Page 80 - rp-may-2020

CPD ACTIVITY 78
RET AIL PHARMA C Y • MA Y 2020
FROM PAGE 77
and is a significant risk factor for asthma in
adults and children. There is evidence
11,12
that in a patient with both allergic rhinitis
and asthma, the asthma symptoms are more
difficult to control. Treatment of allergic
1
rhinitis has been associated with improved
outcomes from asthma and vice versa,
13
10
and reduces asthma-related emergency
department visits and hospitalisations.
14
Signs and symptoms
The symptoms typical of allergic rhinitis are
caused by an allergic reaction in the inner
linings of the nose, resulting in inflammation.
Patients may frequently complain of
sneezing and itchy nose, eyes and throat.
Common signs and symptoms include:
• Nasal itching.
• Nasal congestion.
• Itching, redness, excessive tearing of eyes.
• Itching of palate.
• Sneezing.
• Post-nasal drip.
• Cough.
• Facial fullness and pain.
• Obstruction.
• Snoring.
• Sleep interference.
In clinical practice, patients frequently
present with a predominant symptom.
Congestion is frequently reported as
the most bothersome nasal symptom.
15
For some patients the most bothersome
symptoms of allergic rhinitis are
of ocular origin. These symptoms
16
(rhinoconjunctivitis) include tears, itching,
and redness of the eyes.
Uncontrolled or poorly controlled
symptoms of allergic rhinitis can lead to:
• Sleep disturbance.
• Daytime fatigue.
• Lack of concentration.
• Learning impairment.
• Reduction in cognitive functioning.
Management
Although there is no cure for allergic rhinitis,
effective treatment is available. Optimal
symptom control can be achieved through
allergen avoidance, pharmacotherapy, non-
medicated treatments, and immunotherapy.
Evidence of the effectiveness of allergen
avoidance measures, particularly house dust
mite, is limited.
17
Patient self-management requires
education, support and good adherence
and persistence to therapy. The frequency
and severity of symptoms guides optimal
pharmacotherapy choices. Most treatments
for allergic rhinitis are now available OTC
in pharmacies. When patients are not
responding adequately to OTC treatments,
referral to a GP for prescription-only
products should be made.
Saline nasal irrigation may be effective
in reducing rhinitis symptoms but should
not be considered a replacement for
pharmacotherapy. It works to clear
aeroallergens and inflammatory mucus.
However, it’s uncertain whether adding
nasal saline to pharmacological treatment
helps to improve the symptoms compared
with using pharmacological treatment
alone. Large volume (>60ml) and positive
18
pressure devices appear to be more
effective than simple sprays (<1ml).
19
Pharmacotherapy
Duration and severity of allergic
rhinitis symptoms are useful in guiding
therapy (Figure 2).
Initial treatment of allergic rhinitis should
be guided by presenting symptoms, with
intranasal corticosteroids (INCS) the most
effective across all symptoms (Table 1).
Treatment options (Table 2) for allergic
rhinitis include:
• Intranasal corticosteroids.
• Oral antihistamines.
• Intranasal antihistamines.
• Decongestants.
• Leukotriene receptor antagonists.
• Immunotherapy.
Intranasal corticosteroids
Intranasal corticosteroids are first-line
therapy for the treatment of moderate/
severe intermittent and persistent allergic
rhinitis. INCS are effective against all
symptoms, including eye symptoms and
reduced sense of smell.
21,22
They reduce
inflammation and decrease mucus
production. There is no evidence to suggest
one INCS is more effective than another.
In general, maximal efficacy is seen after
one to three weeks of regular use.
22
Long-term safety and efficacy of
INCS are well established. The
23
lowest dose that will control symptoms
should be used. The total steroid dose
should be considered if used with
intercurrent asthma.
INCS are well tolerated. Local adverse
effects include epistaxis, throat irritation
and nasal dryness, burning and stinging.
Epistaxis may be related to drying and
thinning of the nasal mucosa. Checking
and reinforcing correct installation
technique, directing the spray laterally,
away from the septum, is important.
Systemic absorption with second-
generation agents (ciclesonide,
fluticasone furoate, fluticasone
propionate, mometasone furoate) is
minimal (<1%) compared with older INCS
(eg, triamcinolone, beclomethasone).
24
Nasal saline spray can be used before
INCS to clear mucus, improving contact
of the mucosa with the steroid and
potentially reducing the dose required to
be effective.
Intranasal corticosteroid/
antihistamine
Patients with moderate to severe disease
with persistent symptoms may benefit
from fixed-dose combination of intranasal
azelastine and fluticasone propionate
nasal spray. The fixed-dose combination
product containing intranasal fluticasone
propionate and azelastine has been
shown to have a more rapid onset of
action than oral antihistamine plus an
INCS, with relief from all symptoms
25
including ocular and nasal congestion.
26
The combination is more effective
in relieving symptoms than either
medication alone.
22,23
Antihistamines
Antihistamines can be used regularly
for the treatment of intermittent and
Intermittent and mild
Persistent and mild
Intermittent and
moderate/severe
Persistent and
moderate/severe
Intranasal corticosteroid sprays.
Intranasal corticosteroid and antihistamine sprays.
+/- Other therapies (intranasal antihistamines, intranasal cromones, intranasal
anticholinergic sprays, leukotriene receptor antagonists).
Oral non-sedating or intranasal antihistamines.
+/- Nasal saline irrigation.
Allergen avoidance.
Allergen immunotherapy.
Figure 2.
Treatment options for allergic rhinitis.