US Pharm. 2015;40(7):8-11.
Allergic rhinitis (AR) is one of the most common chronic disorders affecting both children and adults in the United States.1 The prevalence of AR is estimated to be as high as 30% in adults and up to 40% in children, and is the most common allergic disease in children.2,3 Overall, it is the fifth most common chronic disease in the U.S., affecting approxi-mately 60 million Americans, although this number may be underestimated, as patients often do not recognize AR as a disease and therefore do not consult a physician.1,3,4 AR can negatively impact a patient’s quality of life, leading to difficulties with daily activities, reduced sleep quality, and decreased feelings of mental well-being.5
The total direct cost of AR is about $3.4 billion, with almost half of this cost attributed to prescription drugs; the average number of prescriptions for patients with AR is almost double that for patients without any allergies.6,7 It is not uncommon for prescription medications to be used in combination with OTC products to help alleviate AR symptoms.
Management of AR usually begins in the pharmacy, with patients asking pharmacists for recommendations. It is important for pharmacists to have an understanding of AR and the various options available to prevent and treat this condition.
Pathophysiology
AR is a chronic inflammatory disease affecting the upper airways. This inflammation of the nasal mucosal lining is a result of inhaled aeroallergens, which the patient has been previously sensitized to, binding to immunoglobulin E (IgE) on the surface of mast cells, leading to mast cell degranulation and release of preformed mediators, such as histamine and leuko-trienes.1,8 These newly released mediators bind to receptors in the nose, causing many of the manifestations of AR within minutes after exposure, which include nasal itching, sneezing, clear rhinorrhea, and some degree of nasal congestion.9
Four to 12 hours after allergen exposure, patients can experience a late-phase response characterized by a second release of the same mediators, reactivating many of the same proinflammatory reactions of the immediate response.9 The most predominant manifestation during this phase is nasal congestion that is often severe and long-lasting.8,9
Classification
AR can be classified according to the temporal pattern of exposure to allergens, frequency of symptoms, and severity.1 Traditionally, the temporal categorization has been utilized; AR has been categorized as either seasonal or perennial. Seasonal allergic rhinitis (SAR) has a seasonal variation and is dependent on geographic location and climatic conditions; trees, grass, weed pollens, and outdoor mold spores are usually the most common triggers. SAR symptoms usually appear during a particular season when these aeroallergens are abundant.1,10 Perennial allergic rhinitis (PAR) is attributed to aeroallergens that the patient is exposed to continuously and is usually encountered indoors. Common PAR aeroallergens include dust mites, cockroaches, indoor molds and fungi, animal allergens, as well as pollen where pollen is prevalent perennially.10
Other patients may have episodic manifestations. Episodic AR describes allergic nasal symptoms in patients who have sporadic exposure to aeroallergens that are not normally encountered in their usual indoor or outdoor environments.10
This traditional classification system has limitations, making it difficult at times to determine if a patient is suffering from allergic symptoms induced by seasonal pollen or caused by exposure to allergens that are perennial. Using a classification system that is based on frequency and severity allows for more appropriate treatment selection.1,4 There are two divisions of frequency: intermittent and persistent. Intermittent frequency is defined as AR symptoms occurring ≤4 days per week or ≤4 weeks per year, and persistent frequency is defined as symptoms occurring >4 days per week and for >4 weeks per year.
AR severity is classified as mild or moderate/severe.1,4 AR is considered mild when symptoms are present but not troublesome and do not affect the patient’s quality of life. Moderate/severe AR is when symptoms are considered troublesome and interfere with the patient’s daily activities, affecting their sleep and performance at work or school.
Management Strategies
The goals of treatment for AR include symptom relief, improving the patient’s quality of life, minimizing sleep disturbances, improving work and school performance, and limiting adverse effects of therapy.
One of the most important strategies to suggest is preventing or minimizing contact with environmental triggers.1,4,10 Ideally, patients should avoid these allergens entirely, although this is not always practical and difficult to achieve. Because of this, most patients will require drug therapy for management and prevention of AR symptoms. When walking down the pharmacy aisle, patients have many self-care options to choose from to help with AR symptom relief. OTC medications include antihistamines, mast cell stabilizers, and decongestants. More recently, we have seen the introduction of intranasal corticosteroids to the self-care market with the Rx-to-OTC switch of triamcinolone acetonide (Nasacort Allergy 24HR) and fluticasone propionate (Flonase Allergy Relief).
Intranasal Corticosteroids
Intranasal corticosteroids are the most potent and effective agents for the treatment of AR; they are recommended as first-line agents for moderate/severe or persistent AR.1,8,10 These agents effectively reduce inflammation of the nasal mucosa and improve mucosal pathology through their anti-inflammatory mechanism of action.10,11 Studies have shown intranasal corticosteroids to be more effective than leukotriene antagonists and intranasal and oral antihistamines, even when combined with a leukotriene antagonist.1,10 Intranasal corticosteroids provide relief for the four major symptoms of AR: sneezing, itching, rhinorrhea, and nasal congestion when used both continuously and on an as-needed basis; however, as-needed may not be as effective as continuous use.10 These agents also appear to have beneficial effects on ocular symptoms, including itching, tearing, redness, and puffiness.1
When comparing the available intranasal corticosteroids, clinical efficacy does not appear to vary, making sensory attributes an important factor for patient preference and adherence.1,10 The onset of therapeutic effect occurs between 3 and 12 hours with maximal effect not apparent until after 2 weeks of therapy.10,12
Intranasal corticosteroids are well tolerated by most patients. The most common adverse effects are a result of local irritation and include dryness, burning, stinging, and epistaxis; in rare cases, nasal septal perforation can occur. These effects can be avoided with proper administration techniques, pointing away from the septum.1,10,12 There have been concerns over systemic side effects with intranasal corticosteroid use. When used at recommended doses, these agents do not appear to cause adrenal insufficiency or growth suppression in children, or to increase bone fracture rates in the elderly.10
Nasacort Allergy 24HR: The first intranasal corticosteroid to become available without a prescription was Nasacort Allergy 24HR (triamcinolone acetonide).13 It was introduced in February 2014, at which time prescription Nasacort AQ was discontinued; generic triamcinolone acetonide nasal spray is still available by prescription. Nasacort Allergy 24HR delivers 55 mcg/spray of triamcinolone acetonide, just as Nasacort AQ did. It is approved for use in individuals aged ≥2 years for the temporary relief of nasal congestion, runny and itchy nose, and sneezing due to hay fever or other upper respiratory allergies. The appropriate dose for children 2 to <6 years of age is one spray in each nostril once daily. Children 6 to <12 years of age should start with one spray in each nostril once daily and increase to two sprays in each nostril if symptoms do not improve. For those aged ≥12 years, the appropriate dose is 2 sprays in each nostril once daily, decreasing to one spray in each nostril per day once allergy symptoms have improved. This product is scent-free.13
Flonase Allergy Relief: In February 2015, Flonase Allergy Relief (fluticasone propionate) became the second intranasal antihistamine available without a prescription.14 It is the same as the prescription version, delivering 50 mcg/spray of fluticasone propionate. Just as with Nasacort AQ, prescription Flonase was discontinued; however, fluticasone propionate nasal spray is still available with a prescription. Unlike Nasacort Allergy 24HR, Flonase Allergy Relief is the only OTC nasal spray that is approved for both nasal and ocular allergies. It is approved for use in individuals aged ≥4 years. The dose for children 4 to 11 years of age is 1 spray in each nostril once daily. In children and adults ≥12 years of age, the recommended dosing is as follows: for the first week use 2 sprays in each nostril once daily, then use 1 or 2 sprays in each nostril once daily as needed to treat symptoms. After 6 months of daily use, patients should consult their primary care provider about continued use.14
Conclusion
AR is a common condition that can adversely affect a patient’s quality of life. Many patients will consult their pharmacists regarding management strategies to alleviate their bothersome symptoms. With the availability of intranasal corticosteroids without a prescription, patients now have greater access to agents that will effectively control their symptoms with proper use.
PATIENT INFORMATION
What Causes Allergic Rhinitis (AR)?
AR differs from the common cold or other illnesses in that it is caused by an allergen and not by a virus or infection. Common allergens include dust mites, animal dander, mold, and tree, grass, and weed pollens.
Avoiding Allergens
One way to treat symptoms of AR is to avoid what causes them. Ventilation systems and frequent thorough household cleanings may help reduce indoor allergens. For outdoor allergens, try to stay indoors during periods of poor air quality.
OTC Treatments
Nasal Irrigation: Rinsing out the nasal passages with saline nasal irrigations or sprays can help clear out allergens and mucus from the nose and reduce drainage to the back of the throat. This is very safe when done correctly and can be performed once or twice daily, as needed.
Intranasal Corticosteroids: These drugs are administered directly into the nose by spray and work to reduce inflammation and discomfort. They are now available OTC as Nasacort Allergy 24HR (triamcinolone) and Flonase Allergy Relief (fluticasone). Symptom improvement can be seen almost immediately, though maximal efficacy can take a few days. Discontinue use and call your doctor if symptoms do not improve within 7 days, or if new symptoms occur. Side effects are minimal and include dry nose and unpleasant smell or taste. Ask your pharmacist about the proper technique to administer intranasal medications.
Antihistamines: These products help reduce the symptoms of runny nose, itchy eyes, and itchy throat, but will not help nasal congestion. They are taken orally either once or twice daily. These products can be taken every day during allergy seasons, or as needed. Use a nondrowsy product like Allegra (fexofenadine), Claritin (loratadine), or Zyrtec (cetirizine). Side effects are mild but may include dry mouth and constipation. Do not take this medication without consulting a doctor or pharmacist if you are over 65 years old, have glaucoma, difficulty urinating, prostate enlargement, thyroid disorders, or other medical conditions.
Decongestants: Nasal and oral decongestants can alleviate congestion or stuffiness associated with AR and may work best when combined with an intranasal corticosteroid or antihistamine. Nasal decongestants, such as Afrin (oxymetazoline), should not be used for more than 3 days due to the risk of rebound congestion. Oral decongestants, such as Sudafed (pseudoephedrine), can be taken throughout the day. However, side effects include increased heart rate, nervousness, and insomnia, so they are best taken in the morning. These drugs should not be used if you have uncontrolled hypertension, heart disease, closed-angle glaucoma, or hyperthyroidism, or are on certain medications.
Remember, if you have questions, Consult Your Pharmacist.
REFERENCES
1. Seidman MD, Gurgel RK, Lin SY, et al. Clinical practice guideline: allergic rhinitis. Otolaryngol Head Neck Surg. 2015;152(1 suppl): S1-S43.
2. Carr WW. Pediatric allergic rhinitis: current and future state of the art. Allergy Asthma Proc. 2008;29(1):14-23.
3. Gentile D, Bartholow A, Valovirta E, et al. Current and future directions in pediatric allergic rhinitis. J Allergy Clin Immunol Pract. 2013;1(3):214-226; quiz 227.
4. Bousquet J, Khaltaev N, Cruz AA, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen). Allergy. 2008;63(suppl 86):8-160.
5. Meltzer EO, Gross GN, Katial R, Storms WW. Allergic rhinitis substantially impacts patient quality of life: findings from the Nasal Allergy Survey Assessing Limitations. J Fam Pract. 2012;61(2 suppl):S5-S10.
6. Bhattacharyya N. Incremental healthcare utilization and expenditures for allergic rhinitis in the United States. Laryngoscope. 2011;121(9): 1830-1833.
7. Meltzer EO, Bukstein DA. The economic impact of allergic rhinitis and current guidelines for treatment. Ann Allergy Asthma Immunol. 2011;106(2 suppl):S12-S16.
8. Agency for Healthcare Research and Quality. Evidence-based Practice Center Systematic Review Protocol. Treatments for seasonal allergic rhinitis. March 2012. http://effectivehealthcare.ahrq.gov/ehc/products/376/1000/SAR_Protocol_20120308.pdf. Accessed May 19, 2015.
9. Skoner DP. Allergic rhinitis: definition, epidemiology, pathophysiology, detection, and diagnosis. J Allergy Clin Immunol. 2001; 108(suppl 1):S2-S8.
10. Wallace DV, Dykewicz MS, Bernstein DI, et al. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008;122(2 suppl):S1-S84.
11. Small P, Kim H. Allergic rhinitis. Allergy Asthma Clin Immunol. 2011;7(suppl 1):S3.
12. Scadding GK, Durham SR, Mirakian R, et al; British Society for Allergy and Clinical Immunology. BSACI guidelines for the management of allergic and non-allergic rhinitis. Clin Exp Allergy. 2008;38(1):19-42.
13. Nasacort Allergy 24HR. Drug facts label. http://nasacort.com/hcp/. Accessed June 17, 2015.
14. Flonase Allergy Relief. Drug facts label. www.flonaseprofessional.com/resources/#drugFacts. Accessed June 17, 2015.
To comment on this article, contact rdavidson@uspharmacist.com.
