In my experience, the three most important things to consider when selecting allergy medications: efficacy, dosing, and patient cost. Efficacy and dosing are extremely important for patient compliance. Patient compliance is best for drops that are dosed once per day at the highest concentration of medication. Drop efficacy is directly related to the mechanism of action. An allergy drop can be an antihistamine, mast cell stabilizer, or combination drug (which seems to be the most effective).
The following list represents the opinions of the author and not Eyes On Eyecare®. For more information on this topic, please check out our other ocular surface content!
This article, based on my reading and research, will act as a quick reference for optometrists on the best RX and OTC allergy drops and new treatments soon available on the market.
Best allergy drops for children
Pataday® (olopatadine hydrochloride 0.2%/olopatadine hydrochloride 0.7%)
Mechanism of action: mast cell stabilizer, histamine h1 antagonist.
Although Pataday has been around for a while, it has established itself as a quality drop. Many pediatricians prescribe Pataday for their patients. Pataday is safe and effective for long-term use and with a low side effect profile.
Pataday can be used in children 2 years and up! Safety and efficacy have not been determined for children under 2. In contrast, other antihistamine drops are recommended only for children 3 years and up.
Best allergy drops overall
Pataday® (olopatadine hydrochloride 0.7%)
Mechanism of action: mast cell stabilizer, histamine h1 antagonist; decreased chemotaxis and inhibition of eosinophil activation has been demonstrated.
The best overall ranking goes to Pazeo for its once-a-day dosing and high concentration of medication. These drops work for an entire 24 hours making them ideal for patients. The most common side effects ( seen in as few as 2% to 5% of patients) include blurred vision, dry eye, superficial punctate keratitis, impaired taste, and abnormal sensation in the eye. Studies have not been conducted on pregnant women.
Pazeo is now available OTC and patient cost can be reduced further by a coupon.
Best affordable allergy drops
Pataday® or Patanol® (Same drop, different concentration)
Mechanism of Action: 2nd generation histamine h1 antagonist, prevents type 1 immediate hypersensitivity reactions.
I prefer Pataday because the dose is only 1 gt QD at a higher concentration of 0.2%. As of 2020, Pataday/Patanol is now available over the counter for patient purchase. Coupons are also available online for your patients. I typically pull up the website and have patients take a screenshot so they know what to purchase.
Common side effects are similar to other topical ophthalmic drops. Reported side effects include:
- Headache
- Blurred vision
- Burning/stinging/redness/dryness/ irritation/itching of the eye
- Swollen or puffy eyelids
- Stuffy or runny nose
- Cough
- Sore throat
- Weakness
- Back pain
- A feeling as if something is in the eye
- Unusual or unpleasant taste in your mouth
Best allergy drops for contact lens wearers
No topical ophthalmic eye drop can be used with contact lenses in the eye. Most prescribing details warn patients to wait 5-10 minutes before lens insertion. For my lens wearers, I prefer drops dosed QD such as Pazeo, Pataday, or Lastacaft. It’s preferable to recommend 1 gt prior to lens insertion at the beginning of each day or at night after lens removal. This may eliminate future office calls about blurry vision with buildup of the drop on extended wear or monthly contact lenses.
Best OTC allergy drops
Systane ZATIDOR® or Alaway® (Ketotifen 0.035%, Ketotifen 0.025% )
Mechanism of action: inhibits vascular permeability and may prevent chemokine-induced migration of eosinophils into inflamed conjunctiva
Zaditor and Alaway are the same drop with slightly different percent concentrations. I usually recommend Alaway because the price is usually half that of Zaditor. Whichever you choose, these drops are dosed twice per day. These medications are considered to be second generation mast cell/ selective antihistamine combination medications. Note: Ketotifen is a category C pregnancy drug and is not recommended for use for children.
Side effects may include:
- Conjunctivitis
- Headache
- Eye pain
- Lacrimation disorder
- Keratitis
- Mydriasis
- Eyelid disorder
- Rhinitis
- Photophobia
Just like dry eye medications, you may have to try a generic option before you can offer a prescription medication with some insurance plans. In this case, patients should be educated on the superiority of the prescription drop and how it differs from the OTC drop. I also explain their insurance doesn’t allow for us to try the prescription medication until we fail with the OTC drops. Be sure to warn your patients that some OTC allergy drops can lead to pupil dilation if used excessively.
As of 2020, Pataday/Pazeo is now available OTC and may be an alternative to OTC Zaditor/Alaway. Patient preference may depend on symptom relief and cost.
Allergy eye drops can be similar to using oral allergy medications; sometimes a drop may lose efficacy, and you may need to change brands!
Best allergy drops for concurrent sinus and systemic allergy issues
BEPREVE® (bepotastine besilate ophthalmic solution 1.5%)
Mechanism of Action: direct H1-receptor antagonist, an inhibitor of the release of histamine from mast cells.
Bepreve is a highly selective, H1 receptor antagonist which is to be dosed twice per day. It does not have significant affinity for the muscarinic, adrenergic, and serotonergic sites. For this reason, it may not cause sedation, dryness, and blurry vision. This is beneficial for patients who may be taking oral medication for systemic allergies.
Bepreve is also the only drop that can reduce sinus congestion. This can be most beneficial to patients who may need systemic treatment, but want to avoid the dry eye caused by oral allergy medications.
Paul Karpecki, OD, FAAO , a leading dry expert notes with Bepreve, “Patients comment, almost unequivocally, how much this particular eye drop relieves the nonocular symptoms, especially nasal congestion.” Within 1-2 days, patients note a decrease in nasal congestion and itchy throat. Due to the overall systemic effects, Bepreve may also be the choice in dry eye patients.
Patients may also be able to use a coupon to reduce their costs.
The most common adverse reaction (occurring in 25% of patients) was a mild taste following drop use. Other adverse reactions (occurring in 2%-5% of patients) were:
- Eye irritation
- Headache
- Nasopharyngitis
There is no data on its use during pregnancy or in the pediatric population.
New to market allergy medications
Two new medications for allergic conjunctivitis have demonstrated efficacy in clinical trials and are expected on the market soon.
Reproxalap by Aldeyra Therapeutics is a new anti-inflammatory for dry eye and potential allergies without the side effects of steroids. In phase 3 clinical trials as of November 2021, patients experienced improvements in dryness, redness, and itching within a few hours after treatment. Reproxalap is dosed for 12 weeks, QID.
IC265 by Iacta Pharma is a syk kinase inhibitor in development for the treatment of dry eye and allergic conjunctivitis. In a phase 2 allergy study, IC265 demonstrated it is fast to act, well-tolerated, and reduces both redness and inflammation.
In 2022, we have exceptional options for both OTC and RX allergy treatments. The availability of Pataday/Pazeo OTC has changed my prescribing habits. According to the Lastacaft website, it was also approved in December 2021 to be available OTC soon. We now have several great allergy solutions and can avoid the insurance approval process.
Patients may respond better to one drop or another even if the mechanism of action is the same, but combo medications tend to be better in efficacy and patient compliance.
“Efficacy, dosing, and cost should be considered when selecting a treatment plan.”
Future advancements in treatment appear promising for our allergy sufferers.
