Treating Allergic Rhinitis

Patients need pharmacists' help to pinpoint the cause of allergy symptoms and find effective OTC treatment.

Sneezing, nasal congestion, rhinorrhea, and itchy, watery eyes are the most common symptoms associated with allergic rhintitis (AR). The degree of severity of these symptoms varies from patient to patient, and can be so severe that patients’ quality of life is affected, causing impairment of daily activities, fatigue, and sleep disturbances.¹ In the United States, AR affects an estimated 10% to 30% of adults and about 40% of pediatric patients, representing approximately 60 million individuals; its prevalence is increasing each year.^1-3 The symptoms commonly associated with AR typically present in patients after 2 years of age. ³ AR is a prevalent condition among pediatric patients and among individuals aged 18 to 64 years.³

Types of Allergic Rhinitis

AR can be classified as seasonal or perennial. ^3,4 Seasonal allergic rhinitis symptoms occur in spring, summer, and/or early fall and are caused by allergic sensitivity to pollen from trees, grasses, weeds, or airborne mold spores. ^3,4 Perennial allergic rhinitis (PAR) symptoms occur yearround and are caused by hypersensitivity to dust mites, animal dander, cockroaches, and/or mold spores.^1,3,4 Patients may experience 1 or more symptoms, including episodes of repetitive sneezing, rhinorrhea, postnasal drip, nasal congestion, loss of smell, headaches, earache, excessive tearing, red itchy eyes, eye swelling, fatigue, drowsiness, and malaise.^3,5

Some individuals may experience both types of rhinitis. Patients with PAR may exhibit more severe symptoms during specific pollen seasons.³ Allergic rhinitis can be associated with complications such as otitis media, sinusitis, recurring sore throats, cough, headaches, changes in sleep patterns, sleep apnea, depression, fatigue, anxiety, irritability, poor school performance, and impaired cognitive function.^4-6 In addition, some children may develop delayed speech, altered facial growth, and dental problems.^4-6

According to the American Academy of Allergy, Asthma & Immunology, an estimated 1 of 3 individuals with rhinitis do not have allergies.⁷ Causes of nonallergic rhinitis may include hormones (eg, pregnancy, puberty, thyroid conditions), structural defects (eg, septal deviation, adenoid hypertrophy), lesions (eg, nasal polyps and neoplasms), and the use of certain medications such as beta blockers, oral contraceptives, clonidine, angiotensin-converting enzyme inhibitors, aspirin and other nonsteroidal anti-inflammatory drugs, or overuse of topical decongestants.^4-7

Pharmacologic Therapy

Although the ideal treatment for the management of AR is avoidance of allergy triggers, some allergy triggers are unavoidable. In this case, AR needs to be managed with the use of pharmacologic agents to reduce or prevent symptoms.

Typically, AR is treated in 3 steps: environmental control measures and allergen avoidance, pharmacologic therapy, and immunotherapy.^3,5 Many patients may have to try several different treatment options before finding the ideal treatment. The factors to be considered when selecting therapy include the patient’s medical and medication history, specific symptoms and their severity, and the cost and frequency of treatments. Nonprescription agents marketed for the symptomatic relief and management of AR symptoms include oral and ocular antihistamines; oral, nasal, and ocular decongestants; and topical mast cell stabilizers.³

Oral Antihistamines

Antihistamines are considered the standard therapy for providing symptomatic relief of AR (Table 1). They are indicated for the relief of itching, sneezing, and rhinorrhea symptoms. First-generation antihistamines (sedating antihistamines) are associated with drowsiness/sedation, impaired mental alertness, and anticholinergic effects.² The second-generation nonprescription antihistamines (nonsedating antihistamines), including loratadine and cetirizine, usually do not cause significant drowsiness.³ In January 2011, the FDA approved the switch of the second-generation antihistamine fexofenadine (Allegra) from prescription to OTC status. It is available in adult and pediatric formulations.

Some patients may elect to also use a decongestant if experiencing nasal congestion, another common complaint for many allergy sufferers. 3 Decongestants are indicated for the temporary relief of nasal and eustachian tube congestion and cough associated with postnasal drip. 3 Common adverse effects associated with the use of oral decongestants include insomnia, nervousness, and tachycardia. Patients should be advised that the use of decongestants may also exacerbate medical conditions that are sensitive to adrenergic stimulation (eg, hypertension, diabetes, coronary artery disease, prostatic hypertrophy, and elevated intraocular pressure).³ Patients should also be reminded about the potential of rhinitis medicamentosa (rebound congestion) when using topical decongestants for more than 3 to 5 days.³

Many products on the market contain a combination of an antihistamine and a decongestant (Table 2). Patients should be advised to only use combination products when warranted to avoid unnecessary drug use. Because antihistamines and decongestants interact with several medications and are contraindicated in various patient populations, pharmacists are key in identifying potential drug—drug interactions or contraindications.

Cromolyn Sodium

Another option for allergy suffers is the nasal spray cromolyn sodium, which is indicated for preventing and treating the symptoms associated with allergic rhinitis. It is approved for those 5 years and older. Patients should be instructed to administer 1 spray in each nostril 3 to 6 times daily and treatment should be initiated at least a week before seasonal symptoms occur. The most common adverse effects include a burning and stinging sensation in the nasal area.^3,8 There are no known drug interactions associated with intranasal cromolyn.

Ocular Antihistamines

Some patients with AR who also suffer from watery and itchy eyes may elect to use an ocular antihistamine product. OTC ophthalmic antihistamines include pheniramine maleate and antazoline phosphate. These products are available in combination with the decongestant naphazoline. The most common adverse effects associated with the use of ophthalmic antihistamines include burning, stinging, and discomfort upon instillation.⁶ Ketotifen 0.025% is the only nonprescription antihistamine ophthalmic product on the market to relieve ocular itching without the use of a decongestant. Ketotifen is classified as a noncompetitive H₁ -receptor antagonist and mast cell stabilizer that inhibits the release of mediators from cells involved in hypersensitivity reactions.^6,9,10 It is indicated for use in patients 3 years and older and is classified as pregnancy category C.^9,10 It is indicated for the temporary relief of itchy eyes due to exposure to ragweed, pollen, grass, animal hair, and dander. The recommended dosage is 1 drop to the affected eye(s) every 8 to 12 hours, but no more than twice daily.^6,9,10 Common adverse reactions include headache, dry eyes, and rhinitis.^6,9,10 Ketotifen is not indicated for treatment of contact lens—related inflammation. Patients who wear contacts should be instructed to wait at least 10 minutes after instillation of ketotifen before inserting their lenses.^9,10

Final Thought

Prior to recommending any OTC products for AR, pharmacists should evaluate the patient’s medication profile and medication history for potential drug—drug interactions and contraindications, including allergy sensitivities, and refer patients with severe symptoms for further medical evaluation. During counseling, patients should always be advised to adhere to the manufacturer’s directions and be aware of potential adverse effects (Sidebar).

Pharmacists can also offer the suggestion of using a nasal saline solution to relieve nasal irritation and dryness.⁴ Patients should be encouraged to avoid allergens when possible. Other recommendations for decreasing allergy issues include washing bedding in hot water every week; vacuuming carpets and upholstery regularly; using allergy covers on pillows and mattresses; lowering the humidity level in the home to reduce the incidence of mold; keeping car and home windows closed, especially when pollen and mold levels are high; and checking local pollen and mold counts regularly.^3,11,12 PT

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.

References

1. Lambert M. Practice parameters for managing allergic rhinitis. Am Fam Physician. 2009;80(1):79-85.

2. Allergy statistics. America Academy of Allergy Asthma & Immunology Web site. www.aaaai.org/media/statistics/allergy-statistics.asp. Accessed March 9, 2011.

3. Scolaro K. Disorders related to colds and allergy. In: Berardi R, Newton G, McDermott JH, et al, eds. Handbook of Nonprescription Drugs. 16th ed. Washington, DC: American Pharmacists Association; 2009:189-200.

4. Rhinitis. The American Academy of Allergy, Asthma and Immunology Web site. www.acaai.org/public/advice/rhin.htm. Accessed March 11, 2011.

5. Sheikh J, Najib U. Rhinitis, allergic. eMedicine Web site. http://emedicine.medscape.com/article/134825-overview. Accessed March 12, 2011.

6. Fiscella R, Jensen M. Ophthalmic disorders. In: Berardi R, Newton G, McDermott JH, et al, eds. Handbook of Nonprescription Drugs. 16th ed. Washington, DC: American Pharmacists Association; 2009:526-528.

7. Spring and allergic rhinitis. The American Academy of Allergy Asthma & Immunology Web site. www.aaaai.org/patients/topicofthemonth/0307/. Accessed March 12, 2011.

8. NasalCrom product information. Blacksmith Brands Web site. http://nasalcrom.com. Accessed March 12, 2011.

9. Zaditor product information. Novartis Web site. www.zaditor.com/info/about/zaditor-eye-drops.jsp. Accessed March 12, 2011.

10. Alaway Product Information. Bausch and Lomb Web site. www.alaway.com/product-information. Accessed March 12, 2011.

11. Outdoor allergy tips. Schering Plough Claritin Healthcare Products Web site. www.claritin.com/claritin/allergies/spring. Accessed March 12, 2011.