Community pharmacy can play an important role in educating allergy sufferers on the correct use of allergy devices and OTC medications, writes Leanne Philpott.
- It’s predicted that by 2050 the number of people affected by allergic diseases in Australia will increase from 4.1 million to 7.7 million;
- In many patients allergic rhinitis can lead to impaired concentration and sleep problems, which in turn can impact, work, school and sporting performance;
- Pharmacists are well placed to intervene and identify a potential problem, providing advice or referral if necessary; and
- For people with asthma, appropriate treatment of allergies is crucial—they should ensure they have discussed this with their GP and that they have an appropriate asthma management plan in place.
ACCORDING TO THE Australasian Society of Clinical Immunology and Allergy (ASCIA) between a third and a half of the Australian population will be affected by a form of allergy at some stage in their life. And it seems the situation is only getting worse; it’s predicted that by 2050 the number of people affected by allergic diseases in Australia will increase from 4.1 million to 7.7 million.
ASCIA says the most common causes of allergic reactions in Australia are:
- dust mites;
- insect stings; and
ASCIA reports that allergic rhinitis affects around one-in-five people in Australian and New Zealand. Yet because many people self-treat allergic rhinitis, individuals and healthcare practitioners can under-estimate its impact on day-to-day living.
“In many patients allergic rhinitis can lead to impaired concentration and sleep problems, which in turn can impact, work, school and sporting performance,” says the president of ASCIA, Clinical Associate Professor Richard Loh.
“The immediate signs or symptoms of allergic rhinitis include runny nose, rubbing of the nose, itchy nose, sneezing and itchy, watery eyes. But while some of these symptoms may be similar to those caused by infection such as colds and the flu, allergy symptoms tend to persist unless treated appropriately,” says Assoc Prof Loh.
“There is a lack of public awareness about the impact and appropriate management of allergy and immune diseases,” says Assoc Prof Loh.
“Individuals with allergic rhinitis will often self-treat with inappropriate medications such as sedating antihistamines and can underestimate the impact of their condition on day-to-day life,” he adds.
Dr Jim Kokkinakis, optometrist at The Eye Practice in Sydney, says, “oral antihistamines and decongestants can help reduce allergies, but studies show that these drugs also contribute to decrease of tear film production and can cause some patient’s eyes to dry out. This is especially problematic if allergy and dry eyes coexist. Treating one condition will exacerbate the other.
If possible treating allergy locally rather than systemically will have less impact on dry eyes. He recommends that patients with allergies avoid the decongestant type eye drops. “These can actually make eye allergy symptoms worse. This is especially true if preserved options are chosen. Listen carefully for the hallmark symptom, which is itchiness and offer preservative-free topical antihistamines. It is also important to remember that eye allergies and dry eyes often coexist and just treating the allergy sometimes is not enough.
“Topical antihistamines are very effective in treating mild-to-moderate eye allergies and the response is usually within a day or two. It is not unreasonable to add a preservative-free eye spray to treat any dry eye component especially if oral antihistamines are being used and then be referred to a therapeutic optometrist for a more thorough differential diagnosis of their condition if the response is not adequate. More significant allergies occasionally require topical steroids for a week or two to bring things under control,” says Dr Kokkinakis.
Terry White Chemists clinical services pharmacist Krystel Tresillian says pharmacists have a key role to play in cases where allergy symptoms are unidentified or undiagnosed.
“In this instance the customer may not be seeing their GP or any other healthcare professional regarding treatment. As they are managing symptoms without diagnosis they are likely to be self-medicating with OTC medicines and may be using these less effective treatments or using the wrong doses.
Customers may be getting some degree of relief by self-medicating and so never raise their symptoms with a GP. Pharmacists are well placed to intervene—for example at the point of sale of the OTCs—and are able to identify a potential problem providing advice or referral if necessary,” she says.
Assoc Prof Loh agrees: “Pharmacy staff can help educate customers about allergy medications—including their appropriate use, correct administration, and side effects.
“With regards to OTC treatments for allergies, we should ensure we’re providing treatments that will address the underlying cause, not just the symptoms. Customers may be using nasal decongestants long term (which is not recommended), where oral non-sedating antihistamines or steroid-based nasal sprays may be more appropriate. It should be standard practice to query our customers on what symptoms they’re using a product for and how long they’ve been using it. Even if customers insist they’ve used it before or that they know what they’re doing, there may be a more effective solution to the underlying problem and it is our responsibility to ensure, as much as possible, that they are aware of their options,” says Tresillian.
“The most common condition we’ll see associated with allergies is asthma. Asthma is of particular concern, as poorly controlled allergy symptoms will make asthma worse. We should educate our customers to think of the passage from the nose to the lungs as one airway with nasal congestion and mucus likely to trigger worsening asthma symptoms. For people with asthma, appropriate treatment of allergies is crucial and they should ensure they have discussed this with their GP and that they have an appropriate asthma management plan in place,” says Tresillian.
Professor Katie Allen, paediatric gastroenterologist, allergist and researcher with Murdoch Children’s Research Institute (MCRI) says that while food allergy is not the most common allergic disease, its prevalence appears to be rising while others have plateaued. Food-induced anaphylaxis is now the most common form of anaphylaxis.
Nadine Bertalli, research coordinator, Centre for Food and Allergy Research, says, “Food allergy has increased significantly over the past three decades. Pharmacists will come across many parents with a child with a confirmed or suspected food allergy, particularly parents of young children as food allergy is most common in children under five years of age. Our research in the HealthNuts study of 5300 children found that up to 10% of 12-month-olds have clinically confirmed food allergies. This is one of the highest rates ever reported in the world.
“The spectrum of reactions to foods is broad and having an understanding of this can help pharmacists to identify potential food allergy and anaphylaxis. Encouraging those with suspected or confirmed food allergy to see a medical professional is essential,” says Bertalli.
“Adverse food reactions can cause physical symptoms ranging from the mild, for example urticaria, to the severe, such as anaphylaxis. However, not all food reactions are food allergies. A food allergy causes adverse physical symptoms and involves the immune system; food intolerance, on the other hand, does not involve the immune system.
“Food allergies can be further classified as IgE or non-IgE mediated. IgE mediated food allergies are the most serious as they are associated with risk of anaphylaxis.
“Factors such as type of symptoms and timing of onset of symptoms can provide clues to signal a potential food allergy. As an overall guide, reactions likely to be IgE mediated food allergy are immediate (less than one hour) and a small amount of the food can produce a reaction. Symptoms include urticaria, erythema, angioedema, vomiting and breathing difficulties (anaphylaxis),” adds Bertalli.
Bertalli says that more than 90% of IgE-mediated food allergies in children are caused by eight foods.
“The key foods to look out for are: cow’s milk, hen’s egg, soy, peanuts, tree nuts (and seeds), wheat, fish and shellfish.”
ASCIA states that hospital admissions for anaphylaxis (severe life-threatening allergic reaction) have increased four-fold in the last 20 years. Indeed, food-induced anaphylaxis has doubled in the last 10 years.
Earlier this year the World Allergy Organisation (WAO) announced the need for ‘education, preparation, and resources in the treatment and prevention of anaphylaxis’.
Lanny Rosenwasser, president of WAO, says that anaphylaxis needn’t be fatal. “Knowing how to respond when anaphylaxis occurs is critical, as with any emergency response procedures. Everyone should be aware of the possible symptoms, how to position the person, and how to administer adrenaline.”
When to refer
Identifying allergy symptoms and their severity is a critical component in finding the right treatment for patients and helping them achieve optimal symptom control and in many cases this will mean referral to an allergy specialist.
Assoc Prof Loh says pharmacists should encourage patients to see their GP if they don’t get relief from their allergy medication. In this instance allergen immunotherapy may be suitable for the customer.
They will need to be referred to a clinical immunology/allergy specialist for assessment and, where indicated, allergen immunotherapy may be initiated. Allergen immunotherapy can be given as injections and, in some patients, drops or tablets under the tongue may be an option.
“The first step for those with undiagnosed allergies is referral. Once they have been referred, we should counsel on recommended products and ensure the customer fully understands the role of appropriate treatment as prescribed by their GP/specialist. Some customers may ask about allergy avoidance but in some cases, for example, pollen or dust, allergens can’t be avoided completely so effective management will be key,” says Tresillian.
Dr Connie Katelaris, allergist and immunologist says, “if people are repeatedly buying anti-allergy medications then they should be encouraged to seek medical intervention and diagnosis from a specialist.”
“Allergy is a multi-system disease. If a patient is buying asthma medication and self-medicating for nasal symptoms and perhaps a skin rash then this is an indication to refer, as the patient should probably be under medical care,” Dr Katelaris adds.