Jarrod McMaugh and Carlene McMaugh talk device technique, thunderstorm asthma and treatment for allergic rhinitis

Despite the name, seasonal rhinitis is actually a perennial issue for pharmacists – atopy is a persistent condition that waxes and wanes with exposure to allergens, rather than being a condition that disappears, so we need to be mindful of it all year round.

That being said, we are now well in to the season where the peak incidence of allergy among Australians is driving them in to pharmacies for solutions. Treatment options for allergic rhinitis and hayfever haven’t changed much since Karalyn Huxhagen last discussed this topic in 2016, although there have been some updates in the protocols we use with these treatments.

Pharmacists are also now becoming more aware of the impact of thunderstorm asthma, which is partly driven by a person’s response to allergens.

This article is intended to update pharmacists on how treatment options have expanded somewhat, while also linking atopy present in hayfever/rhinitis with other conditions that may have a serious impact on health.

Changes in protocols

Probably the greatest change in how hayfever and seasonal allergic rhinitis is treated is in the step-by-step process of escalating treatment to match symptoms. This traditionally started with non-drowsy antihistamines, may have introduced a first-generation antihistamine due to a perception of being “stronger”, then will add intranasal corticosteroids.

A stepwise process is a logical manner to address any condition, working up through a treatment protocol that starts with minimal side effects through to ‘greater risk but more effective’ options for people who experience more troubling or refractory symptoms.

While this is a valid process to take for most conditions, in the case of hayfever and seasonal allergic rhinitis, we know that the impact of the condition on day-to-day function is significant. We also know that a proportion of people will always need to escalate treatment.

Therefore, it is appropriate to recommend a course of treatment that takes in to account expected symptoms based on previous seasons, ensuring that a person can gain relief as early and efficiently as possible. The therapeutic guidelines categorise two main types (intermittent or persistent symptoms) with two subtypes (mild or moderate/severe).1

Generally speaking, antihistamines would be used as first line treatment for people who are intermittently mild. For all other subgroups, consideration should be given to whether an intranasal corticosteroid should be used as first-line therapy, with the option of adding oral antihistamines in at the same time or a later point, depending on response.

The advice we give usually involves antihistamines with intranasal corticosteroids, with de-escalation as symptoms improve (ie cease oral antihistamines and/or reduce INCS dose) depending on where symptoms are occurring.

After initiating treatment, a stepwise process would still be used to increase or reduce treatment, based on response.

“New” treatment options

Treatment of hayfever and allergic rhinitis has remained practically unchanged for the time that we have been pharmacists. Non-drowsy antihistamines make up the bulk of the treatments that people use, first-generation antihistamines are still popular among those who do not experience drowsiness, and intranasal corticosteroids are underutilised comparatively speaking due to people not liking the sensation or not gaining full benefits due to poor technique.

For the majority of people, utilising these medications that are available over-the-counter can produce effective control when used appropriately and consistently. For a small number of people, the severity of symptoms may require some lateral thinking that leads to the use of medications that require a prescription.

One class of medication that is increasing in use are leukotriene receptor antagonists – specifically montelukast – due to the ability of this medication to alter the immune response to inhaled allergens.

While this may provide an extra option for people who are not able to get complete control over their symptoms, montelukast is probably no better than oral antihistamines and less effective than intranasal corticosteroids for hayfever. Despite this, it is worth referring people if they are not able to use one of these options, or if they are willing to trial a different treatment option.2

Another “new” treatment that is often overlooked are saline rinses – the capacity to use a physical rinse of the sinuses to flush out irritants should not be overlooked, and can have a significant impact on a person’s overall pollen exposure and quality of life.

Technique

With any discussion of the effective use of medications, there needs to be a consideration of device technique – this is no different for hayfever and seasonal allergic rhinitis.

Saline rinses require a particular method for effective use, although it can be argued that once a person has utilised these correctly, it is a memorable experience that can be replicated effectively. Unfortunately, it is not practical to provide a demonstration or ask a person in the pharmacy to demonstrate how they use this treatment option… referral to demonstration videos is strongly advised!

For intranasal sprays, technique is easy to demonstrate in the pharmacy, and it is also easy to get wrong. Similar to pMDIs, incorrect technique easily replaces correct technique over time, so reinforcement of the correct method should be a priority for pharmacists when recommending these products.

When we are advising people on these use of these devices, there are a few points we try to ensure they remember, focusing on the critical points of treatment failure.

➢ We ask people to look at the ground, roughly where their head would be if they were to lay down where they are standing.

➢ The device should be in the hand that is opposite the nostril they will be treating.

➢ The medication is needed in the sinuses and turbinates, not the bridge of the nose! Don’t point the device up, point it toward your ear.

➢ One puff at a time, while gently inhaling.

It is also important to ensure people have cleared their nose (gently) before using a nasal spray – if they are using a sinus rinse, this should be done before (not after) using an intranasal spray. The device itself should also be primed at first use and after extended storage.

Thunderstorm asthma

While on the topic of allergic rhinitis and hayfever, it is important to consider other conditions such as asthma. Hayfever, asthma, and eczema are generally considered to be manifestations of the same condition in different body areas/organs.

This is important in the case of thunderstorm asthma due to the amplified impact of micronized allergens that occur during these events.

For those who are not familiar, thunderstorm asthma is a phenomenon where the cases of acute asthma and wheeze explode during a ‘dry thunderstorm’ wherein electrical storms with little or no rain cause allergens in the atmosphere to become smaller and more irritating.

It is theorised that the electrical activity breaks up pollen, and the lack of rain prevents this pollen from being washed away. A description of the phenomenon can be found in this article from AJP.

Two factors combine here to make thunderstorm asthma important in a pharmacists’ consideration of a person with hayfever – the involvement of allergens in the process, and the chances of a person with seasonal allergies experiencing asthma symptoms due to the related nature of these conditions.

When discussing hayfever and seasonal allergic rhinitis with a person, take the opportunity to discuss asthma in a way that puts these links in to context. Without context, a person won’t heed what you have to say if they have never experienced asthma symptoms before.

Jarrod McMaugh is a community pharmacy practitioner with Capital Chemist in the northern suburbs of Melbourne. He has extensive experience in developing and delivering professional services in the community pharmacy setting.

Carlene McMaugh has worked in the healthcare field for over 20 years in varied roles and as a pharmacist for ten years including three years working as a pharmacist in the UK. She currently works in Capital Chemist Coburg and in the pharmaceutical industry.

References

1 Electronic Therapeutic Guidelines – Rhinitis and Rhinosinusitis

2 Electronic Therapeutic Guidelines – Rhinitis and Rhinosinusitis