Pirinase: Allergic rhinitis & the atopic triangle

Allergic rhinitis & the atopic triangle  – significance and impact in community pharmacy

This training module will provide an important insight into the role of pharmacists and their teams in engaging customers with allergic rhinitis to explore their symptoms and the impact these have on their lives. This will in turn aid recommendation of the most appropriate product from the wide range of Over the Counter (OTC) treatment options available.

This module will also highlight the role Pirinase® Allergy plays in treating the main symptoms of  all allergic rhinitis to help improve your customers’ quality of life.

 

 

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Training Module

Goals and learning objectives

Allergic Rhinitis & The Atopic Triangle  – significance and impact in community pharmacy

This training module will provide an important insight into the role of pharmacists and their teams in engaging customers with allergic rhinitis to explore their symptoms and the impact these have on their lives. This will in turn aid recommendation of the most appropriate product from the wide range of Over the Counter (OTC) treatment options available.

 This module will also highlight the role Pirinase® Allergy plays in treating the main symptoms of  all allergic rhinitis to help improve your customers’ quality of life.


After completing this module you will be able to:

  • Discuss the common symptoms of allergic rhinitis and how to assess customers for this common condition
  • Recognise the profound effect prescribed medication can have on the development of allergic rhinitis
  • Understand the impact allergic rhinitis symptoms can have on your customers and the importance of your role in managing them
  • Compare the different treatment options for customers with allergic rhinitis symptoms
  • Discuss the role of Pirinase® Allergy 0.05% Nasal Spray in managing symptoms of allergic rhinitis
  • Understand the link to other conditions and the Atopic Triangle

 

Overview of allergic rhinitis

Allergic rhinitis is an inflammatory, immunologically-mediated disease that results in symptoms such as clear rhinorrhea, nasal congestion, nasal itching, sneezing and postnasal drip [Ref 1]. It is a global health problem affecting up to 20% of the population [Ref 1].

The symptoms of allergic rhinitis can have a significant impact on a sufferer’s performance of daily activities, quality of sleep, work/school productivity and psychosocial wellbeing [Ref 2]; therefore, the advice and recommendations from the pharmacy team can have a positive effect on their wellbeing.

There are several allergens associated with allergic rhinitis, with common ones being dust mites, pollens (e.g. grass, tree and weed pollen), animal dander and moulds.[Ref 4]

Recognising allergic rhinitis

You might assume that the symptoms of allergic rhinitis only affect the nose; however, there are various symptoms that can indicate the disorder. Scroll below to explore typical symptoms that your customers may present within the pharmacy.

What are the common symptoms of allergic rhinitis? [Ref 5]

Tick the symptoms below and see if you're right.

  • Nasal congestion
  • Rhinorrhea (if the dishcharge is coloured, this may indicate another condition)
  • Itching of nose, eyes, palate
  • Postnasal drip
  • Frequent throat clearing
  • Cough
  • Malaise (may present more in children)
  • Fatigue (may present more in children)

Effect of medication

Certain medicines are associated with rhinitis. Make sure you use your consultations with customers to explore this further. For example, when you are conducting Medicines Use Reviews (MURs), be aware of any rhinitis-type symptoms they may be presenting with and whether this is linked to their medication history.


Reflection exercise

When conducting MURs , have you ever come across a customer on the listed medication suffering from symptoms of allergic rhinitis? Did you link the symptoms to this condition?

Impact of allergic rhinitis on your customers

Whatever the cause, the symptoms of allergic rhinitis can have a significant impact on your customers’ performance of daily activities, quality of sleep, work/school productivity and psychosocial wellbeing. [Ref 2] 

Futhermore, rhinitis is a risk factor for the development of asthma and has also been implicated in otitis media with effusion and in sinusitis. [Ref 7]

The importance of your role

Given the scale of allergic rhinitis sufferers, you will no doubt have several conversations with customers about their symptoms throughout the year and will be well aware of the various treatment options available to them.

When considering these different options, it is important to understand the objectives of treating symptoms.  Sufferers may not realise that there is no cure for allergic rhinitis, but you can reassure customers by placing strong emphasis on what can be done to help them [Ref 8]:

  • Prevent allergic symptoms from occurring by avoiding exposure to allergens
  • Suppress and control symptoms produced by the allergic response through OTC treatment options
  • Avoid/minimise medication side effects including the negative impact on activities of daily living (e.g. minimal interference with school or work performance or attendance, leisure activities, sleep) through correct use of medicines.


Reflection exercise

Think about how you would speak to a customer who is feeling distressed by the severity of their allergic rhinitis symptoms. Do you consider the impact their symptoms might have on their mental wellbeing?

Providing a holistic approach

The number of products in the pharmacy for allergic rhinitis can seem overwhelming for customers. Although many will self-select a product for their symptoms, some may choose products that don’t address their specific symptoms or should not be used with their current medication. By selecting an inappropriate product, the customer may not experience the necessary symptom relief or might have unwanted side effects.

Given the large number of allergic rhinitis products available, it is important for pharmacy team to take an active role in selecting an option based on the customer’s:

  • Symptoms
  • Medical conditions
  • Current medication 
  • Personal preference 
  • Previous experience with a product

Learning Scenario

Jacob, a 36 year old regular customer, is suffering from a stuffy nose, watery eyes and nasal itchiness. He has had trouble getting a restful night’s sleep due to his symptoms. He had the same symptoms last summer, but they resolved in autumn without treatment. He works seasonally as a park manager during the spring and summer. This year, he finds that his symptoms are preventing him from performing well in his job and being active outdoors and he needs something to help. 

How should you respond to Jacob’s query? Hover over each flashing icon to find out more.

Exploring the treatment options - antihistamines

Based on the previous scenario, if OTC treatment of a customer’s symptoms is appropriate and you have identified the most suitable option for them, they will then benefit from an explanation on how the product works. This will help to ensure that the customer is compliant with their medication, especially as they will most likely need to use it long term. It will also help to reassure the customer of your clinical expertise and they will be more likely to stay loyal to the pharmacy for future advice.

1.  Antihistamines 

Explain to customers that antihistamines work by blocking the action of histamine at the histamine receptor5, which will help to treat symptoms such as itching, sneezing and rhinorrhoea9. However, it is important to understand when making recommendations that histamine is just one of many substances released upon allergen exposure9, so antihistamines block only one of the pathways causing the inflammation seen in allergic rhinitis.9

Exploring the treatment options - topical intranasal corticosteroids

2.  Topical intranasal corticosteroids

  • Topical intranasal corticosteroids are first-line therapy for moderate to severe persistent symptoms of allergic rhinitis and when treatment with antihistamines alone have not relieved symptoms9. They act by suppressing inflammation at multiple points in the inflammatory cascade and reduce all symptoms of rhinitis by about 17% greater than placebo9.  Intranasal corticosterioids also have beneficial effects on allergic eye symptoms, including itching, tearing, redness and puffiness5

Key facts

Key points about intranasal corticosteroid treatment for customers:

  • Intranasal corticosteroids have an onset of action k six to eight hours after the first dose [Ref9]
  • Clinical improvement may take a few days [Ref9]
  • Maximal effect may not be seen for at least two weeks [Ref9]
  • Customers who can predict onset of their symptoms should start treatment two weeks before allergen exposure and continue regularly until the end of the season [Ref9] 

(Please check individual product SPC for details).

Recommending Pirinase® Allergy 0.05% Nasal Spray (fluticasone propionate)

Mode of action

Pirinase® Allergy 0.05% Nasal Spray is an intranasal corticosteroid indicated for prophylaxis and treatment of allergic rhinitis including hay fever and that caused by other airborne allergens, such as house dust mites and animal dander10. It provides symptomatic relief of sneezing, itchy and runny nose, itchy and watery eyes, nasal congestion and associated sinus discomfort.

Pirinase® Allergy 0.05% Nasal Spray key features:

  • Provides superior nasal symptom relief, including nasal congestion, compared to oral antihistamines [Ref 9]
  • Also treats itchy, watery eyes and helps relieve the blocked-up groggy feeling to provide all-round hayfever relief [Ref 12]
  • Has a well-established suitability profile, with negligible systematic absorption [Ref 10]
  • Provides up to 24 hours’ allergy relief [Ref 10]

Using Pirinase® Allergy 0.05% Nasal Spray

Ensuring that customers know how to use the product correctly will aid effective symptom relief and reduce the likelihood of local adverse effects such as nasal irritation, sore throat and nose bleeds. 

Explaining the following five-step application method to customers when selling Pirinase® Allergy 0.05% Nasal Spray will help improve their compliance to achieve the maximum benefits from the medicine:

Atopic Triangle

REPLACE all content with video

The Atopic Triangle links the three main allergic conditions: Asthma, Allergy, Eczema.

It is called the Atopic triangle as the term ‘ATOPY’  refers to a sufferer being more predesposed to suffer from all three conditions if they suffer from one.

It gradually becomes more apparent to sufferers as they progress through from childhood to adulthood.

The 4 main allergic conditions are eczema (also called atopic dermatitis), food allergies, environmental allergies (also called allergic rhinoconjunctivitis or "hay fever" or just "allergies"), and asthma. These conditions and their symptoms often appear in a particular sequence with age, hence another reason for the term "march". BUT they can also overlap. For example a child with a food allergy can go on to develop environmental allergies before they have outgrown their food allergy.

What are the symptoms and when do they appear?

Typically the first allergic condition to manifest is eczema which is a skin condition characterized by itchy rashes which come and go. Eczema most commonly develops between 2-12 months of age. 

Allergies to pollen typically develop between 3 to 5 years of age at the earliest (after exposure to a few pollen seasons). Symptoms of environmental allergies include runny nose, frequent sneezing, itchy nose, blocked nose, or itchy, red, watery eyes. 

Finally, a child with eczema has a 50% risk of developing asthma which can manifest at 3 to 5 years of age or later. Asthma is a chronic lung disease characterized by inflammation (swelling and mucous) in the airways (breathing tubes) AND "twitchiness" of the airways causing them to constrict (narrow). When the airways constrict, symptoms of asthma occur and can include repeating coughing or wheezing (high pitched whistling noise with breathing) or chest tightness (a sensation where breathing seems constricted or difficult) or a combination of these. The symptoms of asthma can be triggered by colds (illness) or allergies.

References and Product Information

References

1. Brożek, J.L., et al., Allergic Rhinitis and its Impact on Asthma (ARIA) 2010 Revision. Allergic Rhinitis and its Impact on Asthma Guidelines, 2010: p. 1-153.

2. Canonica GW, Bousquet J, Mullol J, et al. A survey of the burden of allergic rhinitis in Europe. Allergy 62(suppl. 85):17–25, 2007.

3. https://www.allergyuk.org/information-and-advise/statistics (Last accessed May 2017)

4. http://www.nhs.uk/Cnnditions/Rhinitis---allergic/Pages/Causes.aspx (last accessed May 2017)

5. Seidman, M.D., et al., Clinical practice guideline: Allergic rhinitis. Otolaryngol Head Neck Surg, 2015. 152(1 Suppl): p. S1-43.

6. Kendrick,J. Allergic Rhinitis.2016

7. 5BSACI. Rhinitis. [cited 2017 February 10]; Available from:http://www.bsaci.org/resources/rhinitis.

8. Keith,P. Allergic Rhinitis,in Compendium of therapeutic choices.2016

9. Scadding, G.K., et al., BSACI guidelines for the management of allergic and non-allergic rhinitis. Clin Exp Allergy, 2008. 38(1): p. 19-42.

10. eMC. Pirinase Allergy 0.05% Nasal Spray. 2016 December 23, 2016 [cited 2017 February 10, 2017]; Available from: https://www.medicines.org.uk/emc/medicine/24352

11.. Derendorf, H. and E.O. Meltzer, Molecular and clinical pharmacology of intranasal corticosteroids: clinical and therapeutic implications. Allergy, 2008. 63(10): p. 1292-300.

12.GSK, Pirinase Information Leaflet.

13.https://www.allergypartners.com/triangle/allergic-atopic-march-gets-2/

Long Form PI- Pirinase Allergy

Take action

Take action

  • Advise customers on how to manage allergic rhinitis
  • Recommend Pirinase® Allergy 0.05% Nasal Spray to customers as an effective treatment choice allergic rhinitis
  • Explain how to use Pirinase® Allergy 0.05% Nasal Spray correctly for maximum benefits


Now that you have completed the module, answer the following questions to test your knowledge and understanding.



V1.21.03.18. 

Take Quiz

Which of the following statements about allergic rhinitis is TRUE?

  • a. It is an inflammatory response
  • b. It is often accompanied by a fever
  • c. It is not triggered by environmental allergens
  • d. It occurs when the immune system doesn’t react to allergens

Symptoms of allergic rhinitis include:

  • a. Clear rhinorrhea
  • b. Nasal congestion
  • c. Red, watery eyes
  • d. All of the above

Which of the following should you explore with a customer to find out the root cause of their allergic rhinitis symptoms?

  • a. If they have had any of the symptoms in the past
  • b. How long they have had their current symptoms
  • c. If they are on any other medication
  • d. If they have tried anything else to treat the symptoms

Approximately what percentage of allergic rhinitis sufferers report that their symptoms impact on their school or work performance?

  • a. 100%
  • b. 90%
  • c. 80%
  • d. 70%

Which of the following recommendations would NOT be useful for dealing with allergic rhinitis symptoms?

  • a. Avoid any exposure to potential allergens
  • b. Use OTC treatment options to control symptoms
  • c. Use medication correctly and regularly
  • d. Only use intranasal corticosteroids after symptoms have started

What is the % chance of a child with eczema going on to develop asthma

  • a. 50%
  • b. 6%
  • c. 23%
  • d. 65%

Which of the following regarding Pirinase® Allergy 0.05% Nasal Spray is FALSE?

  • a. It acts on multiple inflammatory substances to prevent and relieve symptoms
  • b. It may cause drowsiness
  • c. It provides superior control of nasal symptoms compared to oral antihistamines
  • d. It provides up to 24 hours’ allergy relief

Pirinase® Allergy 0.05% Spray provide symptom relief for up to:

  • a. Two to four hours
  • b. 12 hours
  • c. 24 hours
  • d. Three to four days