SEARCH

SEARCH BY CITATION

Allergic rhinitis is a symptomatic disorder of the nose induced by an immunoglobulin (IgE)-mediated inflammation of the nasal membranes in response to allergen exposure (1). Predominant symptoms are rhinorrhea, nasal obstruction, nasal itching and sneezing, which improve spontaneously or with treatment (1–3).

The high prevalence of allergic rhinitis and its effect on quality of life have led to its being classified as a major chronic respiratory disease (1, 4). It is reported to affect 10% to 40% of the global population and its prevalence is increasing both in children and adults. Allergic rhinitis can significantly reduce quality of life (5), impairing sleep and adversely affecting leisure, social life, school performance (6) and work productivity (7). The direct and indirect financial costs of allergic rhinitis are substantial. Indirect costs include sick leave, school and work absenteeism and loss of productivity (8, 9).

Asthma and rhinitis are common co-morbidities suggesting the concept of “one airway, one disease” (1). In addition, allergic rhinitis is associated with conjunctivitis and sinusitis.

Recently, advances in our understanding of the mechanisms underlying inflammation of the upper and lower airways have led to improved therapeutic strategies for managing allergic rhinitis. Practice guidelines incorporating these advances have been developed (1). In addition, a new classification of allergic rhinitis aids the establishment of appropriate initial treatment strategy based on the duration and intensity of the patient's symptoms and lifestyle limitations (1, 10).

Many patients who suffer with allergic rhinitis do not recognise the process as such and do not consult a physician (10, 11). Others commonly seek self-treatment for relief of symptoms using proven or unproven therapies.

Worldwide, pharmacists receive sophisticated clinical training. Given the well-known and well-publicised recognition of iatrogenic disease, pharmacists’ skills represent an enormous potential resource to maximise the benefits and minimise the adverse events associated with pharmacotherapy (12). Pharmaceutical care includes prevention, treatment or cure of a disease (13). Interest and expectation that pharmacists provide broader “pharmaceutical care” services has therefore increased (14). Pharmaceutical care for the patient is likely to be optimal when there is collaboration between pharmacists, patients and other health care professionals, specifically physicians.

In many countries, advice in pharmacies may not necessarily be from a qualified pharmacist but from a member of staff under the supervision of a pharmacist.

As trusted healthcare professionals in the community, pharmacists are well placed to identify the symptoms of allergic rhinitis and to recommend appropriate treatment. In some countries, there has recently been an increase in effective and safe medicines available without prescription for the treatment of allergic rhinitis. This guide provides a practical, step-by-step approach to aid pharmacists in advising patients:

  • in recognising allergic rhinitis and assessing its severity,
  • in understanding the effect of treatment on rhinitis and co-morbidities,
  • in determining whether management in the pharmacy is appropriate,
  • in initiating an appropriate treatment and monitoring plan,
  • and proposing appropriate preventive measures.

This should:

  • increase collaboration between pharmacists, physicians and other health care professionals,
  • reduce the burden incurred by allergic rhinitis and its co-morbidities,
  • aid in the identification of undiagnosed or uncontrolled asthma,
  • and improve cost-effectiveness in the management of allergic rhinitis.

This document is a guide. It is not intended to be a mandatory standard of care document for individual countries. It is provided as a basis for pharmacists and their staff, as well as for organisations involved in the treatment of respiratory allergic diseases in various countries to develop relevant local standards of care for their patients. When implementing recommendations, the local plan should consider the infrastructure of pharmacy practice, workforce and regulations in the individual country.

In the present document, the physical examination and testing of patients for allergic rhinitis will not be detailed as relevant information has been published in the ARIA (Allergic Rhinitis and its Impact on Asthma) workshop report (1). Likewise, allergen avoidance, allergen specific immunotherapy and patient education are not emphasised to the extent they are utilised on the overall management. The pharmacist's role in providing education and in recommending strategies for avoiding exposure to allergens and irritants is recognised; however, this document focuses on appropriate initial pharmacotherapy recommendations from the pharmacist. For greater detail about these other areas, the reader is referred to the ARIA workshop report (1).

Medications available without a prescription (over the counter: OTC) from a physician vary in countries throughout the world. Pharmacists can advise and treat patients, depending on the symptoms presented by the patient and the medications which are available. When there is any doubt about what should or should not be recommended, or if a question exists about an alternative diagnosis, the patient should be referred to a physician for further evaluation.

Recognising allergic rhinitis

  1. Top of page
  2. Recognising allergic rhinitis in the pharmacy
  3. Recognising allergic rhinitis
  4. Differentiating allergy from other causes including infection
  5. Assessing the severity of allergic rhinitis
  6. Management by pharmacists or referral to physician
  7. Asthma co-morbidity
  8. Conjunctivitis
  9. Management of allergic rhinitis
  10. Environmental control
  11. Options for pharmacological treatment of allergic rhinitis
  12. Allergen-specific immunotherapy (vaccination)
  13. Alternative therapies
  14. A pharmacy protocol for treating allergic rhinitis
  15. Management of ocular symptoms
  16. The management of allergic rhinitis and asthma
  17. Conclusion
  18. References
  19. Appendices

Some patients who consult the pharmacist will have had allergic rhinitis previously diagnosed by a physician, others will have made an appropriate self-diagnosis, some will not have any diagnosis of rhinitis or may even have an incorrect diagnosis (e.g. a viral infection, cold). The pharmacist should always therefore ask patients to give an account of his or her symptoms to assist in recognising the disease and assessing the severity. The most commonly reported symptoms are sneezing, an itchy, congested nose (nasal blockage) and runny nose (nasal discharge or rhinorrhea) (Table 1) (11, 15).The eyes, paranasal sinuses and eustachian tube may be affected, resulting in itchy, watery or red eyes, temporary ear fullness and popping, itchy throat and pressure over the cheeks and forehead. Other symptoms may include malaise, headache, weakness, inability to concentrate and fatigue.

Table 1.  Clinical classification of rhinitis (2,10)
 “Sneezers and runners”“Blockers”
SneezingEspecially paroxysmal in boutsLittle or none
RhinorrheaAlways present: watery, anterior and sometimes posteriorVariable, can be thick mucous, and generally more posterior
Nasal itchingYes, oftenNo
Nasal blockageVariableOften severe
Diurnal rhythmWorse on awakening, improves during the day and usually worsens again in the eveningConstant day and night, may be worse at night and is often severe
ConjunctivitisOften presentNone

If the patient does not give sufficient information about symptoms to arrive at a diagnosis, more information can be elicited by structured questioning (Table 2). It is often relatively easy to differentiate “sneezers and runners” who may have allergic rhinitis from isolated “blockers” who are almost never allergic.

Table 2.  Questions to elicit information
• What is your main symptom? (Check for rhinorrhea, 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?

Differentiating allergy from other causes including infection

  1. Top of page
  2. Recognising allergic rhinitis in the pharmacy
  3. Recognising allergic rhinitis
  4. Differentiating allergy from other causes including infection
  5. Assessing the severity of allergic rhinitis
  6. Management by pharmacists or referral to physician
  7. Asthma co-morbidity
  8. Conjunctivitis
  9. Management of allergic rhinitis
  10. Environmental control
  11. Options for pharmacological treatment of allergic rhinitis
  12. Allergen-specific immunotherapy (vaccination)
  13. Alternative therapies
  14. A pharmacy protocol for treating allergic rhinitis
  15. Management of ocular symptoms
  16. The management of allergic rhinitis and asthma
  17. Conclusion
  18. References
  19. Appendices

Allergic rhinitis presents with symptoms similar to those of a number of other conditions and may be confused with a viral infection such as the common cold and with chronic sinusitis. Figure 1 presents an algorithm for differentiating allergic rhinitis from another cause or infectious diseases. The presence of nasal itching, rhinorrhea, sneezing, and eye symptoms are usually consistent with allergic rhinitis.

image

Figure 1. Differentiating allergic rhinitis from other causes.

Download figure to PowerPoint

Assessing the severity of allergic rhinitis

  1. Top of page
  2. Recognising allergic rhinitis in the pharmacy
  3. Recognising allergic rhinitis
  4. Differentiating allergy from other causes including infection
  5. Assessing the severity of allergic rhinitis
  6. Management by pharmacists or referral to physician
  7. Asthma co-morbidity
  8. Conjunctivitis
  9. Management of allergic rhinitis
  10. Environmental control
  11. Options for pharmacological treatment of allergic rhinitis
  12. Allergen-specific immunotherapy (vaccination)
  13. Alternative therapies
  14. A pharmacy protocol for treating allergic rhinitis
  15. Management of ocular symptoms
  16. The management of allergic rhinitis and asthma
  17. Conclusion
  18. References
  19. Appendices

A recent classification of allergic rhinitis (intermittent or persistent) has replaced the previous classification of seasonal and perennial forms (1). This classification is more appropriate as it is based on the patient's symptoms and needs, and forms a practical basis for assessing and managing allergic rhinitis (Figure 2).

image

Figure 2. Classification of allergic rhinitis according to ARIA (1).

Download figure to PowerPoint

Management by pharmacists or referral to physician

  1. Top of page
  2. Recognising allergic rhinitis in the pharmacy
  3. Recognising allergic rhinitis
  4. Differentiating allergy from other causes including infection
  5. Assessing the severity of allergic rhinitis
  6. Management by pharmacists or referral to physician
  7. Asthma co-morbidity
  8. Conjunctivitis
  9. Management of allergic rhinitis
  10. Environmental control
  11. Options for pharmacological treatment of allergic rhinitis
  12. Allergen-specific immunotherapy (vaccination)
  13. Alternative therapies
  14. A pharmacy protocol for treating allergic rhinitis
  15. Management of ocular symptoms
  16. The management of allergic rhinitis and asthma
  17. Conclusion
  18. References
  19. Appendices

Once allergic rhinitis has been identified, its severity can be assessed by asking the patient to what extent symptoms affect daily life. Where symptoms are intermittent, i.e. occurring fewer than 4 days per week or for less than 4 weeks, or mild, i.e. causing minimal interference with daily living, pharmacist management may be appropriate depending on medication availability.

Referral to a physician should be considered in cases where:

  • persistent, moderate to severe symptoms of rhinitis are present, (although initial treatment might be provided by a pharmacist whilst waiting to see a physician),
  • symptoms are suggestive of undiagnosed asthma or uncontrolled asthma in patients with a diagnosis of asthma (e.g. wheezing or shortness of breath),
  • symptoms of infection (mucopurulent discharge, sore throat, myalgia, asthenia, fever) are reported,
  • subjects whose symptoms do not respond to initial pharmacy management within 2 to 4 weeks,
  • bothersome side effects are experienced.

Referral to a physician is also advisable during pregnancy, because some medications should be administered with caution.

Management by a physician is also appropriate for children under 12, because of difficulties in establishing the diagnosis, selecting the proper medications to avoid side effects, and the frequent off-label use of medicines in this age group.

Table 3 lists these and other circumstances in which referral to a physician is desirable.

Table 3.  Circumstances when referral to a physician is advisable before treatment for allergic rhinitis
• Children under 12
• Pregnant or breast-feeding women
• Symptoms not usually associated with allergic rhinitis:
 – Unilateral obstruction
 – Anosmia (loss of smell)
 – Nasal obstruction without rhinorrhea (discharge)
 – Thick green or yellow mucous secretion
 – Posterior rhinorrhea
 – Recurrent epistaxis (nose bleed)
• Severe persistent allergic rhinitis
• Symptoms of undiagnosed asthma
• Symptoms of uncontrolled asthma
• Earache (may indicate otitis)
• Symptoms unresponsive to treatment
• Unacceptable side effects of treatment

Asthma co-morbidity

  1. Top of page
  2. Recognising allergic rhinitis in the pharmacy
  3. Recognising allergic rhinitis
  4. Differentiating allergy from other causes including infection
  5. Assessing the severity of allergic rhinitis
  6. Management by pharmacists or referral to physician
  7. Asthma co-morbidity
  8. Conjunctivitis
  9. Management of allergic rhinitis
  10. Environmental control
  11. Options for pharmacological treatment of allergic rhinitis
  12. Allergen-specific immunotherapy (vaccination)
  13. Alternative therapies
  14. A pharmacy protocol for treating allergic rhinitis
  15. Management of ocular symptoms
  16. The management of allergic rhinitis and asthma
  17. Conclusion
  18. References
  19. Appendices

Allergic rhinitis and asthma often co-exist. Allergic rhinitis is regarded as a risk factor for the development of asthma (1). In patients with asthma, rhinitis may be associated with a poor control of the disease. Patients with persistent rhinitis should be questioned for symptoms of asthma. Patients with asthma should be questioned for symptoms of rhinitis. Patients with undiagnosed asthma or those with uncontrolled asthma should be advised to consult a physician for proper evaluation. This is particularly important in children (see also “The management of allergic rhinitis and asthma”).

Conjunctivitis

  1. Top of page
  2. Recognising allergic rhinitis in the pharmacy
  3. Recognising allergic rhinitis
  4. Differentiating allergy from other causes including infection
  5. Assessing the severity of allergic rhinitis
  6. Management by pharmacists or referral to physician
  7. Asthma co-morbidity
  8. Conjunctivitis
  9. Management of allergic rhinitis
  10. Environmental control
  11. Options for pharmacological treatment of allergic rhinitis
  12. Allergen-specific immunotherapy (vaccination)
  13. Alternative therapies
  14. A pharmacy protocol for treating allergic rhinitis
  15. Management of ocular symptoms
  16. The management of allergic rhinitis and asthma
  17. Conclusion
  18. References
  19. Appendices

Eye symptoms are common in patients suffering from allergic rhinitis but do not exist in all patients with rhinitis. In some cases, eye symptoms may predominate over rhinitis (16), hence the term “rhinoconjunctivitis” cannot replace the term “rhinitis”. The presence of conjunctivitis should always be considered. On the other hand, conjunctivitis is not always induced by allergic triggers (Figure 3).

image

Figure 3. Differentiating allergic conjunctivitis from other causes and selection of treatment by pharmacists.

Download figure to PowerPoint

Photophobia (light sensitivity) is an important symptom to be noted and, if present, needs a physician evaluation. Eye itching is common in allergic conjunctivitis. In contrast, eye burning is rarely a sign of allergic conjunctivitis.

Environmental control

  1. Top of page
  2. Recognising allergic rhinitis in the pharmacy
  3. Recognising allergic rhinitis
  4. Differentiating allergy from other causes including infection
  5. Assessing the severity of allergic rhinitis
  6. Management by pharmacists or referral to physician
  7. Asthma co-morbidity
  8. Conjunctivitis
  9. Management of allergic rhinitis
  10. Environmental control
  11. Options for pharmacological treatment of allergic rhinitis
  12. Allergen-specific immunotherapy (vaccination)
  13. Alternative therapies
  14. A pharmacy protocol for treating allergic rhinitis
  15. Management of ocular symptoms
  16. The management of allergic rhinitis and asthma
  17. Conclusion
  18. References
  19. Appendices

There is some controversy about allergen avoidance. In asthma, a recent meta-analysis showed that some measures were effective in reducing symptoms (18). If avoidance measures are to be considered in allergic rhinitis, allergen sensitivity should be documented. However, a meta-analysis in rhinitis did not show that mite avoidance was clinically effective possibly because of methodological problems (19). More studies are needed to evaluate avoidance measures for other inhalant allergens.

Reduction of active and passive smoking should be advised and assistance provided (pharmacotherapy and support) when appropriate.

Options for pharmacological treatment of allergic rhinitis

  1. Top of page
  2. Recognising allergic rhinitis in the pharmacy
  3. Recognising allergic rhinitis
  4. Differentiating allergy from other causes including infection
  5. Assessing the severity of allergic rhinitis
  6. Management by pharmacists or referral to physician
  7. Asthma co-morbidity
  8. Conjunctivitis
  9. Management of allergic rhinitis
  10. Environmental control
  11. Options for pharmacological treatment of allergic rhinitis
  12. Allergen-specific immunotherapy (vaccination)
  13. Alternative therapies
  14. A pharmacy protocol for treating allergic rhinitis
  15. Management of ocular symptoms
  16. The management of allergic rhinitis and asthma
  17. Conclusion
  18. References
  19. Appendices

Pharmacological treatment should take into account the efficacy, safety and cost-effectiveness of medications, the patient's preference and the objective of treatment (20), severity of the disease as well as the presence of co-morbidities (Table 4). Medications used for rhinitis are most commonly administered intranasally or orally. The efficacy of medications may differ between patients.

Table 4.  Responses to commonly asked questions
• Medications are for the relief of symptoms and have no long-lasting effect when stopped. Therefore, in persistent disease, maintenance treatment is required.
• Tachyphylaxis does not usually occur with prolonged treatment except for intranasal decongestants. Continuous treatment with other medications is effective.
• Most medications recommended in this guideline do not have significant long-term side effects and can be administered for prolonged periods.

Many medications used in the treatment of allergic rhinitis are available without a medical prescription, although there is a large disparity between countries. There are proposals for harmonisation across the European Union (EU). In many countries, new generation H1-antihistamines, intranasal glucocorticosteroids and chromones are available without a prescription. In other countries, only sedating antihistamines and decongestants are available without a prescription. Non-sedating H1-oral antihistamines are recommended because of their considerably lower incidence of side effects compared to sedating antihistamines (21, 22). Patients may not always perceive sedation and mental impairment. Common treatments currently available for allergic rhinitis (including prescription-only medicines) are listed in Table 5 (10) and pharmacists are able to advise patients on both prescribed and OTC medications.

Table 5.  Medications available for the treatment of allergic rhinitis (including prescription-only medicines) (10)
ClassificationGeneric namesMechanism of actionSide effectsComments
Oral H1 antihistamines2nd generation Acrivastine Azelastine Cetirizine Desloratadine Ebastine Fexofenadine Levocetirizine Loratadine Mizolastine– Blockage of H1 receptor – Some anti-allergic activity – New generation medications can be used once daily – No development of tachyphylaxis2nd generation – No sedation for most medications – No anti-cholinergic effect – No cardiotoxicity – Acrivastine has sedative effects – Oral azelastine may induce sedation and has a bitter taste– 2nd generation oral H1-antihistamines are preferred for their favourable efficacy/safety ratio and pharmacokinetics – 2nd generation medications can be used once daily – Rapidly effective (less than 1 hour) on nasal and ocular symptoms – Poorly effective on nasal congestion – Cardiotoxic medications should be avoided
1st generation Chlorpheniramine Clemastine Diphenhydramine Hydroxyzine Ketotifen Mequitazine Oxatomide Others Cardiotoxic Astemizole Terfenadine 1st generation – sedation is common and may not be perceived – potentiation of impairment induced by alcohol anti-cholinergic effect may occur 
Local H1 antihistamines (intranasal, ocular)Azelastine Levocabastine Olopatadine– Blockage of H1 receptor – Some anti-allergic activity for azelastine– Minor local side effects – Azelastine: bitter taste and sedation in some individuals– Rapidly effective (< 30 mins) on nasal or ocular symptoms
Intranasal glucocorticosteroidsBeclomethasone Budesonide Ciclesonide Fluticasone Flunisolide Mometasone Triamcinolone– Reduce nasal hyperreactivity – Potently reduce nasal inflammation– Minor local side effects – Wide margin for systemic side effects – Growth concerns raised by BDP in young children – In young children, consider the combination of intranasal and inhaled medications– The most effective pharmacological treatment of allergic rhinitis – Effective on nasal congestion – Effect on smell – Effect observed after 7-8 hrs but maximal effect up to 2 weeks
Local chromones (intranasal, ocular)Sodium cromoglycate Nedocromil– Poorly known– Minor local side effects– Intraocular chromones are effective – Intranasal chromones less effective than other therapies; their effect is short-lasting – Overall excellent safety
Oral decongestantsEphedrine Phenylephrine Phenylpropanolamine Pseudo-ephedrine Others– Sympathomimetic medications – Relieve symptoms of nasal congestion– Hypertension – Palpitations – Restlessness – Agitation – Tremor – Insomnia – Headache – Dry mucous membranes – Urinary retention – Exacerbation of glaucoma or thyrotoxicosis– Use oral decongestants with caution in patients with other diseases – Oral H1-antihistamine/decongestant combination products may be more effective than either product alone but side effects are combined
Intranasal decongestantsEpinephrine Naphazoline Oxymethazoline Phenylephrine Tetrahydrozoline Xylomethazoline Others– Sympathomimetic medication – Relieve symptoms of nasal congestion– Same side effects as oral decongestants but less intense – Rhinitis medicamentosa (a rebound phenomena occurring with prolonged use > 10  days)– Act more rapidly and more effectively than oral decongestants – Limit duration of treatment to < 10 days to avoid rhinitis medicamentosa
Intranasal anticholinergicsIpratropium– Anticholinergics block almost exclusively anterior watery rhinorrhea– Minor local side effects – Almost no systemic anticholinergic activity– Effective in allergic and non-allergic patients with rhinorrhea
AntileukotrienesMontelukast Pranlukast Zafirlukast– Block CystLT receptor– Well tolerated– More data needed to position these medications
Oral/IM glucocorticosteroidsBetamethasone Deflazacort Dexamethasone Hydrocortisone Methylprednisolone Prednisolone Prednisone Triamcinolone– Potentially reduce nasal inflammation – Reduce nasal hyperreactivity– Systemic side effects common, in particular with IM medications – Depot injections may cause local tissue atrophy– When possible, intranasal glucocortico-steroids should replace oral or IM medications – However, a short course of oral glucocortico-steroids may be needed with severe symptoms

The pharmacological treatment of allergic rhinitis proposed by ARIA is an evidence-based (23) and step-wise approach depending on the classification of the symptoms. Figure 4 provides the overall approach to treatment.

image

Figure 4. Stepwise approach for the treatment of allergic rhinitis according to ARIA (10).

Download figure to PowerPoint

Oral and local H1-antihistamines  Both oral and topical (intranasal and ocular) antihistamine preparations are available without prescription for the treatment of allergic rhinitis in many but not all countries. H1-blockers or H1-antihistamines are medications blocking histamine at the H1-receptor level (neutral antagonists or inverse agonists) (24). Some also possess additional anti-allergic properties. During the last 20 years, pharmacological research has produced compounds with minimal sedative effect and impairment: the so-called second-generation H1-antihistamines, as opposed to the first generation H1-antihistamines (25) (Table 5).

Oral antihistamines are effective against symptoms mediated by histamine, including rhinorrhea, sneezing, nasal itching, and eye symptoms (1, 26), but are less effective on nasal congestion (27, 28). They improve the quality of life of the patient. They are used regularly for the treatment of intermittent and persistent allergic rhinitis, and can also be used to prevent symptoms associated with occasional allergen exposure.

First-generation oral H1-antihistamines are associated with sedation and central nervous system impairment (21). These include performance of cognitive and skilled tasks such as learning and driving. These impairments can be potentiated by alcohol, other sedative medications and compound the sleep disturbance of the disease. Side effects may not always be perceived by the patients. If administered, patients should be advised of the potential side effects of first-generation oral H1-antihistamines. First-generation oral antihistamines may also have anticholinergic side effects, including dry mouth, dry eyes, difficulty in urinating and worsening of glaucoma (1, 29). Second-generation H1-antihistamines are in general less likely to cause sedation and impairment. They do not have anticholinergic effects. Second generation H1-oral antihistamines are recommended because they are equally effective and have fewer side effects, resulting in a better risk-benefit ratio.

Some, but not all, oral H1-antihistamines undergo hepatic metabolism via the cytochrome P450 system and may be prone to drug interactions. Certain medications, herbal products, foods and dietary supplements can affect the bioavailability of some second-generation antihistamines.

Major concerns exist about the arrhythmogenic action of terfenadine, astemizole and high doses of diphenhydramine which have exceptionally been associated with fatalities. This is not a class effect (27). The use of terfenadine and astemisole is therefore not advised.

H1-antihistamines are also approved for young children (30).

In general, first-generation antihistamines have a short duration of action and require dosing several times daily (31). Most of the second-generation oral H1-antihistamines have a rapid onset of action (20 minutes to 2 hours) and a long duration of effect (up to 24 hours) allowing once daily dosing (27). Acrivastine has a shorter duration of action and should be administered twice daily (27).

H1-antihistamines given topically (intranasally or ocularly) are as effective as oral antihistamines at the site of their administration in reducing itching, sneezing, runny nose and eye symptoms (1, 26, 27, 32). They can be effective within 20 minutes of administration (33). Topical H1-antihistamines require twice-a-day dosing. In general, topical antihistamines are well tolerated. However, intranasal glucocorticosteroids are significantly more effective than oral or topical antihistamines for the treatment of allergic rhinitis (34) and nasal congestion.

Intranasal glucocorticosteroids  Intranasal glucocorticosteroids are currently the most effective class of medications available for the treatment of allergic and non-allergic rhinitis (35). Intranasal glucocorticosteroids are available without medical prescription in some countries. The effectiveness of intranasal glucocorticosteroids is based on their local activity; the administration of an equivalent amount of medication orally produces no benefit. The rationale for using intranasal glucocorticosteroids in the treatment of allergic rhinitis is that high medication concentrations can be achieved at receptor sites in the nasal mucosa, with minimal risk of systemic adverse effects (1).

Glucocorticosteroids can suppress many stages of the allergic inflammatory process (36) by interacting with transcription factors (37). Due to their mechanism of action, efficacy appears after 7–8 hours of dosing, but maximum efficacy may require up to 2 weeks. These medications are effective at improving all symptoms of allergic rhinitis.

Intranasal glucocorticosteroids have also been shown to improve quality of life, increase a users’ sense of well being, improve performance at work and school and reduce sleep problems associated with nasal congestion (38, 39). They may also have a prophylactic effect when administered before the onset of the pollen season (40).

Intranasal glucocorticosteroids are the most appropriate first-line treatment for allergic rhinitis if there is nasal congestion and if symptoms occur frequently or are persistent (41). Intranasal glucocorticosteroids have been shown to be more effective against nasal symptoms than oral or topical antihistamines (35) or topical sodium cromoglycate (42).

In past studies, regular treatment with glucocorticosteroids was found to be more effective than as-needed treatment (43), and regular treatment was thought to be necessary. However, recent studies show that glucocorticosteroids administered as needed (prn) have a similar or better efficacy than oral H1-antihistamines on nasal symptoms (44), but “as needed” (prn) use is less effective than continuous treatment.

In clinical studies, intranasal glucocorticosteroids are well tolerated, and adverse effects are few in number, mild in severity and have the same incidence as placebo (45). The current intranasal preparations are well tolerated. Crusting, dryness and minor epistaxis may occur in about 5% of patients which are occasionally persistent and may be a reason for stopping treatment. The occurrence of epistaxis under treatment needs physician evaluation. Evidence shows that long-term use of intranasal glucocorticosteroids is free of the concerns associated with long-term use of oral glucocorticosteroids. Even with long-term use, modern formulations of intranasal glucocorticosteroids have no effect on the hypothalamic-pituitary-adrenal axis and do not induce nasal mucosal atrophy (46–48). In children, the rate of growth was slightly reduced in those regularly treated with beclomethasone over one year by intranasal route (49).The clinical significance of this reduced rate of growth is unknown. This effect does not appear to be a class effect since recent studies have shown normal growth rates in children treated with newer intranasal glucocorticosteroids (50). However, it is reasonable to monitor the growth of children receiving long-term treatments with intranasal glucocorticosteroids.

The pharmacist should advise patients on the proper method to administer intranasal glucocorticosteroids; including the importance of directing the spray laterally and not medially (towards the nasal septum).

Systemic glucocorticosteroids  Oral glucocorticosteroids are rarely needed to control severe symptoms of allergic rhinitis. Although these medications are effective, they cause unacceptable systemic side effects if used for a prolonged period of time.

The intramuscular injection of glucocorticosteroids is not usually recommended due to the possible occurrence of systemic side effects.

The intranasal injection of glucocorticosteroids is not usually recommended due to the possible occurrence of blindness.

Chromones  Intranasal and ocular formulations of chromones, such as sodium cromoglycate, are available without medical prescription in many countries.

Sodium cromoglycate or nedocromil have an excellent safety profile. They reduce the symptoms of allergic rhinitis, but limited efficacy and the need for frequent dosing (as frequent as 4 times daily) are disadvantages. Chromones are generally less effective than other medications used for the treatment of allergic rhinitis (1).

Ocular sodium cromoglycate or nedocromil are effective and have a place in the treatment of allergic conjunctivitis (32). Single-dose formulations without preservatives are often better tolerated by the patients.

N-acetyl-aspartyl glutamic acid (NAAGA), a C3 convertase inhibitor, is used topically as an intranasal or ocular formulation (51). In rhinitis, it was found to have a slightly greater efficacy than cromoglycate, but it was less well tolerated.

Decongestants  Oral, intranasal and ocular decongestants are often available without prescription.

Both oral and intranasal decongestants may be used in the treatment of nasal congestion associated with allergic rhinitis. Nasal decongestant sprays have a greater effect on nasal obstruction than oral decongestants (1). However, the use of nasal decongestant sprays is limited by rebound congestion, the potential for irreversible tissue hypertrophy (52) and a decreasing duration of effect after 10 days of use (53). Rhinitis medicamentosa is a condition of nasal hyperreactivity, mucosal swelling and tolerance that is induced or aggravated by the overuse of topical decongestants with or without a preservative. Package inserts for these medications therefore place strict limits on their recommended duration of use. Ocular decongestants can be used in the treatment of conjunctivitis, but they are also capable of causing rebound eye congestion.

Attention should be paid to a range of possible contraindications and warnings associated with oral decongestants, including those regarding use in the elderly, in patients suffering from hypertension, hyperthyroidism, prostate hypertrophy, glaucoma and psychiatric disorders, as well as in patients taking beta-blockers and monoamine oxidase inhibitors (1). Due to its side effects, phenylpropanolamine has been withdrawn in the US and some other countries.

Short courses (less than 10 days) of topical decongestants may be useful in reducing severe nasal blockage when starting the administration of other medications (1).

Oral or ocular combination products containing antihistamines and decongestants are available and are effective for symptomatic relief of nasal and ocular symptoms.

Anticholinergics  Anticholinergic agents can help reduce anterior watery rhinorrhea, but they have no effect on nasal blockage or on other symptoms of allergic rhinitis.

Antileukotrienes  Antileukotrienes are a new class of medication for the treatment of allergic rhinitis. They modulate inflammation. They have an efficacy comparable to that of oral antihistamines (54).

Allergen-specific immunotherapy (vaccination)

  1. Top of page
  2. Recognising allergic rhinitis in the pharmacy
  3. Recognising allergic rhinitis
  4. Differentiating allergy from other causes including infection
  5. Assessing the severity of allergic rhinitis
  6. Management by pharmacists or referral to physician
  7. Asthma co-morbidity
  8. Conjunctivitis
  9. Management of allergic rhinitis
  10. Environmental control
  11. Options for pharmacological treatment of allergic rhinitis
  12. Allergen-specific immunotherapy (vaccination)
  13. Alternative therapies
  14. A pharmacy protocol for treating allergic rhinitis
  15. Management of ocular symptoms
  16. The management of allergic rhinitis and asthma
  17. Conclusion
  18. References
  19. Appendices

Allergen specific vaccination is the practice of administering gradually increasing quantities of an allergen extract to an allergic subject to ameliorate the symptoms associated with the subsequent exposure to the causative allergen. The efficacy of immunotherapy using inhalant allergens to treat allergic rhinitis and asthma is evidence-based when optimally administered (1, 17, 55). Standardised therapeutic vaccines which are available for the most common allergens are favoured.

In some countries, immunotherapy is dispensed by pharmacists, but it is not recommended to be administered by pharmacists.

Subcutaneous immunotherapy raises contrasting efficacy and safety issues. Thus, the use of optimal doses of vaccines labelled either in biological units or in mass of major allergens has been proposed. Maintenance doses of 5–20 μg of the major allergen are optimal doses for most allergen vaccines.

Subcutaneous immunotherapy should be performed by trained personnel supervised by a physician, and patients should be monitored for 30 minutes after injection. Medications and equipment for treatment of rare but potentially life-threatening acute allergic reactions triggered by subcutaneous immunotherapy should be available.

Subcutaneous specific immunotherapy (not available in all countries) is indicated in patients:

  • with moderate-severe or persistent allergic rhinitis who are inadequately controlled by conventional pharmacotherapy,
  • who do not wish to be on pharmacotherapy,
  • in whom pharmacotherapy produces undesirable side effects,
  • who do not want to receive long-term pharmacological treatment.

High dose nasal and sublingual-swallow specific immunotherapy may be used:

  • with doses at least 20 to 100 times greater than those used for subcutaneous immunotherapy,
  • in patients who had side effects or refused subcutaneous immunotherapy,
  • the indications follow those of subcutaneous injections.

Allergen specific immunotherapy interferes with the basic mechanisms of the allergy and alters the natural course of allergic diseases, resulting in symptomatic relief and offering the patient a long-lasting and preventive effect. These are observed using both subcutaneous (56) and sublingual routes (57). Subcutaneous immunotherapy was shown to reduce the onset of new sensitisations (58) as well as the development of asthma in patients with allergic rhinitis (59).

Immunotherapy is now recognised as complementary to the pharmacological treatment for respiratory allergy. It is suggested that immunotherapy should be initiated early in the course of the disease, when irreversible damages are not yet established and when it is still possible to modify the progression of the disease. However, it is usual to start this treatment after the age of 5.

Alternative therapies

  1. Top of page
  2. Recognising allergic rhinitis in the pharmacy
  3. Recognising allergic rhinitis
  4. Differentiating allergy from other causes including infection
  5. Assessing the severity of allergic rhinitis
  6. Management by pharmacists or referral to physician
  7. Asthma co-morbidity
  8. Conjunctivitis
  9. Management of allergic rhinitis
  10. Environmental control
  11. Options for pharmacological treatment of allergic rhinitis
  12. Allergen-specific immunotherapy (vaccination)
  13. Alternative therapies
  14. A pharmacy protocol for treating allergic rhinitis
  15. Management of ocular symptoms
  16. The management of allergic rhinitis and asthma
  17. Conclusion
  18. References
  19. Appendices

The use of complementary and alternative therapies (e.g., homeopathy, herbal medicines, acupuncture) for the treatment of rhinitis is increasing. In the ARIA document (1), a review of the literature found that there was insufficient evidence to support the efficacy of alternative therapy. Since then, there have been a few further publications, but the design of the trials or their outcome measures did not make it possible to reach a definitive conclusion and recommend their use in the management of allergic rhinitis (60–65). A recent Cochrane Collaboration study has been carried out in asthma and concluded that there is not enough evidence to reliably assess the possible role of homeopathy in asthma (66). There is an urgent need for well-designed, large, randomised, controlled and properly powered clinical trials to evaluate the efficacy and safety of alternative therapies in the management of allergic diseases.

Herbal medicine can induce pharmacological interactions with medications used in the treatment of allergic rhinitis or other illnesses (67). Health care professionals should ask their patients about the use of herbal products and consider the possibility of herb-drug interactions (67).

A pharmacy protocol for treating allergic rhinitis

  1. Top of page
  2. Recognising allergic rhinitis in the pharmacy
  3. Recognising allergic rhinitis
  4. Differentiating allergy from other causes including infection
  5. Assessing the severity of allergic rhinitis
  6. Management by pharmacists or referral to physician
  7. Asthma co-morbidity
  8. Conjunctivitis
  9. Management of allergic rhinitis
  10. Environmental control
  11. Options for pharmacological treatment of allergic rhinitis
  12. Allergen-specific immunotherapy (vaccination)
  13. Alternative therapies
  14. A pharmacy protocol for treating allergic rhinitis
  15. Management of ocular symptoms
  16. The management of allergic rhinitis and asthma
  17. Conclusion
  18. References
  19. Appendices

With recent changes in the regulatory status of some medications for allergic rhinitis symptoms, pharmacists may recommend more therapies which are available without prescription. The use of these medications is likely to result in cost savings for both patient and health care professional (68). The involvement of the pharmacist in the overall management of the patient is also likely to reduce risks of overdosing and drug interactions (69, 70).

Based on the above considerations, a recommended pharmacy protocol for managing allergic rhinitis is shown in Figure 5.

image

Figure 5. Selection of allergic rhinitis treatment by pharmacists.

Download figure to PowerPoint

Allergic rhinitis, like other chronic diseases, requires monitoring for:

  • improvement of symptoms and quality-of-life,
  • assessment of safety of OTC and prescribed medications,
  • need for referral to a physician,
  • need to discontinue or reinstate medications.

Management of ocular symptoms

  1. Top of page
  2. Recognising allergic rhinitis in the pharmacy
  3. Recognising allergic rhinitis
  4. Differentiating allergy from other causes including infection
  5. Assessing the severity of allergic rhinitis
  6. Management by pharmacists or referral to physician
  7. Asthma co-morbidity
  8. Conjunctivitis
  9. Management of allergic rhinitis
  10. Environmental control
  11. Options for pharmacological treatment of allergic rhinitis
  12. Allergen-specific immunotherapy (vaccination)
  13. Alternative therapies
  14. A pharmacy protocol for treating allergic rhinitis
  15. Management of ocular symptoms
  16. The management of allergic rhinitis and asthma
  17. Conclusion
  18. References
  19. Appendices

With the exception of nasal decongestants and anticholinergics, all the major treatments discussed above are effective against the ocular symptoms of allergic rhinitis (Figure 3). Sodium cromoglycate, nedocromil sodium, NAAGA and H1-antihistamines (azelastine, levocabastine, ketotifen, olopatadine) are also available as eye drops. Intranasal glucocorticosteroids have shown some effect in eye symptoms associated with allergic rhinitis (35). Intraocular glucocorticosteroids are effective but, because of known side effects, should only be prescribed and monitored by eye care professionals. The use of antihistamine or chromone eye drops is justified if ocular symptoms are the predominant and/or persistent feature of the patient's allergic rhinitis, persisting despite use of oral H1-antihistamines and/or intranasal glucocorticosteroids.

The management of allergic rhinitis and asthma

  1. Top of page
  2. Recognising allergic rhinitis in the pharmacy
  3. Recognising allergic rhinitis
  4. Differentiating allergy from other causes including infection
  5. Assessing the severity of allergic rhinitis
  6. Management by pharmacists or referral to physician
  7. Asthma co-morbidity
  8. Conjunctivitis
  9. Management of allergic rhinitis
  10. Environmental control
  11. Options for pharmacological treatment of allergic rhinitis
  12. Allergen-specific immunotherapy (vaccination)
  13. Alternative therapies
  14. A pharmacy protocol for treating allergic rhinitis
  15. Management of ocular symptoms
  16. The management of allergic rhinitis and asthma
  17. Conclusion
  18. References
  19. Appendices

Asthma may be severe and even life threatening. When pharmacists identify patients with undiagnosed or untreated asthma, or asthma which is not optimally controlled, they should encourage these individuals to obtain appropriate medical care.

There are many similarities between the nasal and bronchial mucosa, the major difference being the rich vascular supply to the nose that accounts for nasal obstruction being a symptom of allergic rhinitis. In the bronchi, smooth muscle accounts for the bronchospasm seen in asthma. The upper and lower airways may well be affected by a common inflammatory process (71) with interconnected mechanisms, suggesting the concept of “one airway, one disease” (72).

Epidemiological studies consistently show that allergic rhinitis and asthma often co-exist: at least 75% of patients with asthma complain from rhinitis symptoms, and 20–30% of those with allergic rhinitis also have asthma (73). Allergic rhinitis is also a risk factor for asthma (74). Therefore, patients with persistent symptoms of allergic rhinitis should be referred to their physician to be evaluated for asthma. In the ARIA document (1), it is recommended that evaluation should include a medical history, chest examination and assessment of airflow obstruction before and after taking a bronchodilator. The diagnosis of asthma should follow the guidance in the recent update of the GINA guidelines (75).

If a patient has persistent allergic rhinitis, the patient should be questioned about his or her symptoms of asthma (Figure 6 and Table 6). If there is any suspicion of undiagnosed asthma, the patient should be referred to a physician.

image

Figure 6. Assessing asthma in a patient with persistent allergic rhinitis. *From the National Asthma Campaign, “conquering asthma”.

Download figure to PowerPoint

Table 6.  Questions that should be asked if a patient is suspected of having asthma (76)
• Do you find yourself short of breath?
• Do you make whistling noises (wheeze) when you breathe?
• Does your chest feel tight?
• Do you have a cough regularly?
• Are these symptoms particularly noticeable first thing in the morning, during the night or with exercise?

If a patient has a diagnosis of asthma, he/she should be questioned to assess the level of asthma control (Table 7).

Table 7.  Questions to ask patients diagnosed with asthma to reveal the level of asthma control (77)
In the last month:
• Have you had difficulty sleeping because of your asthma symptoms (including cough)?
• Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)?
• Has your asthma interfered with your usual activities (e.g. housework, work, school)?
• Have you used your β2-agonist more than once a day in the past week?

If there is poor control (any positive answer to the Table 7 questions), the patient should be advised to consult a physician.

The treatment of asthma should follow the recently published guidelines (75, 76).

It is important to manage co-morbidity of allergic rhinitis and asthma. Treatment of allergic rhinitis has been associated with improved outcomes from asthma (78).

Conclusion

  1. Top of page
  2. Recognising allergic rhinitis in the pharmacy
  3. Recognising allergic rhinitis
  4. Differentiating allergy from other causes including infection
  5. Assessing the severity of allergic rhinitis
  6. Management by pharmacists or referral to physician
  7. Asthma co-morbidity
  8. Conjunctivitis
  9. Management of allergic rhinitis
  10. Environmental control
  11. Options for pharmacological treatment of allergic rhinitis
  12. Allergen-specific immunotherapy (vaccination)
  13. Alternative therapies
  14. A pharmacy protocol for treating allergic rhinitis
  15. Management of ocular symptoms
  16. The management of allergic rhinitis and asthma
  17. Conclusion
  18. References
  19. Appendices

Allergic rhinitis is an increasing global health problem. The ARIA classification distinguishes between intermittent and persistent allergic rhinitis. Allergic rhinitis that is intermittent or mild may be appropriate for management by the pharmacist. Referral to a physician should be considered in cases of symptoms that are moderate to severe-persistent, suggestive of undiagnosed or uncontrolled asthma, suggestive of infection or non-allergic rhinitis, and for symptoms poorly responsive to treatment after 2 to 4 weeks.

The management of allergic rhinitis represents a collaboration between pharmacists, physicians, other health care professionals and patients. The cost-effectiveness of these approaches should be tested in allergic rhinitis as it has been for asthma (79), reactive airway diseases (80, 81) and other chronic diseases (68).

References

  1. Top of page
  2. Recognising allergic rhinitis in the pharmacy
  3. Recognising allergic rhinitis
  4. Differentiating allergy from other causes including infection
  5. Assessing the severity of allergic rhinitis
  6. Management by pharmacists or referral to physician
  7. Asthma co-morbidity
  8. Conjunctivitis
  9. Management of allergic rhinitis
  10. Environmental control
  11. Options for pharmacological treatment of allergic rhinitis
  12. Allergen-specific immunotherapy (vaccination)
  13. Alternative therapies
  14. A pharmacy protocol for treating allergic rhinitis
  15. Management of ocular symptoms
  16. The management of allergic rhinitis and asthma
  17. Conclusion
  18. References
  19. Appendices
  • 1
    Bousquet J, Van Cauwenberge P, Khaltaev N. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol 2001;108(5 Suppl):S147334.
  • 2
    International Consensus Report on Diagnosis and Management of Rhinitis. International Rhinitis Management Working Group. Allergy 1994;49(19 Suppl):134.
  • 3
    van Cauwenberge P, Bachert C, Passalacqua G, et al. Consensus statement on the treatment of allergic rhinitis. European Academy of Allergology and Clinical Immunology. Allergy 2000;55: 116134.
  • 4
    Strachan D, Sibbald B, Weiland S, et al. Worldwide variations in prevalence of symptoms of allergic rhinoconjunctivitis in children: the International Study of Asthma and Allergies in Childhood (ISAAC). Pediatr Allergy Immunol 1997;8: 161176.
  • 5
    Tripathi A, Patterson R. Impact of allergic rhinitis treatment on quality of life. Pharmacoeconomics 2001;19: 891899.
  • 6
    Simons FE. Learning impairment and allergic rhinitis. Allergy Asthma Proc 1996;17: 185189.
  • 7
    Blanc PD, Trupin L, Eisner M, et al. The work impact of asthma and rhinitis. Findings from a population-based survey. J Clin Epidemiol 2001;54: 610618.
  • 8
    Weiss KB, Sullivan SD. The health economics of asthma and rhinitis. I. Assessing the economic impact. J Allergy Clin Immunol 2001;107: 38.
  • 9
    Sullivan SD, Weiss KB. Health economics of asthma and rhinitis. II. Assessing the value of interventions. J Allergy Clin Immunol 2001;107: 203210.
  • 10
    Bousquet J, van Cauwenberge P, Khaltaev N. Allergic rhinitis and its impact on asthma (ARIA)- Executive summary. Allergy 2003;57: 841855.
  • 11
    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: 478518.
  • 12
    Pincus T, Sokka T, Stein CM. Pharmacist scope of practice. Ann Intern Med 2002;136: 7985.
  • 13
    Dessing RP. Ethics applied to pharmacy practice. Pharm World Sci 2000;22: 1016.
  • 14
    Strom BL, Hennessy S. Pharmacist care and clinical outcomes for patients with reactive airways disease. JAMA 2002;288: 16421643.
  • 15
    Nathan A. How to treat hay fever and associated allergic conditions in the pharmacy. Pharm J 2002;268: 575578.
  • 16
    Bonini S, Bonini S. Pathogenesis: allergic conjunctivitis. In: DenburgJ, eds. Allergy and allergic diseases: the mechanisms and therapeutic. Tollawa, USA: Human Press Inc; 1998. p. 509519.
  • 17
    Bousquet J, Lockey R, Malling H. WHO Position Paper. Allergen Immunotherapy: Therapeutic Vaccines for allergic diseases. Allergy 1998;53(suppl 54).
  • 18
    Gotzsche PC, Johansen HK, Burr ML, Hammarquist C. House dust mite control measures for asthma. Cochrane Database Syst Rev 2001;3.
  • 19
    Sheikh A, Hurwitz B. House dust mite avoidance measures for perennial allergic rhinitis. Cochrane Database Syst Rev 2001: CD001563.
  • 20
    Marinker M. From compliance to accordance: achieving shared goals in medicine taking. Report of the Royal Pharmaceutical of Great Britain Working party 1998.
  • 21
    Milgrom H, Bender B, Wamboldt F. Of injuries and antihistamines and dosing. Ann Allergy Asthma Immunol 2002;89: 221223.
  • 22
    Weiler JM. The real-world risk of taking sedating antihistamines. Ann Allergy Asthma Immunol 2002;89: 224225.
  • 23
    Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines:developing guidelines. BMJ 1999;318: 593596.
  • 24
    Leurs R, Church MK, Taglialatela M. H1-antihistamines: inverse agonism, anti-inflammatory actions and cardiac effects. Clin Exp Allergy 2002;32: 489498.
  • 25
    Bousquet J, van Cauwenberge P, Bachert C, et al. Requirements for medications commonly used in the treatment of allergic rhinitis. Allergy 2003;58: 192197.
  • 26
    Howarth P. Antihistamines in rhinoconjunctivitis. Clin Allergy Immunol 2002;17: 179220.
  • 27
    Passalacqua G, Canonica GW, Bousquet J. Structure and classification of H1-antihistamines and overview of their activities. Clin Allergy Immunol 2002;17: 65100.
  • 28
    Nielsen LP, Mygind N, Dahl R. Intranasal corticosteroids for allergic rhinitis: superior relief? Drugs 2001;61: 15631579.
  • 29
    Passalacqua G, Bousquet J, Bachert C, et al. The clinical safety of H1-receptor antagonists. An EAACI position paper. Allergy 1996;51: 666675.
  • 30
    Simons FE. H1-antihistamines in children. Clin Allergy Immunol 2002;17: 437464.
  • 31
    Simons FE, Simons KJ. The pharmacology and use of H1- receptor-antagonist drugs. N Engl J Med 1994;330: 16631670.
  • 32
    Friedlaender M. Overview of ocular allergy treatment. Curr Allergy Asthma Rep 2001;1: 375379.
  • 33
    Noble S, McTavish D. Levocabastine. An update of its pharmacology, clinical efficacy and tolerability in the topical treatment of allergic rhinitis and conjunctivitis. Drugs 1995;50: 10321049.
  • 34
    Di Lorenzo G, Gervasi F, Drago A, et al. Comparison of the effects of fluticasone propionate, aqueous nasal spray and levocabastine on inflammatory cells in nasal lavage and clinical activity during the pollen season in seasonal rhinitics. Clin Exp Allergy 1999;29: 13671377.
  • 35
    Weiner JM, Abramson MJ, Puy RM. Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials. BMJ 1998;317: 16241629.
  • 36
    Fokkens WJ, Godthelp T, Holm AF, Klein-Jan A. Local corticosteroid treatment: the effect on cells and cytokines in nasal allergic inflammation. Am J Rhinol 1998;12: 2126.
  • 37
    Adcock IM, Caramori G. Cross-talk between proinflammatory transcription factors and glucocorticoids. Immunol Cell Biol 2001;79: 376384.
    Direct Link:
  • 38
    Ratner PH, Paull BR, Findlay SR, et al. Fluticasone propionate given once daily is as effective for seasonal allergic rhinitis as beclomethasone dipropionate given twice daily. J Allergy Clin Immunol 1992;90: 285291.
  • 39
    Brogden RN, McTavish D. Budesonide. An updated review of its pharmacological properties, and therapeutic efficacy in asthma and rhinitis [published errata appear in Drugs 1992;44: 1012 and 1993;45: 130]. Drugs 1992;44: 375–407.
  • 40
    Graft D, Aaronson D, Chervinsky P, et al. A placebo - and active-controlled randomized trial of prophylactic treatment of seasonal allergic rhinitis with mometasone furoate aqueous nasal spray. J Allergy Clin Immunol 1996;98: 724731.
  • 41
    Craig TJ, Teets S, Lehman EB, et al. Nasal congestion secondary to allergic rhinitis as a cause of sleep disturbance and daytime fatigue and the response to topical nasal corticosteroids. J Allergy Clin Immunol 1998;101: 633637.
  • 42
    Bousquet J, Chanal I, Alquie MC, et al. Prevention of pollen rhinitis symptoms: comparison of fluticasone propionate aqueous nasal spray and disodium cromoglycate aqueous nasal spray. A multicenter, double-blind, double-dummy, parallel-group study. Allergy 1993;48: 327333.
  • 43
    Juniper EF, Guyatt GH, O'Byrne PM, Viveiros M. Aqueous beclomethasone diproprionate nasal spray: regular versus “as required” use in the treatment of seasonal allergic rhinitis. J Allergy Clin Immunol 1990;86: 380386.
  • 44
    Kaszuba SM, Baroody FM, DeTineo M, et al. Superiority of an intranasal corticosteroid compared with an oral antihistamine in the as-needed treatment of seasonal allergic rhinitis. Arch Intern Med 2001;161: 25812587.
  • 45
    Meltzer EO, Orgel HA, Bronsky EA, et al. A dose-ranging study of fluticasone propionate aqueous nasal spray for seasonal allergic rhinitis assessed by symptoms, rhinomanometry, and nasal cytology. J Allergy Clin Immunol 1990;86: 221230.
  • 46
    Minshall E, Ghaffar O, Cameron L, et al. Assessment by nasal biopsy of long-term use of mometasone furoate aqueous nasal spray (Nasonex) in the treatment of perennial rhinitis. Otolaryngol Head Neck Surg 1998;118: 648654.
  • 47
    Holm AF, Fokkens WJ, Godthelp T, et al. A 1-year placebo-controlled study of intranasal fluticasone propionate aqueous nasal spray in patients with perennial allergic rhinitis: a safety and biopsy study. Clin Otolaryngol 1998;23: 6973.
  • 48
    Laliberte F, Laliberte MF, Lecart S, et al. Clinical and pathologic methods to assess the long-term safety of nasal corticosteroids. French Triamcinolone Acetonide Study Group. Allergy 2000;55: 718722.
  • 49
    Skoner D, Rachelefsky G, Meltzer E, et al. Detection of growth suppression in children during treatment with intranasal belcomethasone dipropionate. Pediatrics 2000;105: e23.
  • 50
    Schenkel E, Skoner D, Bronsky E, et al. Absence of growth retardation in children with perennial allergic rhinitis following 1 year treatment with mometasone furoate aqueous nasal spray. Pediatrics 2000;101: e22.
  • 51
    Althaus MA, Pichler WJ. Nasal application of a gel formulation of N-acetyl-aspartyl glutamic acid (NAAGA) compared with placebo and disodium cromoglycate in the symptomatic treatment of pollinosis. Allergy 1994;49: 184188.
  • 52
    Graf P. Rhinitis medicamentosa: aspects of pathophysiology and treatment. Allergy 1997;52(40 Suppl):2834.
  • 53
    Graf P, Enerdal J, Hallen H. Ten days’ use of oxymetazoline nasal spray with or without benzalkonium chloride in patients with vasomotor rhinitis. Arch Otolaryngol Head Neck Surg 1999;125: 11281132.
  • 54
    Meltzer E, Malmstrom K, Lu S, et al. Concomitant montelukast and loratadine as treatment for seasonal allergic rhinitis: placebo-controlled clinical trial. J Allergy Clin Immunol 2000;105: 917922.
  • 55
    Abramson M, Puy R, Weiner J. Immunotherapy in asthma: an updated systematic review. Allergy 1999;54: 10221041.
  • 56
    Durham SR, Walker SM, Varga EM, et al. Long-term clinical efficacy of grass-pollen immunotherapy [see comments]. N Engl J Med 1999;341: 468475.
  • 57
    Di-Rienzo V, Marcucci F, Puccinelli P, et al. Long-Lasting effect of sublingual immunotherapy in children with asthma due to house dust mite: a 10-year prospective study. Clin Exp Allergy 2003;33: 206210.
  • 58
    Des-Roches A, Paradis L, Ménardo J-L, et al. Immunotherapy with a standardized Dermatophagoides pteronyssinus extract. VI. Specific immunotherapy prevents the onset of new sensitizations in children. J Allergy Clin Immunol 1997;99: 450453.
  • 59
    Moller C, Dreborg S, Ferdousi HA, et al. Pollen immunotherapy reduces the development of asthma in children with seasonal rhinoconjunctivitis (the PATstudy). J Allergy Clin Immunol 2002;109: 251256.
  • 60
    Taylor MA, Reilly D, Llewellyn-Jones RH, et al. Randomised controlled trial of homoeopathy versus placebo in perennial allergic rhinitis with overview of four trial series. BMJ 2000;321: 471476.
  • 61
    Aabel S. No beneficial effect of isopathic prophylactic treatment for birch pollen allergy during a low-pollen season: a double-blind, placebo-controlled clinical trial of homeopathic Betula 30c. Br Homeopath J 2000;89: 169173.
  • 62
    Aabel S, Laerum E, Dolvik S, Djupesland P. Is homeopathic ‘immunotherapy’ effective? A doubleblind, placebo-controlled trial with the isopathic remedy Betula 30c for patients with birch pollen allergy. Br Homeopath J 2000;89: 161168.
  • 63
    Aabel S. Prophylactic and acute treatment with the homeopathic medicine, Betula 30c for birch pollen allergy: a double-blind, randomized, placebo-controlled study of consistency of VAS responses. Br Homeopath J 2001;90: 7378.
  • 64
    Lewith GT, Watkins AD, Hyland ME, et al. Use of ultramolecular potencies of allergen to treat asthmatic people allergic to house dust mite: double blind randomised controlled clinical trial. BMJ 2002;324: 520.
  • 65
    Schapowal A. Randomised controlled trial of butterbur and cetirizine for treating seasonal allergic rhinitis. BMJ 2002;324: 144146.
  • 66
    Linde K, Jobst KA. Homeopathy for chronic asthma. Cochrane Database Syst Rev 2000;2.
  • 67
    Izzo AA, Ernst E. Interactions between herbal medicines and prescribed drugs: a systematic review. Drugs 2001;61: 21632175.
  • 68
    Steinwachs DM. Pharmacy benefit plans and prescription drug spending. JAMA 2002;288: 17731774.
  • 69
    Meltzer EO, Ehrlich PM. A step approach to the clinical management of allergic rhinitis: prescription andover the- counter therapeutic reference summary. Manag Care Interface 1999;12: 7077.
  • 70
    Bond C, Matheson C, Williams S, et al. Repeat prescribing: a role for community pharmacists in controlling and monitoring repeat prescriptions. Br J Gen Pract 2000;50: 271275.
  • 71
    Chanez P, Vignola AM, Vic P, et al. Comparison between nasal and bronchial inflammation in asthmatic and control subjects. Am J Respir Crit Care Med 1999;159: 588595.
  • 72
    Simons FE. Allergic rhinobronchitis: the asthma-allergic rhinitis link. J Allergy Clin Immunol 1999;104: 534540.
  • 73
    Leynaert B, Bousquet J, Neukirch C, et al. Perennial rhinitis: An independent risk factor for asthma in nonatopic subjects: Results from the European Community Respiratory Health Survey. J Allergy Clin Immunol 1999: 301304.
  • 74
    Wright AL, Holberg CJ, Martinez FD, et al. Epidemiology of physician-diagnosed allergic rhinitis in childhood. Pediatrics 1994;94: 895901.
  • 75
    Global strategy for asthma management and prevention. GINA. Update from NHLBI/WHO Workshop Report 1995, Revised 2002. NIH Publication N°02–3659 2002.
  • 76
    British Thoracic Society. Scottish Intercolleagiate Guidelines Network. 2003;Thorax 2003;58(suppl1);i1i94.
  • 77
    National Asthma Campaign. Conquering asthma. Action Plan. http://www.asthma.org.uk 1996.
  • 78
    Adams RJ, Fuhlbrigge AL, Finkelstein JA, Weiss ST. Intranasal steroids and the risk of emergency department visits for asthma. J Allergy Clin Immunol 2002;109: 636642.
  • 79
    Cordina M, McElnay JC, Hughes CM. Assessment of a community pharmacy-based program for patients with asthma. Pharmacotherapy 2001;21: 11961203.
  • 80
    Weinberger M, Murray MD, Marrero DG, et al. Issues in conducting randomized controlled trials of health services research interventions in nonacademic practice settings: the case of retail pharmacies. Health Serv Res 2002;37: 10671077.
  • 81
    Weinberger M, Murray MD, Marrero DG, Brewer N, Lykens M, Harris LE, et al. Effectiveness of pharmacist care for patients with reactive airways disease: a randomized controlled trial. JAMA 2002;288: 15941602.

Appendices

  1. Top of page
  2. Recognising allergic rhinitis in the pharmacy
  3. Recognising allergic rhinitis
  4. Differentiating allergy from other causes including infection
  5. Assessing the severity of allergic rhinitis
  6. Management by pharmacists or referral to physician
  7. Asthma co-morbidity
  8. Conjunctivitis
  9. Management of allergic rhinitis
  10. Environmental control
  11. Options for pharmacological treatment of allergic rhinitis
  12. Allergen-specific immunotherapy (vaccination)
  13. Alternative therapies
  14. A pharmacy protocol for treating allergic rhinitis
  15. Management of ocular symptoms
  16. The management of allergic rhinitis and asthma
  17. Conclusion
  18. References
  19. Appendices

Appendix

Members of the workshops

Christine Bond, MR Pharm S, PhD, Professor of Primary Care (Pharmacy), Department of General Practice and Primary Care, University of Aberdeen, Aberdeen, UK

Sergio Bonini, MD, Professor of Medicine, Second University of Naples; Scientific Director, San Raffaele H and Institute of Neurobiology and Molecular Medicine, Italian National Research Council, Rome, Italy

Hélène Bousquet, Pharmacist, Analyses Bio-Medicales LR, Montpellier, France

Jean Bousquet, MD, Pharm D, Professor of Pneumology, University of Montpellier, France; Director of the Allergy Programme, Institut Pasteur, Paris, France and ARIA Chairman

G. Walter Canonica, MD, Professor of Pneumology, Allergy and Respiratory Diseases, DIMI- Dept. of Internal Medicine, University of Genoa, Genoa, Italy

Peter Howarth, B.Sc.(Hons), D.M., F.R.C.P., University of Southampton, Southampton, UK

Nikolai Khaltaev, MD, Team Leader, Management of Non-communicable Diseases/Chronic Respiratory Diseases and Arthritis Unit, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland

Marek L Kowalski, M.D., Ph.D., Dept of Clinical Immunology and Allergy, Faculty of Medicine, Medical University of Lodz, Lodz, Poland

Jean-Marc Leder, Doctor of Pharmacy, Grande Pharmacie du 20è, Paris, France

Richard F. Lockey, MD, Director of the Division of Allergy and Immunology, Professor of Medicine, Pediatrics and Public Health and the Joy McCann Culverhouse Chair in Allergy and Immunology, University of South Florida College of Medicine and James A. Haley Veterans Hospital, Tampa, Florida, USA

Eli O. Meltzer, MD, Clinical Professor of Pediatrics, University of California, San Diego, Co-Director Allergy and Asthma Medical Group and Research Center, San Diego, California, USA

Robert Naclerio, MD, Professor and Chief, Otolaryngology, Head and Neck Surgery, University of Chicago, Chicago, Illinois, USA

Kristof Nekam, M.D., PhD, Professor, Dept. of Allergology and Clinical Immunology, Hospital of the Hospitaller Brothers of St John, Budapest, Hungary

Maria Pia Orru, Pharm D, Cagliari, Italy

David Price, General Practice Airways Group, Professor of Primary Care Respiratory Medicine, University of Aberdeen, Aberdeen, UK

F. Estelle R. Simons, MD, Professor, Department of Pediatrics & Child Health, Department of Immunology, University of Manitoba, Winnipeg, Manitoba, Canada

Mary Teresi, Pharm D, Director Pediatric Allergy/Pulmonary Clinical Trials, University of Iowa, Iowa City, Iowa, USA

Erkka Valovirta, MD, PhD, EFA, Brussels, Belgium and Turku Allergy Center,Turku, Finland

Paul van Cauwenberge, MD, PhD, Professor and chairman, Department of Otorhinolaryngology, Ghent University, Belgium and ARIA Co-Chairman

A. Maurizio Vignola, MD, Italian National Research Council and University of Palermo, Palermo, Italy

Dennis Williams, Pharm D Associate Professor, Division of Pharmacotherapy, School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA

Alan Wright, Healthcare Consultant, Beaconsfield, UK

Endorsing organisations

APhA: American Pharmacists Association

ARIA: Allergic Rhinitis and its Impact on Asthma

CESPHARM

EAACI: European Academy of Allergology and Clinical Immunology

EFA: European Federation of Allergy and Airways Diseases Patients’ Associations

IPCRG: International Primary Care Respiratory Group