US Pharm. 2021;46(5):41-46.
Allergic rhinitis (AR) is a highly prevalent atopic disease characterized by clear rhinorrhea, nasal congestion, sneezing, postnasal drip, and pruritus of the eyes, ears, nose, and throat. This condition is caused by an IgE-mediated inflammatory response of the nasal mucous membranes and upper respiratory tract after exposure to aeroallergens that the patient has been previously sensitized to. Since the 1980s, the overall prevalence of AR has been steadily on the rise. Current data suggest that up to 30% of adults and 40% of children suffer from AR, and it is a common primary diagnosis for outpatient visits. The average number of prescriptions for patients with AR is almost double that for patients without allergies. All of this contributes to the estimated $5 billion in annual direct healthcare costs attributed to AR. In addition, although not life-threatening, AR can cause significantly decreased quality of life for many, leading to missed school and workdays. AR has been associated with poor sleep quality, impairment in work performance, decreased concentration in school, and overall decreased feelings of mental well-being. Adding to the direct healthcare costs, AR is responsible for up to $4 billion in lost productivity annually.1-7
It is important for pharmacists to have a thorough understanding of AR and the options available for its management. AR is one of the most common allergic diseases that is often underrecognized, misdiagnosed, and ineffectively treated. Identification and treatment of AR often begin at the pharmacy counter; pharmacists play a pivotal role in the management of this condition, guiding treatment based on patients’ symptoms and severity.
Classification
Traditionally, AR has been classified according to the temporal pattern of exposure to allergens, frequency of symptoms, and severity. Temporal patterns may be seasonal, perennial, or episodic. Seasonal and perennial are the classifications that the FDA uses when approving new medications for AR. Seasonal allergic rhinitis (SAR) varies with the seasons and is dependent on geographic location and climatic conditions with trees, grass, weed pollens, and outdoor mold spores being common triggers. Perennial allergic rhinitis (PAR) is attributed to exposure to year-round environmental aeroallergens, including dust mites, mold, animal dander, and certain occupational allergens. The SAR and PAR distinctions do have some limitations because not all patients fit into the classification; some allergens considered seasonal can be considered perennial in certain climates and conditions. Alternatively, the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines recommend classifying AR according to symptom duration (intermittent or persistent) and severity (mild, moderate, or severe), allowing for more appropriate treatment selection (TABLE 1).4,8,9
Clinical Presentation
Patients will typically present with bilateral nasal symptoms including rhinorrhea, sneezing, and nasal congestion. Nonnasal presentation may include itching of the eyes, ears, nose, and throat; up to 70% of patients will also experience allergic conjunctivitis, which is characterized by intense eye itching, swelling, and discharge. Many of the signs and symptoms of the common cold overlap with AR; ocular itching is often a hallmark of allergy while an accompanying sore throat, fever, and body aches are indicative of an infectious etiology.10,11
This condition is rarely found in isolation and is associated with a number of comorbid conditions, especially asthma. More than 80% of people with asthma have AR, but this condition is very often underdiagnosed in this patient population. Patients with AR should be assessed for asthma as well; treatment of AR can reduce asthma-related emergency room visits and hospitalizations by up to 80%. Other comorbidities include chronic otitis media, rhinosinusitis, and obstructive sleep apnea. If left untreated, AR can worsen comorbidities.12,13
Management Strategies
There is currently no cure for AR. The goals of therapy include symptom relief, minimizing sleep disturbances, improving work and school performance, and improving quality of life. One of the most important strategies is the prevention or avoidance of environmental triggers, although this is not always practical and is oftentimes difficult to achieve. A successful treatment plan will incorporate nonpharmacologic strategies with pharmacologic therapy for the management and prevention of AR symptoms. There are many self-care options available to help with AR symptom relief. OTC medications include intranasal corticosteroids, antihistamines, decongestants, and mast cell stabilizers. Other treatment options available with a prescription or medical supervision include leukotriene receptor antagonists, intranasal anticholinergics, monoclonal antibody therapy, and immunotherapy (these therapies are beyond the scope of this article). Treatment should be individualized based on patient factors including age, frequency and severity of symptoms, history of response to past therapies, and comorbid conditions.4,8,9
Nonpharmacologic Approaches
Implementing nonpharmacologic approaches can help reduce or eliminate AR symptoms, minimizing the need for pharmacologic therapies. The primary nonpharmacologic strategy is to reduce exposure to allergens through allergen avoidance and lifestyle modifications; however, this is not always possible or practical. The most common allergens include pollens, mold, dust mites, fungi, and animal dander. Environmental control measures to help reduce exposure to these agents should be discussed with patients and implemented when possible (TABLE 2).4,14-16
Topical nasal saline is another option for patients to help reduce AR symptoms. Saline provided either as a spray, pump, squirt bottle, nebulizer, or irrigation can provide a modest benefit and improve quality of life in patients. Nasal saline irrigation may help thin mucus, making it easier to remove. In addition, rinsing the nasal mucosa also removes allergens causing irritation. This can be used alone or in conjunction with other treatment regimens. Although not as effective as intranasal corticosteroids, this provides a low-cost and relatively safe option for patients suffering from AR.15,17
Pharmacologic Approaches
Intranasal Corticosteroids: Intranasal corticosteroids are the most effective medications for the treatment of AR. They are potent anti-inflammatory agents that relieve all symptoms of AR, including sneezing, rhinorrhea, nasal congestion, nasal itching, and ocular symptoms. This relief has been seen with both continuous use and an as-needed basis; however, as-needed use may not be as effective as continuous use, and regular use prior to allergen exposure may be most effective. These agents are recommended as first-line agents for mild, persistent, or moderate/severe symptoms and may be used as monotherapy or in combination with oral antihistamines. Intranasal corticosteroids have been shown to be superior to antihistamines and leukotriene receptor antagonists in controlling AR symptoms, including nasal congestion and rhinorrhea, but their efficacy is similar to antihistamines for the relief of ocular symptoms. It is important to educate patients about the onset of action of these agents; the onset of action after the first dose ranges anywhere from 3 to 36 hours, but it may take up to 1 week for patients to experience full relief. By improving symptoms, these agents significantly improve the quality of life of patients with AR.4,8
The efficacy and adverse-event profiles of all intranasal corticosteroids are similar among available formulations. When recommending an agent for a patient, factors including product sensory attributes, such as aftertaste, nose runout, throat rundown, and smell should be considered. Generally, the intranasal corticosteroids are well tolerated. The most common adverse effects are a result of local mucosal irritation, which include dryness, burning, stinging, and epistaxis; in rare cases nasal septal perforation can occur. Proper administration technique is important to optimize efficacy and minimize adverse effects. Topical administration of corticosteroids greatly reduces bioavailability, reducing the concern for systemic side effects.4,18
Antihistamines: Oral antihistamines are recommended for patients with mild-to-moderate AR with primary complaints of rhinorrhea, sneezing, and itching. Since they block the binding of histamine to the H1 receptor, preventing the release of histamine from mast cells, they are most effective at preventing symptoms before allergen exposure; for best results, antihistamines should either be taken prophylactically 2 to 5 hours before allergen exposure or on a regular basis rather than as needed.4,19
Antihistamines are categorized as first- and second-generation agents. First-generation antihistamines, which include diphenhydramine and chlorpheniramine, are highly lipophilic and cross the blood-brain barrier easily, contributing to adverse central nervous system effects including sedation, drowsiness, and decreased cognitive processing. Because of their anticholinergic profile, they should be avoided in the elderly population. In young children, diphenhydramine has been associated with paradoxical excitation, resulting in irritability, hyperactivity, and insomnia.19,20
Second-generation antihistamines are more lipophobic, leading to poorer penetration of the blood-brain barrier, and are therefore less likely to be sedating compared with first-generation agents. These medications have longer half-lives, permitting once- or twice-daily dosing compared with the first-generation antihistamines, which have relatively short half-lives, necessitating multiple daily doses. Second-generation agents are generally nonsedating; however, cetirizine and levocetirizine carry a modest risk of sedation. Although first-generation antihistamines have been proven to control symptoms of AR, second-generation antihistamines are the preferred agents based on their safety and efficacy profile and improved selectivity for the histamine receptor.4,8,9
Decongestants: Systemic and topical decongestants are effective in AR patients who experience nasal congestion. They work by stimulating the alpha-adrenergic receptors to constrict dilated arteries within the nasal mucosa.21 The two systemic decongestants available in the United States, pseudoephedrine and phenylephrine, are both nonprescription medications. Oral pseudoephedrine appears to relieve nasal congestion more effectively than phenylephrine.22,23 They are generally well tolerated and relatively safe, but their use is associated with adverse effects resulting from their stimulation of the central nervous system. Common adverse effects include insomnia, increased blood pressure, tachycardia, palpitations, arrhythmias, hallucinations, and urinary dysfunction.24 Their use should be avoided in patients with uncontrolled hypertension, thyroid disease, diabetes, and benign prostatic hypertrophy.24 Topical decongestants, such as oxymetazoline, provide a local effect at the nasal mucosa, limiting the occurrence of systemic adverse effects. These agents should only be used episodically and never for more than 3 to 5 days to avoid the occurrence of rhinitis medicamentosa or rebound congestion.21-25
Mast Cell Stabilizers: The use of intranasal cromolyn sodium, a mast cell stabilizer, is considered a second-line agent in the management of AR; it is less effective than antihistamines and intranasal corticosteroids. However, this agent may be considered a reasonable therapeutic option for patients, especially if their only symptoms are sneezing, rhinorrhea, and nasal itching. Cromolyn inhibits the influx of calcium into the mast cell, preventing mediator release of the allergic response and inflammation. If degranulation has already occurred, cromolyn will have no effect; it is more useful as a preventive agent rather than a treatment. If symptoms are already present, a second agent may be needed during the first few days of treatment. Although relatively well tolerated, it is administered multiple times a day, which can make it less desirable for many patients.21,26
Role of the Pharmacist
The management of AR often begins with the pharmacist. Most patients will attempt to seek self-care options before seeing their primary care provider. Normal symptoms of AR are often confused with an infection or a cold. Pharmacists can help identify those patients who require further evaluation. Normally, AR symptoms consist of bilateral nasal symptoms, which include clear rhinorrhea, sneezing, nasal congestion, and pruritus. If patients present with unilateral symptoms, congestion without other symptoms, purulent nasal discharge, or loss of smell, a referral to a primary care provider is warranted.
With assistance from the pharmacist, many patients’ symptoms may be well controlled with nonpharmacologic approaches and use of the available nonprescription medications. Pharmacists are well positioned to help patients identify symptoms of AR, educate about allergen avoidance, and guide treatment to effectively manage bothersome symptoms while minimizing the risk of adverse effects. For patients using nonoral formulations of medications, pharmacists should provide education about the proper administration techniques. Following up with patients after providing recommendations is another important step in the management of AR. The follow-up should include assessment of the patient’s response to therapy and the need for further evaluation of modification to the current treatment regimen.
Conclusion
AR is a common disorder that can adversely affect quality of life. Pharmacists can help patients understand the chronicity and ultimately help reduce the burden of AR. Management strategies should include the combination of allergen avoidance and pharmacotherapy. Treatment should be individualized based on the frequency and severity of bothersome symptoms. With appropriate questioning and education, pharmacists can aid the patient in achieving optimum symptom control.
The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.
What options are available to help relieve my symptoms?
There is no cure for allergic rhinitis. However, it can be managed with allergen avoidance and treatment with medicine recommended by your pharmacist or healthcare provider.
How can I avoid allergens?
You can help control your symptoms by doing a few simple things to reduce your exposure to allergens. If you have seasonal allergies, stay indoors when the pollen count is high. Keep windows and doors shut at home and in your car during allergy season. Take a shower, wash your hair, and change your clothes after you’ve been outdoors.
If you have dust-mite allergies, use pillow and mattress covers. Wash your sheets and bedding in hot water every week. Use a vacuum cleaner with a HEPA filter. Try to keep your indoor humidity at about 40%.
If you are allergic to animals, the most effective treatment is removing the pet from the home, but many people do not want to do this. Avoid having the pet spend time in your bedroom. Washing your pets at least twice a week may also help reduce allergen levels.
You may also find that rinsing your nasal passages with a saltwater solution may be helpful. Nasal irrigation flushes allergens out of your nasal passages and may help relieve throat irritation, nasal dryness, and nasal congestion.
What OTC treatment options are available at the pharmacy?
There are many OTC treatment options for allergic rhinitis, including:
Intranasal Corticosteroids: Intranasal corticosteroids are the most effective treatments available for relief of symptoms associated with allergic rhinitis. Symptom improvement can be seen almost immediately, but it may take up to 7 days to feel full relief. The most common side effects include a bad taste, dry nose, and unpleasant smell. When using intranasal corticosteroids, it is important to spray toward your ears to prevent nosebleeds. Ask your pharmacist about the proper technique to administer nasal medications.
Antihistamines: Antihistamines help withsneezing and an itchy, runny nose, but they will not help with nasal congestion. You may find better relief if you combine these agents with an intranasal corticosteroid or decongestant. Use a nondrowsy product such as Allegra (fexofenadine), Claritin (loratadine), Xyzal (levocetirizine), or Zyrtec (cetirizine). Do not take this medication without consulting a pharmacist or healthcare provider if you are older than age 65 years or have glaucoma, difficulty urinating, prostate enlargement, thyroid disorders, or other medical conditions.
Decongestants: Nasal and oral decongestants can help provide relief from nasal congestion. Nasal decongestants such as Afrin (oxymetazoline) should not be used for more than 3 days because they can cause a rebound effect, causing more nasal congestion. Oral decongestants such as Sudafed (pseudoephedrine) can raise your blood pressure and make you feel jittery. They may also cause insomnia if taken too close to bedtime. These drugs should not be taken if you have uncontrolled hypertension, heart disease, closed-angle glaucoma, or hyperthyroidism, or are on certain medications.
Mast Cell Stabilizer: Cromolyn sodium is available as a nasal spray. This product is most helpful when used to prevent an allergic reaction. It will not do much to relieve your symptoms if you are already suffering from them. This agent may take up to 2 weeks to have an effect.
When should I seek medical attention?
Seek medical help when your allergy symptoms worsen while you are taking any nonprescription medication or do not decrease after 2 to 4 weeks of therapy. In addition, seek medical attention if you develop signs and symptoms of a secondary bacterial infection, such as thick nasal or respiratory secretions that are not clear, oral temperature higher than 100.4°F, shortness of breath, chest congestion, wheezing, or significant ear pain.
Where can I find more information?
More information is available from the American Academy of Allergy, Asthma, & Immunology: www.aaaai.org, or the Asthma and Allergy Foundation of America: www.aafa.org.
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