Supporting the World Allergy Organization’s commitment to awareness

The World Allergy Organization’s commitment to raising awareness of appropriate antihistamine use was a central message of the Kyoto session. Patients and healthcare professionals need to understand the benefits of second-generation, non-sedating antihistamines compared with older, first-generation medicines when treating allergic rhinitis and urticaria.

In this article, I explain why that message matters for patients. My emphasis is on choosing treatment that controls symptoms while protecting alertness, sleep and daily functioning. An allergy treatment plan should consider how a person feels and functions throughout the day, as well as whether their itching or sneezing has improved.

We also need to make these conversations routine: in consultations, at the pharmacy and when reviewing treatment after emergency care. Familiarity with an older medicine should not prevent a discussion about a more suitable, less-sedating option.

Allergy care needs to look beyond visible symptoms

A blocked nose or an itchy rash can sound minor until it repeatedly interrupts sleep, school or work. I believe a consultation should explore the effects patients may have come to accept as normal: waking at night, feeling exhausted, struggling to concentrate or being less productive.

Someone may report fewer sneezes yet still wake unrefreshed. Another person may have fewer hives but feel too sleepy to function comfortably. These are reasons to review the plan, rather than assuming treatment has achieved its goal.

Useful questions at a review

• Are symptoms waking you or making it difficult to fall asleep?
• Can you concentrate at work, at school or during examinations?
• Have symptoms affected exercise, social activities or confidence?
• Do you feel sleepy after taking your medicine or the following morning?
• Are you taking treatment consistently, and is the schedule practical?

Describe what has changed in your daily life as well as the symptoms themselves. A short diary can make this easier.

Is it hay fever, another nasal allergy or a cold?

Allergic rhinitis is inflammation of the nose caused by an allergic response. Hay fever is the form associated with pollen; other triggers include house dust mites, animals and mould. Recognising a pattern helps distinguish allergy from repeated infections. [1]

These are clues, not a diagnostic test. Allergy and infection can occur together, and persistent blockage can have other causes. Seek assessment when symptoms persist, disturb sleep or are accompanied by wheeze, breathlessness or reduced sense of smell. [1] [2]

Why antihistamine selection matters

Antihistamines reduce the effects of histamine, a chemical involved in itching, sneezing and hives. Different antihistamines can differ in their tendency to cause sleepiness and in their suitability for an individual patient.

Older, sedating antihistamines

For routine treatment of allergic rhinitis and urticaria, I support the move away from older, sedating first-generation antihistamines towards suitable second-generation options. The concerns include impaired alertness, slower reactions and effects on learning and daily functioning. Feeling sedated does not mean a medicine is more effective at treating the allergy.

Taking a sedating medicine at bedtime does not automatically remove the problem: unwanted effects may continue the next morning. Sedation should not be used as a substitute for assessing why a patient is sleeping poorly.

Newer, less-sedating antihistamines

Second-generation antihistamines are generally preferred when an oral antihistamine is needed for routine allergic rhinitis or urticaria. However, “non-drowsy” does not guarantee that every person will remain fully alert. Some people still experience sleepiness, particularly when doses are increased. [3] [4]

Individual responses matter: a medicine that suits one person may be less effective or less well tolerated by another. A clinician may recommend a change after reviewing response, side effects and how the treatment is being taken.

Treatment should fit your health and circumstances

Tell your clinician about other medicines, kidney or liver problems, pregnancy or breastfeeding, and any previous adverse reactions. Older adults and people taking several medicines need particular attention to interactions and unwanted effects. Children require an age-appropriate product and dose. [3]

Antihistamines are one part of treating allergic rhinitis

A tablet alone may not adequately address persistent nasal blockage. Depending on the symptoms, the treatment plan may include a steroid nasal spray, saline rinses and practical measures to reduce relevant allergen exposure. A pharmacist or clinician can help with product choice and correct use. [1]

A full clinical history is essential. Cough, wheeze, facial discomfort, changes in smell, ear symptoms and disturbed breathing during sleep may require additional assessment. Not every associated problem is caused by allergy, and treating the nose does not replace appropriate asthma or ENT care.

If symptoms remain troublesome, review the diagnosis, treatment technique and regularity of use before simply adding more medication. Allergy testing should answer a clinical question and be interpreted alongside the history.

Children: protect learning, sleep and participation

Children may not explain that their nose is blocked or that they are exhausted. Parents and teachers may instead notice repeated nose rubbing, mouth breathing, restless nights, irritability or difficulty concentrating. These everyday effects need to be considered when choosing treatment.

Persistent snoring, mouth breathing or breathing pauses during sleep deserve assessment. Allergy can coexist with enlarged adenoids, tonsil problems or other causes of obstruction. These signs do not establish an allergy diagnosis on their own.

• Choose treatment suitable for the child’s age and circumstances, with professional advice.
• Discuss daytime sleepiness, behaviour and school performance at follow-up.
• Check that parents and children understand how and when to use the treatment.
• Seek coordinated allergy, paediatric and ENT input where symptoms suggest more than one problem.

The aim is to help the child sleep, learn, play and participate comfortably. Neither surgery nor medication is automatically the right answer for every child with nasal obstruction; assessment determines the appropriate approach.

Chronic urticaria: sustained control without unnecessary sedation

Urticaria causes raised, itchy swellings known as wheals or hives, sometimes with deeper swelling called angioedema. Symptoms recurring for more than six weeks are described as chronic. Chronic spontaneous urticaria often has no identifiable external trigger and should not automatically be treated as a food allergy. [4]

For me, successful care means more than reducing the number of wheals. It should also reduce itching, disturbed nights and disruption to daily activities.

What if the usual antihistamine dose does not work?

Second-generation H1 antihistamines are first-line treatment. Current international guidance supports a clinician-supervised increase to as much as four times the standard dose in suitable patients whose symptoms remain uncontrolled. This is generally outside the licensed dose and requires an individual assessment. Do not increase the dose or combine antihistamines yourself. [5]

There is no universal dose schedule or single medicine that is best for everyone. The appropriate next step depends on response, tolerability, age, other conditions and the treatment already tried.

When additional specialist treatment is needed

If symptoms persist despite an appropriate antihistamine plan, specialist assessment can establish whether add-on treatment, including a biologic, is appropriate. Eligibility and choice depend on clinical circumstances and applicable prescribing guidance. Long-term oral steroid treatment is not a routine solution for chronic urticaria. [5]

Long-term treatment and stepping down

Some people need antihistamines for months or years. Continued treatment should be reviewed for benefit, side effects and whether the dose remains necessary. There is no single duration suitable for everyone. [4]

When control is sustained, the clinician may gradually reduce treatment and agree what to do if symptoms return. After successful biologic treatment, any reduction in antihistamines should follow an individual plan. Patients should not halve or stop medicines independently.

Keeping a record of itch, wheals, swelling, sleep and treatment use supports shared decisions. The UKallergy urticaria symptom tracker and decision tool can help structure that conversation.

Emergency care: antihistamines do not replace adrenaline

The Kyoto session also addressed the continued use of injectable first-generation antihistamines in emergency settings. This raises an important educational issue: treatment choices and discharge prescriptions should reflect the patient’s current needs, rather than simply continuing a familiar medicine.

For UK patients, the crucial distinction is between treating skin symptoms and treating anaphylaxis. Antihistamines do not treat the dangerous airway, breathing or circulation problems of anaphylaxis. Intramuscular adrenaline is the first-line emergency treatment; an antihistamine must never delay it. After stabilisation, a clinician may use a non-sedating oral antihistamine for persisting skin symptoms. [6]

For ongoing treatment after an emergency assessment, ask whether a less-sedating oral antihistamine is appropriate. The choice should follow the diagnosis and clinical circumstances.

My approach to specialist allergy assessment

As a Consultant in Allergy and Immunology at the London Allergy and Immunology Centre, my focus is on understanding the person behind the symptoms. The priorities are a clear diagnosis, an appropriate treatment plan and meaningful improvement in everyday life. Our centre also offers information and decision support for people with chronic urticaria. [7]

To help us make the most of your assessment, please bring a symptom diary, photographs of intermittent rashes, previous test results and a list of current and recently tried treatments. Note whether each treatment helped and whether it caused sleepiness or other unwanted effects.

The consultation should clarify the likely diagnosis, identify relevant associated conditions and establish how we will measure improvement together. For persistent nasal symptoms or hives, that means discussing sleep, work, learning and wellbeing alongside the physical symptoms.

Frequently asked questions

About the congress session

This article is based on the session on optimising antihistamine selection in allergic rhinitis and urticaria during the JSA/WAO/APAPARI Joint Congress 2026, Kyoto, Japan, 15–18 October 2026. The meeting brought together the 75th Annual Meeting of the Japanese Society of Allergology, World Allergy Congress 2026 and APAPARI 2026. The session’s chair and expert speakers were:

• Chair: Ignacio J. Ansotegui — Hospital Quirónsalud Bizkaia, Spain.
• Bryan L. Martin — The Ohio State University, USA. Burden of allergic rhinitis and ARIA updates.
• Sandra N. González-Díaz — Universidad Autónoma de Nuevo León, Mexico. Comorbidities and personalised care.
• Mário Morais-Almeida — CUF Descobertas Hospital, Portugal. Non-drowsy treatment and everyday functioning.
• Alessandro Fiocchi — Bambino Gesù Pediatric Hospital, Italy. Paediatric efficacy, safety and daily functioning.

This article presents my explanation of the session’s educational themes for patients, alongside the UK clinical information referenced below. It supports awareness of appropriate antihistamine selection and does not constitute an official World Allergy Organization guideline.