Clearing the air: managing allergic rhinitis

CaseJL, a 25-year-old female, has experienced recurrent nasal congestion, sneezing, rhinorrhea and itchy eyes every spring and early summer for two years. These symptoms persist almost daily during these seasons, disrupting her sleep and daily activities. Despite partial relief from several over-the-counter (OTC) oral antihistamines, she struggles with nighttime symptoms and avoids outdoor activities during peak pollen season, which affects her social and work life. She has no asthma history, drug allergies or pets, and lives in a pet-free building. Her father has similar seasonal symptoms, suggesting an atopic predisposition.BackgroundAllergic rhinitis (AR) affects approximately 20% of Canadians and is characterized by IgE-mediated inflammation, leading to rhinorrhea, nasal congestion, sneezing and often ocular symptoms such as itching, redness and watery eyes.1The burden of AR is well documented, with significant negative impacts on daily activities, sleep, work productivity, school performance and overall health-related quality of life.1,2 The condition often coexists with other atopic conditions, particularly asthma, which occurs in about 40% of AR patients.AR can be classified as seasonal or perennial based on trigger exposure patterns, although mixed patterns are common. The ARIA (Allergic Rhinitis and its Impact on Asthma) guidelines suggest classifying AR based on symptom duration and severity. Symptoms of intermittent AR last for less than four days a week or for fewer than four weeks at a time, while symptoms of persistent AR occur more than four days a week or for more than four consecutive weeks. AR severity is categorized as mild, moderate or severe, depending on the extent to which symptoms affect sleep and daily activities, or cause significant discomfort.3,4Diagnosis typically involves a careful history and either skin prick testing (SPT) or serum-specific IgE (sIgE) testing to confirm allergic sensitization.5,6 Both testing methods are considered equally valid for diagnosis and guiding immunotherapy decisions.Pharmacist’s RolePharmacists play a critical role in confirming AR and guiding treatment (Box 1), even without access to SPT or sIgE testing. Through targeted symptom-based assessments, pharmacists can differentiate AR from other conditions such as sinusitis or the common cold.7 By asking questions about the patient’s main symptoms, such as sneezing or nasal congestion, and identifying specific triggers such as pollen or pets, pharmacists can gain valuableinsights. Additionally, evaluating the nature of the nasal discharge—clear and watery, which suggests AR, versus purulent, which indicates an infection—helps confirm the diagnosis.Pharmacists must also exclude other potential conditions. For example, drug-induced rhinitis (e.g., from PDE5 inhibitors, oral contraceptives, ACE inhibitors, α-blockers, β-blockers) or infectious rhinitis can be identified by examining drug history and presenting symptoms such as facial pain, fever or discharge characteristics. When symptoms such as unilateral nasal issues or recurrent epistaxis arise, pharmacists should refer patients to a physician or nurse practitioner for further evaluation.7To assess the severity of AR, pharmacists can utilize tools like the Visual Analogue Scale (VAS; Figure 1) to measure symptom impact on daily life.7,8 Complementing this, validated tools like the CARAT questionnaire (available at https://www.new.caratnetwork.org/) can help screen for co-existing conditions, such as asthma, ensuring a comprehensive evaluation.9Integrated care and education are also pivotal. Pharmacists can initiate treatment as well as advise patients on strategies to avoid allergens, demonstrate the proper use of intranasal medications, and emphasize adherence to treatment.When symptoms suggest alternate diagnoses or fail to respond to standard treatment, pharmacists should refer patients for diagnostic testing. By combining these strategies, pharmacists can effectively manage AR and ensure patients receive high-quality care, even without traditional diagnostic tools.General treatment approach2,7,8Management of AR should follow an evidence-based, stepwise approach tailored to symptom severity and patient preferences. Initial treatment begins with comprehensive patient education and nonpharmacologic strategies, particularly allergen avoidance where feasible. Pharmacologic therapy (Table 1) forms the cornerstone of symptomatic treatment and is effective in most patients with proper implementation and adherence. The selection of specific agents depends on several factors including symptom type, frequency and severity, patient preferences and prior treatment response. For patients with an inadequate response to symptom-relieving pharmacotherapy or those seeking long-term modification of their allergic response, allergen immunotherapy (AIT) may be considered. This can be administered either subcutaneously (SCIT) or sublingually (SLIT). Regular follow-up is essential to assess treatment response, adjust therapy as needed, and monitor for comorbid conditions such as asthma.Nonpharmacologic strategies7,10,11Allergen avoidance is a cornerstone of allergic rhinitis management. Measures such as washing pets, using impermeable bedding covers and room air filtration can reduce allergen levels, but do not consistently alleviate symptoms, with benefits potentially taking weeks or months to manifest. Avoidance of tobacco smoke, both first- and second-hand, is essential, as smoke exacerbates symptoms. Patients should also limit exposure to other irritants such as insect sprays, air pollution, and fresh tar or paint fumes.12Intranasal saline irrigation has shown efficacy in reducing nasal symptoms and the need for pharmacologic therapy in children and adults. Either isotonic or hypertonic saline can be used; however, optimal dosing and frequency for these methods haven’t been established.13 In addition, where feasible, advise patients to use high-efficiency particulate air (HEPA) filters in the bedroom.12Pharmacologic optionsWhen allergen avoidance is impractical or insufficient, pharmacologic therapy should be initiated. For predictable symptom onset (e.g., seasonal allergies), medications should be started prophylactically before allergen exposure.2 Treatment efficacy should be assessed after two to four weeks of consistent use, with therapy modification if response is inadequate.Treatment selection is guided by several factors:Pattern of symptoms (intermittent vs persistent)Severity of symptoms (mild vs moderate-severe)Predominant symptoms (e.g., congestion vs rhinorrhea)Patient preferences and previous treatment experiencesMedication accessibility and cost (OTC vs. prescription).The 2024 Canadian Practice Parameter’s stepwise algorithm (Figure 2) provides a structured approach to treatment.2 Ultimately, it stresses that choosing the right therapy should involve shared decision-making between the patient and healthcare provider, carefully balancing the factors mentioned above.According to the 2020 ARIA guidelines, treatment strategies vary depending on whether AR is intermittent or persistent (Figure 3):8For intermittent AR with mild symptoms, second-generation oral antihistamines (OAH) are first-line treatment, although they have only a modest effect on nasal congestion. Intranasal antihistamines (INAH) offer quicker relief, but no single-entity products are currently available in Canada. When symptoms are moderate to severe, intranasal corticosteroids (INCS) are considered the most effective first-line therapy; if response is insufficient, a combination of INCS and INAH may be recommended.For persistent AR, regular use of INCS is the first-line treatment for mild symptoms. For more severe cases, INCS remain the first-line choice, with combination therapy (INCS + INAH) considered if the response to monotherapy is inadequate.Guidelines now state that first-generation OAH (e.g., diphenhydramine) are no longer recommended due to their side effect profiles, including potential cognitive impacts.2,8Case AnalysisJL’s symptoms align with seasonal AR, likely triggered by tree and/or grass pollen. Her moderate-to-severe presentation and limited response to OAH suggest the need for optimized treatment. Her prominent nighttime symptoms further highlight the impact on her quality of life, and the need for comprehensive management.Case recommendationTo reduce allergen exposure, recommend JL track pollen counts, limit outdoor activities during peak pollen times and keep windows closed. Suggest air conditioning, showering and changing clothes after outdoor exposure. Advise using intranasal irrigation with saline prn for symptom relief. While JL currently lives in a pet-free home, discuss the potential impact of future pet exposure, given her allergic predisposition. Additionally, consider the use of HEPA filters in her bedroom. Symptom tracking can further help JL identify specific triggers and refine avoidance strategies and treatment decisions.Prescribe an INCS for JL’s moderate-to-severe symptoms, emphasizing consistent use and proper spray technique. Advise initiating prophylactic treatment with the INCS before the start of pollen season.2Alternatively, for rapid relief, consider prescribing a combination INCS/INAH formulation.2,8 Discontinue her current OAH, as combining it with an INCS provides no additional benefit over an INCS alone.2,8Educate her on the chronic nature of AR and the importance of preventive and maintenance therapy during pollen season. Schedule follow-up in two to six weeks to assess treatment response and adherence. Explore allergen immunotherapy if symptoms persist. Plan for an annual review before the next allergy season to optimize her prevention strategy.SummaryPharmacists play an integral role in managing AR by selecting appropriate therapies, educating patients on medication administration, and monitoring symptom control. A combined approach involving pharmacologic and nonpharmacologic measures, along with regular follow-up, can significantly enhance outcomes for patients like JL.Dr. Nardine Nakhla is a practising community pharmacist and a faculty member at the University of Waterloo School of Pharmacy.References:Keith PK, Desrosiers M, Laister T, et al. The burden of allergic rhinitis (AR) in Canada: perspectives of physicians and patients. Allergy Asthma Clin Immunol 2012;8(1):7. doi:10.1186/1710-1492-8-7.Ellis AK, Cook V, Keith PK, et al. Focused allergic rhinitis practice parameter for Canada. Allergy Asthma Clin Immunol 2024;20(1):45. doi:10.1186/s13223-024-00899-3.Bousquet J, Van Cauwenberge P, Khaltaev N, Aria Workshop G, World Health O. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol 2001;108(5 Suppl):S147-334.Valero A, Ferrer M, Sastre J, et al. 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