There are three important things to consider when selecting allergy medications: efficacy, dosing, and unfortunately, insurance coverage. Efficacy and dosing are extremely important for patient compliance. When permitted by insurance, I will prescribe a drop that only needs to be dosed once per day with the highest concentration of medication to make maintained use as easy on my patients as possible. Efficacy of the drop is also directly related to whether the drop is an antihistamine, mast cell stabilizer, or combination drug (which seem to be the most effective).
Note: Choosing allergy eye drops can be similar to using allergy oral medications; sometimes a drop may lose efficacy, and you may need to change brands!
Best for children
Pataday/Pazeo (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 and Pazeo can be used in children 2 years and up! Safety and efficacy have not been determined for children under 2 so be wary of the age of the patient though Pataday and Pazeo provide a fairly wide range as, in contrast, antihistamine-only drops like Zaditor are recommended only for children 3 years and up.
Pazeo (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 a whole 24 hours making them ideal for my patients. I have also been quite successful in providing patients with coupons to significantly cut the cost of these drops.
Savings can be found on their website.
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. There have not been any studies yet conducted on pregnant women so bear that in mind as well.
Best bang for your buck
Pataday/Patanol (Same drop, different percent)
Mechanism of Action: 2nd generation histamine h1 antagonist, prevents type 1 immediate hypersensitivity reactions.
The greatest thing about Pataday/Patanol is that it seems to be covered on a majority of insurance plans. If both are covered, prescribe Pataday because the dose is only 1 gt QD at a higher concentration of 0.2%. Patanol is the generic form and may be less costly, and both are equal as far as efficacy goes. Most prescription allergy drops can cost hundreds of dollars, however, this one is often covered with a small co-pay.
Common side effects are similar to other topical ophthalmic drops. Reported side effects include:
- Blurred vision
- Burning/stinging/redness/dryness/ irritation/itching of the eye
- Swollen or puffy eyelids
- Stuffy or runny nose
- Sore throat
- Back pain
- A feeling as if something is in the eye
- Unusual or unpleasant taste in your mouth
Best 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 once-a-day dosed drops such as Pazeo, Pataday, or Lastacaft. It’s preferable to recommend 1 gt prior to lens insertion at the beginning of each day. This can prevent calls later about blurry vision with contacts due to drop build-up on lenses.
Zaditor/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. Be sure to warn your patients to stick to that regimen; I caution patients to not use these excessively as they may dilate their pupils.
These drops are considered to be second generation mast cell/anti-histamine combination medications. It is a selective antihistamine.
Note: Ketotifen is a category C pregnancy drug and is not recommended for use for children.
Side effects may include:
- Eye pain
- Lacrimation disorder
- Eyelid disorder
I have most recently found that with allergy meds, just like dry eye meds, you must try using more basic options before you can offer the prescription medications with some insurance companies. If this is ever the case, I educate the patient on the superiority of the prescription drop and how it differs from the OTC drop, but I also explain their insurance doesn’t allow for us to try the prescription until we fail with the OTC drops.
Best for concurrent sinus/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. Dr. Karpecki, 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 from Bausch & Lomb to reduce their costs at http://www.bauschaccessprogram.com.
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
And there you have it! These are some of the most effective eye drops available in 2019. When selecting eye drops for your allergy-prone patients, it's important to consider not only the efficacy, but the dosing requirements, as well. You want to choose something that will work as quickly as possible to ensure that your patients get the most out of their prescription.