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62 CPD ACTIVITY FROM PAGE 61 and pharmacotherapy. Assessing symptom patterns helps pharmacists advise patients on trigger identification and avoidance techniques. If AR is triggered or worsened by seasonal allergens, patients may be able to predict oncoming symptoms and begin preventative therapy shortly preceding an expected relapse (at least two weeks before suspected onset).4,6,14 While some pollen triggers may be more prevalent during certain seasons, eg. spring, patient sensitivity to multiple allergens, as well as regional variation in plant lifecycles, can cause symptoms from traditionally seasonal allergens to present persistently (sometimes with seasonal flares).4 Classification criteria The classification of AR is based on two variables:20 • Symptom frequency. • Symptom burden. As shown in Figure 1, the differentiation is made between intermittent and persistent presentation based on the frequency of symptoms. The burden of symptoms is then distinguished as ‘mild’ or ‘moderate to severe’. Non-pharmacological management Even people with stable AR may find benefit from non-pharmacological approaches, which can result in increased control, reduced flares, or less need for medicines.4,5 Allergen minimisation The primary objective of allergen minimisation is to reduce patient contact with the allergen and thereby moderate the inflammatory cascade at its triggering point.4,5 It’s used as an adjunctive technique in combination with pharmacological treatment and can decrease or eliminate symptom burden and reduce the need for pharmacological intervention. Allergen minimisation ranges from prevention of dust mite accumulation in the home, to monitoring online tracking of high pollen count days.4 Intranasal saline Intranasal saline can be a useful adjunct at any stage of AR treatment. As well as washing away allergens, it can dislodge mucous and clear the nasal passage, allowing for better application of other intranasal treatment.15,16 OTC treatment options for AR in adults Management of AR should follow an individualised stepwise approach. Consideration should be given to the severity and persistence of symptoms, as well as any current management, the success of previous treatments, comorbidities and patient preference.5,7 Patient factors to consider when recommending AR treatment include: • Potentially contributing medicines or disease states. • Drug-drug interactions. • Drug-disease interaction. • Pregnancy and breastfeeding status. • Allergies to medicines. • Known allergens. • Patient health literacy. The aim of effective management is to:5 • Reduce or eliminate presenting symptoms and prevent future flares. • Lessen the impact of AR on functioning and quality of life. • Avoid adverse effects. Treatment options • Non-sedating antihistamines – first line therapy, for mild intermittent AR only.4 • Intranasal corticosteroids (INCS) – first line for moderate-severe intermittent AR, and mild and moderate-severe persistent AR. Combining an oral antihistamine with INCS may be appropriate, during exacerbation of AR symptoms, although some evidence indicates regular concomitant antihistamine provides little added benefit.4,5 It may be appropriate to add another medication to first line therapy if it doesn’t achieve the desired results. Multiple treatments can be initiated concomitantly to manage symptoms quickly. Multiple agents are then systematically withdrawn as the AR burden eases.4,5,8 A written management plan to summarise treatment recommendations can be constructed in consultation with the patient, such as adding an antihistamine (oral/ocular/intranasal) to a regular INCS for AR flares.4 Intranasal corticosteroids Intranasal corticosteroids are primarily a preventative that arrest the early release of inflammatory mediators.5,12,17 This provides local anti-inflammatory effects, which decreases capillary permeability of the nasal mucosa, resulting in vasoconstriction and reduced mucous production.14 They should be used every day to maintain their anti-inflammatory and allergy suppressant effects5,6 and they may take a few days to reach the maximal effect.6,14 INCS use has been shown to significantly reduce ocular symptoms,6 as in many cases the allergen causing allergic conjunctivitis still enters through the nasal passage.4 The duration of INCS use depends on the symptom frequency and patient response.4,6,14 Usage duration varies from short term, seasonally for a few months, to indefinitely, depending on the patient circumstances.4,6 INCS can safely be used long term,4,6 though the need for long term therapy may indicate a necessity for further review. Best-practice dosing of INCS involves starting at the highest standard dose, then reducing to the lowest effective daily dose once symptoms are controlled.6,14 Other therapies such as antihistamines (tablets, nasal spray, or eye drops) can be used at the same time as INCS if needed:14 • For flares. • Initially to help control symptoms until the INCS reaches its maximum effect. • If the patient has symptoms not controlled with INCS alone. INCS are well tolerated but can cause mild adverse effects, including local nasal irritation, dry mouth, and nosebleeds.14,17 As with other forms of local corticosteroids (inhalations and dermal topicals) some concern exists over systemic absorption as a pathway to more serious adverse effects.17,18 There is variability in systemic bioavailability and absorption between different INCS. Newer agents have pharmacokinetic characteristics that minimise systemic bioavailability while increasing local retention and potency. Hence, they only require once-daily application.17,18 Intranasal mometasone furoate, fluticasone furoate and fluticasone propionate all have negligible systemic absorption, with betamethasone having the greatest.19 As no evidence has shown the efficacy of any one INCS to be significantly superior,17,18 newer agents with lower systemic absorption represent added benefit for the patient.17,18 Antihistamines Both oral and intranasal antihistamines have faster responses than INCS. Therefore, combining antihistamines with Intermittent < 4 days/week OR < 4 weeks Persistent ≥ 4 days/week & ≥ 4 weeks Mild • Normal sleep. • No impairment of daily activities, sport or leisure. • Normal work and school performance. • No troublesome symptoms. Moderate-severe Has one or more of: • Abnormal sleep. • Impairment of daily activities, sport or leisure. • Abnormal work and school performance. • Troublesome symptoms. RETAIL PHARMACY • JUN 2021