Clinical tips: seasonal allergic rhinitis


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Pharmacists can help clear up a lot of the myths around hayfever, writes Jarrod McMaugh

Seasonal rhinitis may well be considered a pharmacist’s “bread and butter” – from the peaks in spring and autumn, to the less-hectic winter months, hayfever and upper respiratory allergies would be part of a pharmacist’s activities on most days.

Despite this, there are a number of myths and misconceptions that perpetuate amongst the public and even health professionals about the nature and treatment of this group of symptoms.

Importantly, while these may all be seen as annoying conditions, they can cause significant morbidity for some individuals. Getting treatments right and addressing misunderstandings should be an integral part of the “bread and butter” interactions we have with our clients.

Allergy and Atopy

Atopy is the predisposition to have an allergy, and is often used to describe the grouping of two or three common conditions; eczema, hayfever, and asthma.

Importantly, atopy may predict the presence of further allergic-type responses when exposure to triggers are increased. For instance, a person with hayfever may experience symptoms of asthma in extreme circumstances such as thunderstorms.

Allergy is – at its core – a ‘misguided’ defence mechanism designed to prevent the noxious impact of irritants that inadvertently cause some level of harm. This harm may be minimal (itch, redness) or severe (oedema affecting organ function, systemic inflammation).

Seasonal allergies, rhinitis, hayfever etc are at the “minimal” end of the spectrum, but can certainly have a large impact on the individual’s experience and quality of life.

Treatment Escalation

For classic hayfever and associated conditions, there is an accepted treatment escalation based on the individual’s response to treatment. The first step is to use an antihistamine appropriate to the presenting symptoms. This may include topical (eye drops, nasal delivery) or systemic antihistamines depending on the extent of these symptoms.

Second-line treatment involves the addition of a corticosteroid to further suppress symptoms. Intranasal corticosteroids have been available without prescription for some time, and provide excellent symptom control for nasal symptoms, and can improve the impact of antihistamines on nasal and ocular symptoms.

For patients with severe and/or disruptive symptoms, systemic corticosteroids may be indicated – a single intramuscular corticosteroid injection is not uncommon for people who experience these severe symptoms. Pharmacists should be aware that a referral will be useful for those individuals who are not achieving significant symptom control.

Additional treatments: While anaphylaxis and asthma are beyond the scope of this article, it should be noted that seasonal allergies and atopy can impact on significantly on people who have other allergic conditions. All people who experience asthma should be counselled on trigger factors (which may include pollen, for instance) and how to alter their asthma plan based on seasonal variation.

For some upper respiratory allergies, there are some new treatments available to desensitise the individual. Dust mite allergen is available as an oral tablet course for people who have sensitivity to dust mites.

Misconceptions

As with most health conditions and treatments, there are a number of misconceptions that pharmacists may encounter. Addressing these misconceptions can improve the outcomes for patients, and may save the health system resources due to poor outcomes and utilisation of treatments options.

Antihistamines should be “cycled”

Individuals who experience hayfever (and not a few health professionals) have a misconception that people can become desensitised to antihistamines. Individuals may be advised to change from one agent to another each year to prevent this desensitisation. There is no evidence that this occurs, and variation in symptoms from season to season is to be expected, based on the pollen count and other factors that influence severity of symptoms.

While changing from one agent will not cause any harm, there is unlikely to be an improvement in symptoms. The correct course of action is to escalate treatment by adding a second agent (such as an intranasal corticosteroid) and maintain oral antihistamines (regardless of which one is being used).

Intranasal corticosteroids are harmful

Intranasal corticosteroids do not have a systemic affect – people may worry that intranasal corticosteroids should not be used long term (or at all), but this is not the case, since long term use does not have a systemic effect or suppress the normal production of endogenous cortisone.

Nasal Sprays – aim high

If you observe an individual who is using a nasal spray, chances are they will aim the device straight up. This will ensure that the medication is delivered to the bridge of the nose, and has little effective impact on the sinuses or turbinates.

We want to treat the mucosal membranes – to ensure this happens, the nasal spray needs to be aimed in their general direction! Pharmacists should advise people to aim the spray more towards the ear than the bridge of the nose to ensure correct distribution of intranasal medication.

Saline lavage causes infection

Saline lavages are an effective way of removing irritants such as pollen from the nasal passages and sinuses. Using these prior to intranasal medications can be an effective method of improving the effect of these medications.

When used according to the instructions, saline lavages are very safe and will not introduce infection into the sinuses. Despite this, there has been some bad press due to the people not pre-boiling the water they use to reconstitute the saline sachets.

As with all medications, ensuring the individual uses the medications as per the instructions will ensure correct and safe outcomes.

Complications

Seasonal allergies, hayfever, allergic rhinitis et al are rarely life-threatening conditions, but there are a number of complications of these conditions that can impact on the quality of life of the individual.

This includes sleep disruption, susceptibility to asthma exacerbations, damage and minor infections of the skin due to scratching, and bacterial conjunctivitis due to scratching/rubbing of the eyes.

Offering best treatment

The role of the pharmacist is clear in seasonal allergy – ensure that the individual is availing themselves of the right combination of products for their symptoms; escalate (rather than replace) treatments based on response; address misconceptions that contribute to poor compliance; and identifying people who have symptoms are so severe or disruptive that a referral for additional treatment is necessary.

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.

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