the role of the pharmacist in allergic rhinitis management · 2019-09-24 · the role of the...

The Role of the Pharmacist in Allergic Rhinitis Management

Date of preparation: November 2018

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CEM/FF/0006/18

Disclaimer

Please check the prescribing information relevant to your country

The whole deck need not be used – sections/slides can be removed to reflect the needs of your audience and time allowed, however, when presenting efficacy data the appropriate safety data must be shown to ensure fair balance and scientific integrity of the presentation. The questions asked in the presentation are to make the session interactive, no data from the answers given by the audience to those questions will be collected by GSK

If you require access to your local prescribing information or have any questions, please contact your local GSK Medical Advisor

Objective

• To support pharmacists in managing patients with allergic rhinitis

What is the Role of the Pharmacist in Managing Patients with Allergic Rhinitis?

1. Cote L, et al. Can Fam Physician 2013;59:e413–e420. 2. Kuehl BL, et al. SAGE Open Med 2015;3: 2050312115595822. 3. May JR, Dolen WK. Clin Ther 2017;39:2410–2419. 4. Bousquet J, et al. Allergy 2004;59:373–387.

• It may be easier for a patient to approach a pharmacist rather than a doctor.

• Pharmacists are trained to optimise medicines management, including drug interactions and contraindications.1-3

Pharmacists can provide information, education and advice:1-4

• Identification of allergic rhinitis• Discussion of symptoms and severity• Allergen avoidance• Medication adherence

More than 60% of patients with allergic rhinitis talk to their pharmacist about medication2

© 2016 GSK Group of Companies

The Role of the Pharmacist in Allergic Rhinitis ManagementPart 1 – Scientific Discussion



CEM/FF/0006/18

An Overview of Allergic Rhinitis

Contents

• An overview of allergic rhinitis– Definition– Symptoms– Burden– Pathophysiology

• Management– Asking patients about their symptoms– Allergen avoidance – Pharmacological treatment– Nasal sprays– Referral– Patient education

What is allergic rhinitis?

• Rhinitis is defined as an inflammation of the lining of the nose and is characterised by nasal symptoms including:1, 2

– Anterior or posterior rhinorrhoea (the nasal cavity is filled with mucus fluid)

– Sneezing– Nasal blockage/congestion and/or itching

of the nose

• Rhinitis is also often associated with ocular symptoms1, 2

• For a diagnosis of rhinitis, these symptoms must occur during ≥2 consecutive days for >1 hour on most days1

• Allergic rhinitis is caused by an immune response against certain allergens1

1. Bousquet J, et al. Allergy 2008;63(Suppl 86):8–160. 2. Brozek JL, et al. J Allergy Clin Immunol 2017;140:950–958.

Healthy nasal cavity

Nasal cavity of a person with rhinitis

Rhinorrhoea

Dripping mucus

© 2018 GSK Group of Companies

The Most Common Symptoms of Allergic Rhinitis are:1

• Blocked nose• Runny nose• Itchy nose • Sneezing• Sinus pressure• Postnasal drip• Snoring

• Itchy/red eyes• Watery eyes

• Sore throat• Itchy palate

• Cough• Wheeze

• Headache• Nocturnal

wakening

The same results were first published in 1. Canonica GW, et al. Allergy 2007;62(Suppl 85):17–25. This graphic has been independently created by GSK from the original data.

Allergic Rhinitis is a Serious Problem

1. Zuberbier T, et al. Allergy 2014;69:1275–1279. 2. Bousquet JP, et al. Int Arch Allergy Immunol 2013;160:393–400. 3. Canonica GW, et al. Allergy 2007;62(Suppl 85):17–25. 4. Yoo K, et al. Allergy Asthma Immunol Res 2016;8:527–534.

• Poor sleep quality1-3

• Fatigue3

• Decreased work/school performance1, 2

• High healthcare resource use1, 4

• Irritability3

• Altered mood3

• Lost productivity1

Question

• How many patients who consult you suffer with allergic rhinitis?

Question

• How do you educate patients suffering from allergic rhinitis?

Management of Allergic Rhinitis

Important Questions to Ask Your Patients…1

• Symptoms can be intermittent or persistent (rather than ‘seasonal’ or ‘perennial’)• Consider other causes for their symptoms, e.g. viral infections or colds

1. The same results were first published in Bousquet J, et al. Allergy 2004;59:373–387. This graphic has been independently created by GSK from the original data.

• Primary symptoms: look out for rhinorrhea, sneezing, itchy nose, nasal blockage and eye symptoms

• Ask about wheezing, shortness of breath, pain in the face or ears

!

• Has a doctor ever diagnosed allergic rhinitis?

• Is there anything that makes their symptoms worse?

• How long have they had their symptoms?• Are their symptoms there all the time or do they come and go?

• Have they tried any medication for their symptoms?• Have they got any other medical conditions and are they taking any other

medication?

Ask Them About Potential Allergens or Triggers…

Indoors1-3

• Fungi/moulds• Pets• House dust mites• Perfumes

Outdoors1-3

• Pollens from:• Grasses• Flowering plants• Trees

Environmental pollution1, 2, 4

• Tobacco smoke• Traffic fumes• Wind/dust storms

Occupational exposures4

• Toxic gases• Particulate matter

1. Smith L, et al. Health Expect 2014;17:154–163. 2. Green RJ, et al. Prim Care Respir J 2007;16:299–303. 3. Meltzer EO, et al. J Allergy ClinImmunol Pract 2017;5:779–789. 4. Hajat S, et al. Am J Epidemiol 2001;153:704–714.

Make it Easy For Them to Tell You How Their Allergic Rhinitis Makes Them Feel

• Using a visual analogue scale can be useful for patients to show the severity of their symptoms and which are the most troublesome to them1, 2

1. The same results were first published in Texeira RUF, et al. Braz J Otorhinolaryngol 2011;77:473–480. This figure has been independently created by GSK from the original data; 2. Klimek L, et al. Allergol J Int 2017;26:16–24.

0 1 2 3 4 5 6 7 8 9 10

VISUAL ANALOGUE SCALE

MILD MODERATE SEVERE

Treatment Should be Guided by Symptom Frequency and Severity1

The same results were first published in 1. Bousquet J, et al. Allergy 2004;59:373–387. This figure has been independently created by GSK fromthe original data.

Mild:• Normal sleep• No impairment of daily activities, sport or leisure • Normal work and school• No troublesome symptoms

Moderate-severe: ≥1 of the following:• Abnormal sleep• Impairment of daily activities, sport or leisure • Impairment of work and school activities • Troublesome symptoms

Persistent>4 days/week and >4 weeks

Intermittent≤4 days/week or ≤4 weeks

Symptom frequency

Symptom severity

Allergen Avoidance: Seasonal Trends

1. Bousquet J, et al. Allergy 2015;70:1372–1392. 2. Demoly P, et al. BMC Pulm Med 2016;16:85. 3. The same results were first published in Church DS, et al. Clinical Pharmacist, Vol 8, No 8, online DOI: 10.1211/CP.2016.20201509 Downloadable free pollen calender from: https://www.streme.co.uk/news-single/free-printable-pollen-calendar/. Accessed February 2018. This is a tentative calendar, the actual pollen count may vary depending on different factors

Trees Grasses

Crops

Weeds

March April May June July Aug Sept

March

April May June July Aug Sept

Hazel



Yew

Elm

Alder

Willow

Ash

Poplar

Birch

Oak

Pine

Plane

Lime

Dock

Nettle

Plantain

Mugwort

Oil & Rapeseed

Including: Rye,Timothy& Cocksfoot

March

Pollen season releasePeak period for pollen release

• Awareness of pollen counts and the start of the pollen season is important1, 2

• Symptoms due to house dust mites can occur throughout the year, although this may be lower during the summer months2, 3

Allergen Avoidance: Lifestyle Changes

1. Bousquet J, et al. Allergy 2004;59:373–387. 2. Scadding GK, et al. Clin Exp Allergy 2017;47:856–889.

• Stop smoking1

• Avoid passive smoking1

• Cover mattress and bedclothes in allergen-proof fabric2

• Use mite killer on carpets and soft furnishings2

• Minimise outdoor activities during early morning and early evening2

• Avoid mowing the grass2

• Avoid drying washing outside when pollen count is high2

• Take a shower after being outside when pollen is high2

• Keep house and car windows shut2

• Avoid going outdoors during or after thunderstorms2

Guidelines for the Pharmacological Management of Allergic Rhinitis1

Non-sedating OAHor INAHor decongestantor intranasal cromone

Non-sedating OAHor INAHand/or decongestantor INCSor intranasal cromone

Refer to physician

INAH: intranasal antihistamine; INCS: intranasal corticosteroid; OAH: oral antihistamineThe same results were first published in 1. Bousquet J, et al. Allergy 2008;63(Suppl 86):8–160. This figure has been independently created by GSK from the original data.

Mild intermittent

Mild persistent or moderate-severe

intermittent

Moderate-severe persistent

Symptoms of allergic

rhinitisIf no

improvement

Check for Comorbidities as These are Common in People with Allergic Rhinitis

1. Passali D, et al. Asia Pac Allergy 2018;8:e7. 2. Cingi C, et al. Clin Transl Allergy 2017;7:17. 3. Kim BR, et al. J Dermatol 2018;45:10–16. 4. Heck S, et al. npj Prim Care Respir J 2017;27:28. 5. Bozek A. Drugs Aging 2017;34:21–28.

• Asthma1, 2

• Sinusitis1, 2

• Conjunctivitis1, 2

• Otitis media2

• Nasal polyposis1, 2

• Eczema2

• Food allergy2

• Throat and laryngeal disorders2

• Sleep problems2

• Many patients with chronic diseases also have allergic rhinitis3, 4

• A thorough medicines review can help patients to manage treatments for all their conditions more effectively and safely5

Overview of Allergic Rhinitis Pharmacotherapy1

Therapy class Mode of action Targeted symptoms

Intranasal corticosteroids Decreases influx of inflammatory cells and mediator release

OcularNasopharyngeal itchingSneezingRhinorrhoea

Oral/intranasal antihistamines

Blocks H1 receptors and effects of histamine (smooth muscle constriction, mucus secretion, vascular permeability)

Nasopharyngeal itchingSneezingRhinorrhoea

Intranasal corticosteroid plus antihistamines

Blocks H1 receptors and effects of histamine (smooth muscle constriction, mucus secretion, vascular permeability)

OcularNasopharyngeal itchingSneezingRhinorrhoea

Decongestants Acts on adrenergic receptors, causing vasoconstriction in nasal mucosa and decreased inflammation

Rhinorrhoea

Intranasal cromolyn May inhibit mast cell degranulation Nasopharyngeal itchingSneezingRhinorrhoea

Intranasal anticholinergics Blocks acetylcholine receptors Rhinorrhoea

Leukotriene receptor antagonists

Blocks leukotriene receptors OcularRhinorrhoeaSneezing

The same results were first published in 1. Sur D, et al. Am Fam Physician 2015;92(11):985–992. This table has been independently created by GSK from the original data.

Second-generation Oral H1-antihistamines (OAHs)

1. Brozek JL, et al. J Allergy Clin Immunol 2017;140:950–958. 2. Bousquet J, et al. Allergy 2008;63(Suppl 86):8–160. 3. Bousquet J, et al. Allergy2004;59:373–387.

ARIA guidelines1, 2

• Seasonal allergic rhinitis in children and adults• Second-generation OAH monotherapy • Second-generation OAH + INCS in patients with ocular symptoms

• Perennial allergic rhinitis in children and adults• INCS monotherapy preferable to INCS + OAH• Second-generation OAH may be preferable to an LTRA

Second-generation OAHs:2, 3

• Can be dosed once daily• Poorly effective on nasal congestion• Are mostly non-sedating

INCS: intranasal corticosteroid; LTRA: leukotriene receptor antagonist; OAH: oral antihistamine

Intranasal Corticosteroids (INCSs)

1. Brozek JL, et al. J Allergy Clin Immunol 2017;140:950–958. 2. Bousquet J, et al. Allergy 2008;63(Suppl 86):8–160. 3. Derendorf H, Meltzer EO. Allergy 2008;63:1292–1300.

ARIA guidelines1

• Seasonal or perennial allergic rhinitis in adults and children• INAH + INCS rather than INAH monotherapy• INCS monotherapy rather than INAH monotherapy

INCSs:• One of the most effective drugs (and a first-line treatment option) for

the treatment of allergic rhinitis2

• Systemic corticosteroid-related adverse effects much less likely than with oral corticosteroids3

INAH: intranasal antihistamine; INCS: intranasal corticosteroid

Intranasal H1-antihistamines (INAHs)

1. Brozek JL, et al. J Allergy Clin Immunol 2017;140:950–958. 2. Horak F, et al. Curr Med Res Opin 2006;22:151–157. 3. LaForce CF, et al. AnnAllergy Asthma Immunol 2004;93:154–159.

ARIA guidelines1

• Seasonal or perennial allergic rhinitis in adults and children• INAH + INCS rather than INAH monotherapy• INAH or OAH

INAHs:• Superior to OAHs for rhinitis symptoms and nasal congestion2

• Rapid onset of action (<15 minutes)2

• Can be effective in patients where OAH therapy has been unsuccessful3

INAH: intranasal antihistamine; INCS: intranasal corticosteroid; OAH: oral antihistamine

Leukotriene Receptor Antagonists (LTRAs)

1. Brozek JL, et al. J Allergy Clin Immunol 2017;140:950–958. 2. Brozek J, et al. J Allergy Clin Immunol 2010;126:466–476. 3. Scadding GK, et al. Clin Exp Allergy 2017;47:856‒889.

ARIA guidelines1, 2

• Montelukast recommended for treatment of allergic rhinitis• Seasonal allergic rhinitis

• OAH rather than LTRA• INCS rather than LTRA

• Perennial allergic rhinitis• OAH rather than LTRA

LTRAs:3

• Add to INCS + INAH if poor treatment response, catarrh is present or the patient has asthma

LTRA: leukotriene receptor antagonist; OAH: oral antihistamine

Intranasal Cromones

1. Bousquet J, et al. Allergy 2008;63(Suppl 86):8–160.

ARIA guidelines1

• Recommended in the treatment of allergic rhinitis

Intranasal cromones:1

• Mechanism of action unclear• Only modestly effective and effect lasts only

a short time

• Excellent safety profile

Decongestants

1. Bousquet J, et al. Allergy 2008;63(Suppl 86):8–160.

ARIA guidelines1

• Intranasal decongestants may be used for a short period of time in patients with severe nasal obstruction

• Oral decongestants (±OAHs) may be used in the treatment of allergic rhinitis in adults, but side effects are common

Intranasal decongestants:1

• Rhinitis medicamentosa is a rebound phenomenon occurring with use >10 days

OAH: oral antihistamine

Check That Patients Are Using Their Intranasal Therapy Correctly

• Get them to show you how they use their intranasal spray1

• It’s important not to spray the nasal septum or to spray into the back of the throat1, 2

• Explain its importance in the effectiveness of their treatment1

• Make sure they read the package insert for their particular product1

1. May JR, Dolen WK. Clin Ther 2017;39:2410–2419. 2. Church DS, et al. Clinical Pharmacist, Vol 8, No 8, online DOI: 10.1211/CP.2016.20201509

1. Choose any position they feel comfortable with1

2. Shake the bottle well3. Look down4. Use the opposite hand for each nostril5. Put the nozzle just inside the nostril, aiming

towards the outside wall6. Squirt once or twice (depending on product

instructions)

Important Features of Intranasal Sprays

1. Meltzer EO. Ann Allergy Asthma Immunol 2007;98:12–21. 2. Keith PK, et al. Allergy Asthma Clin Immunol 2012;8:7. 3. Marple BF, et al. Otolaryngol Head Neck Surg 2007;136:S107–S124. 4. Petty DA, Blaiss MS. Am J Rhinol Allergy 2013;27:510–513.

Taste2, 3 Smell2

Spray volume1, 2, 4

(likelihood of running down the back of the throat or out

of the nose)

Ease of use1, 3

Adverse effects on the nasal tissues2

(dryness)

Studies have shown that a number of features of intranasal sprays can impact on a patient’s likely compliance1

Question

• What do you think are the most troublesome features of nasal sprays?

Check Your Patients’ Medication Adherence

Check their prescription fills – are they overusing their medication?

Talk to them about how they feel about their medication – do they believe they need it?2

How satisfied are they with its effectiveness and side effects?2, 3

Are they concerned about particular side effects, e.g. with steroids?1, 4

Would they prefer a different formulation, e.g. oral vs. intranasal?2, 4

Do they feel their medication costs too much?1, 2

1. Meltzer EO, et al. J Allergy Clin Immunol Pract 2017;5:779–789. 2. Green RJ, et al. Prim Care Respir J 2007;16:299–303. 3. Frati F, et al. Med Sci Monit 2014;20:2151–2156. 4. Hellings PW, et al. Clin Transl Allergy 2012;2:9.

Adherence with allergic rhinitis medication is reported as around 65%1

Question

• When would you refer a patient to a physician?

When to Refer Your Patient to A Physician1

1. Bousquet J, et al. Allergy 2004;59:373–387.

Severe and persistent symptoms

Pregnancy

Suspicion of asthma Symptoms of

infection

Troublesome side effects Unresponsive

symptoms

Education – Improve Your Patients’ Understanding of Allergic Rhinitis and Its Treatment

1. Asthma and Allergy Foundation of America. Rhinitis (nasal allergies). http://www.aafa.org/page/rhinitis-nasal-allergy-hayfever.aspx. 2. Hellings PW, et al. ClinTransl Allergy 2012;2:9. 3. Meltzer EO, et al. J Allergy Clin Immunol Pract 2017;5:779–789. 3. May JR, Dolen WK. Clin Ther 2017;39:2410–2419.

They may confuse their symptoms with having a cold1

Discuss the roles of the different types of

medication2, 3

Explain what to expect from treatment, e.g. how quickly symptoms might

improve4

Reproduced with permission from iStock

Goal Setting: Empower Your Patients to Take Responsibility for Their Own Health

1. Smith L, et al. Health Expect 2014;17:154–163. 2. Demoly P, et al. Allergy Asthma Clin Immunol 2015;11:8. 3. O’Connor J, et al. Pat Educ Couns 2008;70:111–117. 4. Meltzer EO, et al. J Allergy Clin Immunol Pract 2017;5:779–789. 5. Hellings PW, et al. Clin Transl Allergy 2012;2:9. 6. Bousquet J, et al. Allergy 2004;59:373–387.

Talk to your patient about their allergic rhinitis symptoms and triggers1

Offer follow-up and monitor their symptoms, the safety of their medication and their satisfaction4, 6

Ask what matters most to them about treatment, e.g. rapid response, complete symptom resolution, etc.4,5

Identify their goals, e.g. minimising specific symptoms1-3

Discuss how they can achieve this: practical measures, types of treatment, etc.1-3

Summary

• Allergic rhinitis is a serious condition, with many troublesome symptoms1

• AR affects all aspects of daily life, including sleep, work and school performance and mood1-3

• Pharmacists can play a key role in managing allergic rhinitis, including:4-13

– Asking about their symptoms and their impact, and any potential triggers

– Giving advice regarding the avoidance of symptom triggers

– Discussing and educating patients about pharmacotherapy options, including oral and intranasal second-generation H1-antihistamines and intranasal corticosteroids

– Understanding potential issues with nasal sprays, checking nasal spray technique and treatment adherence

– Empowering patients to manage their condition effectively

1. Canonica GW, et al. Allergy 2007;62(Suppl 85):17–25. 2. Zuberbier T, et al. Allergy 2014;69:1275–1279. 3. Bousquet JP, et al. Int Arch Allergy Immunol 2013;160:393–400. 4. Bousquet J, et al. Allergy 2004;59:373–387. 5. Scadding GK, et al. Clin Exp Allergy 2017;47:856–889. 6. Brozek JL, et al. J Allergy Clin Immunol 2017;140:950–958. 7. Bousquet J, et al. Allergy 2008;63(Suppl 86):8–160. 8. May JR, Dolen WK. Clin Ther 2017;39:2410–2419. 9. Church DS, et al. Clinical Pharmacist, Vol 8, No 8, online DOI: 10.1211/CP.2016.20201509. 10. Meltzer EO. Ann Allergy Asthma Immunol 2007;98:12–21. 11. Green RJ, et al. Prim Care Respir J 2007;16:299–303. 12. FratiF, et al. Med Sci Monit 2014;20:2151–2156. 13. Hellings PW, et al. Clin Transl Allergy 2012;2:9.

The Role of A Pharmacist in Allergic Rhinitis ManagementPart 2 – Case Studies



CEM/FF/0006/18

Case Study 1

• Daniel is a 14-year-old boy living in the UK

• He has had nasal symptoms of itching, sneezing and runny nose since the age of 11 years, starting in March each year and persisting through to late August

• Daniel is free from symptoms at other times of the year

Meet Daniel

Reproduced with permission from iStockThis is a hypothetical case study reflective of real-world evidence.

Question

• What do you think is the cause of Daniel’s problem?

Pollen Calendar for the UK

Downloadable free pollen calendar from: https://www.streme.co.uk/news-single/free-printable-pollen-calendar/. Accessed February 2018This is a tentative calendar, the actual pollen count may vary depending on different factors

Trees Grasses

Crops

Weeds


March


Hazel



Yew

Elm

Alder

Willow

Ash

Poplar

Birch

Oak

Pine

Plane

Lime

Dock

Nettle

Plantain

Mugwort

Oil & Rapeseed

Including: Rye,Timothy& Cocksfoot

March

Pollen season release

Peak period for pollen release

Question

• What advice would you give to Daniel or his parents?

Case Study 1

• In early June, Daniel’s parents were worried as his symptoms were troublesome: he was constantly sniffing and his nose was blocked

• Daniel was irritable and not concentrating at school

• Examinations were due to begin soon

Daniel


Seasonal Allergic Rhinitis – School and Examination Performance1

• Case-control analysis in the UK of 1834 students (age 15–17 years; 50% girls) sitting for national examinations.

• Between 38% and 43% of students reported symptoms of seasonal allergic rhinitis on any 1 of the examination days.

• There were 662 cases (36% of students) and 1172 controls. After adjustment, cases were significantly more likely than controls to have had allergic rhinitis symptoms during the examination period, to have taken any allergic rhinitis medication or to have taken sedating antihistamines.

• Conclusion: current symptomatic allergic rhinitis and rhinitis medication use are associated with a significantly increased risk of unexpectedly dropping a grade in summer examinations.

1. Walker S, et al. J Allergy Clin Immunol 2007;120:381–387.

Question


Case Study 1

• Daniel’s mother took him to a physician

• The doctor prescribed an intranasal antihistamine

Daniel


Case Study 1

• Daniel’s symptoms were only partially modified by intranasal antihistamines

– He was sneezing less frequently and not sniffing so much but his blocked nose had not improved

• He was still irritable and not sleeping well, tired in the morning, and feeling generally unwell

• He was missing school due to his symptoms

Daniel


Question


Case Study 1

• Daniel was taken back to the doctor by his mother after 2 weeks

– He had an important tennis tournament coming up – His mother also wanted Daniel’s symptoms to be

better controlled at school

• The doctor changed Daniel’s treatment to an intranasal corticosteroid, however, Daniel’s mother was worried about side effects

Daniel


Summary of Allergic Rhinitis Pharmacological Therapy Guidelines for Adults and Adolescents

50

INS alone OAH / OAHs + INS INAH + INS INAH alone

ARIA (global)1 • SAR and PAR: use first-line

• SAR: use first-line • SAR: option first-line• PAR: use first-line

• SAR: use INS rather than INAH

Joint Task Force on Practice Parameters (US)2

• SAR: first-line for initial treatment in patients aged ≥12 years

• SAR: no clinical benefit vs. INCS alone

• SAR: option for first-line treatment of moderate-severe SAR

• No recommendation

American Academy of Otolaryngology -Head and Neck Surgery (AAOHNS)3

• Strong recommendation: first-line for symptoms affecting quality of life

• OAHs are an option for primary symptoms of sneezing and itching

• An option for symptoms persisting despite either as monotherapy

• An option for SAR, PAR and episodic AR

British Society of Allergy and Clinical Immunology (BSACI)4

• First-line for moderate-severe persistent symptoms

• OAHs are recommended as first-line for moderate-severe symptoms, especially ocular symptoms

• Second-line for moderate-severe symptoms uncontrolled on monotherapy

• Specifically FP + AZE

• First-line for mild-moderate and mild persistent nasal symptoms

UK Expert Consensus5

• First-line for moderate-severe symptoms

• Second-line for moderate-severe symptoms

• Second-line for moderate-severe symptoms after failure of IS monotherapy

• Specifically FP + AZE

• First-line for mild-moderate intermittent and mild persistent symptoms

Japanese Society of Allergology6

• SAR: primary therapy option

• PAR: first-line

• Second-line for mild symptoms after failure of INS alone

• First-line for moderate and severe symptoms

• INAH not recommended • INAH not recommended

1. Brozek JL, et al. J Allergy Clin Immunol 2017;140:950–958. 2. Wallace DV, et al. Ann Intern Med 2017;167:876–881. 3. Seidman MD, et al. Otolaryngol Head Neck Surg 2015;152:S1–S43. 4. Scadding GK, et al. Clin Exp Allergy 2017;47:856–889. 5. Lipworth B, et al. npj Prim Care Respir J 2017;27:3. 6. Okubo K, et al. Allergol Int 2017;66:205–219.

AR: allergic rhinitis: AZE: azelastine; FP: fluticasone propionate; PAR: perennial allergic rhinitis; SAR: seasonal allergic rhinitis

Question


Systemic Bioavailability of Intranasal Steroids

0

10

20

30

40

50

60

Bio

avai

labi

lty(%

)

From 1. Derendorf H and Meltzer EO, Molecular and clinical pharmacology of intranasal corticosteroids: clinical and therapeutic implications, Allergy 2008;63:1292-1300, © 2008 The Authors, Journal compilation © 2008 Blackwell Munksgaard. Reprinted with permission from John Wiley and Sons.

<0.1%

Newer-generation intranasal steroids have low systemic bioavailability which reduces the likelihood of systemic side effects1

Bioavailability data not obtained from a single, head-to-head study. No clinical implications to be drawn from for individual medicines presented.

Case Study 1: Pharmacist’s Role

Daniel

• In order to assist Daniel and his concerned parents, the pharmacist could:

– Recognise seasonal allergic rhinitis and offer allergy avoidance advice and over-the-counter medication

– Advise visiting the physician when symptoms persist– Help with patient (parent) education about treatment– Offer support and advice about concerns


Case Study 2

Tracey

• Tracey is a 35-year-old sales executive with a 12-year history of nasal disease with perennial symptoms, made worse since she got a pet cat

• She has particularly troublesome nasal blockage and some post-nasal catarrh

• Aerosol sprays and cigarette smoke exposure worsen her nasal blockage

• She has so far self-managed her condition with over-the-counter antihistamines; but this has not been very effective

• She has not visited the doctor

Reproduced with permission from iStockThis is a hypothetical case study reflective of real-world evidence.

Case Study 2

Tracey

• Tracey has now started to cough at night, disturbing her sleep

• She cannot exercise as much as she used to as she gets breathless

• She is frustrated with the impact of her symptoms on her life and wants to get better


Question

• What advice would you give to Tracey?

When to Refer Your Patient to A Clinician1

1. Bousquet J, et al. Allergy 2004;59:373–387.

Severe and persistent symptoms

Pregnancy

Suspicion of asthma Symptoms of

infection

Troublesome side effects Unresponsive

symptoms

Case Study 2

• Tracey visited the doctor and discussed her symptoms

• During the consultation the physician addressed the following:

– Allergic vs. non-allergic rhinitis– Perennial allergic rhinitis– Chronic rhinosinusitis– Allergen avoidance – Medical management – Link between upper and lower airways

Tracey


The Copenhagen Allergy Study1

A prospective population-based study of incident asthma cases in individuals without the diagnosis of asthma at baseline

The same results were first published in 1. Linneberg A, et al. Allergy 2002;57:1048‒1052. This graph has been independently created by GSK fromthe original data.

14.116.0

26.3

1.8 0.9 0.7

0

5

10

15

20

25

30

To pollen To animal To mite

Yes (patients with allergicrhinitis at baseline)No (patients without allergicrhinitis at baseline)

(18/128)(4/25)

(5/19)

(10/544)(6/657) (5/682)

Allergic rhinitis at baseline (1990)

Inci

dent

alle

rgic

ast

hma

at fo

llow

-up

(199

8) (%

)At follow-up incident allergic asthma cases were higher in those groups who had allergic rhinitis at baseline to

the same allergen

Participants in a population-based study of 15–69-year-olds in 1990 were invited to a follow-up in 1998. A total of 734 subjects were examined on two occasions eight years apart.

OR: 8.2 (95% CI: 3.6-18.5)

OR: 18.9 (95% CI: 4.8-73.9)

OR: 46.5 (95% CI: 10.8-199.9)

The same results were first published in 1. Leynaert B, et al. J Allergy Clin Immunol 1999;104:301‒304. This graph has been independently createdby GSK from the original data.

2.3

0.5

19.1

7.8

0

5

10

15

20

25

Atopic Non-atopic

Controls (n=5198)Rhinitis (n=1412)

p=0.001

p = 0.001

OR=11.6 (95%CI:6.2–21.9)

% s

ubje

cts

with

ast

hma

There is a strong association between perennial allergic rhinitis and asthma in atopic and non-atopic subjects

Data from 34 centres participating in the European Community Respiratory Health Survey were analysed. Random samples of subjects (20‒44 years) were invited to complete a detailed questionnaire and undergo total and specific IgE measurements, skin prick tests to 9 allergens, and bronchoprovocation challenges with methacholine. Atopy was present in 74.7% of subjects with rhinitis and 25.6% of control subjects.

OR=8.1 (95%CI:5.4–12.1)

Perennial Allergic Rhinitis: An Independent Risk Factor for Asthma1

Case Study 2

• Tracey’s doctor diagnosed perennial rhinitis with a possible link to asthma

• The doctor prescribed an intranasal antihistamine and a decongestant

• Tracey was asked to measure her morning and evening peak flow for 6 weeks and to return sooner if her symptoms did not improve

Tracey


0.8

1.0

1.2

1.4

1.6

1.8

2.0

Severe Moderate Mild

Influence of Co-existent Rhinitis on Asthma Control in the Community1

62The same results were first published in 1. Clatworthy J, et al. Prim Care Resp J 2009;18:300‒305. This graph has been independently created by GSK from the original data.

UK practices (n=85)

Patients (n=3916)

Variable predicting poor asthma control* OR** (95% CI)

Significant rhinitis 4.62 (3.71–5.77) p<0.001

Mild rhinitis 2.09 (1.72–2.5) p<0.001

Patients prescribed ICS for asthma at 85 UK practices were sent validated questionnaire measures of control (Asthma Control Questionnaire; ACQ) and adherence (Medication Adherence Report Scale). Complete anonymised questionnaires were available for 3916 participants. CI: confidence interval; OR: odds ratio

Degree of rhinitis

Mea

n A

CQ

sco

re (9

5% C

I)*Poor asthma control defined as ACQ score >15. **OR: Comparison based on comparing with patients with no rhinitis

Case Study 2

• After 2 weeks there was some improvement in Tracey’s symptoms

• Her nasal blockage and post-nasal catarrh was slightly improved and she was able to do some light exercise

Tracey


Question

• What advice would you give to Tracey?

Case Study 2

• Tracey went back to see her doctor after 2 weeks

• The doctor changed the treatment to an intranasal corticosteroid

Tracey


Treatment of Allergic Rhinitis Reduces Asthma Severity

• Treating allergic rhinitis has been shown to reduce healthcare use for comorbid asthma:– In 4944 patients with allergic rhinitis and asthma the risk for an asthma-related event

(hospitalizations, emergency department visits) for the treated group was about half that for the untreated group1

– in 13,844 patients with asthma, those who received intranasal corticosteroids had a reduced risk for emergency department visits compared with those who did not2

The same results were first published in 1. Crystal-Peters J, et al. J Allergy Clin Immunol 2002;109:57‒62. This graph has been independently created by GSK from the original data. 2. Adams RJ, et al. J Allergy Clin Immunol 2002;109:636‒642.

*Significant differences between treated and untreated cohort where p<0.01

00.5

11.5

22.5

33.5

44.5

5

Yes No

1 visit 2+ visits

% o

f tot

al

*

0

0.5

1

1.5

2

2.5

Yes No

% o

f tot

aln=91 n=20 n=60 n=18 n=31 n=31

*

Rhinitis treatment

Hospitalization

Rhinitis treatment

Emergency department visit

*

*p<0.01 (treated vs. untreated)*p<0.01 (treated vs. untreated)

Intranasal Corticosteroids and Asthma Control

• Relative risk for an ED visit among those who received any INCS* was reduced by 30%

• When different rates of dispensing for INCS were examined, a relative risk reduction of 26% was seen in ED visits in those with greater than 0 to 1 dispensed prescriptions per year

1. Adams RJ, et al. J Allergy Clin Immunol 2002;109:636–642.

A retrospective analysis of managed care programme data including 13,844 subjects, of whom 7.4% had an emergency department visit for asthma

*Adjusted for age, sex, frequency of inhaled corticosteroids and beta-agonist dispensing, amount and type of ambulatory care forasthma, and diagnosis of an upper airways condition (rhinitis, sinusitis, or otitis media). CI: confidence interval; ED: emergency department; INCS: intranasal corticosteroid; RR: relative risk

Case Study 2: Pharmacist’s Role

• In order to assist Tracey, the pharmacist could:– Recognise the possibility of perennial allergic

rhinitis and offer allergy avoidance advice– Advise visiting the physician if more serious

symptoms persist– Help with patient education about treatment– Offer support and advice about concerns

Tracey


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