Antihistamines’ Generation Gap

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Are You Ready For Allergy Season?

For those of us in the Northern Hemisphere, fall will be upon us soon, and we have a few weeks to be ready for it. A common seasonal ailment is of course seasonal allergies—it’s not serious for most of us, but it can be very annoying, and can disrupt a lot of our normal activities.

Suddenly, a thing that notionally does us no real harm, is making driving dangerous, cooking take three times as long, sex laughable if not off-the-table (so to speak), and the lightest tasks exhausting.

So, what to do about it?

Antihistamines: first generation

Ye olde antihistamines such as diphenhydramine and chlorpheniramine are probably not what to do about it.

They are small molecules that cross the blood-brain barrier and affect histamine receptors in the central nervous system. This will generally get the job done, but there’s a fair bit of neurological friendly-fire going on, and while they will produce drowsiness, the sleep will usually be of poor quality. They also tax the liver rather.

If you are using them and not experiencing unwanted side effects, then don’t let us stop you, but do be aware of the risks.

See also: Long-term use of diphenhydramine ← this is the active ingredient in Benadryl in the US and Canada, but safety regulations in many other countries mean that Benadryl has different, safer active ingredients elsewhere.

Antihistamines: later generations

We’re going to aggregate 2nd gen, 3rd gen, and 4th gen antihistamines here, because otherwise we’ll be writing a history article and we don’t have room for that. But suffice it to say, later generations of antihistamines do not come with the same problems.

Instead of going in all-guns-blazing to the CNS like first-gens, they are more specific in their receptor-targetting, resulting in negligible collateral damage:

CSACI position statement: Newer generation H1-antihistamines are safer than first-generation H1-antihistamines and should be the first-line antihistamines for the treatment of allergic rhinitis and urticaria

Special shout-out to cetirizine and loratadine, which are the drugs behind half the brand names you’ll see on pharmacy shelves around most of the world these days (including many in the US and Canada).

Note that these two are very often discussed in the same sentence, sit next to each other on the shelf, and often have identical price and near-identical packaging. Their effectiveness (usually: moderate) and side effects (usually: low) are similar and comparable, but they are genuinely different drugs that just happen to do more or less the same thing.

This is relevant because if one of them isn’t working for you (and/or is creating an unwanted side effect), you might want to try the other one.

Another honorable mention goes to fexofenadine, for which pretty much all the same as the above goes, though it gets talked about less (and when it does get mentioned, it’s usually by its most popular brand name, Allegra).

Finally, one that’s a little different and also deserving of a special mention is azelastine. It was recently (ish, 2021) moved from being prescription-only to being non-prescription (OTC), and it’s a nasal spray.

It can cause drowsiness, but it’s considered safe and effective for most people. Its main benefit is not really the difference in drug, so much as the difference in the route of administration (nasal rather than oral). Because the drug is in liquid spray form, it can be absorbed through the mucus lining of the nose and get straight to work on blocking the symptoms—in contrast, oral antihistamines usually have to go into your stomach and take their chances there (we say “usually”, because there are some sublingual antihistamines that dissolve under the tongue, but they are less common.)

Better than antihistamines?

Writer’s note: at this point, I was given to wonder: “wait, what was I squirting up my nose last time anyway?”—because, dear readers, at the time I got it I just bought one of every different drug on the shelf, desperate to find something that worked. What worked for me, like magic, when nothing else had, was beclometasone dipropionate, which a) smelled delightfully of flowers, which might just be the brand I got, b) needs replacing now because I got it in March 2023 and it expired July 2024, and c) is not an antihistamine at all.

But, that brings us to the final chapter for today: systemic corticosteroids

They’re not ok for everyone (check with your doctor if unsure), and definitely should not be taken if immunocompromised and/or currently suffering from an infection (including colds, flu, COVID, etc) unless your doctor tells you otherwise (and even then, honestly, double-check).

But! They can work like magic when other things don’t. Unlike antihistamines, which only block the symptoms, systemic corticosteroids tackle the underlying inflammation, which can stop the whole thing in its tracks.

Here’s how they measure up against antihistamines:

❝The results of this systematic review, together with data on safety and cost effectiveness, support the use of intranasal corticosteroids over oral antihistamines as first line treatment for allergic rhinitis.❞

~ Dr. Robert Puy et al.

Read in full: Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials

Take care!

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  • Yes, we still need chickenpox vaccines

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    For people who grew up before a vaccine was available, chickenpox is largely remembered as an unpleasant experience that almost every child suffered through. The highly contagious disease tore through communities, leaving behind more than a few lasting scars. 

    For many children, chickenpox was much more than a week or two of itchy discomfort. It was a serious and sometimes life-threatening infection.

    Prior to the chickenpox vaccine’s introduction in 1995, 90 percent of children got chickenpox. Those children grew into adults with an increased risk of developing shingles, a disease caused by the same virus—varicella-zoster—as chickenpox, which lies dormant in the body for decades. 

    The vaccine changed all that, nearly wiping out chickenpox in the U.S. in under three decades. The vaccine has been so successful that some people falsely believe the disease no longer exists and that vaccination is unnecessary. This couldn’t be further from the truth. 

    Vaccination spares children and adults from the misery of chickenpox and the serious short- and long-term risks associated with the disease. The CDC estimates that 93 percent of children in the U.S. are fully vaccinated against chickenpox. However, outbreaks can still occur among unvaccinated and under-vaccinated populations. 

    Here are some of the many reasons why we still need chickenpox vaccines.

    Chickenpox is more serious than you may remember

    For most children, chickenpox lasts around a week. Symptoms vary in severity but typically include a rash of small, itchy blisters that scab over, fever, fatigue, and headache. 

    However, in one out of every 4,000 chickenpox cases, the virus infects the brain, causing swelling. If the varicella-zoster virus makes it to the part of the brain that controls balance and muscle movements, it can cause a temporary loss of muscle control in the limbs that can last for months. Chickenpox can also cause other serious complications, including skin, lung, and blood infections. 

    Prior to the U.S.’ approval of the vaccine in 1995, children accounted for most of the country’s chickenpox cases, with over 10,000 U.S. children hospitalized with chickenpox each year. 

    The chickenpox vaccine is very effective and safe

    Chickenpox is an extremely contagious disease. People without immunity have a 90 percent chance of contracting the virus if exposed. 

    Fortunately, the chickenpox vaccine provides lifetime protection and is around 90 percent effective against infection and nearly 100 percent effective against severe illness. It also reduces the risk of developing shingles later in life. 

    In addition to being incredibly effective, the chickenpox vaccine is very safe, and serious side effects are extremely rare. Some people may experience mild side effects after vaccination, such as pain at the injection site and a low fever.

    Although infection provides immunity against future chickenpox infections, letting children catch chickenpox to build up immunity is never worth the risk, especially when a safe vaccine is available. The purpose of vaccination is to gain immunity without serious risk. 

    The chickenpox vaccine is one of the greatest vaccine success stories in history

    It’s difficult to overstate the impact of the chickenpox vaccine. Within five years of the U.S. beginning universal vaccination against chickenpox, the disease had declined by over 80 percent in some regions. 

    Nearly 30 years after the introduction of the chickenpox vaccine, the disease is almost completely wiped out. Cases and hospitalizations have plummeted by 97 percent, and chickenpox deaths among people under 20 are essentially nonexistent

    Thanks to the vaccine, in less than a generation, a disease that once swept through schools and affected nearly every child has been nearly eliminated. And, unlike vaccines introduced in the early 20th century, no one can argue that improved hygiene, sanitation, and health helped reduce chickenpox cases beginning in the 1990s.

    Having chickenpox as a child puts you at risk of shingles later

    Although most people recover from chickenpox within a week or two, the virus that causes the disease, varicella-zoster, remains dormant in the body. This latent virus can reactivate years after the original infection as shingles, a tingling or burning rash that can cause severe pain and nerve damage.  

    One in 10 people who have chickenpox will develop shingles later in life. The risk increases as people get older as well as for those with weakened immune systems. 

    Getting chickenpox as an adult can be deadly

    Although chickenpox is generally considered a childhood disease, it can affect unvaccinated people of any age. In fact, adult chickenpox is far deadlier than pediatric cases. 

    Serious complications like pneumonia and brain swelling are more common in adults than in children with chickenpox. One in 400 adults who get chickenpox develops pneumonia, and one to two out of 1,000 develop brain swelling.

    Vaccines have virtually eliminated chickenpox, but outbreaks still happen

    Although the chickenpox vaccine has dramatically reduced the impact of a once widespread disease, declining immunity could lead to future outbreaks. A Centers for Disease Control and Prevention analysis found that chickenpox vaccination rates dropped in half of U.S. states in the 2022-2023 school year compared to the previous year. And more than a dozen states have immunization rates below 90 percent.

    In 2024, New York City and Florida had chickenpox outbreaks that primarily affected unvaccinated and under-vaccinated children. With declining public confidence in routine vaccines and rising school vaccine exemption rates, these types of outbreaks will likely become more common.

    The CDC recommends that children receive two chickenpox vaccine doses before age 6. Older children and adults who are unvaccinated and have never had chickenpox should also receive two doses of the vaccine.

    For more information, talk to your health care provider.

    This article first appeared on Public Good News and is republished here under a Creative Commons license.

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  • The Compass of Pleasure – by Dr. David Linden

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    There are a lot of books about addiction, so what sets this one apart?

    Mostly, it’s that this one maintains that addiction is neither good nor bad per se—just, some behaviors and circumstances are. Behaviors and circumstances caused, directly or indirectly, by addiction.

    But, Dr. Linden argues, not every addiction has to be so. Especially behavioral addictions; the rush of dopamine one gets from a good session at the gym or learning a new language, that’s not a bad thing, even if they can fundamentally be addictions too.

    Similarly, we wouldn’t be here as a species without some things that rely on some of the same biochemistry as addictions; orgasms and eating food, for example. Yet, those very same urges can also inconvenience us, and in the case of foods and other substances, can harm our health.

    In this book, the case is made for shifting our addictive tendencies to healthier addictions, and enough information is given to help us do so.

    Bottom line: if you’d like to understand what is going on when you get waylaid by some temptation, and how to be tempted to better things, this book can give the understanding to do just that.

    Click here to check out The Compass of Pleasure, and make yours work in your favor!

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  • What are the most common symptoms of menopause? And which can hormone therapy treat?

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    Despite decades of research, navigating menopause seems to have become harder – with conflicting information on the internet, in the media, and from health care providers and researchers.

    Adding to the uncertainty, a recent series in the Lancet medical journal challenged some beliefs about the symptoms of menopause and which ones menopausal hormone therapy (also known as hormone replacement therapy) can realistically alleviate.

    So what symptoms reliably indicate the start of perimenopause or menopause? And which symptoms can menopause hormone therapy help with? Here’s what the evidence says.

    Remind me, what exactly is menopause?

    Menopause, simply put, is complete loss of female fertility.

    Menopause is traditionally defined as the final menstrual period of a woman (or person female at birth) who previously menstruated. Menopause is diagnosed after 12 months of no further bleeding (unless you’ve had your ovaries removed, which is surgically induced menopause).

    Perimenopause starts when menstrual cycles first vary in length by seven or more days, and ends when there has been no bleeding for 12 months.

    Both perimenopause and menopause are hard to identify if a person has had a hysterectomy but their ovaries remain, or if natural menstruation is suppressed by a treatment (such as hormonal contraception) or a health condition (such as an eating disorder).

    What are the most common symptoms of menopause?

    Our study of the highest quality menopause-care guidelines found the internationally recognised symptoms of the perimenopause and menopause are:

    • hot flushes and night sweats (known as vasomotor symptoms)
    • disturbed sleep
    • musculoskeletal pain
    • decreased sexual function or desire
    • vaginal dryness and irritation
    • mood disturbance (low mood, mood changes or depressive symptoms) but not clinical depression.

    However, none of these symptoms are menopause-specific, meaning they could have other causes.

    In our study of Australian women, 38% of pre-menopausal women, 67% of perimenopausal women and 74% of post-menopausal women aged under 55 experienced hot flushes and/or night sweats.

    But the severity of these symptoms varies greatly. Only 2.8% of pre-menopausal women reported moderate to severely bothersome hot flushes and night sweats symptoms, compared with 17.1% of perimenopausal women and 28.5% of post-menopausal women aged under 55.

    So bothersome hot flushes and night sweats appear a reliable indicator of perimenopause and menopause – but they’re not the only symptoms. Nor are hot flushes and night sweats a western society phenomenon, as has been suggested. Women in Asian countries are similarly affected.

    Woman sits on chair, looking deflated
    You don’t need to have night sweats or hot flushes to be menopausal.
    Maridav/Shutterstock

    Depressive symptoms and anxiety are also often linked to menopause but they’re less menopause-specific than hot flushes and night sweats, as they’re common across the entire adult life span.

    The most robust guidelines do not stipulate women must have hot flushes or night sweats to be considered as having perimenopausal or post-menopausal symptoms. They acknowledge that new mood disturbances may be a primary manifestation of menopausal hormonal changes.

    The extent to which menopausal hormone changes impact memory, concentration and problem solving (frequently talked about as “brain fog”) is uncertain. Some studies suggest perimenopause may impair verbal memory and resolve as women transition through menopause. But strategic thinking and planning (executive brain function) have not been shown to change.

    Who might benefit from hormone therapy?

    The Lancet papers suggest menopause hormone therapy alleviates hot flushes and night sweats, but the likelihood of it improving sleep, mood or “brain fog” is limited to those bothered by vasomotor symptoms (hot flushes and night sweats).

    In contrast, the highest quality clinical guidelines consistently identify both vasomotor symptoms and mood disturbances associated with menopause as reasons for menopause hormone therapy. In other words, you don’t need to have hot flushes or night sweats to be prescribed menopause hormone therapy.

    Often, menopause hormone therapy is prescribed alongside a topical vaginal oestrogen to treat vaginal symptoms (dryness, irritation or urinary frequency).

    Doctor talks to woman
    You don’t need to experience hot flushes and night sweats to take hormone therapy.
    Monkey Business Images/Shutterstock

    However, none of these guidelines recommend menopause hormone therapy for cognitive symptoms often talked about as “brain fog”.

    Despite musculoskeletal pain being the most common menopausal symptom in some populations, the effectiveness of menopause hormone therapy for this specific symptoms still needs to be studied.

    Some guidelines, such as an Australian endorsed guideline, support menopause hormone therapy for the prevention of osteoporosis and fracture, but not for the prevention of any other disease.

    What are the risks?

    The greatest concerns about menopause hormone therapy have been about breast cancer and an increased risk of a deep vein clot which might cause a lung clot.

    Oestrogen-only menopause hormone therapy is consistently considered to cause little or no change in breast cancer risk.

    Oestrogen taken with a progestogen, which is required for women who have not had a hysterectomy, has been associated with a small increase in the risk of breast cancer, although any risk appears to vary according to the type of therapy used, the dose and duration of use.

    Oestrogen taken orally has also been associated with an increased risk of a deep vein clot, although the risk varies according to the formulation used. This risk is avoided by using estrogen patches or gels prescribed at standard doses

    What if I don’t want hormone therapy?

    If you can’t or don’t want to take menopause hormone therapy, there are also effective non-hormonal prescription therapies available for troublesome hot flushes and night sweats.

    In Australia, most of these options are “off-label”, although the new medication fezolinetant has just been approved in Australia for postmenopausal hot flushes and night sweats, and is expected to be available by mid-year. Fezolinetant, taken as a tablet, acts in the brain to stop the chemical neurokinin 3 triggering an inappropriate body heat response (flush and/or sweat).

    Unfortunately, most over-the-counter treatments promoted for menopause are either ineffective or unproven. However, cognitive behaviour therapy and hypnosis may provide symptom relief.

    The Australasian Menopause Society has useful menopause fact sheets and a find-a-doctor page. The Practitioner Toolkit for Managing Menopause is also freely available.The Conversation

    Susan Davis, Chair of Women’s Health, Monash University

    This article is republished from The Conversation under a Creative Commons license. Read the original article.

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    It’s Q&A Day at 10almonds!

    Have a question or a request? You can always hit “reply” to any of our emails, or use the feedback widget at the bottom!

    In cases where we’ve already covered something, we might link to what we wrote before, but will always be happy to revisit any of our topics again in the future too—there’s always more to say!

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    “It was superb !! Just loved that healthy recipe !!! I would love to see one of those every day, if possible !! Keep up the fabulous work !!! ”

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  • Thinner Leaner Stronger – by Michael Matthews

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    First, the elephant in the training room: this book does assume that you want to be thinner, leaner, and stronger. This is the companion book, written for women, to “Bigger, Stronger, Leaner”, which was written for men. Statistically, these assumptions are reasonable, even if the generalizations are imperfect. Also, this reviewer has a gripe with anything selling “thinner”. Leaner was already sufficient, and “stronger” is the key element here, so “thinner” is just marketing, and marketing something that’s often not unhealthy, to sell a book that’s actually full of good advice for building a healthy body.

    In other words: don’t judge a book by the cover, however eyeroll-worthy it may be.

    The book is broadly aimed at middle-aged readers, but boasts equal worth for young and old alike. If there’s something Matthews knows how to do well in his writing, it’s hedging his bets.

    As for what’s in the book: it’s diet and exercise advice, aimed at long-term implementation (i.e. not a crash course, but a lifestyle change), for maximum body composition change results while not doing anything silly (like many extreme short-term courses do) and not compromising other aspects of one’s health, while also not taking up an inordinate amount of time.

    The dietary advice is sensible, broadly consistent with what we’d advise here, and/but if you want to maximise your body composition change results, you’re going to need a pocket calculator (or be better than this writer is at mental arithmetic).

    The exercise advice is detailed, and a lot more specific than “lift things”; there are programs of specifically how many sets and reps and so forth, and when to increase the weights and when not to.

    A strength of this book is that it explains why all those numbers are what they are, instead of just expecting the reader to take on faith that the best for a given exercise is (for example) 3 sets of 8–10 reps of 70–75% of one’s single-rep max for that exercise. Because without the explanation, those numbers would seem very arbitrary indeed, and that wouldn’t help anyone stick with the program. And so on, for any advice he gives.

    The style is… A little flashy for this reader’s taste, a little salesy (and yes he does try to upsell to his personal coaching, but really, anything you need is in the book already), but when it comes down to it, all that gym-boy bravado doesn’t take away from the fact his advice is sound and helpful.

    Bottom line: if you would like your body to be the three things mentioned in the title, this book can certainly help you get there.

    Click here to check out Thinner Leaner Stronger, and become thinner, leaner, stronger!

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  • Grapefruit vs Orange – Which is Healthier?

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    Our Verdict

    When comparing grapefruit to orange, we picked the orange.

    Why?

    It’s easy, when guessing which is the healthier out of two things, to guess that the more expensive or perhaps less universally available one is the healthier. But it’s not always so, and today is one of those cases!

    In terms of macros, they are very similar fruits, with almost identical levels of carbohydrates, proteins, and fats, as well as water. Looking more carefully, we find that grapefruit’s sugars contain a slightly high proportion of fructose; not enough to make it unhealthy by any means (indeed, no whole unprocessed fruit is unhealthy unless it’s literally poisonous), but it is a thing to note if we’re micro-analysing the macronutrients. Also, oranges have slightly more fiber, which is always a plus.

    When it comes to vitamins, oranges stand out with more of vitamins B1, B2, B3, B6, B9, C, and E, while grapefruit boasts more vitamin A (hence its color). Still, we’re calling this category another win for oranges.

    In the category of minerals, oranges again sweep with more calcium, copper, iron, magnesium, manganese, potassium, and selenium, while grapefruit has just a little more phosphorus. So, another easy win for oranges.

    One final consideration that’s not shown in the nutritional values, is that grapefruit contains furanocoumarin, which can inhibit cytochrome P-450 3A4 isoenzyme and P-glycoptrotein transporters in the intestine and liver—slowing down their drug metabolism capabilities, thus effectively increasing the bioavailability of many drugs manifold. It can also be found in lower quantities in Seville (sour) oranges, and it’s not present (or at least, if it is, it’s in truly tiny quantities) in most oranges.

    This may sound superficially like a good thing (improving bioavailability of things we want), but in practice it means that in the case of many drugs, if you take them with (or near in time to) grapefruit or grapefruit juice, then congratulations, you just took an overdose. This happens with a lot of meds for blood pressure, cholesterol (including statins), calcium channel-blockers, anti-depressants, benzo-family drugs, beta-blockers, and more. Oh, and Viagra, too. Which latter might sound funny, but remember, Viagra’s mechanism of action is blood pressure modulation, and that is not something you want to mess around with unduly. So, do check with your pharmacist to know if you’re on any meds that would be affected by grapefruit or grapefruit juice!

    All in all, today’s sections add up to an overwhelming win for oranges!

    Want to learn more?

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