The synthesis of art and science is lived by the nurse in the nursing act

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1 Art & science If you would like to contribute to the Art & science section, The synthesis of art and science is lived by the nurse in the nursing act Josephine G Paterson Treatment of rhinitis in pregnancy Odedra KM (2014) Treatment of rhinitis in pregnancy. Nursing Standard. 29, 8, Date of submission: April ; date of acceptance: July Abstract Rhinitis, a condition involving inflammation and irritation of the nasal membranes, is a common condition that can be allergic or non-allergic in origin. Pre-existing rhinitis can worsen during pregnancy, and new rhinitis can occur. Rhinitis has a significant effect on quality of life. Where rhinitis co-exists with asthma, it is a major risk factor for poor asthma control, which can have adverse effects on fetal development during pregnancy. Prescribing any drug treatment during pregnancy carries risks that must balance the benefits of symptom control with pregnancy outcome. Attaining control of rhinitis during pregnancy requires appropriate drug treatment, alongside careful patient education, monitoring and support. This article outlines the safety profile of common treatments used for rhinitis in women who are pregnant and/or breastfeeding. The aim is to aid the nurse in providing safe, effective treatment and information, thereby allowing patients to make informed decisions. Author Katy Mara Odedra Asthma and allergy clinical nurse specialist, Imperial College Healthcare NHS Trust, St Mary s Hospital, London. Correspondence to: katyodedra@gmail.com Keywords Asthma, breastfeeding, education, pregnancy, rhinitis, treatment Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software. Online For related articles visit the archive and search using the keywords above. Guidelines on writing for publication are available at: rcnpublishing.com/r/author-guidelines RHINITIS IS A CONDITION involving inflammation and irritation of the nasal mucosa. It may be triggered by many factors, including (NHS Choices 2014a, 2014b): Allergens, such as pollen. Diet. Drugs. Hormones related to the menstrual cycle. Irritants, such as viruses. Pollution. Temperature change. Typical rhinitis symptoms include sneezing, itching, rhinorrhoea (runny nose), nasal congestion and postnasal drip. Two or more of these symptoms, occurring for more than one hour a day, is a classification for rhinitis (Allergic Rhinitis and its Impact on Asthma (ARIA) 2010). Rhinitis may also be associated with ocular symptoms, including itch, watering and redness. Additionally, it can present with systemic symptoms, including fatigue and malaise as well as headache. When a diagnosis of rhinitis is made, it is then further defined as allergic or non-allergic in origin and classified according to the severity of symptoms (mild, moderate or severe) and their duration (persistent or intermittent) (ARIA 2010). Some individuals may have a mixed classification. Rhinitis affects 10-30% of the worldwide population (Pawankar et al 2011). School-aged children and adolescents are most commonly affected by intermittent (seasonal) allergic rhinitis, and adults with persistent (perennial) allergic rhinitis (ARIA 2010). The true prevalence is unknown, since there are likely to be high numbers of unreported, self-medicating individuals. In 2002, the worldwide direct and indirect costs for allergic rhinitis alone were estimated to be $7.3 billion and $4.28 billion, respectively (Schoenwetter et al 2004). In pregnancy, pre-existing rhinitis may worsen, improve or remain unchanged. Pregnancy-induced NURSING STANDARD / RCN PUBLISHING october 22 :: vol 29 no 8 ::

2 Art & science respiratory nursing BOX 1 Case study rhinitis (PIR) can occur without, or alongside, pre-existing rhinitis. PIR affects approximately 20-30% of pregnant women (Keles 2004) and can arise at any time during pregnancy (Ellegård 2003). The way in which pregnancy affects pre-existing rhinitis is not well understood, but PIR is attributed to hormonal changes, including placental growth hormone (Ellegård 2004). These hormonal changes cause increased blood flow and activity of the seromucous glands in the nasal mucosa, resulting in nasal congestion and rhinorrhoea. These symptoms typically resolve spontaneously when the mother s hormones stabilise within two weeks of delivery. Rhinitis affects quality of life significantly having a detrimental effect on work, home and social activities (Scadding et al 2000, ARIA 2010, Greiner et al 2011). It can lead to rhinosinusitis or sinus infection % of people with rhinitis also have asthma (Sibbald and Rink 1991, ARIA 2010). In pregnant woman who have a diagnosis of asthma, symptomatic rhinitis is a major risk factor for poor asthma control, which can have adverse effects on fetal development (Greiner and Meltzer 2006, Angier et al 2010). This highlights the importance of effective treatment of rhinitis during pregnancy (Box 1). Selecting the appropriate Sarah, a 33-year-old woman with known intermittent (seasonal) rhinitis triggered by grass pollen in the summer, presented to the clinic during the winter with a four-week history of new-onset nasal congestion and rhinorrhoea. She was 12 weeks pregnant and this was her second pregnancy. She did not have these symptoms during her first pregnancy. She reported initially using an over-the-counter nasal decongestant, which helped for two weeks and then made her symptoms worse. The symptoms had been affecting her sleep, which resulted in her taking several sick days from work. She could not highlight any triggers and reported her hayfever symptoms the previous summer had been well controlled with a prescribed, once-daily nasal glucocorticoid. On examination, her nasal mucosa was inflamed and swollen with thin clear mucus visibly dripping from her nose. It was explained that the diagnosis was likely to be pregnancy-induced rhinitis or worsening of pre-existing rhinitis. Sarah was keen to treat her symptoms but expressed concern over using any treatments that might be harmful to her baby. The treatment options were discussed. Since her condition was having a significant effect on her quality of life, she agreed to start saline nasal douching twice daily, to be used before taking the nasal glucocorticoid she was prescribed previously (also twice daily). Review was arranged at one month with a plan to reduce the nasal glucocorticoid. Telephone contact details and a management plan were provided. At the one-month review, Sarah reported a significant improvement. She did admit to stopping her treatment a few weeks previously, but her symptoms returned after three days and so she restarted with good effect. She was, therefore, advised to reduce to a once-daily nasal glucocorticoid but to increase to the original dose if required and continue nasal douching twice daily. This was updated in her management plan. She continued on this treatment until her delivery, following which, the rhinitis symptoms resolved within two weeks. treatment requires knowledge of the different treatment options and their potential effects on the developing fetus. Non-pharmacological treatment The British Society for Allergy and Clinical Immunology (BSACI) guidelines briefly outline some recommendations for treating rhinitis in pregnancy (Scadding et al 2008). It recommends that the first-line non-pharmacological treatment is allergen and irritant avoidance. Non-pharmacological treatments include the use of barrier ointment around the edge of the nares. Ointments such as petroleum jelly or a beeswax/ wax-based ointment can help trap large pollens. Nasal filters can also be useful for pollen avoidance in allergic rhinitis (Scadding et al 2008). Nasal saline douching can be effective and its regular use is particularly recommended for PIR (Scadding et al 2008). This is also known as nasal lavage and involves inserting a solution of salty water (this may be bought or home-made using a teaspoon of salt in a pint of previously boiled and cooled water). This helps to wash away excess mucus and allergens, thereby reducing inflammation. Pharmacological treatment If non-pharmacological treatment and allergen avoidance are unsuccessful, medications can be started in a stepped approach in combination with non-pharmacological treatment and allergen avoidance. Mast cell stabilisers that prevent the release of histamine, such as sodium cromoglicate, are recommended as an option in the first three months of pregnancy. There are studies showing this group of medications has no teratogenic effects in animals and a good tolerability record in humans (Scadding et al 2008, ARIA 2010). This group of medications is not particularly effective in the treatment of rhinitis, however, and requires multiple daily applications, therefore raising issues of adherence. Intranasal glucocorticoids, by contrast, have a similar safety record and superior efficacy (Gilbert et al 2005) and a simple, once or twice-daily dosing schedule. Antihistamines and glucocorticoids Safety data for oral histamine H1 receptor antagonist (antihistamine) use in pregnancy is extensive, because it has been one of the mainstays of allergy treatment for decades (Seto et al 1997). It was previously regarded as good practice to prescribe antihistamines as the first-line pharmacological treatment of rhinitis in pregnancy (Scadding et al 2008). Newer generation oral 38 october 22 :: vol 29 no 8 :: 2014 NURSING STANDARD / RCN PUBLISHING

3 histamine H1 antagonists are favoured over older generation drugs. These newer drugs do not cause sedation or interact with cytochrome p450 an important liver enzyme involved in drug metabolism, which can be adversely affected in some individuals (ARIA 2010). Recent observational studies have demonstrated the safety of newer generation histamine H1 antagonists, for example, cetirizine and loratadine, in pregnancy (Diav-Citrin et al 2003, Moretti et al 2003, Weber-Schoendorfer and Schaefer 2008). The latest guidelines (ARIA 2010), however, recommend intranasal glucocorticoids as the first-line pharmacological treatment in pregnancy, superseding the use of histamine H1 antagonists. Intranasal glucocorticoids are regarded as having a good safety record, based on their wide use in inhaled form for pregnant women with asthma (Lim et al 2011). The latest guidelines (ARIA 2010) recommend intranasal glucocorticoids over oral histamine H1 receptor antagonists in both persistent and intermittent allergic rhinitis. This recommendation is based on their higher efficacy in relieving rhinorrhoea and congestion and is supported by a recent review (Sato 2012). Furthermore, intranasal preparations have increased local activity with lower systemic absorption, therefore reducing the risk to the fetus. In 2001, a placebo-controlled, double blind, randomised, parallel group study, in which 53 pregnant women were treated with intranasal fluticasone for eight weeks and then followed up, demonstrated no adverse effects on fetal growth or pregnancy outcome (Ellegård et al 2001). Furthermore, a study that followed up children exposed to systemic and inhaled corticosteroids while in utero showed no adverse effects with regard to fetal development or congenital malformations (Wilson et al 2006). Leukotriene antagonists Other drug treatment options for rhinitis include oral leukotriene antagonists. Leukotrienes are inflammatory mediators found in leukocytes. Leukotriene overproduction is a major cause of inflammation in asthma and allergic rhinitis. Leukotriene antagonists are recommended for intermittent allergic rhinitis in adults and children over 15 years of age (ARIA 2010). They should not be initiated during pregnancy, but can be continued if already in use, since the benefits of continuing the medication may outweigh the risk of side effects (ARIA 2010). There is limited data available on oral leukotriene antagonist use during pregnancy and breastfeeding (Lim et al 2011). However, in the author s professional experience, patients who continued to take oral leukotriene antagonist medication (montelukast) throughout pregnancy did not experience any adverse effects. Other therapies It is recommended that decongestants should be avoided in pregnancy, since there is insufficient safety data and their effect is to cause narrowing of blood vessels, which may have an adverse effect on the fetus (Scadding et al 2008, ARIA 2010). A recent study demonstrated a higher risk of birth defects in children born to women using oral or nasal decongestants (Yau et al 2013). There is no evidence for the use of complementary therapies, including acupuncture, phototherapy or herbal remedies such as echinacea and elderflower (ARIA 2010). Safety data There is often limited evidence-based information regarding medications suitable for use during pregnancy. This shortage is because of the reliance on case reports and animal studies arising from ethical issues of testing drugs during pregnancy. Consequently, any medication may carry a risk if used during pregnancy. The benefits of controlled rhinitis during pregnancy should therefore be balanced against potential danger to the mother and fetus. Table 1 outlines medications used in rhinitis and the safety profile of their use during pregnancy and while breastfeeding. Breastfeeding Exclusive breastfeeding is recommended for the first three months of a baby s life, to help provide protection for the newborn against the development of allergic disease (ARIA 2010). Using the lowest effective dose of medication, for the shortest time necessary, to control rhinitis in women following childbirth, helps to minimise the baby s exposure to medication in breast milk. Most medications used to manage asthma and many medications used to treat rhinitis, have long been shown to be safe to use by women who are breastfeeding (Turner et al 1980). The Breastfeeding Network (BFN (2009)) in the UK also provides helpful guidance on antihistamine use while breastfeeding and supports the use of such medications. The BFN specifies the use of second-generation nasal and oral antihistamines, mast cell stabilisers in the form of eye drops, and intranasal glucocorticoids in the treatment of rhinitis while breastfeeding. Intranasal medication acts locally and has the advantage of low systemic exposure. It is, therefore, unlikely to pass into breast milk, while oral medication is present at 1% or less in breast milk. Information available regarding rhinitis medication use in pregnancy and NURSING STANDARD / RCN PUBLISHING october 22 :: vol 29 no 8 ::

4 Art & science respiratory nursing breastfeeding is summarised in Table 1. There are less data available with newer medications. Trigger avoidance Pollutants and tobacco smoke act as adjuvant factors boosting the existing allergic antibody immunoglobulin E (IgE) responses which can result in exacerbations of allergic rhinitis and concomitant asthma. A multi-centre allergy study in Germany demonstrated that mothers who smoke up to the end of pregnancy and beyond birth have an increased risk of allergic sensitisation in their children (Lau et al 2002). There is no convincing evidence that avoidance of any foods during pregnancy affects rhinitis symptoms or prevents the child from developing allergies. Therefore, dietary allergen avoidance is not recommended (ARIA 2010). If sensitised to allergens, allergic triggers such as pet dander and pollens, should be avoided or minimised where possible throughout pregnancy, as would be advised with any individual experiencing allergic symptoms with identifiable triggers. Monitoring Appropriate and ongoing care throughout pregnancy helps to ensure control of rhinitis symptoms and promote a positive pregnancy outcome. It requires careful education, monitoring and support, and maintenance on appropriate medication, which in turn requires effective assessment, examination and communication TABLE 1 Safety profile of rhinitis medication Name Oral/intranasal/ocular H1 antihistamines: first generation Oral/intranasal/ocular H1 antihistamines: second generation Intranasal/oral decongestants Ocular mast cell stabiliser Intranasal glucocorticoids Safe in pregnancy Comments Safe in breastfeeding Comments Long safety profile. Avoid long-term use, as may cause drowsiness in baby. Evidence base for loratadine and cetirizine only (Diav-Citrin et al 2003, Weber-Schoendorfer and Schaefer 2008). No Teratogenic in animals (Sato 2012). Risk of rhinitis medicamentosa (rebound congestion from prolonged decongestant use). Unknown Limited data. Unknown Limited data. Data based on wide use of inhaled form by pregnant women with asthma (Lim et al 2011). Oral glucocorticoids Risks: cleft palate, pre-eclampsia, preterm labour (Gregerson and Ulrik 2013). However, patients in the trial had severe asthma possibly affecting fetal development, rather than medication (Gregerson and Ulrik 2013). Intra-ocular/ intranasal mast cell stabilisers Good safety record, but not as effective as intranasal glucocorticoids. Leukotriene antagonists /no Not to be commenced during pregnancy. Intranasal ipratropium bromide No Unknown Limited effectiveness. Unknown Immunotherapy /no Recommended to be continued during pregnancy, but initiation and increasing dosage are contraindicated (Scadding et al 2008). Less than 0.03% excreted in breast milk (Hilbert et al 1988). Optimal treatment choice (The Breastfeeding Network (BFN) 2009). Can reduce prolactin levels and, therefore, milk supply (Aljazaf et al 2003). Less than 0.1% excreted in breast milk (Greenberger et al 1993). Optimal choice (BFN 2009). Less than 0.1% excreted in breast milk (Greenberger et al 1993). Localised action. Optimal choice (BFN 2009). Excreted in breast milk in animal studies. Unknown No data in humans. 1.5% passed into milk in animals. Immunoglobulin G excreted in milk. Use with caution. 40 october 22 :: vol 29 no 8 :: 2014 NURSING STANDARD / RCN PUBLISHING

5 skills. These need to be coupled with a written management plan and a practical demonstration of nasal spray and/or eye drop use. Cooperation with other healthcare providers involved in the pregnant woman s care is essential to ensure effective rhinitis management. Conclusion Rhinitis has a significant effect on the quality of life of pregnant women and breastfeeding mothers. It requires safe, prompt and effective treatment. Poor rhinitis control is likely to pose a greater risk with regard to pregnancy outcome than the medication necessary to control the condition. Careful education, monitoring and support throughout pregnancy are essential alongside maintenance on appropriate medication. Most rhinitis medications are safe to use in both pregnancy and breastfeeding. Pregnancy-induced rhinitis is self-limiting, which may be of some comfort to those experiencing symptoms NS References Aljazaf K, Hale TW, Ilett KF et al (2003) Pseudoephedrine: effects on milk production in women and estimation of infant exposure via breastmilk. British Journal of Clinical Pharmacology. 56, 1, Angier E, Willington J, Scadding G, Holmes S, Walker S, British Society for Allergy & Clinical Immunology (BSACI) Standards of Care Committee (2010) Management of allergic and non-allergic rhinitis: a primary care summary of the BSACI guideline. Primary Care Respiratory Journal. 19, 3, Allergic Rhinitis and its Impact on Asthma (2010) Allergic Rhinitis and its Impact on Asthma (ARIA) 2010 Revision. tinyurl.com/qar27a8 (Last accessed: September ) Diav-Citrin O, Shechtman S, Aharonovich A et al (2003) Pregnancy outcome after gestational exposure to loratadine or antihistamines: a prospective controlled cohort study. 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