Finding Relief: Allergic Rhinitis

Patient therapy must be tailored to an individual's symptoms and medication history.

In the United States, allergic rhinitis affects approximately 20% of adults and 40% of pediatric patients. Allergic rhinitis negatively impacts quality of life and the ability to take part in daily activities for many allergy sufferers by impairing concentration and causing fatigue and sleep disturbances.^1-3

Unfortunately, the number of newly diagnosed cases continues to increase annually.^1-5 Among the symptoms commonly associated with allergic rhinitis are episodes of repetitive sneezing, nasal congestion, rhinorrhea, and itchy and watery eyes.^1-5

Since the severity and incidence of allergic rhinitis can vary from patient to patient, therapy should always be tailored to meet the patient’s individual needs. Patients may have to attempt various treatments, including experimenting with a combination of therapies, before finding an optimal strategy for dealing with allergic rhinitis. When initiating pharmacologic therapy, the clinician should review the patient’s medical and medication history, possible allergens, specific symptoms and the severity of these symptoms, and adverse effects, cost, and frequency of treatments. Symptoms associated with allergic rhinitis typically manifest in patients after the age of 2 years and can occur in children as well as in those aged 18 to 64 years.³

Figure 1: Complications Associated With Allergic Rhinitis^3-6

Otitis media

Sinusitis

Recurring sore throats

Cough,

Headaches

Changes in sleep patterns

Sleep apnea

Depression, fatigue, anxiety, and irritability

Poor school performance

Impaired cognitive function

Types of Allergic Rhinitis

Allergic rhinitis can be classified as seasonal (hay fever) or perennial.^3,4 Seasonal allergic rhinitis (SAR) symptoms can occur from spring through early fall and are caused by allergic sensitivity to pollen from trees, grasses, weeds, or airborne mold spores.^3,4 Those with perennial allergic rhinitis (PAR) typically experience symptoms all year, and these symptoms can be caused by hypersensitivity to dust mites, animal dander, cockroaches, or mold spores.^1,3,4

Common Symptoms of Allergic Rhinitis^{3, 5}

Repetitive sneezing

Rhinorrhea

Postnasal drip

Nasal congestion

Loss of smell

Headaches

Earache

Excessive tearing

Red itchy eyes

Eye swelling

Fatigue

Drowsiness and malaise

In some cases, patients may experience both types of allergic rhinitis and find that they experience more severe symptoms during specific pollen seasons.³

According to the American Academy of Allergy, Asthma, and Immunology, approximately 1 out of 3 patients with rhinitis do not have allergies.⁷ These patients are classified as having non-allergic rhinitis, which can be caused by hormonal changes (eg, pregnancy, puberty, thyroid conditions), structural defects (eg, septal deviation, adenoid hypertrophy), or lesions (eg, nasal polyps and neoplasms.^3-7 Pharmacists should be sure to inform patients about those pharmacologic agents (such as beta blockers, oral contraceptives, clonidine, angiotensin-converting enzyme inhibitors, aspirin and other NSAIDs, or topical decongestants when overused) that may increase the risk of rhinitis.^3-7

Pharmacologic Therapy

There is no cure for allergic rhinitis, but many treatment options are available to manage or reduce the severity of its symptoms.³ Treatment is typically the same for SAR and PAR. However, those with PAR may be able to alleviate their symptoms through environmental control measures (eg, elimination of dust mites, mold, pet dander, etc). The ideal way to manage allergic rhinitis is to avoid allergy triggers, but this is not always practical or feasible, and the use of pharmacologic agents to reduce or prevent allergic rhinitis symptoms may be warranted. Overall, successful treatment of allergic rhinitis may require a combination of environmental control measures, allergen avoidance, pharmacologic therapy, and immunotherapy.^3,5

Nonprescription Allergy Products

Pharmacists are likely to encounter patients seeking advice on the various nonprescription products marketed for symptomatic relief and management of allergic rhinitis symptoms. These products include oral and ocular antihistamines; oral, nasal, and ocular decongestants; and mast cell stabilizers.³ Formulations available to meet the needs of adult and pediatric patients include single-entity or multiple-ingredient products in a variety of dosage forms, including immediate- and sustained-release formulations, tablets, capsules, oral disintegrating tablets, and liquids.

Antihistamines

Antihistamines are often used as a first-line therapy for allergic rhinitis and are considered the standard therapy for providing symptomatic relief. They are indicated for the relief of itching, sneezing, and rhinorrhea symptoms.³ Patients should be advised that first-generation antihistamines (sedating antihistamines) such as diphenhydramine are often associated with drowsiness, sedation, impaired mental alertness, and anticholinergic effects.³ There are also several second-generation nonprescription antihistamines (non-sedating antihistamines) currently available: loratadine, cetirizine, and fexofenadine. Second-generation antihistamines are quickly absorbed after oral administration, with time to peak plasma concentrations in the range of 1 to 3 hours.³ The second-generation antihistamines typically do not cause significant drowsiness³

Decongestants

Many patients with allergic rhinitis elect to use decongestants in combination with antihistamines because nasal congestion is a common symptom of the condition.³ Available nonprescription decongestants include pseudoephedrine and phenylephrine. These agents are indicated for the temporary relief of nasal and eustachian tube congestion and cough associated with postnasal drip.³ The most prevalent 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 certain medical conditions that are sensitive to adrenergic stimulation, such as hypertension, diabetes, coronary artery disease, prostatic hypertrophy, and elevated intraocular pressure.³ When using topical decongestants for longer than 3 to 5 days, patients should also be advised about the potential of rhinitis medicamentosa (rebound congestion).³

Many products on the market contain a combination of an antihistamine and a decongestant. Patients should be advised o use combination products only when warranted to avoid unnecessary drug use. Since antihistamines and decongestants interact with a number of medications and are contraindicated in various patient populations, pharmacists are in a pivotal position to identify those patients at risk for potential drug—drug interactions or who have contraindications.

Cromolyn Sodium

The nasal spray cromolyn sodium is another nonprescription option for allergy suffers and is indicated for preventing and treating symptoms associated with allergic rhinitis.³ It is approved for those 5 years and older. Cromolyn sodium should be administered as 1 spray in each nostril 3 to 6 times daily and is more effective when initiated at least a week before the onset of seasonal symptoms.3 Initial treatment efficacy typically becomes apparent in 3 to 7 days, but takes at least 2 to 4 weeks of continued therapy to achieve optimal effect.3 The most common adverse effect of cromolyn sodium is sneezing. Other adverse effects include a burning and stinging sensation in the nasal area.^3,8 Intranasal cromolyn sodium is not associated with any known drug interactions.

Ocular Allergies

Some patients with allergic rhinitis also suffer from watery and itchy eyes and may wish to use an ocular antihistamine product. Available ophthalmic nonprescription antihistamines include pheniramine maleate and antazoline phosphate.⁶ These antihistamine products are available in combination with the decongestant naphazoline. The most common adverse effects associated with the use of ophthalmic antihistamines are burning, stinging, and discomfort upon instillation.⁶

Ketotifen 0.025%, which is the only nonprescription antihistamine ophthalmic product on the market, offers an option for those seeking relief from ocular itching without the use of a decongestant. Ketotifen is classified as a non-competitive H1-receptor antagonist and mast cell stabilizer that inhibits the release of mediators from cells involved in hypersensitivity reactions. It is indicated for 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 It is approved for use in those 3 years and older and is classified as pregnancy category C.⁹ 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 before inserting their lenses after instillation of ketotifen.^9,10

Conclusion

Prior to recommending any nonprescription products for allergic rhinitis, pharmacists should always screen for possible drug— drug interactions and contraindications, including allergy sensitivities, to ascertain appropriateness. Pharmacists should also encourage patients with severe or persistent symptoms to seek further medical evaluation, especially if nonprescription products do not alleviate their symptoms. During counseling, patients should always be advised to adhere to the manufacturer’s directions and to be aware of potential adverse effects.

In addition to drug information, pharmacists can suggest various non-pharmacologic measures, such as using nasal saline solutions to relieve nasal irritation and dryness or non-medicated nasal strips for congestion.^3,4 Other non-pharmacologic measures for decreasing allergy issues include washing bedding in hot water every week, vacuuming carpets and upholstery regularly, using allergy covers on pillows and mattresses, keeping the relative humidity level in the home between 40% and 50% to reduce the incidence of mold, keeping car and home windows closed (especially when pollen and mold levels are high), and regularly checking pollen and mold counts in the area.^3,11-14 Since peak pollen production occurs between 5 am and 10 pm, advise patients to plan outside activities at other times of the day when possible.^11-14 Patients with allergies that are severe or do not respond to non-prescription therapies should discuss other treatment options with their primary health care provider.

Patient Counseling Tips

Pregnant or lactating women, patients with pre-existing medical conditions (ie, hypertension, diabetes, elevated intraocular pressure, chronic bronchitis, prostatic hypertrophy), or individuals taking other medications (ie, MAOIs, CNS depressants, etc) should seek advice from their primary health care provider prior to using any nonprescription products for allergic rhinitis.

Compliance with allergy medication is essential for controlling symptoms, and patients should not exceed the recommended dosage of the selected product.

If allergy symptoms return or worsen, patients should talk to their primary health care provider about different options.

Those with intermittent allergies should take allergy medications as soon as symptoms appear or before exposure to allergens.

Always exercise caution when taking antihistamine products because of the potential adverse sedating effects and avoid alcohol consumption when using these products.

Allergy Resources

National Institutes of Health’s National Institute of Allergy and Infectious Diseases website www.niaid.nih.gov

American Academy of Allergy Asthma & Immunology website. http://www.aaaai.org/conditions-and-treatments/allergies/rhinitis.aspx

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

References:

• Lambert M. Practice parameters for managing allergic rhinitis. Am Fam Physician. 2009;80(1):79-85.
• Allergy statistics. America Academy of Allergy Asthma and Immunology website. www.aaaai.org/media/statistics/allergy-statistics.asp. Accessed March 3, 2013.
• Scolaro K. Disorders related to colds and allergy. In: Krinsky D, Berardi R, Ferreri S, et al, eds. Handbook of Nonprescription Drugs. 17th ed. Washington, DC: American Pharmacists Association; 2012.
• Rhinitis. The American Academy of Allergy, Asthma and Immunology website. www.acaai.org/public/advice/rhin.htm. Accessed March 3, 2013.
• Sheikh J, Najib U. Rhinitis, allergic. eMedicine website. http://emedicine.medscape.com/article/134825-overview. Accessed March 3 2013.
• Fiscella R, Jensen M. Ophthalmic disorders. In: Krinsky D, Berardi R, Ferreri S, et al, eds. Handbook of Nonprescription Drugs. 17th ed. Washington, DC: American Pharmacists Association; 2012.
• Rhinitis (hay fever). The American Academy of Allergy, Asthma and Immunology website. www.aaaai.org/conditions-and-treatments/allergies/rhinitis.aspx. Accessed March 3, 2013.
• NasalCrom product information. Blacksmith Brands website. http://nasalcrom.com. Accessed March 1, 2013.
• Zaditor product information. Alcon website. www.alcon.com/en/docs/zaditor-drug-facts.pdf . Accessed March 2, 2013.
• Alaway product information. Bausch and Lomb website. http://alaway.com/index.html?utm_source=Google&utm_medium=Paid%2bSearch&utm_content=Brand&utm_campaign=Alaway. Accessed March 1, 2013.
• Allergy Management Tips. Schering Plough Claritin Healthcare Products website. www.claritin.com/claritin/en/manage/tips.jspa. Accessed March 1, 2013.
• Allergy Information. Wyeth Consumer website. www.alavert.com/allergy_info.asp. Accessed March 1, 2013.
• Manage your allergy environment. McNeil PPC website. www.zyrtec.com/my-allergy-guide/manage-allergy-environment. Accessed March 1, 2013.
• Allergic rhinitis. United States National Library of Medicine website. www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001816/. Accessed March 1, 2013.