Ask an expert: My allergy meds aren’t working

Q: "I've tried just about every medication on the market for my seasonal allergies, and nothing has helped. In fact, since switching to my current nasal spray, I'm now getting nosebleeds, on top of the usual dripping and sniffling. Am I doing something wrong? Should I keep trying other sprays and drugs? Do I need sinus surgery?"

Answer provided by Steven Olsen, M.D., ear, nose and throat physician, and Mark Pruitt, MSN, FNP, Providence Hood River Memorial Hospital.

We understand your frustrations, and we see a lot of people who share them. While surgery can be a helpful option for people who don't respond to medications, we've found that about 90 percent of people who aren't getting relief either are on the wrong medications or are simply using their medications incorrectly. Make sure you are not making these three common mistakes:

Pointing sprays the wrong way: Nasal steroids are one of the most effective treatments we have for seasonal allergy symptoms, but many people stop using these sprays when they get nosebleeds. A nosebleed is a sign that you may be spraying the medication in the wrong direction. Directing the spray onto your septum – the center divider of your nose – can cause irritation, and may miss the part of the nose where the medication can do its best work. To optimize effectiveness and minimize bleeding, nasal steroids should be sprayed at an angle so that the spray is directed toward the side of your nose, where inflammation is greatest, rather than toward the septum. I generally instruct patients to aim the nozzle toward their ear, and to avoid sniffing to allow the medication to settle in the nose. Ask your doctor or pharmacist to show you exactly how to do it.

Giving up too soon: A lot of people expect to feel better within 30 minutes of using a nasal steroid, but that's not how these medications are designed to work. Nasal steroids reduce inflammation in the nose so that, over time, your nasal passages will become less sensitive to allergens. Most people don't get the full benefit until the medication has been used regularly for about two months. It's tough to stick with a medication when you feel like it isn't doing anything, but you need to give it time to see whether it will work for you. When starting any new medication, ask your doctor when you should expect results, and how long you should give it to take effect before you switch to something else.

Mismatching medications: Different types of allergy medications relieve different types of symptoms, and people often choose the wrong ones for their particular problems. For one person, the most annoying symptom may be a runny nose or nasal itching, in which case an antihistamine may be very helpful. For another, the biggest problem may be dryness and crusting inside the nose, in which case the drying effect of an antihistamine might only make the problem worse. Effective treatment requires understanding the benefits of each type of medication, and choosing those that are designed to relieve your worst symptoms. Your doctor can help, but it may require a few trials before you hit on the right combination. To help with the process, make sure your doctor knows which symptoms are the most bothersome to you, and ask your doctor what benefits you should expect from each medicine you try.

When to consider surgery

If you have been working with your primary care provider for several months, have given medications a lengthy trial, and still are not making the headway that you want, then it's probably time to see a specialist. By the time most people see an allergist or an ear, nose and throat specialist, they're generally frustrated, miserable and ready to talk surgery. However, in Dr. Olsen's experience, most of these people still can get their allergies under good control with allergen avoidance and medical therapy alone. Sometimes it just takes an aggressive regimen up front to get the inflammatory response under control before a person can transition to a good maintenance regimen.

Dr. Olsen ends up operating on only about 10 to 15 percent of the people who come to him for allergy treatment. For those who don't respond to medications, two surgical procedures can be very helpful:

Turbinate surgery: Turbinates are structures on the inner sides of the nose that function to warm and humidify air and to regulate airflow in the nose. Chronic inflammation from allergies can cause these to grow so large that they obstruct the nasal passage, causing a lot of nasal drainage. Turbinate surgery reduces the bulk of the turbinate, improving breathing and facilitating delivery of medications to the nasal passageways.

Sinus surgery: Allergies that cause a lot of swelling inside the nose sometimes close off the sinus openings, causing chronic sinus diseases and infections. When medications fail to reopen the sinuses, the openings can be enlarged surgically, and diseased tissue such as nasal polyps can be removed, reducing sinus infections and improving delivery of sinus medications.

It is important to note that surgery does not cure allergies, but in properly selected patients, surgery can be very helpful, working synergistically with sinus medications to open blocked pathways and allow allergy medications in to do their job.

One option that you didn't ask about is allergy testing and immunotherapy – the allergy shots or drops that can desensitize certain people to specific allergens. Allergy testing can identify the specific allergens that affect individuals so those people can modify their environment and behavior to reduce their allergen exposure. Testing also opens the door for some people to have targeted desensitizing therapy. This approach can be tremendously beneficial, but it's not right for everyone. Read our article "Should I try allergy shots?"

We encourage you to continue your efforts to get your allergies under control. Poorly controlled allergies can cause recurring sinusitis and complications, can worsen asthma and other pulmonary diseases, and can keep your immune system in a constant state of overdrive, which can lead to depression and a lower quality of life. Effective treatments are available, and though they may not completely eliminate every symptom forever, they certainly can make most days much more comfortable and enjoyable.