Allergic Rhinitis: Counseling Points for Better Patient Outcomes

Felicia Spadini, MSN, NP-C
Friday April 01, 2016
Allergic rhinitis (AR) is a common health complaint that affects patients of all ages.1 Depending on the sensitizing agent, it may be seasonal or perennial. Typical triggers include molds, dust mites, animal dander, and pollen from trees, grasses, and weeds. AR may decrease quality of life significantly by causing missed work, school absences, disrupted sleep, and impaired cognition.2 It is also linked to multiple secondary complications such as sinusitis, acute otitis media, asthma, eczema, allergic conjunctivitis, attention-deficit/hyperactivity disorder, depression, and anxiety.3
 
Many OTC treatment options are available for AR, and yet it still accounts for 2.5% of all primary care visits.4 Clinicians should counsel patients that allergen avoidance is of utmost importance and equip them with methods for minimizing exposure. Clinicians should also advise patients of efficacious combination therapy and proper administration of medications to ensure full benefit. Prescription medications may be added or substituted for OTC therapy as needed, and patients should be referred to an allergy specialist when further evaluation and treatment are deemed appropriate.2
 
Symptoms
Symptoms of AR vary depending on the amount of exposure and the severity of the individual’s allergic reaction. Common complaints include sneezing, headache, cough, running/stuffy nose, sinus pressure, itching, eye and ear irritation, hives, and sore/itchy throat.1 Unlike viral or bacterial infections, there is no fever and the secretions are usually thin and clear. In addition, allergy symptoms frequently last longer than symptoms of acute illness.5
 
Patient Education for Prevention
A primary focus of patient education is the importance of avoiding exposure to allergens.2 Patients should be well prepared with multiple methods to eliminate or minimize indoor allergens such as mold, pet dander, and dust mites. For example, indoor mold may be controlled by eliminating excess moisture with dehumidifiers and frequently cleaning damp areas such as bathrooms with a bleach-and-water solution. Pets may be avoided altogether, or dander may be limited by using high-efficiency particulate arrestance (HEPA) air filters and allergen-resistant bedding. Dust mites may be reduced by avoiding carpet, frequently washing drapes and bedding, and wiping surfaces with a damp cloth or mop daily. Outdoor allergens, such as pollen from trees, grasses, and weeds are more difficult to control. Exposure may be decreased by showering before bed, keeping windows shut, and using an air conditioner.6
 
Treatment
The goal of treatment is to minimize or eliminate symptoms in order to decrease suffering and increase quality of life. Patients require counseling on which medications are most appropriate for their symptoms and which meds may be combined safely for better management. Additionally, patients should be provided guidance on alternate medical treatment options when medications fail to provide adequate relief or cause unwanted side effects.7
 
OTC Medications
The typical therapy for mild, intermittent symptoms is OTC oral antihistamines such as loratadine, cetirizine, fexofenadine, desloratadine, levocetirizine, and diphenhydramine. These medications are most effective at decreasing rhinorrhea, nasal itching, and sneezing. For moderate to severe or persistent symptoms, medications that shrink inflamed tissue and reduce nasal congestion are recommended. OTC intranasal corticosteroids (INCs) such as triamcinolone, fluticasone, mometasone, and budesonide are usually considered first for monotherapy.7
 
A suitable alternative for patients who do not tolerate INCs is the mast cell stabilizer cromolyn sodium.8 Other OTC options are decongestants such as oral pseudoephedrine and intranasal oxymetazoline. Decongestants may offer faster relief, but they are only suitable for short-term use.9
 
Prescription Medications
Leukotriene receptor agonists are effective treatment for patients with AR and asthma. They can also serve as an alternate medication for individuals who do not tolerate INCs.7 Intranasal antihistamines, such as Azelastine, offer effective treatment against rhinorrhea, nasal itching, and sneezing. Dymista is an intranasal antihistamine (azelastine)/corticosteroid (fluticasone) combination that some patients may prefer over taking multiple medications.10 Prescription medications may be added to the existing regimen or substituted for OTC medications as appropriate.

Proper Administration
In order to increase medication adherence, produce better results, and avoid secondary complications, patients should be educated regarding proper medication administration.7
 
Neti Pots and Saline Rinses
Patients should be advised to use saline rinses or neti pots before—rather than after—administering intranasal medications. These devices should be cleaned regularly to decrease the risk for contamination.11 Additionally, neti pot users should be instructed to use sterile or distilled water and avoid tap water unless it has been boiled and cooled.12
 
Antihistamines
Patients should be advised that they will generally feel fewer systemic anticholinergic adverse effects (eg, fatigue, dryness) by using second- or third-generation antihistamine formulations such as loratadine, cetirizine, fexofenadine, desloratadine, or levocetirizine rather than first-generation formulations such as diphenhydramine.7
 
Intranasal Medications
Instruct patients to clean the nose first and then apply intranasal medications with the head tilted slightly forward while directing the spray away from the septum and toward the temple. If a bloody nose develops secondary to intranasal medication administration, patients should be instructed to discontinue the medication for a few days. They should be counseled that INCs are designed for long-term use and take 3 to 7 days to reach full potential.10
 
Decongestants
Oral decongestants are not suitable for patients with uncontrolled hypertension or comorbid cardiac disease.9 Patients should be warned that decongestant sprays are designed for short-term use and that overuse may cause a serious rebound syndrome called medicamentosa.13
 
When to Refer
Referral to an allergy specialist is appropriate when a patient is experiencing severe symptoms, recurrent otitis media, coexisting asthma, recurrent sinusitis, or symptoms that are not responding to treatment. Patients may also be referred if they have chronic symptoms and do not want to take daily medications or if skin testing is necessary to confirm an unclear allergy diagnosis.14 Prompt referral for children is also warranted because subcutaneous immunotherapy (SCIT) has been proven to reduce the occurrence of subsequent allergic asthma development.15 SCIT has been shown to be an effective treatment for both allergic asthma and AR from inhaled allergens such as pollen, pet dander, and dust mites.16 Sublingual immunotherapy (SLIT) has been shown to be an effective treatment for pollen allergies.17
 
Subcutaneous Immunotherapy
The goal of SCIT is long-term resolution of allergies without the need for daily medications.16 Not all types of allergies respond to SCIT, however, and patients will require evaluation by an allergy specialist and allergen skin testing.18 This method generally takes 3 to 5 years to complete and consists of a buildup phase and a maintenance phase. It starts with an intense buildup phase, which involves 1 to 3 injections per week. The maintenance phase lasts for 3 to 5 years and generally consists of biweekly or monthly injections.17
 
Patients should be counseled that they may experience minor local reactions such as erythema, swelling, and itching. Additionally, there is a risk for severe reactions such as anaphylaxis. Therefore, patients will be monitored postinjection for approximately 30 minutes.18
 
Sublingual Immunotherapy
SLIT is a safer and more convenient (albeit somewhat less effective) alternative to SCIT. This method uses sublingual tablets or drops instead of subcutaneous injections. There is less risk for severe systemic reactions, so usually only the first dose must be given under medical supervision. Subsequent doses may be taken at home as long as the patient has access to an epinephrine autoinjector (EpiPen).16
 
As with SCIT, the duration of treatment is 3 to 5 years with drops or dissolvable tablets taken daily.16 Because SLIT is a relatively new form of treatment, studies are ongoing regarding optimal duration of both therapy and efficacy. Currently, SLIT is FDA-approved in the United States only for treatment of pollen allergies.19
 
Felicia Spadini is a board-certified nurse practitioner. She began her career as a registered nurse in emergency medicine and then worked in the cardiothoracic stepdown unit for several years as a certified diabetes resource nurse and a certified wound/skin care nurse. As a nurse practitioner, she has worked in the retail health care setting since graduating in 2013. Her passion is research and providing education for peers and patients alike.

References
  1. Long A, McFadden C, DeVine D, et al. Management of Allergic and Nonallergic Rhinitis (Evidence Report/Technology Assessment No. 54). AHRQ Publication No. 02-E024. Rockville, MD: Agency for Healthcare Research and Quality; 2002.
  2. D’Alonzo GE Jr. Scope and impact of allergic rhinitis. J Am Osteopath Assoc. 2002;102(6[suppl 2]):S2-S6.
  3. Cuffel B, Wamboldt M, Borish L, Kennedy S, Crystal-Peters J. Economic consequences of comorbid depression, anxiety, and allergic rhinitis. Psychosomatics. 1999;40(6):491-496.
  4. Bhattacharyya N. Incremental healthcare utilization and expenditures for allergic rhinitis in the United States. Laryngoscope. 2011;121(9):1830-1833. doi: 10.1002/lary.22034.
  5. Colds, allergies and sinusitis—how to tell the difference. American Academy of Allergy, Asthma & Immunology website. www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Libraries/EL-allergies-colds-allergies-sinusitis-patient.pdf. Published March 2012. Accessed March 14, 2016.
  6. Environmental trigger avoidance. American College of Allergy, Asthma & Immunology website. http://acaai.org/allergies/allergy-treatment/environmental-trigger-avoidance. Published 2014. Accessed March 14, 2016.
  7. Woods L, Craig TJ. The importance of rhinitis on sleep, daytime somnolence, productivity and fatigue. Curr Opin Pulm Med. 2006;12(6):390-396.
  8. Norris AA, Alton EW. Chloride transport and the action of sodium cromoglycate and nedocromil sodium in asthma. Clin Exp Allergy. 1996;26(3):250-253.
  9. Passàli D, Salerni L, Passàli GC, Passàli FM, Bellussi L. Nasal decongestants in the treatment of chronic nasal obstruction: efficacy and safety of use. Expert Opin Drug Saf. 2006;5(6):783-790.
  10. Berger WE, Meltzer EO. Intranasal spray medications for maintenance therapy of allergic rhinitis. Am J Rhinol Allergy. 2015;29(4):273-282. doi: 10.2500/ajra.2015.29.4215.
  11. Psaltis AJ, Foreman A, Wormald PJ, Schlosser RJ. Contamination of sinus irrigation devices: a review of the evidence and clinical relevance. Am J Rhinol Allergy. 2012;26(3):201-203. doi: 10.2500/ajra.2012.26.3747.
  12. Li H, Sha Q, Zuo K, et al. Nasal saline irrigation facilitates control of allergic rhinitis by topical steroid in children. ORL J Otorhinolaryngol Relat Spec. 2009;71(1):50-55. doi: 10.1159/000178165.
  13. Graf P. Rhinitis medicamentosa: a review of causes and treatment. Treat Respir Med. 2005;4(1):21-29.
  14. White P, Smith H, Baker N, Davis W, Frew A. Symptom control in patients with hay fever in UK general practice: how well are we doing and is there a need for allergen immunotherapy? Clin Exp Allergy. 1998;28(3):266-270.
  15. Jacobsen L, Niggemann B, Dreborg S, et al; The PAT Investigator Group. Specific immunotherapy has long-term preventive effect of seasonal and perennial asthma: 10-year follow-up on the PAT study. Allergy. 2007;62(8):943-948.
  16. Cox L, Nelson H, Lockey R, et al. Allergen immunotherapy: a practice parameter third update. J Allergy Clin Immunol. 2011;127(suppl 1):S1-S55. doi: 10.1016/j.jaci.2010.09.034
  17. Norman PS. Immunotherapy: 1999-2004. J Allergy Clin Immunol. 2004;113(6):1013-1023.
  18. Roy SR, Sigmon JR, Olivier J, Moffitt JE, Brown DA, Marshall GD. Increased frequency of large local reactions among systemic reactors during subcutaneous allergen immunotherapy. Ann Allergy Asthma Immunol. 2007;99(1):82-86.
  19. Amar SM, Harbeck RJ, Sills M, Silveira LJ, O'Brien H, Nelson HS. Response to sublingual immunotherapy with grass pollen extract: monotherapy versus combination in a multiallergen extract. J Allergy Clin Immunol. 2009;124(1):150-156.e1-5. doi: 10.1016/j.jaci.2009.04.037.


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