Hay fever. Vol.14. QCPP Approved Refresher Training AUGUST Professional development and practice support for the self care program.

Transcription

1 Professional development and practice support for the self care program AUGUST 2013 Hay fever Vol.14 Number 7 QCPP Approved Refresher Training (Counter Connection) Print Post approved PP255003/05274

2 John Bell sayscontents AUGUST 2013 Vol.14 Number 7 Managing editor Andrew Daniels Production coordinator Kylie Davis Contributor Jill Malek Peer Review Marnie Firipis Layout Caroline Mackay This publication is supplied to subscribers of the Self Care program. For information on the program, contact PSA at the address below. Advertising policy: inpharmation will carry only messages which are likely to be of interest to members and which do not reflect unfavourably directly or by implication on the pharmacy profession or the professional practice of pharmacy. Messages which do not comply with this policy will be refused. Views expressed by authors of articles in inpharmation are their own and not necessarily those of PSA, nor PSA editorial staff, and must not be quoted as such. The information contained in this material is derived from a critical analysis of a wide range of authoritative evidence. Any treatment decisions based on this information should be made in the context of the clinical circumstances of each patient. PSA3846 ISSN: Photographs in non-news articles in inpharmation are for illustrative purposes only and the models appearing in these photographs should not be presumed to endorse any product mentioned in the article or suffer from any condition mentioned in the article. Pharmaceutical Society of Australia Ltd. ABN Pharmacy House PO Box 42, Deakin West ACT 2600 P: or E: psc.nat@psa.org.au Hay fever and persistent allergic rhinitis affect around 15% of the Australian population. See page 04, Facts Behind the Fact Card: Hay fever Pharmacist CPD 04 Facts Behind the Fact Card: Hay fever Pharmacy assistants education 12 Counter Connection: Hay fever Regulars 03 John Bell says 16 Noticeboard Self Care Fact Cards Keep your Fact Cards up to date. Re-order any Fact Card title at any time. Sponsorship For sponsorship and advertising enquiries contact Tony Craig Sponsorship Manager (02) tony.craig@tremedia.com.au Display units The Plastics Factory Pty Ltd (ABN: ) Pharmaceutical Society of Australia Ltd., 2013 This magazine contains material that has been provided by the Pharmaceutical Society of Australia (PSA), and may contain material provided by the Commonwealth and third parties. Copyright in material provided by the Commonwealth or third parties belong to them. PSA owns the copyright in the magazine as a whole and all material in the magazine that has been developed by PSA. In relation to PSA owned material, no part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968 (Cth), or the written permission of PSA. Requests and inquiries regarding permission to use PSA material should be addressed to: Pharmaceutical Society of Australia, PO Box 42, Deakin West ACT Where you would like to use material that has been provided by the Commonwealth or third parties, contact them directly. 2 inpharmation August 2013 I Pharmaceutical Society of Australia Ltd.

3 Ear, Nose and Throat Self Care is a program of the Pharmaceutical Society of Australia. Self Care is committed to providing current and reliable health information. John Bell says Hay fever can really get up your nose By John Bell, Self Care Principal Adviser It seems we Australians are a sensitive bunch. About 20% of us suffer with some kind of allergic condition asthma, eczema and allergic rhinitis but intermittent allergic rhinitis (that is, hay fever) is the most common (this despite the fact that fever is not one of the symptoms and hay is only rarely implicated in the allergic reaction). Of course, many people suffer from all these allergic conditions. Indeed, asthma and hay fever so frequently occur together that they are often considered just different forms of the one disease. Traditionally, spring is said to be the start of the peak season for hay fever; however, due in part to the generally subtropical and temperate climate conditions in Australia, intermittent allergic rhinitis sometimes becomes perennial and persistent. In any event, it s pretty well accepted that August is the windy month. And that means all those airborne pollutants and newly sprung pollens begin to be blown into our nasal passages. Certainly, spring time is the time of year when the most likely trigger factors (or allergens as they re called) will be the windblown variety. But, other common exacerbating factors include exposure to dust mite, mould, cigarette smoke, chemical fumes and other air pollutants. Symptoms of hay fever can sometime be confused with those of other conditions such as the common cold; and questions to ask to aid diagnosis, and therefore to aid selection of a therapy to recommend, are given at Practice Point 1. Also, rhinitis and especially nasal congestion can be caused by certain medicines. Practice Point 2 lists some of the more common examples. Of course, preventing hay fever by avoiding trigger factors altogether, is the best option. Clearly, that s not always possible. When medication is required, the one to choose will depend largely on the severity and frequency of symptoms and patient preference. Mild symptoms (see Table 1), occurring less than four days a week or less than four weeks at a time, respond well to the new oral antihistamines. The intra nasal antihistamines also work well and have a much faster onset of action. For moderate to severe symptoms, the intra nasal corticosteroid sprays are the first choice treatments; and when symptoms are especially difficult to control, antihistamines or an antihistamine/decongestant combination can be added. Hay fever is a common and annoying condition, but it can be almost always effectively controlled by therapy we can provide without prescription. Appropriate questioning is essential (refer to the What, Stop, Go protocols) and make sure you add some extra value to your recommendation by providing the Hay Fever Self Care Fact Card. Hay fever, the common name for allergic rhinitis, is an allergic reaction in the nose, throat and eyes. It commonly occurs in spring and summer, when it is caused by airborne pollens from trees, plants and grasses. Medicines can relieve and prevent symptoms of hay fever. Hay fever, or allergic rhinitis, is usually caused by inhaling pollens that are present in the air during certain times of the year. However, some people have symptoms of allergic rhinitis all year round, caused by inhaling allergens such as animal dander, mould spores and house dust mites. A doctor can arrange allergy skin tests to help find the cause of allergic rhinitis. Signs and symptoms Symptoms of hay fever/allergic rhinitis include: Sneezing Running nose Nasal congestion (blocked or stuffy nose) Puffy, itchy, watery and red eyes Hay Fever Electronic delivery Itchy nose, ears, mouth or throat Post-nasal drip (mucus in throat), causing a cough Decreased sense of smell and taste Feeling tired, run-down, irritable Dark circles and bags under the eyes. The John Bell Health Column is available weekly by . If your pharmacy would like to receive the column, please send your details to psc.nat@psa.org.au Wound management for everyday practice. The interactive guide to the latest in wound care access online anywhere, anytime. 7 CPD CReDits GROUP 2 up to PSA3791 inpharmation August 2013 I Pharmaceutical Society of Australia Ltd. 3

4 John Facts Bell says Behind the Fact Card Hay fever Pharmacist CPD Module number 240 Hay fever By Jill Malek This education module is independently researched and compiled by PSA-commissioned authors and peer reviewed. up to 2 CPD Credits GROUP 2 Michael, 27 years of age, comes into the pharmacy with a runny nose and sneezing. He has taken some time off from work as a gardener. Symptoms are often more severe in the morning and evening when pollen counts are highest, as well as when the weather is hot and humid. Learning objectives After reading this article, the pharmacist should be able to: Provide information on the causes, diagnosis and classification of hay fever Recognise the common symptoms of hay fever Identify symptoms that require referral to a doctor Counsel on treatment options for hay fever Provide advice on common trigger factors for hay fever and measures to avoid them. Competency standards (2010) addressed: 3.1, 3.2, 6.1, 6.2. Intermittent allergic rhinitis, commonly known as hay fever, is caused by an allergic reaction after exposure to airborne allergens, including pollens and fungal spores. It is commonly associated with a more complex systemic disease that may involve asthma, sinusitis or oral allergy syndrome (allergic reaction to food). 1,2 Symptoms Symptoms associated with hay fever can vary among patients. Generally, the symptoms include 1 : nasal itching, sneezing, rhinorrhoea sinus-related congestion, postnasal drainage, headache pruritis, red or teary eyes, allergic conjunctivitis. The nasal discharge is usually clear and watery. Sneezing can occur in sudden outbursts of 10 to 20 sneezes at a time. Nasal congestion may cause the person to mouth-breathe, which dries the mouth, leading to nasal speech and halitosis (bad breath). The eyes, eustachian tubes and paranasal sinuses may also be affected resulting in itchy, watery, red eyes, a feeling of ear fullness, a scratchy, itchy throat and pressure over the cheeks and forehead. Impaired nasal venous outflow may cause dark circles to appear under the eyes (known as allergic shiners ). Other symptoms may include frontal or sinus headache, postnasal drip, cough, fatigue, inability to concentrate, frequent sore throats, constant clearing of the throat and anosmia (decreased sense of smell). 3 Symptoms of hay fever are intermittent, lasting for less than four days a week, and tend to worsen with increased exposure to the antigen. The patient may experience an escalation of symptoms throughout the hay fever season due to extended exposure to antigens. Symptoms are often more severe in the morning and evening when pollen counts are highest, as well as when the weather is hot and humid. Hay fever is classified as either mild or moderate-severe. Refer to Table 1. In 2008, the Allergic Rhinitis and its Impact on Asthma guidelines redefined hay fever to more closely reflect the periodic occurrence of the symptoms and its clinical course. 4 inpharmation August 2013 I Pharmaceutical Society of Australia Ltd.

5 Hay fever Pharmacist CPD Module number 240 Facts Behind the Fact Card Previously, allergic rhinitis was classified based on the seasonal appearance of certain antigens. However, this did not allow for the perennial nature of some pollen and moulds, the difficulty in predicting the seasonal appearance of certain pollens, and the appearance of non-specific antigens such as air pollution, which may aggravate symptoms in symptomatic patients and produce symptoms in non-symptomatic patients. Hay fever is now defined as symptoms occurring on less than four days a week and for less than four weeks at a time. 1,2,4 Prevalence Hay fever and persistent allergic rhinitis affect around 15% of the Australian population, or about 3.1 million people. These statistics are based on self reporting and the figure is likely to be higher as many people tend to choose to self-medicate and don t consult a doctor. 2,6 Hay fever commonly affects young people with 10 to 20% of adolescents suffering from this condition. As well, a person is more likely to suffer from hay fever if there is a family history of asthma, eczema or hay fever. 2,3 Cause Hay fever is triggered by exposure and sensitisation to airborne allergens, which induce an allergic reaction. Airborne allergens lodge in the mucus membrane of the nasal passages and cause the production of immunoglobulin E (IgE) antibodies, which have formed from previous exposure to the allergen. Sensitised mast cells release chemical mediators, such as histamines, which mediate an inflammatory and immune response. Sensitisation to an allergen usually occurs in children older than 3 5 years and in people with a family history of allergy. The average age when a child first presents with hay fever symptoms is 9 10 years. 6 Most people with hay fever are sensitised through repeated exposure to many different pollen species. Once an individual is sensitised, even nonspecific triggers or small amounts of the allergen can cause a rapid allergic response and severe symptoms. Table 1: Classification of hay fever (intermittent allergic rhinitis) 4 Mild Hay fever does NOT interfere with: sleep daily activities, leisure or sport school or work Symptoms are not troublesome Pollens of wind pollinated plants are the predominant triggers. The most troublesome pollens tend to be airborne pollens produced by Northern Hemisphere grasses, trees and flowering weed species. Pollens of insect-pollinated plants (such as Australian wattles) are too heavy to remain airborne and pose little risk. 7,8 Symptoms of allergic rhinitis can also be exacerbated rather than caused by certain irritants. Irritants, such as cigarette smoke or paint fumes, are capable of inducing symptoms of rhinitis in people who suffer from allergic rhinitis. Risk factors Moderate-severe One or more of the following are present: sleep disturbance impairment of daily activities, leisure and/or sport impairment of school or work troublesome symptoms There are both genetic and environmental risk factors that influence the development of allergic rhinitis. 6 A risk factor for allergic rhinitis may either: increase the risk of an individual developing an allergic sensitisation induce a nasal response in someone with allergic rhinitis (this may be either through allergic or non-allergic mechanisms) interact with the allergen to increase the individual s level of allergic reaction. Genetic factors if a child has one parent with atopy (allergies), he or she has a 30% risk of developing allergic rhinitis. If both parents are atopic this risk increases to 50 70%. Having other allergic conditions also predisposes a person to allergic rhinitis. Allergic rhinitis and asthma frequently co-exist and allergic rhinitis has been identified as an independent risk factor for asthma. A person with concurrent asthma has an 80% chance of developing allergic rhinitis. 6,7 Age intermittent allergic rhinitis has a lower median age of onset than persistent Practice point 1 Questions to aid diagnosis 7,13 Questions that may help to establish whether or not a person has allergic rhinitis: What are your main symptoms? (Should include rhinorrhoea, sneezing, itchy nose, nasal congestion) Do you have eye symptoms? (e.g. itchy or watery eyes) Have you ever had hay fever, allergic rhinitis or asthma diagnosed by a doctor? (Asthma and allergic rhinitis often co-exist) Do you have a family member with allergies or asthma? How long have you had the symptoms? Do the symptoms occur all year round or at a particular time of the year? Are you aware of anything that seems to trigger the symptoms (e.g. being outdoors or around animals; doing a particular activity at work or at home)? Is your nasal discharge clear and watery? (Purulent discharge suggests infection) Are you experiencing any wheezing or shortness of breath? (May indicate asthma) Do you have earache? (May indicate otitis media) Do you have facial pain? (May indicate sinusitis) What medicines have you already tried for these symptoms? Were they effective? (Ask if the patient is using a nasal decongestant) Do you have any other medical conditions and are you taking any other medicines? Are you pregnant? (May indicate rhinitis of pregnancy) Related Fact Cards Hay fever Asthma Colds and flu Cough inpharmation August 2013 I Pharmaceutical Society of Australia Ltd. 5

6 John Facts Bell says Behind the Fact Card Hay fever Pharmacist CPD Module number 240 Practice point 2 Drugs that can cause rhinitis 5 Drugs that have been reported to cause rhinitis or nasal congestion include: aspirin and other NSAIDs alpha-blockers selective: alfuzosin; prazosin; tamsulosin; terazosin non-selective: phenoxybenzamine; phentolamine angiotensin-converting enzyme (ACE) inhibitors beta-blockers (oral or ophthalmic) chlorpromazine gabapentin methyldopa penicillamine oral contraceptives inhaled cocaine. allergic rhinitis. The median onset age for intermittent allergic rhinitis is 15 years compared with 20 years for persistent allergic rhinitis. 2 Environmental and occupational exposure in susceptible people (e.g. with a personal or family history of atopy) exposure to allergens in the living, school, work or recreational environment may produce sensitisation and increase the risk of developing intermittent allergic rhinitis. 2,4 Diagnosis Hay fever is frequently trivialised and under-diagnosed but due to the wide range of symptoms, it may have a substantial negative impact on a person s overall quality of life and performance at home, school or work. 1 The diagnosis of hay fever requires a systematic approach based on the clinical symptoms the patient is experiencing (these may or may not be season dependant) and a family history of atopy. The pharmacist should always ask patients to describe their symptoms to assist in recognising the disease, assessing the severity and differentiating between other causes. By asking symptom-specific questions, the appropriate treatment can be recommended. If the patient does not give sufficient information about their symptoms to reach a diagnosis, more information can be elicited by using structured questioning. 7 See Practice Point 1. If the diagnosis is in doubt the patient should be referred to a doctor for further investigation. See Practice Point 3. To make the correct diagnosis, you question Michael about his symptoms. He says that they usually occur in springtime and involve itchy, watery eyes and an itchy palate. During these times, his symptoms occur daily with episodes of repeated sneezing and constant nasal congestion. He has had these symptoms since childhood, but over the last three spring seasons, the intensity of the symptoms has become more severe. Differential diagnosis Hay fever may present with symptoms similar to those of a number of other conditions (e.g. a viral infection such as the common cold and chronic sinusitis), which may lead to confusion, misdiagnosis and incorrect management. The presence of nasal itching and congestion, rhinorrhoea, sneezing and eye symptoms that occur intermittently are usually consistent with hay fever. Some allergic and non-allergic rhinitis conditions and their characteristic signs and symptoms are listed in Table 2. Other causes of non-allergic rhinitis include hot, spicy foods (gustatory rhinitis), certain drugs (see Practice Point 2), alcoholic drinks, sudden changes in temperature, cold dry air, inhaled irritants (e.g. tobacco smoke, chemicals) and emotional stress. 5 Referral to the patient s doctor is recommended for certain conditions listed above. See Practice Point 3 When to refer. Michael is presenting with characteristic symptoms of moderate intermittent allergic rhinitis (hay fever). Management Identifying the allergen that is causing the allergic reaction allows for optimal treatment. If this can be achieved, minimising exposure to this allergen will minimise patient symptoms. The management of hay fever involves four main strategies: 1. allergen avoidance 2. pharmacotherapy 3. immunotherapy 4. patient education. Allergen avoidance Avoiding allergens is only possible if the allergen associated with producing an allergic reaction has been identified through allergy testing or history of exposure. Allergens, such as pollens, are very difficult to avoid but a person can attempt to reduce their exposure to an airborne allergen by remaining inside and keeping all windows closed when pollen counts are known to be high, wearing a face mask and eye protection and avoiding activities in areas with high pollen counts. 3,10 Pharmacotherapy The recommended treatment depends on the severity and duration of symptoms 6 inpharmation August 2013 I Pharmaceutical Society of Australia Ltd.

7 Hay fever Pharmacist CPD Module number 240 Facts Behind the Fact Card Table 2: Differential diagnosis: Intermittent allergic rhinitis 3,7 Condition Allergic rhinitis Intermittent allergic rhinitis Persistent allergic rhinitis Non-allergic rhinitis Infective rhinitis Rhinitis medicamentosa Rhinosinusitis Hormonal rhinitis Structural abnormalities Nasal foreign body Characteristic signs and symptoms and patient preference. When treating hay fever, different drug classes may be used alone or in combination from the start of treatment, depending on the age of the patient, degree of disability and cost of therapy. Refer to Table 3. Antihistamines 3,11 Oral antihistamines are effective against symptoms mediated by histamine, including rhinorrhoea, sneezing, nasal itching and eye symptoms but are less effective on nasal congestion. They are the first-line treatment for mild-intermittent allergic rhinitis. See Table 3. Oral antihistamines are grouped into two categories: less sedating and sedating. They all appear to be equally effective, although individual response to specific antihistamines varies widely. Symptoms occur intermittently (occurring fewer than 4 days per week or for less than 4 weeks) Nasal itch Sneezing (often in groups of 8 10 sneezes) Rhinorrhoea Nasal congestion Itchy eyes Less common than hay fever Continual symptoms Nasal congestion is common leading to a poor sense of smell Less frequent sneezing Periods of chronic sinusitis Main allergen often dust mites, moulds and animal dander (minute scales from hair, feathers, or skin) Usually viral (e.g. common cold) but may be bacterial Nasal discharge contains mucous and pus indicating infection Symptoms resolve quickly Sore throat and cough may be evident Due to prolonged use of nasal decongestants (more than 7 days) Inflammation of the nasal mucosa and sinuses Can be acute due to infection Symptoms occur due to hormonal changes Symptoms seen during pregnancy, menstruation, hypothyroidism, acromegaly, use of oral contraceptives Symptoms resolve after childbirth Physical blockage Possible mechanical or anatomical blockage (e.g. deviated septum) May be caused by injury Foreign body trapped in the nostril More common in children May be associated with one-sided nasal discharge Sedating antihistamines (e.g. dexchlorpheniramine, promethazine) can cause sedation and anticholinergic side effects (including dry mouth and eyes, urinary retention and worsening of glaucoma). Less sedating antihistamines (e.g. cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine) are preferred as they are less likely to cause sedation and have little or no anticholinergic effects. Cetirizine and levocetirizine are the most likely of the less sedating antihistamines to cause sedation. Intranasal antihistamines (e.g. levocabastine, azelastine) are as effective as oral antihistamines. They have rapid onset of action, which may last for up to 12 hours. They may cause local irritation Practice point 3 When to refer 9,13 A person requesting treatment for hay fever should be referred to a doctor if: symptoms are severe and/or persistent symptoms have not responded to treatment with an antihistamine and/ or intranasal corticosteroids (INCS) treatment is required for more than four weeks at a time treatment is causing unacceptable side effects the patient has severe allergic comorbidities, e.g. asthma, eczema or food allergies the patient has atypical symptoms such as: unilateral nasal congestion (possible foreign body, nasal polyps or structural abnormality) persistent mucopurulent discharge ± facial pain (possible chronic rhinosinusitis ± infection) nasal crusting (possible Staphylococcus aureus infection) or nose picking; in adults, severe crusting is rare and suggests connective tissue disease anosmia (possible chronic sinusitis or polyps) recurrent nosebleed earache (possible otitis media) unilateral eye symptoms photophobia or burning sensation in eyes the patient is a child under 12 years of age the patient is a pregnant/ breastfeeding woman. inpharmation August 2013 I Pharmaceutical Society of Australia Ltd. 7

8 John Facts Bell says Behind the Fact Card Hay fever Pharmacist CPD Module number 240 Practice point 4 Correct use of INCS 3,7,13 The correct use of INCS will deliver a dose throughout the lining of the nasal cavity including the side wall rather than to the front part of the nose and nasopharynx. Correct technique for using a nasal spray: Clear nasal passages by blowing gently (saline nasal spray/drops/rinse may be used first). Shake the bottle and prime the spray devise following the manufacturer s directions if required. Bend head forward slightly. Place the nozzle gently just inside the nostril. Do not push it hard against the septum. Aim the spray to the side of the nostril not towards the septum or midline. Hold the spray parallel to the roof of the mouth. Use the right hand for the left nostril and vice versa to reduce deposition of medicine directly onto the nasal septum. Squirt once or twice (in two different directions along the outside wall). Avoid sniffing hard during or after spraying. Sniffing could force the spray into the back of the throat instead of inside the nose. Wipe the tip of the spray device with a dry handkerchief or tissue. Remind patients to: prime the spray devise before use tilt their heads forward rather than back not to use saline drops or other nasal irrigations immediately after using an INCS device avoid blowing the nose soon after using the spray device as this could dislodge the medicine. Table 3: Treatment options for hay fever 3 Mild symptoms Oral or intranasal antihistamine and/or Decongestant of the nasal mucosa (e.g. stinging, itching, sneezing) and, infrequently, nosebleed and headache. Azelastine can also cause a bitter taste in the mouth, which may lead to nausea. This is more likely to occur if the head is tilted back too far during administration. Eye drops containing antihistamines (e.g. azelastine, levocabastine) or antihistamine-mast cell stabilisers (e.g. ketotifen, olopatadine) may be used to relieve ocular symptoms. Intranasal corticosteroids 3,11 INCS produce high drug concentrations locally in the nasal mucosa with minimal risk of systemic adverse effects. INCS have local anti-inflammatory effects, decrease capillary permeability and mucus production and produce local vasoconstriction. They inhibit both the early and late response to allergen exposure. INCS relieve all nasal symptoms (including nasal congestion) and may also reduce ocular symptoms. INCS: are recommended as first line therapy for moderate to severe intermittent allergic rhinitis and if nasal congestion is a predominant symptom are recommended as a second-line therapy for mild hay fever if symptoms are not resolved with antihistamines reach optimal effectiveness after several days of regular use but nasal congestion and rhinorrhoea may be relieved within three to seven hours of starting treatment are effective if used as needed to prevent nasal symptoms associated with occasional allergen exposure can cause nasal stinging and itching, sneezing, sore throat, dry mouth, cough and nosebleed are safe for use during pregnancy and breastfeeding. Refer to Practice Point 4 Correct use of INCS. See Table 3 for allergic rhinitis treatment options. Moderate-severe symptoms INCS and/or Oral or intranasal antihistamine and/or Montelukast For moderate/severe intermittent allergic rhinitis, use INCS as the first-line therapy. For patients, whose symptoms are not adequately controlled by INCS, additional use of oral antihistamines is recommended. Other therapies for allergic rhinitis include: Decongestants 3,11 Decongestants are sympathomimetics that produce vasoconstriction of dilated nasal vessels, reducing tissue swelling and nasal congestion. They have no effect on other symptoms of allergic rhinitis. They may be useful for short-term use in allergic rhinitis if nasal congestion is a problem. They are not recommended for use in children under the age of six years. Oral decongestants (e.g. phenylephrine, pseudoephedrine): can cause systemic adverse effects including central nervous system stimulation, insomnia, irritability, dizziness, headache, tremor, palpitations, tachycardia and hypertension are contraindicated in severe coronary artery disease, severe hypertension, and for 14 days after treatment with a monoamine oxidase inhibitor (risk of severe hypertension) should be used with caution in diabetes (may affect blood glucose control), prostatic hypertrophy (may exacerbate symptoms), hypertension (may increase blood pressure), closed angle glaucoma (may induce acute attack) and hyperthyroidism (increases sensitivity to sympathomimetics). Intranasal decongestants (e.g. oxymetazoline, phenylephrine, tramazoline, xylometazoline): are more effective than oral decongestants if nasal congestion is a problem should not be used for more than five days in any age group have significant adverse effects 8 inpharmation August 2013 I Pharmaceutical Society of Australia Ltd.

9 Hay fever Pharmacist CPD Module number 240 Facts Behind the Fact Card Practice point 5 Self care for hay fever 2,3,9,13 The following strategies to minimise exposure to allergens may help to prevent hay fever. Pollens: Remain indoors during the pollen season, especially in the early morning, on windy days and after thunderstorms. Avoid outdoor activities when the trees, grasses or flowers that trigger the allergy are blooming. Shower after outdoor activities. Use a clothes dryer to finish drying washed bedding as this may reduce exposure to pollen deposits. Use re-circulated air in the car and keep house and car windows closed during pollen season. Non-allergenic triggers: Exposure to tobacco smoke, fumes and strong perfumes, sudden change in temperature and outdoor pollution should, if possible, be avoided if they seem to aggravate symptoms. (including somnolence, convulsions, bradycardia, hypoventilation and hypothermia). These have been reported after use of nasal or oral decongestants in children under six years of age. Other medicines Sodium cromoglycate is a mast cell stabiliser preventing the release of histamine. The nasal spray is very safe but less effective than INCS or antihistamines for treating mild-moderate allergic rhinitis. The need for frequent dosing (up to six times a day) is also a disadvantage. It may be preferred to INCS as first-line therapy in children. 3,11 Ipratropium is an anticholinergic medicine with a rapid onset of action and a prolonged effect (4 12 hours). The nasal spray relieves rhinorrhoea but not sneezing or nasal congestion. It can be used in addition to INCS or an antihistamine if rhinorrhoea is severe. Adverse effects include nasal dryness, nosebleed, dry mouth and taste disturbance. There have also been rare reports of visual accommodation disturbance, urinary retention and allergic reactions (urticaria, angioedema, rash, bronchospasm). 3,5,11 Montelukast is a leukotriene receptor antagonist that reduces inflammation. It is as effective as oral antihistamines, but less effective than INCS. In children who also have asthma, a leukotriene receptor antagonist may be used before INCS. 4, 5 Saline nasal drops/spray or a sinus rinse may help to thin nasal secretions and relieve nasal congestion. It can be used before an INCS to clear mucus and improve mucosal contact with the corticosteroid, potentially reducing the dose of INCS required to be effective. Saline is safe and inexpensive. 11 Oral corticosteroids are rarely used for inpharmation August 2013 I Pharmaceutical Society of Australia Ltd. 9

10 John Facts Bell says Behind the Fact Card Hay fever Pharmacist CPD Module number 240 allergic rhinitis; a short course may be given if the patient has severe symptoms which do not respond to other treatment. 3 Immunotherapy 5,8 Immunotherapy ( desensitisation ) may be appropriate if symptoms are severe, other treatments are ineffective or cannot be tolerated, or if there are only one or two causative allergens and these are difficult to avoid (e.g. grass pollen). It has been found to be effective in improving symptoms and reducing medicine use in allergic rhinitis due to pollens. Immunotherapy: involves gradual administration of increasing doses of allergen extracts by subcutaneous injection or as sublingual drops/tablets to desensitise the patient is the only treatment to alter the course of the disease but it requires three to five years of treatment for the effect to be sustained long-term. Effects of treatment for hay fever are usually seen quite clearly in the first seasonal exposure to the causative allergen administered subcutaneously has been shown to reduce the onset of new sensitisations, as well as the development of asthma in patients with allergic rhinitis administered sublingually has been shown to be safe and effective in adults with grass pollen allergy, but there are conflicting results in children injections may cause localised swelling at the injection site, which can be treated with oral antihistamines or ice packs. Up to 10% of patients may experience systemic reactions ranging from mild urticaria, wheezing, dizziness and rhinitis to angioedema, severe asthma and anaphylactic shock administered sublingually may result in itching and swelling of the lips and under the tongue, which can be controlled by temporarily reducing the dose or taking an antihistamine prior to treatment is recommended to be continued for about 3 5 years to decrease the chance of return of the allergies should be used in addition to allergy and asthma medicines. Sublingual immunotherapy is less likely than subcutaneous immunotherapy to cause systemic adverse effects. However, it is about three times more expensive than subcutaneous therapy because a greater quantity of allergen extract is required for effective desensitisation. Michael confirms he is not using any other medicines. You recommend the use of an intranasal corticosteroid spray. You tell Michael that the nasal spray may take several days to reach full effect and it should be used daily to maintain effectiveness. It is important that Michael is instructed in the correct use of the nasal spray to maximise the dose applied and avoid damage to the nasal passages. You demonstrate the correct use of the spray. You also suggest the use of a saline nasal spray to counteract the possible drying effects of the INCS spray and to clear the nasal passages. You instruct Michael to use this spray before the INCS spray. You advise Michael that if he begins to experience facial pain and thick nasal discharge to return to the pharmacy as this could be a sign of an intranasal infection. You also ask him to return to the pharmacy if his symptoms do not improve. References 1. Sussman G, Sussman D, Sussman A. Intermittent allergic rhinitis. CMAJ. 2010; 182(11): At: ca/content/182/11/1210.full.pdf+html 2. Rutter P, Newby D. Community Pharmacy: symptoms, diagnosis and treatment. 1st edn. Australia: Elsevier; etg complete [online]. Melbourne: Therapeutic Guidelines Limited; Mar Bousquet J, Khaltaev N, Cruz AA et al. Allergic Rhinitis and its Impact on Asthma (ARIA) Allergy: European Journal of Allergy and Clinical Immunology 2008: 63 (Suppl. 86): At: com/doi/ /j x/full 5. Australian Institute of Health and Welfare. Allergic rhinitis ( hay fever ) in Australia. 2011Canberra: AIHW. At: 6. National Asthma Council Australia. Living with Asthma. Allergic rhinitis(hay fever) and your asthma. National Asthma Council Australia 14 Aug At: www. nationalasthma.org.au/publication/allergic-rhinitis-hayfever-and-your-asthma 7. ARIA in the pharmacy: Management of allergic rhinitis symptoms in the pharmacy [online]. (Accessed 20 March 2013). At: Guide.pdf 8. The Australasian Society of Clinical Immunology and Allergy (ASCIA). Pollen allergy.january At: www. allergy.org.au/patients/allergic-rhinitis-hay-fever-andsinusitis/pollen-allergy 9. Sansom LN, ed. Australian pharmaceutical formulary and handbook. 22nd edn. Canberra: Pharmaceutical Society of Australia, The Australasian Society of Clinical Immunology and Allergy (ASCIA). Allergen avoidance. ASCIA, Jan At: allergen-avoidance 11. Rossi S, ed. Australian Medicines Handbook. Adelaide: Australian Medicines Handbook; Jan The Australasian Society of Clinical Immunology and Allergy (ASCIA). Immunotherpay. ASCIA, Aug At: infobulletins/2010pdf/aer_immunotherapy.pdf 13. Hu W, Katelaris CH, Kemp A. Allergic rhinitis: practical management strategies. Aust Fam Phys April 2008; 37(4): At: afp/200804/200804hu.pdf 14. National Asthma Council Australia. Information paper for health professionals. Intranasal corticosteroid spray technique. National Asthma Council Australia At: information-papers/intranasal-corticosteroid-spraytechnique 15. The Australasian Society of Clinical Immunology and Allergy (ASCIA). Allergen avoidance. ASCIA, Jan At: allergen-avoidance 10 inpharmation August 2013 I Pharmaceutical Society of Australia Ltd.

11 Hay fever Pharmacist CPD Module number 240 Facts Behind the Fact Card Assessment questions for the pharmacist Hay fever Personal ID number: Full name:... Pharmacy:... Address:... Suburb:... State:...Postcode:... Circle one correct answer from each of the following questions. Before undertaking this assessment, you need to have read the Facts Behind the Fact Card article and the associated Fact Cards. This activity has been accredited by PSA as a Group 2 activity. Two CPD credits (Group 2) will be awarded to pharmacists with four out of five questions correct. PSA is authorised by the Australian Pharmacy Council to accredit providers of CPD activities for pharmacists that may be used as supporting evidence of continuing competence. Assessment due 30 September 2013 Submit answers Submit online at Fax: (03) Mail: Self Care Answers Pharmaceutical Society of Australia VIC Branch Level 1, 381 Royal Parade PARKVILLE VIC 3052 Please retain a copy for your own purposes. Photocopy if you require extra copies. 2 CPD Credits GROUP 2 Accreditation number: CS This activity has been accredited for Group 2 CPD (or 2 CPD credits) suitable for inclusion in an individual pharmacist s CPD plan. up to 1. Which of the following groups is most likely to suffer from intermittent allergic rhinitis? a. Elderly. b. Adolescents. c. Children. d. All of the above. 2. Which ONE of the following is a classic symptom of hay fever? a. Cough. b. Sneezing. c. Anosmia. d. Halitosis. 3. Which ONE of the following counselling points regarding intranasal antihistamines is CORRECT? a. Antihistamines available in intranasal preparations include ketotifen and olopatadine. b. Intranasal antihistamines are as effective as oral antihistamines but have a slower onset of action. c. Intranasal azelastine can cause a bitter taste in the mouth, which may lead to nausea. d. Common side effects of intranasal antihistamines include nosebleed and headache. 4. Which ONE of the following points regarding other treatments for hay fever is CORRECT? a. Intranasal sodium cromoglycate may be preferred to INCS as firstline therapy in children. b. Ipratropium nasal spray requires frequent dosing as its effect lasts for less than two hours. c. Montelukast is less effective than oral antihistamines and INCS. d. Ipratropium nasal spray relieves rhinorrhoea, sneezing and nasal congestion. 5. In a person with intermittent allergic rhinitis, which ONE of the following symptoms would necessitate referral to a doctor? a. Itchy watery eyes. b. Unilateral nasal congestion. c. Paroxysms of sneezing. d. Allergic shiner. inpharmation August 2013 I Pharmaceutical Society of Australia Ltd. 11

12 Ear, Nose and Throat Self Care is a program of the Pharmaceutical Society of Australia. Self Care is committed to providing current and reliable health information. John Bell Counter says Connection Hay fever Pharmacy assistant s education Module 240 Hay fever By Jill Malek This education module is independently researched and compiled by PSA-commissioned authors and peer reviewed. Hay fever is a reaction to substances known as allergens. These include plant pollens and fungal spores which are breathed in. The allergic reaction makes the inside of the nose irritated, swollen and very sensitive (inflamed). It usually happens during spring when plants release pollen (a fine powdery substance) into the air. Hay fever, also known as intermittent allergic rhinitis, is classified as symptoms of rhinitis occurring on less than four days per week and for less than four weeks at a time. Stay inside during pollen season. Hay Fever Hay fever, the common name for allergic rhinitis, is an allergic reaction in the nose, throat and eyes. It commonly occurs in spring and summer, when it is caused by airborne pollens from trees, plants and grasses. Medicines can relieve and prevent symptoms of hay fever. Hay fever, or allergic rhinitis, is usually caused by inhaling pollens that are present in the air during certain times of the year. However, some people have symptoms of allergic rhinitis all year round, caused by inhaling allergens such as animal dander, mould spores and house dust mites. A doctor can arrange allergy skin tests to help find the cause of allergic rhinitis. Signs and symptoms Symptoms of hay fever/allergic rhinitis include: Itchy nose, ears, mouth or throat Sneezing Post-nasal drip (mucus in throat), Running nose causing a cough Nasal congestion (blocked or Decreased sense of smell and taste stuffy nose) Feeling tired, run-down, irritable Puffy, itchy, watery and red eyes Dark circles and bags under the eyes. Sally, 18 years of age, comes in the pharmacy with a runny nose and sneezing. She would like something to stop these symptoms as she has to go to university. Who gets hay fever? Hay fever usually affects young people with about 10 20% of them having hay fever symptoms. Some people are more likely to suffer from hay fever if they have other allergic conditions such as eczema, asthma or food allergies, or if they have family members who have allergies. Symptoms A person with hay fever may have a blocked or runny nose, and may experience itching or soreness in the nose, throat and eyes. It is not an infectious condition, so it cannot be spread from person-to-person. Symptoms of hay fever occur intermittently (not constantly). Symptoms may also be worse when the weather is hot and humid, on windy days and after going outside when the pollen count is high. The common symptoms of hay fever are usually a combination of: runny nose (rhinorrhoea) usually clear and watery sneezing itchy nose nasal congestion (blocked nose) red, puffy, watery, itchy eyes. Hay fever symptoms can gradually worsen. This is called nasal priming. As a result of ongoing exposure to allergens (e.g. pollens), a person may find that their symptoms get worse. Hay fever symptoms are classified as either mild or moderate-to-severe. Classifying symptoms in this way helps to determine what treatment to recommend. See Table 1. Table 1: Symptoms of hay fever Mild Hay fever does not interfere with: sleep daily activities, leisure or sport school or work Symptoms are not troublesome Moderate to severe One or more of the following are present: sleep disturbance impairs daily activities, leisure and/or sport impairs school or work Symptoms are troublesome If a customer is seeking treatment for hay fever, use a protocol such as WHAT-STOP-GO or CARER to gather information about their symptoms. 12 inpharmation August 2013 I Pharmaceutical Society of Australia Ltd.

13 Hay fever Pharmacy assistant s education Module 240 Counter Connection Diagnosis Sometimes it is hard to distinguish between hay fever symptoms and the symptoms of non-allergic conditions. Diagnosis is usually based on: family history of allergies clinical symptoms worsening symptoms at certain times in the year (e.g. spring). By asking the customer questions about their symptoms, you can help to determine the cause of the hay fever, and if referral to the pharmacist is needed. Conditions that may not be due to allergies and that have similar symptoms to hay fever include: viral respiratory infection (e.g. colds, flu) sinusitis (infection or inflammation of the sinuses air-filled spaces in the bones of the face) hormonal changes (e.g. due to pregnancy, menstruation or oral contraceptives) a foreign body or tumour in the nose hot, spicy foods certain drugs, including aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs e.g. ibuprofen, diclofenac, naproxen) and some blood pressure medicines alcoholic drinks cold, dry air or sudden changes in temperature. Refer to Table 2 for a comparison between hay fever and the common cold (a viral infection). It is important to establish through questioning, what symptoms the customer is experiencing, when they are having these symptoms and what is causing them. The customer s answers will guide your recommendations for treatment. Questions pharmacy staff can ask customers to help with assessment: Can you describe your symptoms? Do the symptoms occur all year round or at a particular time of the year? How long have you had the symptoms? Are you aware of anything that seems to trigger the symptoms (e.g. being outdoors, around animals, playing sport; doing a particular activity at work or at home)? Do your hobbies or occupation bring you into contact with any potential allergens? Do you or a family member suffer from asthma, eczema or any other allergies? What medicines have you already tried for these symptoms? Were they effective? Do you have any other medical conditions and are you taking any other medicines? After questioning, Sally tells you her nose is running like a tap and she just keeps sneezing. These symptoms have just started and are particularly bad in the mornings when she likes to go for a walk. She has no family history of allergies and she doesn t take any medicines. The information gathered from Sally indicates that she has mild hay fever. Her symptoms are not bad enough to interfere with her daily activities and the discharge from her nose is clear. If it was coloured and thick, this may indicate a viral or bacterial infection. Treatment Table 2. Comparison of hay fever and the common cold Treatment for hay fever depends on how severe the symptoms are and how long the customer has had the symptoms. In hay fever, the different drug classes may be used one after each other or in combination from the start, considering the age of the patient, degree of disability, and cost of therapy. If the hay fever symptoms are mild, they can be initially treated with an antihistamine. Condition Hay fever Common cold Classification Allergic condition Non-allergic condition Trigger Allergen (e.g. pollen) Generally a virus Family history Common in people who have a close No connection to family medical history relative who has asthma, eczema or hay fever Common symptoms Itchy nose Sneezing Blocked nose Watery nasal discharge Blocked nose Coloured nasal discharge Watery nasal discharge Sneezing Cough Sore throat Time More common at certain times of the year e.g spring Continues while in contact with the allergen (e.g. pollen) Occurs all year Generally self limiting and last for about 7 10 days If the symptoms are moderate-to-severe they should be treated with a corticosteroid nasal spray (INCS intranasal corticosteroid). See Table 3 Treatment options for hay fever. Antihistamines Antihistamines relieve a runny nose, nasal itching and sneezing but are less effective at relieving nasal congestion. People respond differently to different antihistamines. A person may need to try several different products to find the one that is most effective for them. Antihistamines are classified into two groups: less sedating antihistamines and sedating antihistamines which are Pharmacist Only. Antihistamines are available as tablets, liquid preparations, nasal sprays and eye drops. Oral antihistamines (e.g. tablets, liquids): take one or more hours to reach maximum effectiveness should be taken before exposure to a known allergen e.g pollen. Antihistamine nasal sprays: are as effective as oral antihistamines in relieving a runny, itchy nose and sneezing can start acting within 15 minutes of use; may last for up to 12 hours may irritate the nose (e.g. stinging, itching) and cause occasional nosebleeds and headache can cause a bitter taste in the mouth, which may lead to nausea (e.g. azelastine). This is more likely to occur if the head is tilted back too far when using the spray. Antihistamine eye drops: may be used to relieve itchy, watery eyes. As Sally has mild hay fever, you suggest a less sedating antihistamine to treat her symptoms. A tablet would be most appropriate and you suggest loratadine (e.g Claratyne, Allereze) to be taken once a day. You tell Sally to keep taking the tablet when she expects hay fever symptoms (e.g. when the pollen count is high) and that she should avoid taking walks early in the morning. You encourage Sally to return to the pharmacy if her hay fever symptoms are not controlled. You also mention that it may be necessary for her to try a different antihistamine to find one that is effective for her. You give Sally the Hay Fever Self Care Fact Card to read. Intranasal corticosteroids INCS can relieve and prevent symptoms. They are the first choice treatment for inpharmation August 2013 I Pharmaceutical Society of Australia Ltd. 13