Managing allergic rhinitis

Transcription

1 This lesson is supported by an educational grant from Managing allergic rhinitis Introduction Approximately 58 million Americans suffer from allergic rhinitis 1, making it the United State s sixth most-common chronic illness. The most recent estimates establish that 1 percent to 3 percent of adults and 4 percent of children have allergic rhinitis. 2 Since many patients self-medicate with non-prescription medications and herbal remedies rather than seeking medical attention, these estimates may be low. Over the last 3 years, a 1 percent increase in the incidence of allergic rhinitis in developed nations has led some researchers to pronounce it an epidemic. 3 Although the disease may seem trivial because it is not a life-threatening condition, allergic rhinitis can impact quality of life and increase health care costs. In the Allergies in America survey, 4 85 percent of individuals reported that allergic rhinitis impacted their life during allergy season. More than 4 percent stated that their nasal symptoms interfered with their work performance. Surveyed individuals reported their average productivity at 72 percent when allergies In the Allergies in America survey, 85 percent of individuals reported that allergic rhinitis impacted their life during allergy season. were at their worst. Allergic rhinitis is estimated to account for 1 million days of lost work per year and 1.5 million missed school days per year. 5,6 Rhinitis symptoms are responsible for decreased learning in children by causing sleep disturbances, fatigue and irritability. 7 It also is responsible for $5.9 billion annually in direct health care costs, including 16.7 million physician office visits. 8 Another $3.8 billion per year is exhausted by indirect costs, such as lost work days and school days. 9 The classic symptoms of allergic rhinitis include sneezing, nasal itching, runny nose, nasal congestion and itchy eyes, but can also include headache and fatigue. Epidemiological studies have consistently demonstrated that rhinitis and asthma are present in the same patients. Patients with allergic rhinitis have increased non-specific bronchial hypereactivitiy, and allergic rhinitis is a risk for asthma. Approximately 2 percent of patients with allergic rhinitis also have asthma. 1 Pathophysiology The symptoms of allergic rhinitis arise as a result of inflammation induced by IgE-mediated immune response to an allergen. This Type I allergic reaction includes early and late phase responses to an allergen. During these phases, various inflammatory mediators are produced and released, along with activation and recruitment of cells to the involved mucosa. The first stage in the allergic response, known as the early stage, takes place within minutes of the first By: Lauren S. Schlesselman, PharmD, Assistant Clinical Professor, University of Connecticut School of Pharmacy Initial release date: August 1, 27 Planned expiration date: July 3, 28 This program is accredited for 1.5 contact hours. Program Goal: To increase awareness about seasonal allergies and optimizing treatment, along with the role of prevention. Learning Objectives Upon completion of this program, the clinician should be able to: 1. Discuss the immunologic processes involved in allergic reactions. 2. Outline treatment options for allergic rhinitis. 3. List treatment options for allergic rhinitis. 4. Identify adverse effects and contraindiciations of various allergy treatments. 5. Describe the role of the clinician in counseling patients regarding appropriate measures to control allergies. This independent learning activity is accredited for 1.5 contact hours of continuing education by Partners in Healthcare Education, LLC, an approved provider of nurse practitioner continuing education by the American Academy of Nurse Practitioners, provider # To obtain credit: Answer the test questions at the end of this lesson and complete the evaluation online at A statement of credit will be sent to participants achieving a minimum score of 7 percent correct responses. Statements of credit are issued immediately. Questions regarding statements of credit should be directed to W. Lane Edwards Jr. at Lane@4healtheducation.com. This lesson is available free of charge to retail clinicians. Copyright 27 by Lebhar-Friedman Inc. All rights reserved. 34 Fall 27 Retail Clinician

2 encounter with the allergen. The allergen is inhaled through the nose and immediately interacts with T cell and B cell lymphocytes, resulting in the production of IgE antibodies. The antibodies attach themselves to mast cells and basophils. When the same allergen is re-introduced, the IgE-coated mast cells cross the epithelium. These antibodies are activated, leading to degranulation of the mast cell. This degranulation leads to the release of preformed mediators within the mast cells, including histamine, leukotrienes, bradykinin and other mediators of inflammation. Bradykinin causes the local blood vessels to broaden and leak, leading to mucosal edema and rhinorrhea. Along with secreting mucoglycoconjugates and antimicrobial substances, the blood vessels in the mucosal glands also dilate, leading to sinusoidal filling and nasal congestion. Inflammatory mediators in the mucosal glands stimulate sensory nerves, producing nasal itching and sneezing. The second stage in the allergic response, referred to as the late phase, occurs within several hours to a day later. This stage involves the migration of white blood cells and inflammatory mediators to the nasal mucosa. Chemoattractants, including interleukin-3 and interleukin-5, promote infiltration of the mucosa by eosinophils, neutrophils, basophils, T-lymphocytes and macrophages. 11 As these cells become activated, many of the inflammatory mediators from the early phase are reactivated. This results in a hyper-responsive airway and worsening nasal symptoms. Tissue inflammation may last several weeks in intermittent allergy sufferers or become chronic in the case of persistent allergic rhinitis. When patients are repeatedly exposed to an allergen, the amount of allergen necessary to provoke a response decreases. 12 This is known as the priming effect. It is believed the priming effect is due to inflammatory activity during the late phase response. Triggers Intermittent allergic rhinitis is caused by outdoor allergens, including tree and grass pollen or molds. In the United States, tree pollen is problematic in the spring, grass pollen in the late spring and summer, and weed pollen in the late summer and early fall. Persistent allergic rhinitis is more often associated with such indoor allergens as pet Patient Scenario 1 dander, dust mites, cockroaches and mold. Cat dander can remain airborne for six hours. Pet dander can remain in household dust for several months after the animal has left. Dust mites are found in bedding, carpets, upholstered furniture, curtains and soft toys. Mold is common in basements, bathrooms, plants and old newspapers. Clinical presentation The Allergic Rhinitis and its Impact on Asthma (ARIA) 13 classifications for allergic rhinitis, intermittent and persistent, have replaced the traditional nomenclature of seasonal and perennial. These newer classifications utilize duration, symptoms and quality of life parameters to subdivide patients. A patient with intermittent allergic rhinitis Patient Case MK, a 27-year-old woman, presents to the walk-in clinic located in her local pharmacy. She is in her second trimester of pregnancy. She explains to the clinician that she has been experiencing significant sneezing, nasal itching and rhinorrhea for the last three to four weeks. Although she has a history of allergies during ragweed season, she has never had this problem in early spring. She is concerned that she has developed an allergy to a different allergen. Along with being unsure what medications she can take while pregnant, she is hoping the clinician can assist her in identifying possible precipitants in this latest episode. Case Discussion Many conditions present with symptoms similar to allergic rhinitis. Althrough it is possible that MK is experiencing an allergic reaction to a new allergen, her current pregnancy also may play a role in her symptoms. During pregnancy, the incidence of allergies increases. Allergy-like symptoms also may increase due to hormonal changes. Hormone-induced rhinitis typically resolves soon after delivery. exhibits symptoms less than four days a week or for less than four weeks. A patient with persistent allergic rhinitis exhibits symptoms more than four days a week or for more than four weeks. Patients are further subdivided as having mild or moderate-severe symptoms. A patient is diagnosed with mild symptoms if the symptoms do not impact sleep, daily activities, work, school, sports or leisure. A patient is diagnosed with moderate-severe symptoms if the symptoms impact sleep, daily activities, work, school, sports or leisure, or if troublesome symptoms exist. When classifying a patient s allergic rhinitis, the clinician would categorize it by duration and severity. Therefore, a patient with symptoms lasting for three weeks that do not interfere with normal activities would be diagnosed with mild intermittent allergic rhinitis. According to Bousquet and colleagues, 14 1 percent of patients can be classified with mild intermittent rhinitis, 14 percent mild persistent rhinitis, 17 percent moderate/severe intermittent rhinitis and 59 percent moderate/severe persistent rhinitis. Patients with allergic rhinitis are likely to have clear nasal discharge, sneezing, nasal congestion, itching of the nose and eyes, and postnasal drip. The post- Retail Clinician Fall 27 35

3 TABLE 1 Comparison of allergic and nonallergic rhinitis Onset Exacerbations Symptoms Stimuli Response to antihistamines nasal drip can cause some patients to develop a cough. Nasal congestion may lead to a decrease in the sensations of taste and smell. Patients who are heavily congested may be unable to breath through the nose. This puts them at risk to become chronic mouth breathers. People experiencing itching of the eyes can develop red conjunctiva and excessive tearing. Dark circles underneath the eyes, termed allergic shiners, also may be present. Constant rubbing of the nose in pediatric patients can result in a nasal crease across the bridge of the nose. Diagnosis Diagnosis of rhinitis should include a complete history and a physical examination. During the history, the clinician should determine the pattern, chronicity, seasonality of symptoms and response to medications. 15 The frequency of symptoms should be noted, along with the duration and severity of symptoms. To assist the clinician in developing a treatment plan, a complete list of medications previously and currently used to Allergic rhinitis Childhood; often associated with family history of allergic rhinitis, exema or atopy Seasonal Rhinorrhea, ocular symptoms, sneezing, itching and nasal congestion Indoor allergens for persistent; outdoor allergens for intermittent Good Nonallergic rhinitis Later in life, particularly after age 35 Persistent symptoms with exacerbations during winter months Persistent nasal congestion and rhinorrhea without itching/sneezing Hypereactivity to nonspecific stimuli, including strong odors, temperature change, smoke or spicy food Poor treat rhinitis symptoms also should be obtained. Patients with allergic rhinitis are known to change medications frequently, either due to ineffectiveness or adverse effects. In the Allergies in America survey, percent of patients reported changing allergy medications due to lack of efficacy. Bothersome adverse effects The main classes of medications that treat the symptoms of allergic rhinitis are antihistamines and intranasal corticosteroids. Many of these medications are available without a prescription. from medications accounted for medication changes in another 21 percent of patients. The clinician also should develop an environmental history to assess for occupational exposure or other precipitants. Symptoms from intermittent allergic rhinitis due to allergens such as trees and grass can be temporally related to the release of these pollens in a geographic region. The presentation of symptoms related to mold spores increase during harvesting, mowing or leaf raking. The impact of symptoms on the patient s quality of life should be determined. Resolution of clinical symptoms is not the only measure of successful treatment. The overall impact on the patient s ability to function also should be measured. A variety of methods are available to assist in determining the outcome of treatments. The Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) is a validated measurement of the effectiveness of treatment on daily living. 17 Although not specific to rhinitis, the Medical Outcomes Study Short Form Health Survey (SF-36) has also been used to measure outcomes on physical and emotional well-being. 18 An examination of the nose also is indicated for diagnosing rhinitis. The mucosa will appear pale and swollen. When mucosal edema is severe, the mucosa may appear bluish-gray. Watery mucus may be present on the epithelial surface. In contrast to the presentation of allergic rhinitis, during acute infection the mucosa will appear reddened. This is also true in cases of overuse of topical decongestants. Cobblestoning of the pharynx with lymphoid tissue may be present in sinusitis. If nasal polyps are present, they will appear glistening and opaque. Polyps are not sensitive to touch. Two types of tests, allergy skin testing and radioallergosorbent tests (RAST), 36 Fall 27 Retail Clinician

4 are typically used for identifying allergens responsible for rhinitis symptoms. Both types of tests are designed to detect allergen-specific IgE. 19 Allergy skin testing is generally performed by an allergist. It has the advantage of being relatively quick and inexpensive, along with being able to test for a wide variety of allergens. RAST tests, available through most laboratories, utilize serum rather than skin response. The RAST test has the advantage of no interaction with antihistamine use. Differential diagnosis Although rhinitis is typically associated with an allergic response, not all cases have an allergic component. A 21 study reported that 57 percent of rhinitis patients do not have allergic or mixed disease rhinitis. 2 Patients with nonallergic causes of rhinitis may be suffering from infectious rhinitis, rhinitis medicamentosa, atrophic rhinitis, GERD-induced rhinitis or nonallergic rhinitis with eosinophilia. Other more serious causes of rhinitis are nasal septum deviation, foreign body obstruction, cerebrospinal fluid rhinorrhea and sarcoidosis. Table 1 compares typical characteristics of allergic versus nonallergic rhinitis. Infectious rhinitis, classified as acute or chronic, is typically viral in origin but may be complicated by secondary bacterial sinus infections. Responsible viruses generally include rhinovirus, parainfluenza, influenza and adenovirus. Symptoms of acute viral rhinitis include rhinorrhea, nasal obstruction and fever. At onset, rhinorrhea is clear and watery but may become cellular and cloudy due to the presence of virus, white blood cells and epithelial cells. Occlusion of the sinus ostia results in facial pain while occlusion of the Eustachian tube results in ear fullness or discomfort. Without secondary bacterial infection, acute infectious rhinitis is self-limiting, resolving within seven to 1 days. Chronic infectious rhinitis is more common in patients with allergies, mucociliary disturbance or immune deficiency. 21,22 This diagnosis should not be considered until the patient has experienced eight to 12 weeks of symptoms. The symptoms of chronic infectious rhinitis include purulent nasal discharge, nasal congestion, facial pain and pressure, olfactory disturbances, post-nasal drainage and cough. Nonallergic rhinitis with eosinophilia syndrome (NARES) is characterized by perennial symptoms with paroxysmal episodes. The typical symptoms include sneezing, profuse watery rhinorrhea and TABLE 2 Causes of drug-induced rhinitis ACE inhibitors Aspirin Beta-blockers Chlorpromazine Conjugated estrogen Guanethidine Methyldopa NSAIDs Oral contraceptives Phentolamine Prazosin Reserpine nasal pruritus. These patients also may experience loss of the sense of smell. These patients lack a clinically significant positive skin test or serum IgE antibodies to a specific allergen. During pregnancy, rhinitis symptoms may develop due to hormonal changes. Alterations in hormone levels cause intranasal vascular engorgement and mucosal hypertension. 24 These symptoms often develop during the second month and continue until delivery. Symptoms resolve shortly after delivery. 25 Other hormone alterations, such as puberty, the use of oral contraceptives or hormone replacement therapy or hypothyroidism also may precipitate rhinitis symptoms. With food allergies, isolated respiratory symptoms are unusual and are typically present in combination with gastrointestinal or skin symptoms. Allergic reactions to food should be considered when a temporal relationship exists between ingestion and symptoms and the reaction is reproducible each time a sufficient quantity of the food is ingested. The most common clinical manifestations of food allergy are gastrointestinal (including abdominal pain, vomiting and tingling in the mouth), skin (flushing, hives and itching) and respiratory (wheezing or tightness in the throat). Numerous medications are associated with drug-induced rhinitis. Table 2 lists some of the common medicationrelated causes of rhinitis. The most frequently incriminated agents are antihypertensive medications. Illicit drugs, such as cocaine, also have been associated with rhinitis due to nasal irritation and inflammation. Repetitive use of vasoconstricting nasal decongestants also may produce rhinitis, known as rhinitis medicamentosa. These medications, including oxymetazoline and phenylephrine, may produce a rebound nasal congestion upon withdrawal if used for more than five days. Patients with rhinitis medicamentosa present with nasal mucosa that appears inflamed with areas of bleeding, accompanied by very little mucus. Although the incidence has declined in the United States, some elderly patients are prone to primary atrophic rhinitis. These patients report persistent nasal congestion and bad smell in the nose, 26 accompanied by headaches and chronic sinusitis. The bad smell is caused by thick crusts that form on the mucosa. The syndrome is characterized by progressive atrophy of the nasal mucosa and underlying bone. 27 On examination, the nasal cavity is enlarged and squamous metaplasia is present. Nonpharmacologic options Most environmental modifications involve indoor allergens (i.e. dust mites, mold and pet dander). Several studies have shown the effectiveness of avoidance of dust mites in reducing both the Retail Clinician Fall 27 37

5 levels of house-dust mites and rhinitis symptom scores. 28 Dust mites are microscopic insects that thrive in warm, humid places such as carpets, bedding and furniture. Avoidance of these mites can be accomplished by using plastic dust mite covers on pillows and mattresses. To avoid dust mites, the World Allergy Organization 29 recommends washing bedding, including pillow and duvets, every one to two weeks at 55-6 C. Soft toys also can be washed at 55-6 C or put in the freezer to kill mites. Dust mites can be killed by exposing mattresses, rugs and carpets to direct strong sunlight for more than three hours. Other recommendations to reduce dust mites include sufficient ventilation to decrease humidity, use of a dehumidifier or HEPA filter in the bedroom, removal of carpeting in the bedroom and using a dehumidifier or HEPA filter in the bedroom. To reduce exposure to mold indoors, carpeting, wallpaper and houseplants should be removed from the bedroom and/or household. The use of a dehumidifier is recommended if the relative humidity is consistently above 5 percent. Appropriate maintenance of ventilation and air-conditioning systems is essential for reducing mold spores. Firewood should be stored outside since mold can be present in the soil of the plants and bark of the wood. Piles of old newspapers should not be stored in the house. For contaminated surfaces, including bathrooms, a 5 percent ammonia solution is useful for removing mold. When pet owners are found to be allergic to pet dander, pets should be sent to an alternative home if possible. If pet owners cannot bear to part with them, frequent pet shampoos, cleaning with a HEPA vacuum, removal of carpets and applying special sprays that help control pet shedding may help control symptoms. Pets also should be kept out of bedrooms or be kept outside. Outdoor allergens can be avoided by closing car and home windows, limiting outdoor activities during high pollen season or at peak hours (usually between 5 a.m. and 1 a.m.) and wearing a face mask while performing outdoor tasks. When outdoor activities are necessary, wearing glasses or sunglasses may prevent pollens from entering the eyes. Patients also can wear a mask over the nose and mouth to prevent inhalation of pollen. Air conditioners with frequently changed filters also may be helpful to decrease humidity and filter out mites, mold, pollen and dander. Pharmacologic treatment options (OTC and prescription) A wide variety of treatment options are available for the treatment of allergic rhinitis. Medications can provide either symptomatic treatment or target the underlying inflammatory disease state. The main classes of medications that treat the symptoms of allergic rhinitis are antihistamines and intranasal corticosteroids. Other classes of medications TABLE 3 Effect of various agents on symptoms Nasal itching Nasal obstruction Ocular symptoms Rhinorrhea Anticholinergic agents Antihistamines (oral) Antihistamines (intranasal) Antihistamines (ophthalmic) Antileukotrienes Corticosteroids (intranasal) Decongestants (intranasal) Decongestants (oral) Mast cell stabilizers + /+ / / Source: Adapted from van Cauwenberg P, et al. Consensus statement on the treatment of allergic rhinitis. European Academy of Allergology and Clinical Immunology. Allergy 2;55(2): Fall 27 Retail Clinician

6 also are indicated for relief and prevention of various symptoms of rhinitis (see Table 3). Many of these medications are available without a prescription. Patient Scenario 2 Patient Case AS, a 35-year-old housewife, calls her family clinician to request assistance in choosing the best over-the-counter treatment for her allergies. The clinician asks AS about the type of symptoms she is experiencing, the severity of the symptoms and how long she has had these symptoms. AS explains that every spring she develops severe nasal itching, runny nose and sneezing. Typically, her symptoms begin when she starts to get her flower garden ready for planning and around the time that the trees start budding. During their conversation, the clinician can hear that AS is breathing through her mouth and constantly sniffling. The clinician carefully recommends a product for AS, suggests that AS has a pharmacist describe the product s ingredients at point of sale and tells her what to expect. AS repeats back the information to the clinician. AS then asks the clinician if there is anything else she could do to help reduce or eliminate her symptoms. Since she has this problem every year, maybe there is something she could do or not do to prevent an allergy flare-up. Case Discussion Although there have been many recent advances in the treatment of allergic rhinitis, no cure is currently available. Treatment focuses primarily on the reduction of symptoms. One way of controlling symptoms is to minimize exposure to the offending allergen. Many patients do not know exactly what allergen is causing their symptoms. A thorough history can assist in identifying when symptoms are most severe. Patients may even utilize weather-related Web sites to identify which outdoor allergens are highest during symptomatic periods. Allergen testing also is very useful to identify the patient s specific target, as it allows the patient and clinician to develop a treatment plan including allergen avoidance, possibly allergy shots and other pharmacotherapy options. Oral antihistamines Antihistamines have been used to treat allergic rhinitis for many decades. They work clinically to block histamine at the H1 receptor. Antihistamines are more effective in preventing the actions of histamine than they are at reversing the effects of histamine. They relieve the early stage symptoms mediated by histamine that include itching, sneezing, rhinorrhea and allergic conjunctivitis, while having little effect on nasal congestion. Antihistamines are available as oral, intranasal and ophthalmic formulations. Antihistamines are classified as either first generation or second generation. Both classes of antihistamines are effective for long-term treatment and prophylaxis of allergic rhinitis. The agents in these two classifications are differentiated by their selectivity for the H1 receptor and by their ability to cross the blood brain barrier. Oral antihistamines are readily absorbed, reaching peak concentrations within two to three hours. All antihistamines are metabolized via hepatic cytochrome P45 isoenzymes. With some antihistamines, histamine suppressive effects can persist for more than 24 hours, even when serum levels have declined. This post-dose effect may be due to active metabolites. First-generation antihistamines are available without a prescription and include familiar agents such as diphenhydramine (Benadryl), chlorpheniramine (Chlor-Trimeton), brompheniramine and carbinoxamine malate. These agents easily cross the blood brain barrier. The ability to cross the blood brain barrier causes significant sedation, drowsiness, dizziness and impaired work performance. They also block cholinergic receptors that in turn can cause urinary retention, dry mouth, dry eyes/blurred vision and constipation. In young children, first-generation antihistamines can cause an idiosyncratic excitation, rather than sedation. First-generation antihistamines should not be recommended to patients who have narrow-angle glaucoma, benign prostatic hypertrophy or bladder neck obstruction. Second-generation antihistamines are highly selective for the H1 receptor. Some second-generation antihistamines also may inhibit release of mast cell and basophil inflammatory mediators. Unlike their first-generation counterparts, they do not cross the blood brain barrier or bind to cholinergic receptors. Therefore, they do not produce sedating or anti-cholinergic side effects. Another advantage of the second-generation antihistamines are longer half-lives, allowing for once or twice daily dosing, rather than every four to six hours with diphenhydramine. Although some of the second-generation antihistamines, such as fexofenadine (Allegra), desloratdine (Clarinex), and cetirizine (Zyrtec), are available by prescription only, loratidine (Claritin and Alavert) is available overthe counter. Azelastine (Astelin) is an intranasal antihistamine that is available by prescription. It is indicated for patients 5 Retail Clinician Fall 27 39

7 Patient Scenario 3 Patient Case PA, a 25-year-old woman, presents to her local pharmacy. As she stands in the cough/cold aisle looking confused, the clinician approaches her, offering to help. PA explains to the clinician that she has seasonal allergies. During the last two weeks, her symptoms have been controlled by diphenhydramine capsules taken every eight hours. Although her symptoms have improved, she is unable to function at work or while at home caring for her young daughter. She is looking to find an alternative that will control her sneezing, rhinorrhea and itchy nose. Are there any alternatives for PA that will control her symptoms without causing severe drowsiness? Case Discussion Tailoring therapy to provide treatment for the patient s specific symptoms while minimizing adverse reactions is essential. For PA s symptoms (sneezing, rhinorrhea and itchy nose), antihistamines and intranasal corticosteroids are more effective than decongestants and antileukotrienes. Unfortunately, first generation antihistamines, such as diphenhydramine, are associated with significant sedation. If PA is looking for an over-the-counter option, a second generation antihistamine, such as loratadine, would improve her ability to complete activities of daily living without significant sedation. As a prescription option, intranasal corticosteroids also would improve her symptoms without sedation. years and older. The recommended dose for ages 5 to 11 years is one spray each nostril twice daily. The recommended dose for ages 12 years and older is two sprays each nostril twice daily. Patient counseling points on the use of first-generation antihistamines should include a warning that the use of alcohol or other central nervous system depressants concurrently may heighten their sedating effects. Until patients know how they will react to a first-generation antihistamine, they should use caution operating motor vehicles or heavy equipment. Some clinicians have suggested using a combination of a sedating antihistamine at night and a nonsedating antihistamine during the day. Patients also should be told that antihistamines work best if they are taken prior to known allergen exposure. Corticosteroids Intranasal corticosteroids, available as prescription only in the United States, are considered the most effective treatment for allergic rhinitis and the first-line therapy for moderate to severe allergic rhinitis. They relieve all the symptoms caused by both the early and late stages of the allergic response including nasal congestion by exerting anti-inflammatory effects. Corticosteroids decrease the migration of polymorphonuclear (PMN) leukocytes and fibroblasts, stabilizing lysosomal membranes and reversing capillary permeability. Studies comparing nasal corticosteroids with oral antihistamines have shown a statistically significant benefit in relieving nasal congestion and sneezing versus oral antihistamines. 3 Nasal corticosteroids are associated with relatively few side effects compared to first-generation antihistamines. Common side effects include nasal irritation, drying and burning. The drying effects can be minimized by using a saline nasal spray first or by using one of the aqueous preparations (AQ). To prevent nasal septum irritation, patients should be advised to vary the angle of the bottle when spraying. If a patient experiences nasal irritation or bleeding, use of the corticosteroid spray should be discontinued. Non-aqueous formulations of these sprays should be recommended for those patients who have rhinorrhea as a major symptom. Systemic absorption of intranasal corticosteroids is reduced compared to oral and inhaled formulations. Studies have shown fluticasone and mometasone to have low absorption across the nasal mucosa. 31 The long-term effects of intranasal corticosteroids on bone density and bone growth are still being evaluated. Intranasal corticosteroids should be used with caution during pregnancy, only if the potential benefit justifies the potential risk. Depending on the product, most intranasal corticosteroids are dosed one to two sprays in each nostril once or twice daily. Fluticasone (Flonase) is indicated in patients 4 years and older and mometasone (Nasonex) is indicated in patients 2 years and older, while triamcinolone (Nasacort), budesonide (Rhinocort Aqua), flunisolide (Nasarel) and beclomethasone (Beconase AQ), are indicated in patients 6 years and older. The patient should be instructed to start using the intranasal corticosteroid before allergen exposure due to a delayed onset of action. The typical onset of action is 12 hours after the first dose, with maximum effectiveness achieved after three to 14 days of continual use. Emphasis must be placed in counseling that these agents are not to be used on an as needed basis. Oral steroids are typically used only to treat those patients with severe symptoms that have not responded to nasal corticosteroids. Oral steroid treatment generally targets the late phase of the allergic reaction. Prednisone or methylprednisolone are the most com- 4 Fall 27 Retail Clinician

8 monly prescribed oral agents. The usual length of therapy ranges between five and seven days. Systemic side effects are the limiting factor with these medications including osteoporosis, delayed bone growth in children and adrenal axis suppression. Leukotriene modifiers Montelukast (Singulair), available only with a prescription, is a leukotriene-receptor antagonist approved for the treatment of seasonal allergic rhinitis. Leukotrienes contribute to inflammation and nasal congestion by increasing nasal blood flow and airway resistance. They are known to be more potent than histamine for producing nasal congestion. Antileukotriene antagonists inhibit cysteinyl leukotriene CysLT1 receptor to produce attenuation of bronchoconstriction, decreased vascular permeability and decreased mucosal edema and mucus production. Despite several studies comparing the effectiveness of montelukast to second-generation antihistamines, no conclusive evidence supports leukotriene receptor antagonists as a more effective therapy. 32 Another study compared the use of an intranasal corticosteroid with the combination of montelukast and a non-sedating antihistamine. The results were not significant in favor of using the combination treatment over the nasal corticosteroid, although both treatment groups had a significant decrease in symptoms. 33 Anticholinergic agent Intranasal ipratropium (Atrovent) is an anticholinergic agent that blocks acetylcholine activity. Ipratropium is indicated for relief of rhinorrhea. Relief from symptoms is seen within the first day. No rebound effect occurs with prolonged use, unlike intranasal decongestants. Due to a lack of effect on histamine or other receptors, it does not relieve nasal congestion, sneezing, ocular symptoms or post-nasal drip. Ipratropium is approved for patients 6 years and older. The recommended dose is two sprays per nostril two to three times per day of the.3 percent formulation. The most common adverse effects are epistaxis, nasal dryness and headache. Ipratropium should be used with caution in patients with glaucoma, bladder neck obstruction or prostatic hypertrophy. Clinicians should take special care in recommending self-treatment in patients with complex medical conditions. Even OTC medications can cause significant adverse effects in patients with diabetes, asthma and other chronic conditions. Mast cell stabilizer Intranasal cromolyn (Nasalcrom) inhibits degranulation of sensitized mast cells and the release of preformed mediators. It is now available over-the-counter. It is indicated for the prevention and treatment of rhinorrhea, nasal itching and sneezing due to allergies, although it is not as effective as intranasal corticosteroids. Cromolyn is approved for patients 2 years and older. The recommended dose is one spray in each nostril three to four times daily. The maximum effectiveness of this product may not be seen for one to two weeks after initiation of therapy. Whenever possible, patients should initiate cromolyn prior to exposure to allergens, typically just before the allergy season begins until the season has ended. Adverse effects include sneezing, nasal stinging, irritation and burning. Decongestants Decongestants are OTC products approved for the treatment of nasal and sinus congestion. They stimulate alphaadrenergic receptors in smooth muscle resulting in constriction of the blood vessels within the nasal sinuses. They can be an effective treatment alone or in combination with oral antihistamines to relieve nasal congestion. Available products include both oral and intranasal formulations. Intranasal dosage forms, including phenylephrine, naphazoline, tetrahydrozoline, oxymetazoline and xylometazoline, have direct action on alpha-adrenergic receptors and often are preferred to minimize systemic side effects. Oral products, such as phenylephrine and pseudoephedrine, act indirectly and generally have a longer duration of action but slower onset. Under the Combat Methamphetamine Epidemic Act of 25, controls were put into place pertaining to the sale and purchase of medications containing pseudoephedrine. The intent is to limit the sale of large quantities of this key ingredient in the manufacture of methamphetamine. All non-liquid formulations of pseudoephedrine must be sold in blister packs or unit dose packets or pouches. The act limits the amount of pseudoephedrine a patient can purchase to 3.6 grams in a single day and 9 grams in a month at a retail store. These products must be stored such that customers do not have direct access before the sale is made, such as displaying them behind the pharmacy counter, or in a locked cabinet that is located in an area to which customers do have direct access. These new regulations require the patient to show a government-issued photo identification, such as a driver s license, and to sign a logbook. The store is mandated to keep a record of purchases of these Retail Clinician Fall 27 41

9 Patient Scenario 4 Patient Case An elderly gentleman approaches the walk-in clinic located in his local pharmacy to inquire about an over-the-counter medication that he can take for his severe nasal congestion. The clinician asks him what other symptoms he is having, the severity of symptoms and for how long he has had them. He tells the clinician that the loratadine he takes for his allergy to pet dander is usually sufficient. However, his daughter is staying with him while new floors are being installed in her house. This daughter has brought her three dogs with her. As soon as his daughter and her pets arrived, his congestion has gotten progressively worse. He states that the congestion is so bad that he is unable to sleep at night. Seeing this patient s distress, the clinician recommends a short course of decongestants. The clinician also suggests some environmental modifications, including cleaning carpets and upholstery once the dogs have left. After explaining how she would like him to take the decongestants, the clinician asks the patient to verify the directions they went over. As he is doing this, the patient adds that he is also taking HCTZ and metoprolol XL for his high blood pressure. He inquires if the decongestant will interact with these medications. The clinician had forgotten to inquire about concurrent medical conditions and medication history. Should the use of this OTC product be a concern for this patient? Case Discussion Although over-the-counter medications are considered safer than prescription drugs to the average consumer, many have serious side effects, drug interactions and disease state interactions. It is in the best interest of both the patient and the clinician to spend the extra time going over the patient s medication and medical history prior to developing a treatment plan. In this case, the clinician has chosen a product that is not advised due to this patient s high blood pressure. Decongestants may cause an increase in blood pressure. products, including the product name, quantity sold, the name and address of purchaser and the date and time of the sale for at least two years. Patients commonly experience CNS and cardiovascular side effects with oral agents. Although this is also possible with nasal formulations, it typically occurs only with higher doses. CNS stimulation may cause insomnia, dizziness, anxiety, tremors and agitation. Cardiac effects can include elevation in blood pressure, rapid heart rate and palpitations. They should be used with caution in patients with a history of arrhythmias, coronary heart disease or hypertension. They should also be used with caution in patients with hyperthyroidism, glaucoma, diabetes or prostatic hypertrophy. The nasal formulations can cause nasal irritation, burning and dryness. When used for more than three days, rebound congestion, also known as rhinitis medicamentosa, occurs. Decongestants should not be used in patients who are taking tricyclic antidepressants or monoamine oxidase inhibitors, as they may be put at risk for hypertensive crisis. Concerns with concomitant medical conditions Clinicians should take special care in recommending self-treatment in patients with complex medical conditions. Even over-the counter medications can cause significant adverse effects in patients with cardiovascular disease, diabetes, asthma and other chronic conditions. Decongestants should be avoided when possible in patients with any disease state that may be exacerbated by stimulation of adrenergic receptors. Examples of these include hypertension, diabetes mellitus, ischemic heart disease, hyperthyroidism, coronary artery disease, benign prostatic hypertrophy and increased intraocular pressure. Decongestants should only be used in patients with hypertension under medical supervision. Blood glucose levels may fluctuate during any bout of an acute illness, including allergic rhinitis. Caution should be taken when recommending products that may contain sugar, particularly liquid formulations. If a patient with diabetes is prescribed an oral corticosteroid for treatment of their rhinitis symptoms, the clinician should advise them to check their blood glucose more frequently during therapy because hyperglycemia is a known side effect of this medication. Conclusion Not all patients who present with rhinorrhea are suffering from an allergic reaction. With so many conditions exhibiting similar symptoms, the clinician should carefully evaluate patients to determine the appropriate diagnosis. The clinician should evaluate the duration, severity, seasonality and types of symptoms for each patient. The patient s concurrent medical conditions also play a role in the decision-making process. As the frontline in the care of ambulatory patients, the clinician can screen for patients at risk of severe complications, while working to select an appropriate regimen. 42 Fall 27 Retail Clinician

10 Managing allergic rhinitis Learning Assessment Successful completion of Managing allergic rhinitis, is accredited for 1.5 contact hours of credit. To obtain credit, answer the following questions and complete the evaluation online at 1. Which of the following is a symptom of allergic rhinitis? a. sneezing b. nasal itching c. rhinorrhea d. all of the above 2. Approximately 2 percent of patients with allergic rhinitis also have asthma. a. True b. False 3. Persistent allergic rhinitis is not associated with which allergen? a. dust mites b. pet dander c. grass pollen d. cockroaches 4. Which of the following is a typical presentation of allergic rhinitis? a. cobblestoning of the pharynx b. reddened mucosa c. pale and swollen mucosa d. none of the above 5. Which of the following are nonallergic rhinitis disorders? a. NARES b. rhinitis medicamentosa c. drug-induced rhinitis d. all of the above 6. The agents most frequently associated with medication-induced rhinitis are: a. epinephrine b. anti-hypertensives c. antibiotics d. cholesterol-lowering agents 7. Strategies to reduce dust mites include: a. washing bedding at 55-6 C. b. freezing soft toys. c. exposing carpets to three hours of direct sunlight. d. all of the above. 8. Oral antihistamines are least effective at treating: a. sneezing b. nasal itching c. nasal congestion d. rhinorrhea 9. Which of the following is not an adverse effect associated with antihistamines? a. sedation b. hypertension c. dry mouth d. urinary retention 1. Corticosteroids are considered more effective than decongestants for the treatment of allergic rhinitis. a. True b. False 1 Dykewicz MS, Fineman S, Skoner DP, et al. Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma, and Immunology. American Academy of Allergy, Asthma, and Immunology. Ann Allergy Asthma Immunol 1998;81: US Dept of Health and Human Services. AHRQ, Pub No 2-E23, May Aberg N, Sundell J, Eriksson B, et al. Prevalence of allergic disease in schoolchildren in relation to family history, upper respiratory tract infections, and residential characteristics. Allergy 1996;51: Allergies in America Survey. Executive summary. Available at: Accessed June Bellanti JA, Wallerstedt DB. Allergic rhinitis update: epidemiology and natural history. Allergy Asthma Proc 2;21: Law AW, et al. Direct costs of allergic rhinitis in the United States: estimates from the 1996 medical expenditure panel survey. J Allergy Clin Immunol 23;111: Blaiss MS. Allergic rhinitis and impairment issues in schoolchildren: a consensus report. Curr Med Res Opin 24;2(12): Law AW, et al. Direct costs of allergic rhinitis in the United States: estimates from the 1996 medical expenditure panel survey. J Allergy Clin Immunol 23;111: American Academy of Allergy, Asthma, and Immunology. The Allergy Report 2. 1 Dykewicz MS, Fineman S, eds. Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma, and Immunology. Ann Allergy Asthma Immunol 1998;8l: Gelfand EW. Inflammatory mediators in allergic rhinitis. J Allergy Clin Immunol 24;114(5 suppl):s Connell JT. Quantitative intranasal pollen challenges II: The priming effect in allergic rhinitis. J Allergy 1969;43: Bousquet J, Van Cauwenberge P, Khaltaev N. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol 21;18(suppl):S Bousquet J, Annesi-Maesano I, Carat F, Legers D, et al. Characteristics of intermittent and persistent allergic rhinitis: DREAMS study group. Clin Exp Allergy 25; 35: Dykewicz MS, Fineman S, eds. Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma, and Immunology. Ann Allergy Asthma Immunol 1998;8l: Allergies in America Survey. Executive summary. Available at: Accessed June Juniper EF, Thompson AK, Ferrie PJ, et al. Validation of the standardized version of the rhinoconjunctivitis quality of life questionnaire. J Allergy Clin Immunol 1999;14(2 pt 1): Rand Health. The Medical Outcomes Study: 36-item short form survey instrument. Available at: Accessed June Hamilton RG, Adkinson NF. Clinical laboratory assessment of IgE-dependent hypersensitivity. J Allergy Clin Immunol 23;111:S687-S71. 2 Settipane RA. Demogrpahics and epidemiology of allergic and nonallergic rhinitis. Allergy Asthma Proc 21;22: MacKay IS, Cole P Rhinitis, sinusitis and associated chest disease. In: MacKay IS, Null TR, eds. Scott-Brown s otolaryngology. Vol 4. Rhinology. London: Butterworths. 1987; Lund VJ, Scadding GK. Immunologic aspects of chronic sinusitis. Can J Otolaryngol 1991;15: Settipane RA, Charnock DR. Epidemiology of rhinitis: allergic and nonallergic. Clin Allergy Immunol 27;19: Gani F, Braida A, Lombardi C, et al. Rhinitis in pregnancy. Allerg Immunol 23;35(8): Incaudo GA, Shatz M. Rhinosinusitis associated with endocrine conditions: hypothyroidism and pregnancy, In: Schatz M, Zeigler RS, Settipane GA, eds. Nasal manifestations of systemic diseases, Providence: Oceanside, Dutt SM; Kameswaran M. The aetiology and management of atrophic rhinitis. J Laryngol Otol 25;119(11): Goodman WS, DeSouza FM. Atrophic rhinitis. In: English GM, ed. Otolarngology. Philadelphia: JB Lippincott, 1987;2: Sheikh A, Hurwitz B. House dust mite avoidance measures for perennial allergic rhinitis. Cochrane Database Syst Rev 2l;4:CD World Allergy Organization. World Allergy Organization Guidelines for Prevention of Allergy and Allergic Asthma (condensed version). Int Arch Allergy Immunol 24;135: Nielson LP, Dahl R. Comparison of intranasal corticosteroids and antihistamines in allergic rhinitis: a review of randomized, controlled trials. Am J Respir Med 23;2(1): Lumry WR. A review of the preclinical and clinical data of newer intranasal steroids used in the treatment of allergic rhinitis. J Allergy Clin Immunol 1999;14(4 pt 1): Philip G, Malmstrom K, Hampel FC Jr, et al. Montelukast for treating seasonal allergic rhinitis: a randomized, double-blind, placebo-controlled trial performed in the spring. Clin Exp Allergy 22;32: Wilson AM, Sims EJ, Orr LC, et al. Effects of topical corticosteroid and combined mediator blockade on domiciliary and laboratory measurements of nasal function in seasonal allergic rhinitis. Ann Allergy Asthma Immunol 21;87: Retail Clinician Fall 27 43