Australia has been touted as the ‘world’s allergy capital’ due to its high rates of allergies and anaphylaxis, and healthcare professionals say the number of cases continues to rise
Allergies affect more than four million Australians and the rate of both allergies and hospital admissions due to anaphylaxis has steadily increased over the last two decades.
An enquiry by the House of Representatives Health, Aged Care and Sport Committee into allergies and anaphylaxis in Australia reveals the following statistics:
- around 10% of infants in Australia are affected by food allergy by the time they are 12 months old
- one in nine Australians have asthma and of these 3–10% have severe asthma
- one in five Australians have allergic rhinitis
- approximately 25% of the population will suffer from urticaria (hives) at some point in their lives and up to 3% will have chronic urticaria
- anaphylaxis is reported to occur on 0.2% of children and 3% of adults, but an increase in incidence has been reported over time.
It also states that given there is no cure and many Australians are living with more than one allergic disease, allergy has become a major public health issue.
According to the Australian Institute of Health and Welfare (AIHW), more than 4.6 million Australians have had allergic rhinitis (AR), most commonly known as hay fever.
Allergy symptoms include nasal congestion, rhinorrhea, sneezing, sinus pressure, postnasal drip, and itchy or watery eyes. Yet, while the symptoms may be considered minor, the ramifications of uncontrolled or sub-optimally controlled AR symptoms include sleep disturbance and daytime fatigue, which can lead to irritability, poor concentration and reduced productivity.
AR can also affect other chronic conditions. Notably, is it now well known that AR can worsen asthma symptoms and increase the likelihood of flare-ups.
Of course, a longstanding problem is the fact that a large proportion of people with AR tend to self-select their treatment. In fact, Professor Sinthia Bosnic-Anticevich, a leader in respiratory medicine and research at the Woolcock Institute, explains, “60–70% of people self select treatment for allergic rhinitis. In most cases, they simply feel they don’t require any advice. From their perspective, they believe themselves to be suitably equipped to make a selection.
“However, research reveals that for most people with AR, their symptoms are poorly controlled. Australian data shows that only about 15% of people are selecting optimal AR medication.”
Guidelines recommend the use of intranasal corticosteroid sprays (INCS) as the first-line treatment for persistent AR, as well as for moderate/severe intermittent AR. Oral antihistamines and/or INCS are recommended for mild intermittent AR.
A study into the real-life treatment of rhinitis in Australia (Price et al) revealed that the majority people opt for a single therapy and the most frequently purchased treatment, despite the severity or frequency of AR symptoms, is an oral antihistamine.
70.1% of the patients with AR purchased an oral antihistamine and 57.3% of patients with combined AR and asthma/COPD also selected an antihistamine.
‘An enormous barrier’
While people with AR and asthma or COPD were more likely to purchase first-line INCS therapy (15.3% by prescription and 11.7% OTC) than those who only had AR (5.0% by prescription and 9.2% OTC), the rates are still very low.
Prof Bosnic-Anticevich says, “The fact people get into a habit of self-selecting a sub-optimal treatment is a enormous barrier for us as pharmacists.”
Professor Bandana Saini, academic pharmacist and research leader at Woolcock Institute of Medical Research, tells the AJP, “While most of the medication for AR is available OTC or from the pharmacist, it’s important for pharmacists to interact with consumers and this can be done at different time points.
“Initially, you might have someone who comes into the pharmacy seeking treatment but who is unaware they have AR. This is where the pharmacist might step in and consider differential diagnosis. Is it the common cold/flu, or allergies? Is referral needed? In this ongoing pandemic, people with symptoms similar to rhinitis or a cold should be referred for COVID-19 testing.
“Where it’s deemed to be AR, it’s important to differentiate between mild and severe symptoms, as well as whether these occur in a persistent or intermittent manner and then select the appropriate therapy.
“Guidelines state that for anything above mild intermittent symptoms, intranasal corticosteroids are the first-line choice and pharmacists should ensure patients are provided with or informed about that treatment option.
“Other points of intervention include counseling on the intranasal device technique. We know that many people don’t use their devices correctly, so it’s very important that this is demonstrated and that the person demonstrates it back to the pharmacist.
“Particularly if the person has persistent AR, they will need to use their intranasal corticosteroid spray for a while; counselling on adherence and persistence is essential to help optimise treatment outcome.
“Certainly, pharmacists can apply their medication experience to help them not only select the appropriate class of drug but also the best formulation for the patient.
“For example, even if choosing from the same drug class, such as intranasal corticosteroids, the patient might have had an unsatisfactory experience with a particular spray. Perhaps they got a bitter after taste or experienced spray run-off into the throat. These problems might create barriers for them to persist with the treatment.
“It’s also important to ensure the patient has an AR management plan. Pharmacists can help people to access and write up the plan. They can also follow up at regular intervals to see how the medication is going, if the symptoms have subsided. It is important to check if the AR was impacting on other conditions, such as asthma or sleep apnoea.
“Pharmacists can also triage patients. There are other treatments for AR, such as immunotherapy, which would warrant an initial referral to a GP. An immunologist may be needed to find out what exactly the person is allergic to, and decide whether there is a potential role for immunotherapy, ” Professor Saini said.
“Pharmacists can also provide counselling on allergen avoidance tactics, particularly when these allergens have been identified.”
Leading the world in food allergies
In Australia, approximately 1–2% of adults and 4–8% of children under five years of age are affected by food allergy.
While these stats might not seem high, Australia has the highest incidence of food allergy in the world. One in 10 Australian babies will develop a food allergy.
Milk, eggs, peanuts, tree nuts, sesame, fish, shellfish, wheat and soy are the most common triggers, causing 90% of allergic reactions.
From a pharmacy perspective, Prof Saini explains, “Mums and parents are likely to come into the pharmacy to buy infant formula, which can be confusing as there are so many different ones on the market.
“If a parent describes symptoms in their baby that might be indicative of a food allergy, it’s good to refer the parent to their paediatrician or a dietitian in the area.”
According to the Royal Children’s Hospital Melbourne, signs of allergic reaction may include:
- hives, welts or wheals
- a tingling feeling in or around the mouth
- stomach pain, vomiting and/or diarrhoea
- facial swelling
“Following on from the initial referral and assuming food allergy has been diagnosed, it’s likely the parent will return to the pharmacy with a prescription for or recommendations for a certain formula. For example a formula where the protein or carbohydrate content is modified, such as formula containing partially hydrolysed or extensively hydrolysed proteins or with amino acids or lactose/galactose-free formulas. It can be helpful to explain to parents what these terms mean and how such hypoallergenic formulae help with the allergy,” says Prof Saini.
“Also, some parents may ask about a different formula because they’ve been speaking with another parent whose child has an allergy and they believe they should also use this type of formula as a precaution.
“In this case, it’s about offering health education. If they are concerned about their child, you might refer them to a paediatrician or dietitian to find out what their child needs before they go down the path of self-selecting a certain type of formula that might not be necessary and is expensive.
“Pharmacists need to have a good understanding of what the different formula options are for infants with food allergies. They also need to know in which instances they might recommend that particular formula. The recommendation should always be accompanied by a doctor’s review or on the advice of a dietitian.”
A national strategy
As part of the National Allergy Strategy, in late 2019 the Food Allergy Prevention Project was launched nation-wide (following an initial pilot phase in WA). The aim of the project is to increase awareness of the ASCIA guidelines for infant feeding and allergy prevention.
Given the close relationship that many pharmacists have with parents in their community, this puts them in an ideal position to promote the two major components of food allergy prevention.
Firstly, they can advise on the importance of introducing allergy-causing foods within the first year of baby’s life and, secondly, they can promote optimal eczema management to prevent sensitisation to foods through the skin.
The Nip Allergies in the Bub website is a great resource to refer parents to for the latest practical advice and information on how to action the two key components of food allergy prevention.
Prof Saini says, “With regards to food allergy symptoms in adults and older children, it’s likely that someone who experiences these symptoms for the first time may come into the pharmacy for general allergy treatment, such as an oral antihistamine.
“In this instance it’s important to identify what the treatment is for and whether the person has other allergy conditions or a family history of allergies.
“Referral and triage is vital, particularly if food allergy is suspected. It’s also important to pre-empt the need for an autoinjector and if the pharmacist believes the person needs this treatment at that point, they can provide it in the context of first aid,” advises Prof Saini.
Every year fatalities from food-induced anaphylaxis increase by around 10%. While it’s important to understand that not everyone with food allergy will experience anaphylaxis, it’s also imperative to be familiar with the risk factors.
Factors that can increase the risk of developing anaphylaxis include:
- previous anaphylaxis
- history of asthma (particularly if its poorly controlled)
- multiple drug allergies.
Indeed, this year’s World Allergy Week sought to raise awareness of anaphylaxis within the community. This severe and potentially fatal allergic reaction causes around 2,400 hospital admissions and approximately 20 deaths in Australia every year—and these figures are rising.
The most common cause of anaphylaxis in the community is food allergy, which is accountable for 30% of all fatal anaphylaxis cases. Symptoms of anaphylaxis may include:
- difficult/noisy breathing
- swelling of the tongue
- swelling or tightness in the throat
- difficulty talking or hoarse voice
- wheeze or persistent cough
- persistent dizziness or collapse
- pale and floppy (young children).
A study by Sandra Salter et al into pharmacists’ response to anaphylaxis in the community found that despite the seriousness of anaphylaxis, some people choose to visit their local pharmacy instead of calling triple zero.
It’s believed this could be because the person doesn’t recognise the symptoms or the treatment, and they incorrectly seek to purchase antihistamines.
Alternatively, some people may be aware of the need for urgent treatment and choose the pharmacy for its accessibility and the fact it stocks epinephrine autoinjectors.
With regards to pharmacists’ preparedness for acute anaphylaxis and willingness to engage patients in a discussion about anaphylaxis, the results showed that many pharmacists are not prepared for an anaphylaxis emergency.
Most pharmacists could identify the symptoms, and recognised the need for emergency care and the role of antihistamines. However, many (82.7%) incorrectly demonstrated the epinephrine autoinjector and failed to highlight the importance of an Anaphylaxis Action Plan.
Furthermore, less than half of the 300 pharmacists who participated in the study initiated a discussion about anaphylaxis unprompted.
Key advice points pharmacists can counsel on include:
- ensuring the patient knows how to correctly respond in an anaphylactic emergency
- making certain they know how to administer their autoinjector
- checking the patient has an Anaphylaxis Action Plan
- advising on correct autoinjector storage and the need to check the expiry date.
Australasian Society of Clinical Immunology and Allergy (ASCIA). Allergic rhinitis clinical update. 2020. Viewed 02 July 2021: https://www.allergy.org.au/images/stories/pospapers/ar/ASCIA_HP_Clinical_Update_Allergic_Rhinitis_2020.pdf
House of Representatives Standing Committee on Health, Aged Care and Sport. Walking the allergy tightrope. Addressing the rise of allergies and anaphylaxis in Australia. May 2020. Viewed 01 July 2021: https://parlinfo.aph.gov.au/parlInfo/download/committees/reportrep/024422/toc_pdf/Walkingtheallergytightrope.pdf
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