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Development of this article was supported by an unrestricted educational grant from Bayer Australia. Allergic rhinitis Allergic rhinitis (AR) is a common presentation in pharmacy. It is often suboptimally managed by self-selection of products without professional advice.1 Commonly known as “hay fever”, AR is an inflammation of the nasal mucosa caused by an immunoglobulin E (IgE) mediated allergic response to inhaled allergens.2 Inflammation swells the nasal mucosa, increasing vascular permeability, causing the production of extra mucous to flush away allergens, irritants, and infectious agents.3,4 Symptoms Symptoms of AR include:2 • Rhinorrhoea (runny nose). • Congestion. • Itching. • Sneezing. AR is also associated with sinusitis, allergic conjunctivitis, asthma and eczema. Complications of AR include acute or chronic sinusitis, otitis media, sleep disturbances and apnoea, and dental problems caused by excessive mouth breathing.5,6 AR is a risk factor for the development of asthma and is shown to worsen asthma control in children and adults.1,7 Eighty per cent of people with asthma also have AR, and 10-40 per cent of patients with AR also have asthma.8 Asthma and AR can be thought of as different presentations of a united airway disease, manifesting from the same inflammatory process occurring in different parts of the airway.4,9 Appropriate treatment of AR is an important step in the ongoing management of asthma. Burden AR affects one in five Australians. It peaks in early adulthood and remains reasonably steady, reducing somewhat in the elderly.6,10 AR occurs throughout the year, though its incidence can peak seasonally based on the affected individual’s allergen triggers.10 AR can significantly impair quality of life,1,11 interfere with day-to-day activities, and markedly impact on concentration, work productivity and childhood behaviour and development.1,4 Pathophysiology AR begins with a process of sensitisation involving contact of the nasal mucosa with an allergen, which the immune system deems as a potential threat, and creates a corresponding antibody (allergen specific IgE). Ongoing production and presentation of the allergen specific IgE on the surface of mast (and other) cells will identify any future presentation of the allergen, and trigger an allergic response.2,12 Early presentation of symptoms is caused by release of histamine and other inflammatory mediators from mast cells following contact with the allergen. Migration of inflammatory cells to the area leads to a chronic allergy state. Prompt treatment is important to help prevent this progression.5 Triggers and allergens The allergic and inflammatory cascade that causes the symptoms of AR is most commonly triggered by inhalation of airborne allergens (aeroallergens). Common aeroallergen triggers of AR include:4 • House dust mite. • Pollens. • Animal dander. • Moulds. • Insects and rodents. Not everything that triggers AR symptoms is an allergen.4,13 Non-allergic factors are more accurately classified as irritants. These include smoke, cold air, perfumes, and household chemicals. Chemical and physical irritants can initiate and exacerbate symptoms like those of AR. This occurs via very different non- allergenic processes. However, non- allergenic irritants may initiate the allergic process for patients specifically sensitised to these irritants.13 Allergens can be identified by skin prick testing and identification of specific IgE antibodies. However, in most cases, allergen identification is determined by taking a comprehensive patient history. Table 1 compares the distinguishing features of allergic and non-allergic rhinitis. Classification AR is classified as either intermittent or persistent, and by symptom severity.4,8,9 This process describes the frequency of allergy burden and allows for appropriate recommendation of lifestyle modification TO PAGE 62 Table 1. Distinguishing features of allergic compared with non-allergic rhinitis.4 CPD ACTIVITY 61 OTC MANAGEMENT OF ALLERGIC RHINITIS AND URTICARIA Dr Brett MacFarlane Brett is the Chief Pharmacist at the Australasian College of Pharmacy. He also contributes to the college’s development activities and its educational products. Dr MacFarlane is also a visiting fellow in the School of Clinical Sciences, Faculty of Health at the Queensland University of Technology. He graduated with honours from the School of Pharmacy at the University of Queensland and has worked for the Therapeutics Research Group at the Princess Alexandra Hospital Southern Clinical School in Brisbane where he gained a PhD in skin science. Inquiries: brett.macfarlane@acp.edu.au Allergic rhinitis Non-allergic rhinitis Family history of AR or atopy. Co-existing asthma. Known allergens. Pattern of symptoms: • Intermittent or persistent. • Specific times of the day or night. • Improves/worsens when the patient is in another location, eg, on holiday. Bilateral nasal symptoms. Persistent sneezing. Other symptoms of upper respiratory tract infection, eg, fever, sore throat, cough, swollen lymph nodes, purulent mucous, sinus/facial pain. Exposure to irritants, eg, smoke, volatile chemicals, cleaning agents. Foreign body or nasal polyp may cause unilateral nasal congestion. Overuse of decongestant nasal sprays. Drug induced: aspirin, NSAIDs, ACE inhibitors, alpha antagonists, OC pill, chlorpromazine, methyldopa, etc. Possible hormonal changes during pregnancy and the menstrual cycle. Negative allergy test. LEARNING OBJECTIVES After completing this CPD activity, pharmacists should be able to: • Describe the presentation of allergic rhinitis and urticaria. • Describe the pathophysiology and identification of allergic rhinitis and urticaria. • Discuss the management of allergic rhinitis and urticaria with over-the- counter medicines. 2016 Competency Standards: 1.4, 2.3, 3.2, 3.3, 3.5, 3.6. Accreditation Number: A2106RP3 (exp: 31/05/2023) RETAIL PHARMACY • JUN 2021 3 CPD CREDITS