[Full text] Overcoming barriers to intranasal corticosteroid use in patients with | IPRP
Nasal congestion is typically the most bothersome symptom, although rhinorrhea, postnasal drip, and ocular symptoms are also problematic. Together, these symptoms may adversely impact the quality of life, work productivity, sleep quality, and the ability to perform daily activities, particularly when uncontrolled. Practice guidelines recognize that INCSs are the most effective medications for controlling allergic rhinitis symptoms, including nasal congestion.
Available INCS products have comparable safety and efficacy profiles, but they differ in formulation characteristics and sensory attributes. Several barriers can impede the use of INCSs, including concerns about safety, misperceptions regarding the loss of response from frequent use, and undesirable sensations associated with intranasal administration.
Given the increasing number of INCSs available OTC, pharmacists can help allay these concerns by discussing treatment expectations, recommending INCS products with favorable formulation characteristics, and reviewing proper use and technique for the administration of the selected product.
These steps can help to foster a collaborative relationship between the patient and the pharmacist in the treatment of allergic rhinitis. Allergic rhinitis causes a variety of symptoms, including nasal congestion, sneezing, rhinorrhea, postnasal drip, nasal and ocular itching, and watery eyes. National surveys evaluating the burden of allergic rhinitis on affected individuals have found that approximately three-quarters of respondents consider nasal congestion to be bothersome or extremely bothersome.
As with the overall population of allergy sufferers, the majority of allergy symptoms experienced by children and adolescents are attributable to allergic rhinitis. Nasal congestion and other allergy symptoms have a notable impact on the quality of life, work productivity, sleep quality, the ability to perform daily activities, and medical costs, particularly when uncontrolled.
Allergic rhinitis is caused by immunoglobulin E IgE -mediated responses to inhaled allergens, which trigger a series of immunological and biochemical events that produce the clinical symptoms characteristic of the disorder Figure 1. The IgE binds to high-affinity Fc e RI receptors on the surface of nasal mast cells and circulating basophils, thereby sensitizing them to the offending allergen but not yet causing any symptoms.
Histamine activates H 1 receptors on sensory nerve endings to cause sneezing and nasal secretion, as well as both H 1 and H 2 receptors on mucosal blood vessels to cause nasal congestion. The leukotrienes act on receptors located on blood vessels and mucus glands to induce nasal congestion and mucus secretion. Nasal congestion is the most prominent symptom during the late-phase response.
Figure 1 Pathophysiological steps leading to allergic rhinitis symptoms. Based on Figure 2 of Pathophysiology of allergic and nonallergic rhinitis. Sin B, Togias A. Proc Am Thorac Soc. Multiple drug classes are available by prescription or OTC for the treatment of allergic rhinitis. Each set of practice guidelines recognizes that intranasal corticosteroids INCSs are the most effective medication class for controlling allergic rhinitis symptoms Table 1.
Table 1 Relative efficacy of medication classes by allergic rhinitis symptom, symptom frequency, and symptom severity. Otolaryngol Head Neck Surg. Oral antihistamines are effective against histamine-mediated allergic rhinitis symptoms, including rhinorrhea, sneezing, nasal itching, and ocular symptoms.
Oral antihistamines can be categorized into first-generation and second-generation agents. Use of the former eg, diphenhydramine and chlorpheniramine may be limited by sedation and mucosal dryness reflecting their ability to cross the blood—brain barrier and their anticholinergic effects, whereas second-generation agents eg, fexofenadine, cetirizine, levocetirizine, loratadine, and desloratadine exhibit selectivity for the H 1 receptor and minimal penetration across the blood—brain barrier.
Intranasal antihistamines are more effective than oral antihistamines for nasal congestion and at least as effective in controlling other allergic rhinitis symptoms 1 , 18 but, again, not as effective as INCSs 1 , 18 in providing relief of nasal symptoms. The most common side effects are bitter taste, epistaxis, headache, somnolence, and nasal burning.
Allergic rhinitis sufferers may experience ocular symptoms in addition to nasal congestion, as previously described.
Ocular antihistamines and mast cell stabilizers are also available and may be used to alleviate concomitant symptoms of allergic conjunctivitis. Combination therapy may be suggested when monotherapy does not adequately control allergic rhinitis symptoms. Options for patients already using an oral antihistamine include switching to an INCS or an intranasal antihistamine, or adding an oral decongestant. The latter approach, however, is associated with an increased risk of side effects.
Allergen-specific immunotherapy should be considered for patients who respond inadequately to available pharmacologic options. The most common specific fears with INCSs were habituation ie, loss of response due to frequent use , damage to mucous membranes, and side effects on other organs, whereas the most common fear with oral antihistamines was fatigue.
Table 2 Intranasal corticosteroids approved for allergic rhinitis a. Numerous studies of sensory perceptions and patient preferences for INCS products Table 3 38 — 46 have illustrated that patients can detect significant differences in sensory attributes and specify preference for one product over another.
High preference was shown across studies for several products, including fluticasone furoate, mometasone furoate, and triamcinolone acetonide aqueous spray. Finally, practice guidelines recognize that patient preference should be considered when recommending an INCS product. Many patients with allergic rhinitis attempt to self-manage their symptoms, and some will seek advice from pharmacists about choosing appropriate OTC products. Establishing the history of symptoms including the onset and temporal pattern, frequency, severity, and duration and evaluating the exacerbating or mitigating factors and the therapies that have already been tried are critical factors in helping the patient select the proper treatment for their symptoms.
Such patients should be referred to a physician for further evaluation and treatment. The American Pharmacists Association algorithm for the self-care of allergic rhinitis Figure 2 48 outlines a suggested approach to treatment recommendations for individuals with symptoms consistent with intermittent or persistent allergic rhinitis who are appropriate candidates for self-treatment. Exclusions for self-treatment include the presence of symptoms of nonallergic rhinitis; otitis media, sinusitis, bronchitis, or other infection; undiagnosed or uncontrolled asthma eg, wheezing and shortness of breath ; chronic obstructive pulmonary disease; or other lower respiratory disorder, and those who have experienced severe or unacceptable side effects of treatment.
Figure 2 Treatment recommendations for the self-care of allergic rhinitis. Handbook of Nonprescription Drugs. American Pharmacists Association; When possible, pharmacists should advise the use of nonpharmacological measures for the avoidance of known allergens and environmental control. For severe seasonal symptoms caused by outdoor allergens, such as pollen, measures might include staying inside air-conditioned buildings with windows and doors closed, particularly on sunny, windy days with low humidity.
For pet dander, measures include the avoidance or removal of animal allergens from the household. Pharmacists are often the primary source to provide medication counseling to patients with allergic rhinitis.
Several OTC INCS products are available, differing in terms of formulation, number of sprays required per dose, age range approved for use, and, to some extent, dosing frequency Table 2.
The characteristics of nasal spray formulations may influence patient preferences. Additives and preservatives can irritate nasal mucosal membranes, thereby influencing comfort of use, and can confer an unpleasant odor or taste.
Formulations containing phenylethyl alcohol may have a strong odor 43 and cause a feeling of dryness after administration. The pharmacist should clarify any potential misperceptions about INCSs that could be a barrier to their appropriate use when indicated and, after recommending a product, provide counseling regarding its proper use, treatment expectations, and instructions on when to consult a physician.
Moreover, patients should be instructed to continue using the INCS to maintain symptom control and not simply resort to a use-as-needed approach. For seasonal sufferers, treatment should be maintained during the allergy season. Counseling regarding proper medication self-administration, including priming the device and using proper spray technique, in turn, may improve adherence and facilitate better symptom control. Figure 3 General instructions for the use of intranasal corticosteroid sprays.
American Pharmacists Association; ; A number of prescription-to-OTC switches have occurred in the INCS category over the past several years, providing the general public with greater access to these products.
Additional prescription-to-OTC switches may occur in the future, which would expand access to options that allow easier or more preferable drug dosage delivery and self-administration. Given the prevalence of allergic rhinitis and symptom burden associated with the condition, many patients will opt for self-management and seek advice from pharmacists.
Pharmacists, in turn, must keep abreast of the latest clinical evidence related to the prevention and treatment of symptoms, including product efficacy and nuances in product formulation.
In addition to suggesting strategies for avoiding exposure to allergens and irritants, pharmacists are often asked for recommendations regarding which OTC products to use. Current practice guidelines recognize that INCSs are the most effective medications for controlling allergic rhinitis symptoms including nasal congestion, 1 , 2 , 18 which is consistently identified in national surveys as the most bothersome symptom. To implement successful INCS use, pharmacists may have to address and help resolve several barriers, including concerns about safety or loss of response due to frequent use, and recognize that patient preferences and formulation characteristics are important considerations.
All available INCS products have comparable efficacy and safety; 1 however, differences in sensory attributes, formulation characteristics, or spray bottle features may be important factors that influence patient adherence to therapy. By educating and collaborating with patients to set appropriate treatment goals, pharmacists can play an important role in improving symptom control and quality of life in patients with allergic rhinitis.
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