Management of allergic rhinitis symptoms in the pharmacy Pocket guide 2022

Abstract Background Allergic rhinitis (AR) management requires a coordinated effort from healthcare providers and patients. Pharmacists are key members of these integrated care pathways resolving medication‐related problems, optimizing regimens, improving adherence and recommending therapies while establishing liaisons between patients and physicians. Methods Allergic Rhinitis and its Impact on Asthma (ARIA) first published a reference document on the pharmacist's role in allergic rhinitis management in 2004. Several guidelines were developed over the past 20 years improving the care of allergic rhinitis patients through an evidence‐based, integrated care approach. Results This ARIA/EAACI/FIP Position Paper is based on the latest ARIA in the Pharmacy guidelines and provides: (a) a structured approach to pharmacists identifying people with AR and/or allergic conjunctivitis as well as those at risk of poor disease control; (b) an evidence‐based clinical decision support tool for optimising the management of allergic rhinitis in the community pharmacy; and (c) a framework of referral to the physician. Conclusion This document is not intended to be a mandatory standard of care but is provided as a basis for pharmacists and their staff to develop relevant local standards of care for their patients, within their local practice environment. Pharmacy care varies between countries, and the guide should be adapted to the local situation.


| INTRODUCTION
� Allergic rhinitis (AR) is the most common form of non-infectious rhinitis and is one of the most prevalent chronic diseases. [1][2][3][4] � Cardinal symptoms of AR include rhinorrhoea, nasal obstruction, sneezing and nasal itching. In some cases, these symptoms are spontaneously reversible, while, in others, they can be controlled by adequate treatment. 5 � Symptoms associated with AR have a significant impact on work 6 and school productivity, sleep 7 and social interactions. There is an association between symptoms of AR and decreased general health-related quality of life. 8,9 � Allergic conjunctivitis and asthma are common multimorbidities experienced by patients with AR. 10 � Most AR patients choose to manage their condition via selfmedication with non-prescription medicines. [11][12][13] The use of these medicines for self-medication may be appropriate or inappropriate. 14 Community pharmacists play a critical role assisting in the management of AR and advising on the appropriate selfmedication. 15,16 � Pharmacists may also assist in the identification of patients who are inappropriately self-medicating resulting in a suboptimal treatment of their condition. They can also, if necessary, refer these patients for medical assessment. 17 � The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines, which were first released 20 years ago and are continually being updated with the latest evidence, provide a guide to the latest evidence-based integrated care approach to the management of AR. 18

| STEP 1: DIFFERENTIAL DIAGNOSIS OF ALLERGIC RHINITIS IN THE COMMUNITY PHARMACY
� Pharmacists play an important role in confirming an AR diagnosis: some patients purchasing AR medicines in the pharmacy will have a diagnosis of AR by a physician, others will have an appropriate self-diagnosis of AR, and the remainder no diagnosis or an incorrect one 18 (Table 1). � AR symptoms may be similar to those of several conditions and confused with a viral infection such as the common cold/acute rhinosinusitis (including COVID- 19) or chronic rhinosinusitis [19][20][21] ( Figure 1).
� The presence of nasal itching, rhinorrhoea, sneezing and eye symptoms is often consistent with allergic rhinitis. A mild-tomoderate loss of smell (hyposmia) may be present in the most severe patients, and can be sudden, severe and sometimes isolated in COVID-19 patients 22 (Figure 1).

| STEP 2a: ASSESSING COMMON AR COMORBIDITIES -ALLERGIC CONJUNCTIVITIS
� Eye symptoms are common in AR patients. However, they are not experienced by all AR patients. 23 � The presence of conjunctivitis should always be assessed in patients with AR symptoms (Table 2 and Figure 2).
� Importantly, conjunctivitis is not always caused by an allergen (e.g. � AR is a risk factor for the development of asthma. 27 � In patients with asthma, AR may be associated with poor control of the disease. 25  The monitoring and self-management of AR can be supported through the MASK-air App 33 which can be downloaded for iPhone or Android (https://www.mask-air.com/).
The cut-off value for VAS "eye" is based on the results of the AR and the group's opinion, but has not been validated.

| STEP 5: LONG-TERM MONITORING AND PATIENT SUPPORT
It is critical that people with AR should be followed-up over time, to ensure that their treatment is appropriate and to identify patients who require a referral to their physician (APPENDIX III).
Follow-up should occur 5-10 days post-treatment initiation ( Figure 6). 18,31 In considering how to assist the patient in long-term management, it is important to realise that AR is undertreated and underdiagnosed and that patient self-selection is profound. 34 Patients often trivialise AR and do not realise the extent to which their AR presents a burden to their day-to-day living. Therefore, educating patients on recognising the impact of AR and counselling them on the goals they would like to achieve has been shown to be effective. 35,36 At this stage, unfortunately, there is much work to be done over time

ACKNOWLEDGEMENTS
We would like to express great appreciation to the Allergic Rhinitis and Its Impact on Asthma Working Group for valuable and constructive suggestions during the planning and development of this guide.
We are particularly grateful for the assistance given by Adriano Raposo in figure editing. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Open access funding enabled and organized by Projekt DEAL.

CONFLICT OF INTEREST
Sinthia Bosnic-Anticevich reports grants from TEVA, and personal