Allergies may affect up to 40 million people in the United States every year. The manifestations of allergies range from annoying symptoms of a runny nose and sneezing to life threatening obstruction of breathing. Many people may only have allergy symptoms for a few weeks out of the year, while others are bothered by repeated sinus infections or asthma. For the pilot, there are effective treatments for almost the entire spectrum of allergic symptoms that will not ground the pilot, or are easily waiverable after proper reporting.
The most common manifestations of allergies is the runny nose (rhinitis), sneezing and itching eyes. These symptoms may be seasonal when certain grasses, flowers, trees or molds shed pollen or spores (Seasonal Allergic Rhinitis or SAR). Some individuals are plagued with these symptoms nearly continuously regardless of the season (Perennial Allergic Rhinitis). These people may be sensitive to dust, animal dander or other common materials.
Non-allergic rhinitis, also known as vasomotor rhinitis or irritant rhinitis, may be caused by smoke, fumes, odors, chemicals or other unknown sources, may cause symptoms year-round. Common colds, caused by rhino viruses, may have similar symptoms of congestion and runny nose, but are not usually associated with itching eyes. Colds usually resolve within five to ten days and do not occur regularly with a particular season.
Immune System and Allergic Responses
Allergies are caused by the body’s reaction to outside proteins or particles (allergens). The immune system releases chemicals from certain blood cells and tissues called histamines that cause a reaction to the allergens. Generally, the mucus membranes near the site where the allergen reaches the body react by swelling and leaking clear fluid. The tissue is also irritated giving a scratching, itching sensation.
There are a variety of methods for testing for allergies. They include skin tests such as patch testing, intradermal testing and scratch/prick testing. Blood testing is used to look for evidence of allergies in the body.
If the sinus passages are constantly swollen and filled with fluid, an excellent culture site is created for bacteria in the respiratory tract. Sinusitis, ear blocks and sinus blocks may result, particularly with repeated changes in atmospheric pressure. In more severe cases, the histamines and other chemicals released by the body may act not only on the local site of exposure, but on the entire body. The result may be an asthma attack as the breathing airways swell, leak fluid and close down. Allergies can also cause itching over the entire body.
Preventive Medication- Nasal Steroids
Another method of prevention is the use of medication to block the body’s reaction the allergens. The most common symptoms of nasal stuffiness are effectively relieved by nasal steroid sprays. These steroids act by stabilizing the cells in the body exposed to allergens so they do not release histamines. They are not immediately effective, but may take several days to weeks to reach their full effect. If someone can anticipate their allergy season, using these agents several weeks before the season starts may block most symptoms. The steroid nasal sprays should not be confused with anabolic steroids, often illegally used by body builders and athletes.
The nasal steroids are usually well tolerated and act on the nose and upper respiratory tract. They are relatively safe for long term use and the FAA approves their use if they are effective. Reporting their use to the FAA may be done at the airman’s next physical exam. Some of the name brands for these effective products are Beconase, Vancenase, Flonase, Nasalide, Nasacort, Nasonex, Nasarel and Rhinocort.
Prevention by Avoidance
Allergies may be prevented or treated. The most effective prevention is avoidance of the allergen. This is often not practical for the pilot who flies all over the country or is based in a region filled with numerous allergens. Ironically, many pilots note their allergies will improve when they are flying since the cabin air at altitude is usually relatively free of allergens. If someone is allergic to animals, such as cats, getting rid of the animal may cure the symptoms. Many allergy suffers are unable to avoid or even identify the cause of their symptoms.
Non-steroid Nasal Sprays
These nasal non-steroid sprays should not be confused with nasal decongestant sprays such as Afrin and Dristan which cannot safely be used for more than several days and are not permitted by the FAA, except as an emergency “get me down” for sinus and ear blocks occurring in flight.
Cromolyn is an example of a FAA approved non-steroid medication for control of allergic symptoms. It is most effective for relieving itchy eyes when used as a eye dropper or nasal spray.
Atrovent nasal spray decreases nasal secretions in both allergic and non-allergic rhinitis. The FAA will authorize it’s use when flying after an appropriate observation period without side effects.
Astelin (azelastin), a nasal spray form of antihistamine, was previously not approved for use when flying. As of Dec 2014, the FAA now allows use of this medication as long as there is no sedation or side effects. One common brand of this is Astepro, and a it is combined with a nasal steroid in a brand called Dymista.
Preventive Medication – Over-the Counter Antihistamines
Antihistamines work by a different mechanism from nasal steroids, but also result in blocking the body’s allergic response. Antihistamines are available over-the-counter (OTC) or by prescription.
Very few OTC antihistamines are authorized by the FAA for pilots when flying, if they have previously tested the medication and do not have any side effects. The primary non-sedating OTC antihistamines, Claritin (loratidine) and Allegra (fexofenadine), were formerly available by prescription only and are allowed by the FAA.
The over-the-counter products such as chlorpheneramine (Clortrimaton, CTM) and diphenhydramine (Benadryl) found in many commercial products cause drowsiness. Likewise, Zyrtec (certirazine) and a similar medication Xyzal may cause drowsiness. They are not permitted by the FAA. The FAA requires waiting at least five times as long as the dosing recommendation after the last dose to fly. For example, if the directions read “take every six hours”, the pilot should wait at least 30 hours after the last dose before considering flying.
A study published in the Annuals of Internal Medicine in March of 2000 demonstrated that the effect of taking Benadryl, an OTC antihistamine, impaired driving performance significantly more than a blood alcohol concentration of 0.1% (legally intoxicated) or Allegra, a “non-sedating” antihistamine. It also demonstrated that subjective drowsiness was not an accurate measure of driving performance. Two of the study’s authors are consultants to the manufacturer of Allegra.
Like the nasal steroids, the use of the approved medications may be reported at the airman’s next FAA physical. Those approved medications that are combined with pseudoephedrine, the active ingredient in Sudafed, are also approved by the FAA. They include Claritin-D, Clarinex-D and Allegra-D.
Preventive Medication – Prescription Antihistamine Eye Drops and Nasal Sprays
Astelin (azelastin), a nasal spray form of antihistamine, is now approved for use when flying. There is an eye drop form of this medication that is allowed as long as no side effects as well.
Decongestants, such as Sudafed, are often used with allergies to constrict blood vessels in the nose and relieve the running nose. Pseudoephedrine, found in Sudafed, is approved for use while flying. This medication acts throughout the entire body by constricting blood vessels. Side effects may include an increased heart rate, elevated blood pressure and difficulty urinating in men with prostate problems. Because it frequently keeps individuals awake, it is often combined with non-approved antihistamines sold over the counter. These combinations of decongestants and sedating OTC antihistamines are not approved as noted above.
Severe cases of allergies may cause asthma or other symptoms that require treatment with oral steroids such as Prednisone or Medrol, or steroid injections. Pilots having symptoms severe enough to require this type of treatment should not fly until the condition is resolved.
Desensitization – Shots & Oral – Immunotherapy
The FAA will approve pilots to fly when undergoing treatment with allergy desensitization shots. Pilots should be cautious flying after receiving higher strength/concentration serums to insure they do not have a delayed allergic reaction. The FAA requires a four hour wait after immunotherapy injections.
There is a newer form of immunotherapy using drops under the tongue called Sublingual Immunotherapy or SLIT. The FAA now allows SLIT and requires a 24 hour observation time after the first use each season, and then four hours after each subsequent administration. This is not allowed in airmen over 65 years old with significant asthma.
FAA Reporting Requirements
The reporting of seasonal allergic rhinitis (SAR) or other allergies controlled with approved medications should be done on FAA Form 8500-8, in block 17, “Medications”. List the medication used and dose. In the physician visit section, list the name of the physician with date or range of dates of visits. For reason for visit, list “Allergic Rhinitis- treated and controlled. No side effects”, assuming this is true.
Recently, some pilots who have listed Claritin, Clarinex or Allegra as medications they are using to control allergic symptoms have received letters from the FAA indicating the use of these medications are prohibited within 48 hours of flight. These letters were sent because the pilot or AME did not make comments on the FAA Form 8500-8, Airman Medical Application, that the medication was tolerated without side effects. A comment on the application regarding the absence of side effects would not result in a restriction. Discussion with representatives of the FAA confirm that pilots who do not have any side effects from Allegra, Clarinex or Claritin should note the absence of side effects on their physicals and may continue to fly with these medications.
AMAS Aeromedical Assistance
For a more specific personal explanation to your questions or those concerning aeromedical certification, contact AMAS for a private consultation. For help in reporting treatment for and obtaining clearance from the FAA to fly or control with these conditions, please contact one of the AMAS physicians using the Confidential Questionnaire. If you are an AMAS Corporate Member, these services are FREE to you.