Treating Asthma and Comorbid Allergic Rhinitis in Pregnancy: A Review of the Current Guidelines

Barbara Yawn, MD, MSc, FAAFP; Mary Knudtson, DNSc, NP


J Am Board Fam Med. 2007;20(3):289-298. 

In This Article

Safety of AR Drug Classes During Pregnancy Antihistamines

In 1993, the NAEPP Working Group on Asthma and Pregnancy (the predecessor of APWG) recommended the first-generation agents chlorpheniramine and tripelennamine as the antihistamines of choice during pregnancy, based on duration of availability as well as reassuring animal and human data.[14] However, the ARIA guidelines, published in 2001, conclude that the older antihistamines have an overall unfavorable risk/benefit ratio, even in the nonpregnant population, because of their poor selectivity and their sedative and anticholinergic effects. ARIA recommends that where possible, first-generation antihistamines should no longer be prescribed as AR therapy (SOR-C).[29] In general, second-generation antihistamines are more potent, have a longer duration of action, and produce minimal sedation.[29]

In a joint position statement published in 2000, the American College of Obstetricians and Gynecologists and the American College of Allergy, Asthma and Immunology (ACOG-ACAAI) recommended consideration of cetirizine and loratadine, preferably after the first trimester, for pregnant women who need maximal topical therapy and cannot tolerate chlorpheniramine or tripelennamine.[39] ACOG-ACAAI based this statement on reassuring animal data for these second-generation antihistamines, which carry a Pregnancy B rating, and the fact that they are associated with fewer anticholinergic and sedative effects (SOR-B).[39]

APWG does not mention first-generation antihistamines and recommends cetirizine and loratadine as the second-generation antihistamines of choice for treatment of asthma with comorbid AR.[1] A review published in 2005, focusing on the treatment of AR rather than asthma, suggests there is insufficient evidence to support first-line use of cetirizine and loratadine during pregnancy[40] and recommends first considering chlorpheniramine, tripelennamine, or hydroxyzine if an antihistamine is needed during pregnancy (SOR-B).[40]

Physicians must decide on a case-by-case basis whether to select one of the older, better-studied antihistamines, thought to be safe during pregnancy, or a newer agent that has less adverse impact on quality of life but is less well studied in pregnancy.[41] The dilemma can often be averted by prescribing an intranasal steroid (INS) or cromolyn instead of an oral antihistamine.[41]


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