Pharmacy Focus: Navigating Seasonal Allergies

In this episode of Pharmacy Focus, a podcast by Pharmacy Times®, Derek Webb, PharmD, member of the Virginia Board of Pharmacy and pharmacy manager at Food City, joins to discuss the challenges of spring allergies, offering pharmacists and patients valuable insights into identifying and treating seasonal allergy symptoms. Webb explores common allergens, differentiates allergies from other respiratory conditions, provides strategies for reducing allergen exposure, and explains treatment options ranging from OTC medications to emerging immunotherapies for adults and children.

Pharmacy Times: Today, I'm here with Derek Webb, PharmD, to discuss how pharmacists can help manage patients with springtime allergies. This spring allergy season has been a particularly rough one, with reports from across the country from those affected that this season has felt like the worst in years. Derek, thanks for coming onto the podcast today for this discussion. Before we get started, would you care to tell us a little bit about yourself and your expertise?

Derek Webb: Sure, I'm Derek Webb. I am a pharmacist who's been practicing in the community setting now for about 17 years. I work for a regional grocery chain called Food City, operated by K-VA-T Foods. We have about 120 locations, give or take a few. It seems like it changes all the time. As I said, I've been in the community setting for about 17 years, and about 7 years ago, I became an elected official. I've served in that capacity for about 7 years. Last year, I was actually appointed to the Virginia Board of Pharmacy. I've been serving in that role for about a year as well.

Pharmacy Times: Amazing. Thank you, Derek. Now, let's begin our discussion. Like I mentioned, this allergy season feels severe, but for those impacted every year can be arduous and difficult when dealing with allergies, especially as other respiratory conditions remain circulating, which can make it difficult for pharmacists to decipher what exactly a patient is experiencing. Derek, to start us off and make sure our audience is aware, what are some of the most common spring allergens, and how can patients distinguish seasonal allergies from other respiratory conditions, such as the common cold or asthma?

Derek Webb: Sure. It's the perfect time to discuss allergies and asthma, because May is National Asthma and Allergy Month. As you had alluded, the most common spring allergens...typically, we're seeing tree pollen. If you go out to your car to go somewhere, and you notice a kind of yellow film or a haze on the surface of your car, that's most likely tree pollen. It's prevalent; trees are blooming. It's certainly haphazard right now. We also see some grass pollen in the late spring, in the early summer, and throughout the entire summer. Depending on the circumstances, and this could be this year, but if the climate and the conditions are favorable, then mold spores can also be a big problem as well, typically in warmer temperatures where it's really humid and there's a lot of moisture in the air, perhaps the spring, when you get a lot of rain. So, we're seeing some of those mold spores as well. And then, of course, you always have what you call your perennial allergens, so your pet dander, your dust mites, and so on. We're dealing with all of those right now: tree pollen, grass pollen, mold, and your perennial allergens. And as you had talked about just a moment ago, 50 million to 70 million Americans suffer from seasonal allergy symptoms. Obviously, it's a very costly and burdensome illness to treat. To put it into layman's terms, that's 25% of the actual population that's suffering from some sort of allergy right now, at a minimum. Long story short, we're all sneezing, itchy eyes, itchy throat, runny nose, coughing. Most allergies truly do present with the same set of [adverse] effects. Now, as far as how we can distinguish allergies from other respiratory conditions like colds or asthma, I'll begin with colds. Allergies and colds certainly have overlapping symptoms, and it can be tricky to figure out which one is which, but they both typically have sneezing, runny nose, and congestion. However, in my experience, the key difference is the presence of a fever or body aches; those are almost exclusively going to be symptoms of a cold. Allergies typically manifest with itchy and watery eyes as well as an itchy throat, whereas colds typically involve sore throats, dry cough, that sort of thing. Ultimately, the duration of the illness is also very telling. Colds typically last for a couple of days or a week, whereas allergies are persistent for basically as long as the afflicting allergens are present. It can be all year, could be just in the spring or summer, just depending on what you're allergic to. Those are really the ways to distinguish between allergies and a cold. Now moving on to asthma, that's a little more challenging, because often allergies and asthma are kind of interconnected. They do have overlapping symptoms as well, such as the coughing, sometimes the wheezing. However, remember that allergies typically involve the eyes and the nose, whereas asthma is usually centered around the chest, with tightening of the chest, constriction of the bronchioles, and difficulty breathing. It can be a little more challenging to differentiate those two, because they're interconnected anyway. To complicate matters even further, you also have a type of asthma which is called allergic asthma, and it's where allergens precipitate allergy attacks, which actually in turn precipitate an asthma exacerbation. Those are the most difficult cases to actually make recommendations for, because we want to be very proactive. Often, we want to be aggressive to try to prevent those asthma exacerbations. You have to be pretty versed on how to differentiate those and try to pinpoint when someone's going to have some sort of an attack.

Pharmacy Times: Those are some great insights, and I think you were especially on the nose when you said that everybody is sneezing and coughing, which I've been seeing in my daily experience. The good thing is that there are some treatments available for treating seasonal allergies. But before we start discussing treatment options, I was wondering if there are ways that patients could reduce their exposure in their daily lives. So I wanted to ask, what advice can pharmacists give to patients looking to reduce their exposure to allergens throughout their daily routines? You mentioned the pollen going on the cars and such. Are there ways that, before a patient seeks out treatment, they can limit their exposure as much as possible?

Derek Webb: Absolutely. You know, most avoidance or minimization techniques for avoiding those triggers are common sense. However, I want to start by saying, make sure you monitor those pollen counts. There are limitless online resources and news media outlets that will tell you exactly how high or low pollen counts are at any given time. If pollen counts are soaring or starting to rise, be proactive. As far as avoiding exposure to these allergens, like I said, it's common sense. Keep your windows and doors closed at the house and while you're driving, obviously; with those lingering tree pollens, they're going to float right into your eyes and your nose, and that's where they'll cause a reaction. Wear sunglasses or eye protection while outdoors, either gardening or exercising or whatever outdoor activities you do, just try to [prevent] getting those allergens into your eyes. I know, again, it sounds like common sense, but wash your face and your hair, or shower before bedtime. Because what happens is, if you have those allergens on your face, in your hair, and you jump right into bed, you're going to cause those things to float around in the sheets, as well as on your pillow. You're going to breathe them in. You're going to get them in your eyes and nose. Just make sure to wash that face and hair if you can. Another commonsense one is just to change clothes after you've been outside exercising or outdoor activities of whatever kind. Studies have shown that even after you brush off those allergens when you're coming back inside, you're going to keep at least 50% of those things on you. It's better off just changing clothes after you've been outdoors. Another good one is HEPA filters [for indoor use]. If you have an HVAC system, try to get HEPA filters, or filters that filter out a lot of those particulate matters, so that you don't just continually breathe them in. And of course, if you have a serious allergy to grass, either don't mow or mow with a mask on. I know, again, it sounds like common sense. Sometimes we just don't think of these things. And then, it's often the allergen counts are highest early in the morning. If you're one of those people like me who likes to get out and run in the mornings, you may want to put that at a different time of day, at least during the season when the pollen counts are super high. They also make all these sinus rinses. I'll call them "showers for your nose" because you're just flushing out all those allergens once you get them in your nasal passages.

Pharmacy Times: Fantastic. And like you said, sometimes we need to be reminded of some commonsense tactics that we could take to help reduce our exposure. There are some treatment options that pharmacists can advise patients on. How can pharmacists guide patients in choosing between the treatment options available to them, which can include antihistamines, nasal sprays, and decongestants, especially when it comes to adverse effect profiles and timing of treatment?

Derek Webb: We're all fairly familiar with all the different OTC products out there. Like you said, antihistamines, nasal sprays, and decongestants are the big 3. I kind of take a multimodal approach, where you emphasize first minimizing those allergen exposures. Then when you're managing symptoms through medications, you just sort of have to go through a process. It's different for everybody. I start by asking, "Hey, are you taking anything yet? Have you tried anything yet? Do you have any allergies I need to be aware of? If all of those things are no, then I move right along to the first line. Typically, that first-line agent is going to be an antihistamine. Antihistamines are inexpensive, and they're readily available. They work well against most allergy symptoms, although they don't work really well with nasal congestion. I just want to put that as an aside there. But they're very frequently used, and most often the first-line treatment. If you don't want to delve into those antihistamines, you've got first-, second-, and third-generation antihistamines. The first generation are not used really often for seasonal allergies. That's your oldest. They're the ones that have the most [adverse] effects and cause the most drowsiness. So your diphenhydramine (Benadryl; Kenvue), chlortoluron, or chlorophyll. Your second generation is kind of your sweet spot. Those are the ones that have the best duration of action. They're 24-hour products for the most part. They have a low [adverse] effect profile, and they are your cetirizine (Zyrtec; Johnson & Johnson), your loratadine (Claritin; Bayer Healthcare), fexofenadine (Allegra; Sanofi). Those are the most common ones that we recommend in first-line treatment. As I alluded to, you do have third generation. Those are the newest and potentially have the lowest, the least significant [adverse] effect profile, like your levocetirizine (Xyzal; Sanofi) and your desloratadine (Clarinex; Organon). Like I said, we start with a second generation; they're cheap, and have a low [adverse] effect profile. They can be used proactively before the season starts, but they don't have to be antihistamines in general. They will start to work within 30 minutes to an hour. You can take them just as needed, you can take them daily, you can take them for a month, you could take them all year if you need to. But like I said, that's the beauty of an antihistamine: you can just add or take it away as you need to. As you talked about before, the nasal sprays. You've got 2 types of nasal sprays on the market; you've got steroid nasal sprays and antihistamine nasal sprays. Both are kind of used interchangeably, sometimes together as combos, but they have become a very popular treatment over the past few years for seasonal allergies because they do help significantly with that nasal congestion. They can be used as an add-on to an antihistamine, or they can work as a single entity product as well. They work to reduce the inflammation in the nasal passages. Often, they help with that congestion like I talked about when the antihistamines fail. A big thing is you have to use these proactively, because it takes a week to 2 weeks to really see the full effect or even a significant improvement from a nasal steroid or a nasal spray for allergies. They do have low [adverse] effect profiles, but a little more significant than the antihistamines. Sometimes you do see nosebleeds because they thin the lining of the nasal passages, and sometimes you see headaches with those as well. If you use one and have nosebleeds or headaches that are significant, you may want to try something else. They also make antihistamine eye drops, like your ketotifen (Alaway; Bausch + Lomb) and your ketotifen fumarate (Zaditor; Alcon Laboratories, Inc). Those are specifically targeted for eye symptoms. If you have the itchy, red, watery eyes, that may be something that you'd reach for. And then we talked about before, the decongestants. You've got oral decongestants, as well as nasal sprays. I will caution people with nasal sprays that are decongestants. Those are typically recommended for no more than 3 to 5 days. If they're used for longer than 3 to 5 days, then they can cause rebound congestion, otherwise known as rhinitis medicamentosa, and that is very uncomfortable and difficult to get rid of. Just be aware if you're using decongestant nasal sprays. Oral decongestants are pretty commonly used, like your pseudoephedrine (Sudafed; Johnson & Johnson) behind the counter, and they're safe and effective for nasal congestion. They work really well for seasonal allergies. In that way, you can take them as needed, not necessarily scheduled. They make a 4-to 6-hour product, a 12-hour, and a 24-hour. But again, they do have some [adverse] effects and some precautions. They do work by constricting blood vessels, so if you have high blood pressure or heart issues in general, you're not supposed to take the nasal decongestants. Just be cautious. Talk to your pharmacist and make sure and pinpoint those things if that's something that you have.

Pharmacy Times: That was a great overview of those treatment options, and I think it's important to discuss how these options might differ for pediatric and adult patients. Could you explain how these allergy treatments differ for those 2 populations and what pharmacists should keep in mind when counseling pediatric populations experiencing seasonal allergies?

Derek Webb: I find pediatric allergies pretty fascinating myself. As a side note, and I don't think most people realize this, but we're not born with allergies, right? They develop as we grow, as we get exposed to things. Most often in the first year of life with pediatrics, you'll see topical manifestation, so rashes and things of that nature. But most runny noses in pediatrics less than a year old are actually due to viral illnesses and not allergies. Specifically, allergies to tree pollen and grass pollen and that sort of thing begin to set in after the age of 2 years. As we're exposed to more of those allergens, we can develop allergies over time. I preface that by saying those things, because most allergy OTC medications are not recommended in less than 2 years of age, and that's the very reason. Typically, 2 to 6 is what we see with the beginning doses of allergy medications, and then 6 and up, of course, are treated like adults. But back to the original question, how does it differ? Allergy treatment for children is largely the same as adults. We still use the same groups of drugs, antihistamines, nasal steroids, and decongestants, to some degree. Again, first line is the same in children as it is in adults. We still try to use those second-generation antihistamines. If you go to the grocery store or to a big box store or pharmacy and look around, there are 1000 different products for children. They're marketed in many different ways: Claritin, Zyrtec, Allegra, Xyzal. They come in orally disintegrating tablets (ODTs), they come in chewables and liquids. They have all sorts of different bells and whistles, as you would have. The big thing is to pay attention to the age and the dosing. Again, the second-generation antihistamines are typically dosed once a day. With loratadine, like I said, you've got 5- and 10-mg. The 5-mg is recommended for 2 to 6 years of age. 10 mg is above 6 years. There is a similarity with cetirizinel; there's a beginning dose and an adult dose with those. Typically, it's dosed in 2 to 6 and 6 and up. Really, your consideration with children is dosing frequency. You just want to pick a product that's convenient. If you've got a child that's in school or school-age, you don't want to have to do some at school if you don't have to. Of course, pay attention to the flavors and the formulations, because some children will take an ODT, but they won't take a chewable, and vice versa. As I mentioned before, antihistamines in adults and children aren't particularly effective for nasal congestion, so oftentimes you see nasal steroids added on as well. Nasal steroids have been around for decades. At this point in time, most of them are OTC. They're very effective for nasal congestion, but again, you've got to use them for at least a couple of weeks to see the full effect or a significant improvement. The dosing is actually the same for children as it is for adults, but products are marketed differently. One of the ones that I really like with children is the Flonase Sensimist. That one has a different actuator. It's easy for a child's hand to grab and compress this actuator, so it's easier for a child to take and it does have kind of a cooling sensation, which children typically like as well. As far as counseling parents for their children's allergies, it really is a multifaceted approach. You want to focus first on educating parents on minimizing allergen exposure. You want to teach them how to identify symptoms and if it's allergies or not allergies. And of course, be proactive with the treatment. If we know that the tree pollen is scheduled to begin in a few weeks, then maybe start that Flonase ahead of time, or start that antihistamine ahead of time to try to blunt that effect and make that season a little more tolerable. Again, I think the biggest focus for me with children is just, what product will they tolerate and can they use effectively, vs what they won't take and use effectively?

Pharmacy Times: Perfect. I agree that tolerability is easily the most important factor when it comes to pediatric populations. It's important for pharmacists to have a knowledge base and know how to manage patients with more severe or persistent allergic symptoms. What role do pharmacists play in managing such patients, particularly those considering treatments such as immunotherapy or specialist referrals?

Derek Webb: Sure. Obviously, I'll toot the pharmacist's horn for a moment, but pharmacists play a vital role in all health care conditions. Particularly with severe or persistent allergies. It really takes that multipronged approach, because often those patients who have severe, persistent allergies have been to the pharmacy multiple times for your advice. Often, they're taking multiple drugs at the same time to try to prevent those allergy symptoms or mitigate those allergy symptoms. Those are the very ones that are going to have more questions; they're more likely to have drug interactions. We need to educate them on how to take those medications and when to take those medications and which ones can be used together. Now, specifically, if a person is considering immunotherapy, such as allergy shots or seeking specialist help, they are likely going to come to the front line, which is the pharmacist, and ask you questions. First, "Have you heard about this? Do you know how to use this? Is it going to kill me? Is it going to make me better?" We're right there on the front line, and we're the most easily accessible. We really have to focus on educating these patients. You do have to be sort of a jack of all trades. You have to know a little bit about all of these things, even though we're not the ones administering this immunotherapy. We do sort of have to be the quote, unquote experts in the retail world. We just got to educate these patients on avoidance of triggers, which drug combos can be used together and least likely to interact, the potential [adverse] effects of these immunotherapies, and the importance of being adherent to these immunotherapies, because you don't want to start allergy shots and then just not go back, because it's not going to be effective. Ultimately, pharmacists work collaboratively with all other health care professionals in an ideal world to tailor and optimize these treatment plans for patients. As I said before, the ones with severe or persistent allergy symptoms are likely going to be the patients who are at the pharmacy quite frequently anyway.

Pharmacy Times: That was a great overview of those specialty treatments that could be available for patients dealing with severe forms of seasonal allergies. To tie our discussion in a neat little bow and look toward the future of allergy and seasonal allergy treatment, do you know of any new or emerging therapies or OTC updates, perhaps any clinical pearls that pharmacists can be aware of this allergy season that might be emerging now or set to emerge in the coming months?

Derek Webb: There's always new things in the pipeline, right? Over the past couple of years, some of the emerging therapies, we have the biologics that have come into play. Products like omalizumab (Xolair; Novartis), that's one of the examples. It works by targeting the immunoglobulin E (IgE), which causes many of the unwanted and undesirable [adverse] effects associated with allergies. We've also got the SLIT therapy, the sublingual immunotherapy. It can be drops under the tongue or tablets for people who don't like shots. Those are becoming more popular, although, as a side note, for the sublingual immunotherapy, they typically only target 1 large group of allergens. It's usually either tree pollen or ragweed or mold or something to that effect. They don't usually do a multiproduct in one. There's also EPITs, which is the epicutaneous immunotherapy. If you're not familiar with those, that's a patch instead of a shot. It's kind of like putting a Band-Aid on it. It's permeated within the allergy product itself, and it delivers slowly over time. Those products are also out there and available. Most recently, and I thought this one was pretty fascinating, I read about an oral immunotherapy that was released a year or so ago. It lessens peanut allergy anaphylaxis severity. It's a product that you can begin and use once a day sublingually, called Palforzia (Stallergenes Greer), and it can be administered to people beginning at age 4 or maybe even a little younger now. If a person has a severe anaphylaxis to peanuts or a nut allergy, then they can take this product and it will actually prevent them from having an anaphylactic reaction if they're accidentally exposed to these. Because nut allergies have become a big issue over the past, I don't know, 5 years, something to that effect. That's a pretty cool product. One thing that I've heard quite a lot about over the past 6 months or year is OTC phenylephrine. The FDA has been deliberating whether or not phenylephrine is effective as a treatment for nasal congestion. They've actually got an FDA advisory committee that made a recommendation to remove phenylephrine from the shelf and the multisymptom products for cold and flu and allergies. I think that panel is supposed to make a decision pretty soon as to whether that will happen or not. If you're asking my personal opinion, I think phenylephrine is probably as good as gone. I think it will be gone in the next 6 months or year, and to my knowledge, once that happens, they will allow the rest of the product that's on the shelf to be sold, but they just will not allow new manufacturing of that product moving forward. Those are probably the big topics right now. There are always new antihistamines in the pipeline, but I think we've got really effective and good ones now, so they're not being studied quite as much as the others.

Pharmacy Times: Those are some interesting insights, especially the treatment for reducing peanut-induced anaphylaxis. I feel like what you mentioned, the peanut allergies are increasing and prevalent, at least that's what it feels like. Good to investigate that further, and we'll see what happens with those updates in the future. Thank you for this great discussion, Derek. I think it all is going to serve our audience well. Before we finish things up, is there anything else that you wanted to add that you think our pharmacist audience should know about?

Derek Webb: I appreciate that. I always enjoy talking to the audience of pharmacists. It's very rewarding to be in a position to be able to give advice or interviews. The thing that I would encourage pharmacists in the community setting to do is just really get a pulse for the crowd. Often, people will come to the pharmacy and they don't feel comfortable asking questions. If you can sort of target and and recognize those individuals, often we can approach them and really help be a part of their overall health care. We are definitely the most easily accessible health care professionals, and we want to really delve in and try to help the community as much as we can. I've truly made a career in the community setting, and I've truly enjoyed it. You just don't know how big of a difference you make. I would challenge pharmacists just to continue on with that enthusiasm and try to help the general public as much as they can.

Pharmacy Times: Amazing. Well, Derek, thank you so much for coming on to the podcast for this discussion today. Like I was saying, your insights are always valuable and appreciated, and I know our audience came out of this episode learning something new that could help them better manage their seasonal allergies. Thank you again, Derek, and thank you to the audience for listening to another episode of Pharmacy Focus, a podcast by Pharmacy Times, and stay tuned for next month's episode. Thank you for listening.