Changing concepts: Allergic Rhinitis

The concept of how we manage allergic rhinitis in the community is shifting, thanks to a growing understanding of patients’ perceptions and behaviour regarding treatment

Allergic rhinitis is a common chronic disease that affects almost one in five Australians (more than 4.6 million people). Hallmark symptoms include runny nose, nasal congestion, sneezing, and watery or itchy eyes.

The severity of allergic rhinitis (AR) symptoms can range from mild to severe, and can greatly impact day-to-day performance, quality of life and general sense of wellbeing. The burden of AR includes sleep disturbance, daytime fatigue and lack of concentration, which can negatively affect many facets of life.

Furthermore, evidence shows that severe allergic rhinitis can increase the risk of developing asthma and place those people with asthma at higher risk of flare-ups.

Pharmacists remain key to educating patients on the latest treatment guidelines, assisting with adherence and addressing any medicine-related concerns. Yet, in doing so, they face numerous challenges.

Professor Sinthia Bosnic-Anticevich, Woolcock Institute of Medical Research, and the University of Sydney, explains it is not that pharmacists don’t have the knowledge or training to implement AR treatment guidelines, but more so the fact patients choose to self-treat.

“One of the problems is that patients continue to choose to do their own thing. So, we really need to understand what drives patients’ decision-making regarding their AR treatment. We also need to understand some of the barriers pharmacists are experiencing a little better as well.”

Indeed, this is where the work of Dr Biljana Cvetkovski and her fellow colleagues at the Woolcock Institute of Medical Research comes into play. Her recent research not only explores the patient-related factors that impact treatment decision, but also the pharmacist’s views.

By recognising the challenges faced by pharmacists in the management of patients with AR, we can perhaps look at alternative ways to intervene and to translate AR management guidelines into practice.

Nothing but a nuisance

“Traditionally, AR has been portrayed as a minor issue. Often advertisements about ‘hay fever’ have shown it to be a nuisance or an inconvenience,” says Dr Cvetkovski.

“There is also research that shows some healthcare professionals believe AR is a minor ailment. In this instance, if an individual seeks the assistance of a health professional and they trivialise the condition, this reinforces the person’s belief that it is a nuisance disease. We need a collaborative focus to help improve awareness of the significant burden that comes with AR.”

Prof Bosnic-Anticevich adds, “In a lot of other chronic conditions the patient doesn’t have the choice to self-select treatment, because they have to go to the doctor and get a prescription at some point in time. AR seems to have fallen outside the chronic condition treatment framework.

“People are receiving incorrect or unrealistic messaging because it doesn’t get the attention it should from the GP, they come into the pharmacy and treatment is available on the shelf, and some products are even available in the supermarket. Therefore, from a patient perspective, AR is a minor issue.

“We know that only about 60% of patients with asthma and allergic rhinitis have had both conditions diagnosed by their GP. This means 40% of people with asthma as well as AR are yet to have their AR diagnosed—despite the fact poorly controlled AR is associated with worse asthma control and increased chance of flare-ups.”

Dr Cvetkovski explains, “The more pharmacists that can make themselves aware of how influential AR can be on existing co-morbidities and general quality of life, the better equipped they’ll be to communicate that message to their patients.

“There are a number of tools available to pharmacists that many may not be aware of. In particular, there’s the Visual Analogue Scale (VAS) ruler. A large number of the pharmacists who participated in our study found this to be a really handy tool to facilitate conversation about AR with patients who, typically, wouldn’t normally engage in a discussion about their treatment choice.

“The tool is an objective way to show patients the burden of AR and that there might be other treatments available to them. The feedback we received from pharmacists is that the tool was really useful in extending the conversation about the severity of symptoms and which medicines might help to optimise treatment.”

She adds, “In some pharmacy models the pharmacy assistant is heavily relied upon. Education and training should be extended to the pharmacy assistants so that they’re included in the collaborative messaging.”

Managing allergic rhinitis

“Research has revealed that, in the most part, people’s AR treatment strategies are sub-standard. Australian data shows that only about 15% of people are selecting optimal medication to treat their symptoms,” says Prof Bosnic-Anticevich.

Several medicines can be used in the treatment of AR, depending on the severity of the condition.

Medications primarily include intranasal corticosteroids (INCS), intranasal and oral antihistamines, leukotriene antagonists, intranasal cromoglicate, intranasal and oral vasoconstrictors and nasal rinsing.
However, intranasal corticosteroid sprays (INCS) are considered the ‘gold standard’ in the treatment of AR. While overseas research shows a preference for INCS among patients, the same cannot be said for Australia where they remain largely unpopular among patients.

A study conducted by Professor Connie Katelaris involving 300 Australians with AR showed that despite the significant burden of AR that was reported, 17% had never used INCS and 27% had not used them in the past year. Furthermore, respondents’ knowledge about INCS was deemed to be poor.

“It’s really important to understand why the patient doesn’t like using intranasal therapy. It could be they feel it doesn’t work or they don’t like the taste. It’s important to discuss these objections with patients to help overcome their aversion to using INCS,” says Dr Cvetkovski.

“Running through the technique of how to correctly use some of the intranasal inhalers can sometimes overcome their objections. For example, if the taste is an issue, pharmacists can help patients to realise there’s less likelihood of the medicine running down their throat and into the mouth when the inhaler is used correctly.

“In fact, as part of our project pharmacists were given a poster showing correct intranasal technique. Of all the posters provided, this was the one pharmacists reported as opening up the most conversations with their patients. In many cases, seeing the poster was the first time the patient realised there was a specific way to use intranasal inhalers.

“In other cases, patients stop using their INCS because they believe they’re ineffective, so it’s important pharmacists make patients aware that it has a longer onset of action. It’s essential to manage patients’ expectations by advising they won’t get an immediate effect in the same way they would if they took a decongestant or antihistamine. In some instances it can take up to two weeks to ease symptoms.”

Pharmacist intervention is essential to relay product information to the patient and ensure correct use. Patients should be made aware that INCS should be used regularly and with careful attention to the way in which they are operated. It’s also valuable to highlight different brands of INCS vary in strength, dosage, safety profiles and effectiveness.

While the AR treatment guidelines recommend INCS as the first-line treatment for allergic rhinitis, oral antihistamines can be used in conjunction. However, many patients continue to self-select oral antihistamines as their treatment of preference. This is despite the fact they may gain greater symptom relief from an alternative treatment approach.

There’s no denying pharmacists are well-placed to offer information on the evidence supporting the use of INCS, but they can only do this when the opportunity presents.

Prof Bosnic-Anticevich says, “As a pharmacy community, we’re always trying to improve medication use and recommend optimal treatments to our patients. A big issue is that patients get into the habit of self-selecting treatment themselves, they become familiar with a certain type of medication and they’re also used to the type of response they get from these medications. Furthermore, they appear to be satisfied with the results even though their symptoms may not be being treated optimally.

“This is a huge barrier for us as pharmacists; if patients aren’t looking for different medications and they feel comfortable with the treatments they’re using, then where’s the opportunity for us to intervene?”

Start as you mean to go on

Dr Cvetkovski explains the staring point of the patient’s treatment journey (which might be the initial consultation between the pharmacist and patient) is pivotal.

“Although it seems as though the person is self-selecting treatments from over the counter without consulting anyone, a lot of these people will have had an interaction with a pharmacist or GP at some point, and they frequently fall back on the advice they were given at that original consultation.

“In many cases the first recommendation from the pharmacist or even the GP is for an oral antihistamine, so the person will continue to use that advice believing it to be the best option. Also, because antihistamines are available over the counter, this encourages them to continue their current behaviour, which is based on that original recommendation. The problem is that there can be a lack of review over time.

“It’s also important that AR is correctly identified as part of the initial consultation. One of the other issues is that, in many cases, patients’ symptoms are associated with a cold before someone finally figures out it is ‘hay fever’.”

Prof Bosnic-Anticevich adds, “Coming out of winter and into spring, we know that many people will start to experience allergic rhinitis symptoms. A large proportion of these people are very used to these symptoms and most will have a treatment approach or a strategy they use, so it can be a bit of a vicious cycle.”

“Certainly, there is a subset of patients that will ask if there’s anything new on the market and this is an ideal opportunity to review what they have been taking up until now and whether there’s a better option,” says Dr Cvetkovski.

“Any instance where a patient asks the pharmacist for advice relating to their allergic rhinitis symptoms is a key opportunity that shouldn’t be missed.

“Alongside this, another action I would encourage pharmacists to take is to follow up with their patients. While some of the pharmacists we worked with as part of our research invited their patients to follow-up, the nature of pharmacy means you might not routinely see that patient again. The next time they come in there could be a different pharmacist on duty.

“Therefore, it’s useful to provide the patient with multiple options of follow-up. It could be that you offer to text them to see how they’re going or you might invite them back into the pharmacy but advise that if you’re not there they should talk to another pharmacist. Essentially, ensure you communicate that follow-up is a crucial part of optimising treatment.” 

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