184. Dr. Bloom has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Susan E. Marren, OD, FAAO, may be reached at (609) 829-4229; e-mail: SMarren@aol.com. Dr. Marren has no direct financial interest in any of the products mentioned in this article, nor is she a paid consultant for any company mentioned.