Allergic rhinitis is common. More than a nuisance. Complete your CPD points online. Inside AUTHOR

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1 Inside Complete your CPD points online go to pharmacynews.com.au click on education 32 Signs, symptoms and medications 33 Asthma and allergic rhinitis 36 HMR Case study 37 CPD quiz More than a nuisance Allergic rhinitis is common, but under treated, and can coexist with other serious conditions. An HMR can improve treatment. Allergic rhinitis is common condition affecting 15 per cent of the Australian population. It is the most common chronic respiratory condition in Australia. Allergic rhinitis is often viewed as bothersome by patients and medical practitioners, but the impact on quality of life and functioning is substantial. The view that allergic rhinitis is an annoying nuisance often leads to under treatment. Many people with this condition do not report it to their general practitioner, selfmedicate with over-the-counter and pharmacist-only products or have sub-optimal management. Allergic rhinitis coexists with other conditions such as asthma, chronic sinusitis, nasal polyposis, otitis media, rhinoconjunctivitis and sleep problems. The goal of allergic rhinitis management is to achieve optimal symptom control and improve quality of life. New classification The Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 report divides allergic rhinitis into two categories: intermittent allergic rhinitis (IAR) and persistent allergic rhinitis (PER). IAR is defined by symptoms that are present for less than four days per week, or for less than four weeks at a time. PER is defined by symptoms that are present for more than four days per week, and for more than four weeks at a time. Before the 2008 ARIA report, allergic rhinitis was subdivided, based on time of exposure, into seasonal, perennial and occupational. However this is no longer considered relevant. A mixed pattern of seasonal and perennial features is common, so classification by frequency and severity is more useful in guiding management. The severity of allergic rhinitis is classified as either mild or moderate/severe. With mild allergic rhinitis, there is no impairment of sleep, daily activities, leisure or sport; and the symptoms are not considered troublesome by the patient. With moderate/severe allergic rhinitis, these impair- > AUTHOR Debbie Rigby is a consultant clinical pharmacist and a director of NPS (National Prescribing Service Ltd) PharmacyNews September

2 %Figure 1 classification of Allergic rhinitis intermittent Symptoms for less than four days per week, or for less than four weeks at a time. mild Normal sleep Normal daily activities Normal work/school No troublesome symptoms Persistent Symptoms for more than four days per week, and for more than four weeks at a time. moderate/severe One or more of the following: Abnormal sleep Impairment of daily activities, sport, leisure Problems at work or school Troublesome symptoms Medications ments are present and considered troublesome. Intranasal corticosteroids (INCS) Signs and symptoms and oral antihistamines are the The symptoms typical of allergic major categories of medications Although there is rhinitis are caused by an allergic used to treat allergic rhinitis. For reaction in the inner linings of the no cure for allergic persistent allergic rhinitis and nose resulting in inflammation. for moderate/severe intermittent Patients can mistake symptoms of rhinitis, effective allergic rhinitis, guidelines recommend use of intranasal corticoster- allergic rhinitis for asthma. Patients treatment is may frequently complain of oids as the first-line therapy. sneezing, nasal blockage and itchy available. Intranasal corticosteroids are nose, eyes and throat. effective in reducing congestion, Common signs and symptoms rhinorrhoea, sneezing and itching include: itch, rhinorrhea, sneezing, as well as ocular symptoms. They post-nasal drip, cough, facial fullness and pain, blockage, snoring symptoms than other treatments. are more effective in reducing nasal and sleep interference. Intranasal corticosteroids have Although there is no cure for good long-term safety data, but allergic rhinitis, effective treatment is available. Optimal symptom symptoms should be used. The total the lowest dose that will control control can be achieved through steroid dose should be considered if allergen avoidance, pharmacotherapy, non-medicated treatments Patients concerned about used with intercurrent asthma. and immunotherapy. systemic absorption and side effects Evidence of the effectiveness typical of steroids such as osteoporosis, diabetes and hypertension of allergen avoidance measures, particularly house dust mite, is should be reassured that systemic AD_PNASPJUL_12LHS. pdf Page 1 29/ 06/ 12, 1: 51 PM limited. absorption is negligible in recommended doses. Intranasal corticosteroids must be taken for up to two weeks before maximal efficacy is achieved. If patients are not adequately controlled by intranasal corticosteroids, the additional use of oral antihistamines is recommended. Oral antihistamines are effective in allergic rhinoconjunctivitis and histamine-related symptoms such as itching, rhinorrhoea, sneezing and eye symptoms. They are less effective for nasal blockage. Cumulative clinical evidence indicates that H1-antihistamines may have a beneficial effect on asthma symptoms and improve quality of life. Second generation, less sedating antihistamines are preferred in older persons. While all antihistamines are effective, non-responders to one may respond favourably to another. Intranasal antihistamines can reduce all symptoms of allergic rhinitis. They are as effective as oral antihistamines, but not as effective as intranasal corticosteroids. Intranasal anticholinergics (ipratropium bromide spray) are effective in managing persistent rhinorrhoea, but not congestion or itching. They can be used in combination with intranasal corticosteroids. A common reason for treatment failure is non-adherence due to local side effects such as dryness, irritation and epistaxis. Nasal saline spray can be used before intranasal corticosteroids to clear mucus, improving contact with the steroid and potentially reducing the dose required to be effective. Treatment failure may also be due to incorrect administration technique. Patients should be asked to demonstrate administration at every opportunity. Patient education optimises treatment outcomes and maximises adherence. Asthma co-morbidity Allergic rhinitis and asthma frequently coexist. At least 75 YOUR TRUSTED ANALGESIC CALMATIVE FOR OVER 20 YEARS, JUST GOT BIGGER. Al inf 32 September 2012 PharmacyNews

3 To comment %Table 1 Allergy medications Medication class Active ingredient Examples Intranasal steroids Beclomethasone dipropionate Beconase Allergy & Hayfever 12 Hour Oral antihistamines (second generation) per cent of patients with asthma complain of rhinitis symptoms, and 20 to 30 per cent of those with allergic rhinitis also have asthma. In about 700,000 Australians had both allergic Budesonide Rhinocort, Rhinocort Hayfever, Budamax Fluticasone propionate Avamys, Beconase Allergy & Hayfever 24 Hour, Flixonase Allergy & Hayfever 24 Hour, Flixonase Nasule Drops Mometasone furoate Triamcinolone acetonide Ciclesonide Cetirizine hydrochloride Levocetirizine dihydrochloride Fexofenadine hydrochloride Loratadine Desloratadine Nasonex Aqueous Nasal Spray Alcohol Free Telnase Omnaris Zyrtec, Alzene, ZepAllergy, Zilarex, Zodac rhinitis and asthma. The united airway disease hypothesis or one airway, one disease suggests that upper and lower airway disease are both manifestations of a single inflammatory process. IgE-mediated allergic responses to inhaled allergens cause symptoms of both asthma and rhinitis. Allergic rhinitis usually precedes asthma and is a significant risk AD_PNASPJUL_12RHS. pdf Page 1 29/ 06/ 12, 1: 50 PM Xyzal Telfast, Allerfexo, Amcal Fexo, Chemist s Own Fexo, Fexal, Fexotabs, Guardian Fexo, Tefodine, Xergic Claratyne, Alledine, Allerdyne, Allereze, Amcal Loratadine, Chemists Own Loratadine, Guardian Loratadine, Lorano, Lorapaed, Lorastyne Aerius Intranasal antihistamines Azelastine hydrochloride Azep Nasal Spray Levocabastine hydrochloride Livostin Nasal Spray Intraocular antihistamines Olopatadine hydrochloride Pantanol Eye Drops Levocabastine hydrochloride Livostin Eye Drops Intraocular cromones Sodium cromoglycolate Cromolux Eye Drops, Opticrom Intranasal cromones Sodium cromoglycolate Rynacrom 2%, 4% Intranasal anticholinergics Ipratropium bromide Atrovent Nasal, Atrovent Nasal Forte Leukotriene antagonists Montelukast sodium Singulair factor for asthma in adults and children. There is evidence that in a patient with both allergic rhinitis and asthma, the asthma symptoms are more difficult to control. Treatment of allergic rhinitis has been associated with improved outcomes from asthma and vice versa, and reduces asthma-related emergency department visits and hospitalisations. The role of HMRs General practitioners face substantial challenges in caring for patients with chronic comorbidities. Half of people over 65 years of age have at least three coexisting chronic conditions. One in five has five or more. Asthma and allergic rhinitis are a commonly occurring comorbidity. A Home Medicines Review (HMR) may identify undiagnosed or undertreated allergic rhinitis in consumers with asthma. The home visit provides an opportunity to explore the patient s preferences, check device technique and recommend treatment. Analysis of HMR data has shown that number of medications and number of medical conditions independently predicts the number of medication-related problems. HMRs may identify a condition not adequately treated or the need for preventive therapy. An HMR incorporates a comprehensive medication history with exploration of the consumer s general health and concerns about their medicines. The goal is to assist consumers in better medication management. Older patients generally have poor knowledge about their medicines and possible adverse effects. HMRs deliver patient-centred care, which involves three elements: communication with patients, partnerships and focus, beyond specific conditions or medications, on health promotion and healthy lifestyles, and takes into account the > NEW DOLASED ANALGESIC CALMATIVE TABLETS 40 S To order contact your Aspen Consumer Pharmacy Account Manager Always read the label. Use only as directed. Incorrect use could be harmful. If symptoms persist, see your healthcare professional. Your Pharmacist s advice is required. Please review the full Product Information before recommending. Full product information is available from Aspen Customer Service on Chemists Own Pty Ltd. (A member of the Aspen Group of Companies) Aspen Pharma Pty Ltd., Chandos Street, St Leonards NSW ABN Ordering enquiries: PharmacyNews September

4 %Table 2 Assessment of allergic rhinitis and asthma control Assessment for allergic rhinitis The reasons for the medication review include five or more medications, and suspected non-compliance with asthma treatment. What is your main symptom? (Check for rhinorrhoea, sneezing, itchy nose, nasal congestion and/or obstruction, watery or itchy eyes). Has a physician ever diagnosed that you have hay fever, allergic rhinitis or asthma? How long have you had these symptoms? Do you have the symptoms all the time or do they come and go? Are you aware of anything that seems to bring the symptoms on, such as being outdoors, around animals, or related to something you handle 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? ( Yes may indicate asthma). Do you have an earache or pain in your face? ( Yes may indicate otitis media or sinusitis). Do you have eye symptoms? Do you have a family member with allergy problems? What medications have you already tried for these symptoms? Do you have any other medical conditions or are you on any other medication? Assessment of asthma control On average, how often are you woken by your asthma during the night? On average, how bad are your asthma symptoms when you wake up in the morning? In general, how limited are you in your activities because of your asthma? In general, how much shortness of breath do you experience because of asthma? In general, how often did you wheeze over the past few weeks or since the last visit? On average, how many puffs of reliever do you use each day? patient s desire for information and micrograms per ml 2 sprays/ for shared decision making. nostril twice daily; Loratadine 10mg 1 daily for hay fever symptoms; Salbutamol MDI 2 puffs Case study Mr AR is a 76 year old DVA patient when required; Fluticasone referred for a Home Medicine propionate, salmeterol xinafoate Review. The reasons for the medication review include five or more twice daily; Risedronate 35 mg, 250/50 Accuhaler 1 inhalation medications, and suspected noncompliance with asthma treatment. calciferol 22 mcg (combination calcium carbonate 2500 mg, chole- In addition, the GP has pack); Paracetamol 665mg 2 tds requested a comprehensive assessment and education on devices. Mr Solifenacin 10mg 1 daily. prn; Meloxicam 7.5mg 1 daily and AR has a history of asthma, allergic Mr AR s main complaints are rhinitis, atopic dermatitis, hypertension, hypercholesterolaemia, osteo- and allergy problems. Further frequent headaches from sinus porosis and osteoarthritis. He has questioning shows a pattern of no known allergies. Blood pressure allergy symptoms throughout the and lipids are well controlled. year, often exacerbated in high Current medication list includes: pollen seasons, and with cigarette Candesartan, hydrochlorothiazide smoke or viral infections. He also 16/12.5mg daily; Aspirin 100mg suffers from daytime fatigue from daily; Simvastatin 40mg at night; frequent awakenings at night, due Budesonide aqueous nasal spray to coughing, blocked nose and (pump pack) 64 mcg/dose nasal sneezing. He manages the symptoms 50 intermittently PM with prescrip- AD_PNASPJUL_12. pdf spray, Page 1 spray 1 each 29/ nostril 06/ daily; 12, 1: Levocabastine nasal spray 500 tion and over-the-counter medications, but rarely discusses them with his general practitioner. An assessment of asthma control reveals frequent night-time awakenings and use of salbutamol puffer during the day, more than three doses a week, and at least once most nights. Accuhaler technique is good, but Mr AR rarely uses a spacer with the inhaler. A look at Mr AR s medicine cupboard shows a collection of oral antihistamines, eye drops, nasal sprays, topical preparations as well as salbutamol and ipratropium nebules. He has a spacer device but rarely uses it. Medication issues Mr AR complains of frequent headaches attributed by him to sinus and allergy problems. Targeted questioning suggests sub-optimal control of asthma and allergic rhinitis. He only uses oral antihistamines and intranasal corticosteroid or intranasal antihistamine inter- NEW DOLASED ANALGESIC CALMATIVE TABLETS 40 S To order contact your Aspen Consumer Pharmacy Account Manager Always read the label. Use only as directed. Incorrect use could be harmful. If symptoms persist, see your healthcare professional. Your Pharmacist s advice is required. Please review the full Product Information before recommending. Full product information is available from Aspen Customer Service on Chemists Own Pty Ltd. (A member of the Aspen Group of Companies) Aspen Pharma Pty Ltd., Chandos Street, St Leonards NSW ABN Ordering enquiries: September 2012 PharmacyNews

5 To comment mittently, as he doesn t think they work, dislikes the feeling of drip down his throat and suffers nose bleeds. Nose bleeds are usually due to poor technique or crusting on turbinates. A common reason for treatment failure is non-adherence due to local side effects such as dryness, irritation and epistaxis. Treatment failure may also be due to incorrect administration technique. Options for better management of allergic rhinitis, which can be suggested to the patient s GP, include switching to a more potent intranasal steroid such as mometasone and trial regular daily oral antihistamines for three months. Another option is a trial of the new intranasal steroid ciclesonide. Unlike most other intranasal steroid preparations, ciclesonide nasal spray does not use preservatives such as benzalkonium chloride or polysorbates, which are known to irritate or dry nasal tissue and/ or lead to hypersensitivity, and its high mucosa retention causes less throat rundown and nose runout than other formulations. Increased tolerability is a key factor in patient preference and adherence to INCS therapy. Nasal saline spray can be used before intranasal corticosteroids to clear mucus, improving contact with the corticosteroid and potentially reducing the dose required. Ongoing counselling and monitoring by the community pharmacist can reinforce the benefits of regular treatment, regularly assess device technique and provide further education. Summary Pharmacists are well placed to identify the symptoms of allergic rhinitis and to recommend appropriate treatment. Allergic rhinitis is a chronic relapsing condition, often undertreated and difficult to adhere to therapy. Optimal management of allergic rhinitis and asthma is critical to overall control of these common comorbidities. Patient education may improve adherence and persistence with medications and is essential for effective management of comorbidities. A patient-centred approach to HMRs can identify a number of medication-related problems including the need for additional therapy. References are available on request How to gain your CPD points Allergic rhinitis 1. Allergic rhinitis often coexists with other conditions. Which of the following is allergic rhinitis NOT commonly associated with? a) Asthma. b) Hypertension. c) Chronic sinusitis. d) Sleep problems. 2. Which of the following is false regarding the classification of allergic rhinitis? a) Allergic rhinitis is classified as either mild or moderate/severe. b) There is no impairment of sleep or daily activities with mild allergic rhinitis. c) There is impairment of sleep, but not daily activities in moderate/ severe allergic rhinitis. d) The impairments of sleep, daily activities and leisure or sport are considered troublesome in moderate/severe allergic rhinitis. 3. Common signs and symptoms of allergic rhinitis include all but which of the following? a) Rhinorrhea. b) Sneezing. c) Facial fullness and pain. d) Red eyes. 4. Select the correct statement regarding intranasal corticosteroids (INCS): a) INCS are effective in reducing congestion, rhinorrhea, sneezing and itching, but are not effective for ocular symptoms. b) INCS are more effective in reducing nasal symptoms than other treatments. c) Fluticasone propionate and triamcinolone acetonide are available only on prescription. d) Ciclesonide and mometasone furoate are available over the counter. 5. Which of the following is false regarding oral antihistamines? a) Oral antihistamines are effective in allergic rhinoconjunctivitis, but are less effective for nasal blockage. b) Cumulative clinical evidence indicates that H1-antihistamines may be beneficial for asthma symptoms and improve quality of life. c) First-generation antihistamines are preferred in older persons. d) Non-responders to one antihistamine may respond favourably to another. This activity has been accredited by the Australian College of Pharmacy as a Group 2 activity for 2 CPD credits. The College is authorised by the Australian Pharmacy Council to accredit CPD activities for pharmacists that may be used as supporting evidence of continuing competence. Accreditation number: A1209PN0 Members can submit their answers online at To ask about College membership please contact (02) or info@acp.edu.au. 6. A common reason for treatment failure is non-adherence due to adverse side effects. Which answer is most correct? a) Local side effects of intranasal corticosteroids may include dryness, irritation and epistaxis. b) Use of a nasal saline spray before intranasal corticosteroids clears mucus, improves contact with the steroid and may reduce the dose required to be effective. c) Incorrect administration technique is another cause of treatment failure. d) All of the above are true 7. Asthma and allergic rhinitis frequently coexist. Select the correct statement: a) 10 to 15 per cent of those with allergic rhinitis also have asthma. b) In , about 70,000 Australians had both allergic rhinitis and asthma. c) The united airway disease hypothesis suggests that upper and lower airway disease are manifestations of a single inflammatory process. d) Evidence suggests that in a patient with both allergic rhinitis and asthma, the rhinitis symptoms are more difficult to control. 8. Select the false statement regarding HMRs: a) Half of the population over 65 years has at least three coexisting chronic conditions. b) Asthma and allergic rhinitis are a commonly occurring comorbidity. c) Everyone with allergic rhinitis should have an HMR. d) An HMR provides an opportunity to explore the patient s beliefs and preferences, check device technique and recommend appropriate treatments. 9. Which of the following is not part of an assessment for allergic rhinitis? a) How often are you woken during the night by your allergic rhinitis? b) Has a physician ever diagnosed you with hay fever, allergic rhinitis or asthma? c) How long have you had these symptoms? d) Do you have an earache or facial pain? 10. Which of the following is recommended by the author to the doctor in the case study? a) Switching to a more potent intranasal corticosteroid such as mometasone. b) Trial of regular oral antihistamines for three months. c) Using a saline nasal spray before intranasal steroids to clear mucus and improve contact with the steroid. d) All of the above are appropriate recommendations. To submit answers, go to pharmacynews.com.au, click on education PharmacyNews September