PHAR3812 – LECTURE OUTLINE – ALLERGIC RHINITIS
DR LORRAINE SMITH
lorraine.smith@sydney.edu.au
So far:
 Histamines and antihistamines
 Respiratory herbs
 Case study – Mrs Kearns
 Clinical interventions
 Asthma therapy and devices
Case 1: Mrs Kearns – Allergy and Asthma:
Learning Outcomes
 Have an understanding of the link between Asthma and Allergic Rhinitis
 Identify the different structure of antihistamines
 Understand the structural features likely to cause adverse effects with
antihistamines
 Demonstrate an ability to develop appropriate allergic rhinitis and asthma
management plans.
Mrs Kearns:
 Mrs Kearns, a healthy 78 year old female is visiting Sydney to attend her
grandson’s wedding. Active for her age, she is very relieved that she was able to
make the trip as a bout of tonsillitis almost forced her to cancel. She is 5 days in
to a 14-day course of erythromycin therapy.
 Yesterday she had an upset stomach and diarrhoea, (taking Lomotil for this). The
Lomotil has left her feeling a little tired and she also as a dry mouth and slightly
blurred vision.
 Last night she woke in the night coughing and this morning she has woken up
with red itchy, watery eyes and is sneezing frequently. She tells you that when she
lived in Sydney before she retired, she used to suffer from hayfever and her
doctor had treated her with Teldane.
 The antihistamines you have available are Claratyne (loratadine), Phenergan
(promethazine), Telfast (fexofenadine) and Polaramine (dexchlorpheniramine).
 She also presents her asthma card and asks for a Ventolin inhaler.
Your pre-work and tutorial activities:
 Possible causes of her cough
 Link between asthma and allergic rhinitis
 Structures of antihistamines, side effects, pros and cons of each
 Metabolism of erythromycin and interaction with Lomotil
 Devise an allergy and asthma action plan
 Counsel on correct use of antihistamines
 Counsel her on her management of AR (both if she stays in Sydney and goes
home)
Today – the CLINICAL PICTURE
 Causes
 Symptoms
 Triggers
 Classification
 Treatment options
Learning outcomes:
 State the known causes of allergic rhinitis
 Name the common symptoms and triggers of allergic rhinitis
 Describe the classification system of allergic rhinitis
 Describe and give examples of strategies for helping patients control symptoms
and triggers
Resources:
 Case 1: Mrs Kearns
 NAC Guide for Health Professionals: Allergic rhinitis and the patient with asthma
 Lecture notes
 Tutorial workshop notes
 References at the end of these lecture notes
What is allergic rhinitis?
An inflammatory disorder of the nasal mucosa, mediated by specific IgE antibodies in
response to allergen exposure (Bousquet, J., van Cauwenberge, Khaltaev & the WHO
Panel, 2001).
What is an allergy?

 Some common allergens:
 Dust mites
 Pollen / Grasses
 Animal dander
 Mould
Epidemiology:

 Australia has a high incidence of AR
 Prevalence increasing

Co-morbidities – related conditions:
 Asthma
 Eczema, Ottis media (middle-ear infection), Sinusitis, Conjunctivitis, Nasal
polyps
Classification of allergic rhinitis:
OLD:
Traditional classification
 Seasonal
 Perennial
 Based on when one is exposed to triggers
 Seasonal
 Spring/Autumn
 Perennial
 All year round
NEW:
Allergic Rhinitis and Its Impact on Asthma (ARIA) Classification
 Based around the symptoms
 Duration
 Severity (impact on quality of life)
Allergic Rhinitis
DURATION
Intermittent
Persistent
< 4 days/week
or < 4 weeks
> 4 days/week
and > 4 weeks
SEVERITY
Mild
All of the following:
Moderate-severe
One or more items:
•Normal sleep
•No impairment of daily
•Abnormal sleep
•Impairment of daily
activities, sport, leisure
activities, sport, leisure
•No impairment of work and
•Impaired work and
school
school
•No troublesome symptoms
•Troublesome symptoms
Mild
All of the following:
Moderate-severe
One or more items:
•Normal sleep
•No impairment of daily
•Abnormal sleep
•Impairment of daily
activities, sport, leisure
activities, sport, leisure
school
school
•No impairment of work and •Impaired work and
•No troublesome symptoms •Troublesome symptoms
Allergic Rhinitis symptoms:
1
2
3
4
5
6
7
8
What the AR person looks like:

 Swollen nose
 Nasal quality to the voice from continuous mouth breathing
Is is a cold or an allergy?
COLD
ALLERGY
Usually lasts up to a week
Sometimes mild fever
Usually no fever
Nasal discharge is thick and cloudy,
perhaps coloured
Nasal discharge is thin, clear & watery
Infrequent sneezing
Nasal congestion
Nasal or sinus congestion
Unlikely watery eyes
Sore throat
Itchy, rather than sore throat
Unlikely itchy eyes, nose, or throat
Itchy eyes, nose, throat
Sydney sufferers – symptom proportions:
Nasal =
Eye =
Throat =
Physical =
Do symptoms vary according to season?
Yes?
No”?
A little?
Triggers of allergens – proportions Sydney sufferers:
Classical =
Weather =
Chemical =
Other =
Do triggers vary according to season?
Yes?
No”?
A little? - eg:
Quality of life can be ++++ affected by allergic rhinitis:
Typical effects include -
What are the treatment options:
 Allergen control
 Medication
 Immunotherapy
But there is a problem …..
Commonly used treatments:
Antihistamine =
INC =
Saline or nasal sprays =
Oral decongestant =
Other =
Pharmacy practice – care of the patient….. what can you DO?
Just dispense a medication and give dose information? NO!!
Ask the patient:
 What are their specific
 What are their specific
 Collaboratively, work out some strategies to control symptoms and triggers
 Strategies must be
Strategies to help your patients control their hayfever:
Strategy
Explanation
Example
Useful?
Adherence –
Non-specific strategy for .
non specific
reinforcing the taking of
medication.
Adherence –
Strategies including dose [xxxxx] nasal spray – 1
Specific
amounts and daily
puff in each nostril
instructions. More
twice a day.
guidance given for
Take one tablet of
patient adherence.
[xxxx] a day until a
few days after feeling
better.
Avoidance
Non-specific strategy
with reference to the
trigger.
Practical
Action
Specific strategies with
additional instructions on
how, when or why to
achieve the goal.
Other
Strategies unable to be
classified above and more
applicable to general
health.
Close the windows
when the neighbor is
mowing.
Shower and wash hair
every night to remove
pollens.
Wash hands after
patting the cat.
Wear sunglasses to
prevent pollen getting
into eyes.
Personally relevant strategies for controlling AR make the difference for patient
control:
•
For symptoms:
•
For triggers:
There is a greater scope in optimizing strategies for managing AR triggers through
practical advice than for symptoms.
Encouraging adherence to meds will not help to control triggers.
Why is this important?
 Remember, only 35% of patients are adherent to allergic rhinitis medications
 Effective control of allergic rhinitis requires patient self-management strategies
 Pharmacists are the key point of contact for management of allergic rhinitis
Summary:




Allergic rhinitis affects approx. 20% of Australian population
Most patients do not seek professional help with the management of the condition
Most patients are not adherent to meds
Pharmacists intervention is best when:
 individual patient symptoms and triggers are identified
 practical strategies for controlling triggers are devised
 dose info and tips on remembering to meds for controlling symptoms are
devised
 This is done COLLABORATIVELY WITH THE PATIENT
Acknowledgements:
 Dr Celina Seeto, Schering Plough
 Tony Nguyen, Registered Pharmacist
 Lin Brown, Project Manager, Pharmacy Allergic Rhinitis Project
References:
Bousquet, J., van Cauwenberge, P., Khaltaev, N., & the WHO Panel. (2001). Allergic
rhinitis
and its impact on asthma. ARIA, in collaboration with the World Health
Organisation. Journal of Allergy and Clinical Immunology, 108, S1-S315.