Page 65 - Demo

INCS may be particularly beneficial:14 • As a bridging therapy when starting an INCS. • When required for intermittent AR. • Or during symptom flare-ups. It should be noted that best-practice guidelines recommend ongoing use of INCS for persistent or moderate to severe intermittent AR.9,14 Oral antihistamines can reduce symptoms in multiple anatomical areas simultaneously (ie, nasal, ocular and dermal symptoms). Therefore, they can be a better option than topical ocular or intranasal antihistamines for patients with symptoms across multiple body sites.4,14 Response to specific oral antihistamines varies widely between individuals. Therefore, they may need to trial multiple agents before finding their best fit (the most effective and well tolerated).14 Less sedating antihistamines (eg, cetirizine, desloratadine, fexofenadine and loratadine) are preferred for people with persistent AR due to reduced incidence of sedation, lack of development of tachyphylaxis (tolerance) and superior efficacy14 (individual risk category should be considered for pregnant women and those intending to become pregnant). Intranasal antihistamines (eg, azelastine and levocarbastine) are at least as effective as oral antihistamines in the treatment of AR, but not as effective as INCS for nasal discharge, congestion, itch and sneezing.4,14 Intranasal antihistamines have a very rapid onset of action (within 30 minutes) and may be useful for rapid symptom relief.4 Intranasal antihistamines can cause a bitter taste disturbance, which may not be acceptable to the patient.14 In practice, pharmacists may find patients are using oral antihistamine monotherapy to treat persistent or moderate to severe intermittent AR, despite consensus that INCS is first line.1,14 Patient preference for oral treatment is commonly due to ease of dosing compared with nasal sprays, once daily dosing, habit, and lack of knowledge of treatment recommendations and expected outcomes. Ongoing patient education and counselling are imperative for improving management of conditions such as AR, which are predominantly self-managed.1 Community pharmacists should endeavour to remain expertly knowledgeable on the management of AR, as they are ideally placed to help their patients receive the most appropriate treatment. Tips for optimal intranasal spray technique can be found in Box 1. Ocular symptom management Allergic conjunctivitis may be the predominant symptom of some patients with AR or may be present as a distinct condition.6 Typical presentation includes bilateral ocular pruritus, redness and watery discharge.20 Patient confusion between the three primary types of conjunctivitis (allergic, bacterial and viral) is common. Distinct pathophysiology and management options means accurate differentiation and associated patient counselling is vital.14 Other more serious ocular conditions should also be ruled out. Mild allergic conjunctivitis is managed with a combination of saline irrigation, cold compress, and ocular lubricants.14 Moderate symptoms should be treated with the addition of ocular or oral antihistamines. Ocular sodium cromoglycate isn’t usually recommended for acute symptoms as it takes up to two weeks for full effect. It may be useful if started two to four weeks before hay fever season.6,14 Ocular NSAIDS or corticosteroids should not be used for allergic conjunctivitis except under the advice of a specialist.6 Urticaria Urticaria (commonly known as hives) occurs in 15-25 per cent of the general population. It presents as pruritic or burning wheals (swollen skin marks) that have a pale inner swelling and circumferential erythema. The wheals can be as small as a few millimetres and up to a few centimetres in diameter.22 Urticaria may also be associated with angioedema, or swelling under the skin. Angioedema causes a more pronounced swelling, frequently around the mucous membranes of the mouth and tongue, but also the face, eyes, hands and feet. Angioedema takes longer to resolve than the wheals (up to 72 hours). Urticaria doesn’t cause lasting skin changes.21,22 Urticaria is classified as acute (lasting up to six weeks) or chronic (lasting longer than six weeks). It may occur intermittently, where lesions appear for days or weeks with symptom-free intervals lasting weeks or months.22 Chronic urticaria can be spontaneous, or inducible following physical stimuli such as scratching (dermographia), exposure to cold or sunlight, pressure or vibration, and increased body heat. Chronic spontaneous and inducible urticaria can overlap. Chronic urticaria can negatively affect quality of life and become challenging to manage.21,22 Acute urticaria is precipitated by: • Medicines. • Foods. • Viral infections. • Stress. • Parasitic infections. • Insect venom. • Contact allergens such as latex. Common medicine triggers include: • Antibiotics (particularly beta-lactams and sulphonamides). NSAIDs. Salicylates . Opioids. Common food triggers include: • Dairy. • Eggs. TO PAGE 64 CPD ACTIVITY 63 Box 1. Tips for optimal intranasal spray technique:4 1. Ensure nasal passage clear before use to allow maximal contact with the nasal mucosa, eg, with topical saline (sprays or douches), nose blowing and gentle use of tissue spears. 2. Prime spray device as per the manufacturer’s instructions (required with first use and after a period of non-use). 3. Shake the bottle well. 4. Tilt head forward (not back) or look down (opens the path into the sinuses and helps to direct the spray deeper into the nasal cavity, while limiting losing the dose down the oesophagus into the stomach). 5. Direct the nozzle away from the midline to avoid contact with the septum, also raising the base of the device to direct the path of spray slightly down and into the cavity (almost pointing the tip towards the ear). 6. Hold the spray device in the right hand for application to the left nostril and vice versa. 7. Gently breathe in through the nose while actuating the device to draw spray into the nasal cavity (avoid sniffing too hard during or after application, as the dose will be swallowed and have less effect). 8. Separate multiple sprays into the same nostril by a few minutes. RETAIL PHARMACY • JUN 2021