13/09/2016

Cecilia Brata
Eko Setiawan
Farmasi komunitas 1
2016

Learning objectives
Know what is allergic rhinitis along with its
pathophysiology, clinical presentation, and causes.
Know the basic knowledge of allergic rhinitis medications
Explained further in Praktikum session

Understand the BASIC PRINCIPLES of self-medication

consultation for patients with allergic rhinitis
Know the important information that should be gathered when
handling patients with allergic rhinitis.
Able to analyse the information gathered in order to give appropriate
recommendation.
Know what information that should be conveyed when recommending
product and/or non-pharmacological therapy

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Allergic rhinitis

Rhinitis
Rhinitis is an inflammation of the nasal lining;
characterised by nasal symptoms:
Sneezing
Nasal congestion
Nasal itching
Rhinorrhea.
The eyes, ears, sinuses, and throat can be involved.

One of the causes of rhinitis is allergic rhinitis.

Other causes of rhinitis: see next slide

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Causes of non-allergic rhinitis

adopted from Scolaro et.al in Berardi et.al

Differenciation of allergic rhinitis and nonallergic rhinitis

adopted from Scolaro KL. In Berardi et.al. (Table 11.2)

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Allergic rhinitis
Allergic
rhinitis is a
mucosal
reaction in
response
to allergen
exposure;
mediated
by IgE

Airborne outdoor allergens;

e.g., pollen, mold spores

Non-airborne outdoor
allergens; e.g., diesel exhaust
particles

Allergens

Indoor allergens; e.g., house

dust mite, cockroaches,
cigarette smokes, mold spores,
and pet dander
Occupational allergens; e.g.,
latex, wool dusts, organic dust,
various chemicals

Food allergens; usually with

multiple organ involvement

Pathophysiology
adapted from Scolaro KL. In Berardi et.al.

Initial allergen exposure

Sensitization Stimulation of beta-lymphocyte-mediated IgE production
phase

Early phase

Cellular
recruitment

Late phase

Occur within minutes of subsequent allergen exposure

Rapid release of allergic mediators (histamines, leukotriens, prostaglandins,etc), lead to symptoms
such as rhinorrhea, nasal congestion, itching, redness, swelling, etc

Circulating leukocytes, particularly eosinophils, are attracted to the nasal mucosa and release more
inflammatory mediators

Begins within 2 to 4 hours after allergen exposure

Similar symptoms to early phase; but usually less sneezing and itching and more nasal congestion
and mucus production

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Classification of allergic rhinitis (ARIA)

adopted from Scolaro KL. In Berardi et.al

Self-medication consultations for

allergic rhinitis in community
pharmacy

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Basic principle of self-medication consultation

in community pharmacy (simple model)
Patients come to the pharmacy
Information-gathering
Patient assessment
The provision of advice
The types of advice:
Refer to doctor
Product recommendation with the
associated medicine information
Non-pharmacological therapy
Other

Analyse the information

gathered

Monitoring and follow up

Information gathering
Patient identity
Signs and symptoms
chief complaints; CC look at warning signs and
symptoms
Action taken
Medications used (current and past medications)
Medical history (Past MEDICAL history) give
examples
Other appropriate information
Social history
Family history
Allergy and adverse drug reaction history
Tietze KJ. Clinical skills for pharmacists

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Information-gathering
Important information to be gathered when handling patients
with allergic rhinitis (adopted from Blenkinsopp et.al)
Patient identity

Medical conditions

Age (approximate)
Baby, child, adult

Signs and symptoms

Duration
Symptoms
Rhinorrhoea (runny nose)
Nasal congestion
Nasal itching
Watery eyes
Irritant eyes
Discharge from the eyes
Sneezing

Eczema
Asthma

Medication used
Other information
Allergy
Family history
Social history

Previous history

Warning signs and symptoms

When to refer

Next slide

Scolaro KL. In Berardi et.al

Wheezing and
shortness of breath
Tightness of chest
Painful ear
Painful sinuses
Purulent
conjunctivitis
Failed medication
Blenkinsopp et.al

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Signs and symptoms of respiratory

disorders (Scolaro KL. In Berardi et.al)

The provision of advice

The types of advice could be:
Medical referral (warning signs and symptoms)
Product recommendation along with the associated
medicine information
Non-pharmacological advice
Other advice that may be appropriate

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The provision of advice

Product recommendation

Adopted from Bousquet et.al. Allergic rhinitis and its impact on asthma (ARIA) 2008

Medications for allergic rhinitis

Scolaro KL. In Berardi et.al; Min et.al; Bousquet J et.al

Further explanation during praktikum session

Antihistamine
Sedating, e.g.,
chlorpheniramine maleate,
dexchlorpeniramine,
promethazine, triprolidine, etc
Less sedating, e.g., cetirizine,
loratadine, etc
Decongestant
Direct acting, e.g.,
phenylephrine, oxymetazoline,
tetrahydrozoline
Indirect acting, e.g.,ephedrine
Mixed, e.g., pseudoephedrine

Glucorticosteroids, e.g.,
beclomethasone dipropionate,
budesonine, dexamethasone,
prednisone, hydrocortisone , etc.
Chromones, e.g., nedochromil,
cromoglycate
Leukotriene receptor
antagonists, e.g., montelukast,
zafirlukast, etc.
Intranasal anticholinergic, i.e.,
ipratropium bromide
Immunotherapy

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Medications for allergic rhinitis

adopted from Bousquet et.al. Allergic rhinitis and its impact on asthma (ARIA) 2008

Second-generation oral or
intranasal H1-antihistamines are
recommended for the treatment
of allergic rhinitis and
conjunctivitis in adults and
children.

Intranasal glucocorticosteroids
are recommended for the
treatment of allergic rhinitis in
adults andvchildren. They are
the most effective drugs for
thevtreatment of allergic
rhinitis.

First-generation oral H1antihistamines are not

recommended when secondgeneration ones are available,
due to safety concerns.

Intramuscular
glucocorticosteroids and the
longtermvuse of oral
glucocorticosteroids are not
recommendedvdue to safety
concerns.

Topical H1-antihistamines are

recommended for the treatment
of allergic rhinitis and
conjunctivitis.

Topical cromones are

recommended in the
treatmentvof allergic rhinitis
and conjunctivitis, butvthey are
only modestly effective.

Medications for allergic rhinitis

adopted from Bousquet et.al. Allergic rhinitis and its impact on asthma (ARIA) 2008

Montelukast is recommended in
the treatment of seasonal
allergic rhinitis in patients over
6 years of age.
Intranasal ipratropium is
recommended for the treatment
of rhinorrhoea associated with
allergic rhinitis.
Intranasal decongestants may be
used for a short period of time in
patients with severe nasal
obstruction.
Oral decongestants (and their
combination with oral H1antihistamines) may be used in
the treatment of allergic rhinitis
in adults, but side effects are
common.

The treatment of allergic rhinitis

should consider the severity and
duration of the disease, the
patients preference, as well as
the efficacy, availability and cost
of medications.
A stepwise approach depending
on the severity and duration of
rhinitis is proposed.
A tailored approach is needed
for each individual patient.
Not all patients with
moderate/severe allergic rhinitis
are controlled despite optimal
pharmacotherapy

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Adopted from Tietze KJ in Berardi et.al Handbook of non-prescription drugs

The provision of advice

Non-pharmacological advice
(adopted from Scolaro KL in Berardi et.al)

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Monitoring and follow up

Improvement should be noticed in a few days, more
than 5 days no improvement, patients need to be
referred to doctor for other therapy (Blenkinsopp et.al)
Symptomatic relief with initial non-prescription drug
therapy in 3 to 4 days; complete relief 2 to 4 weeks
(Scolaro KL in Berardi et.al)

Reference
Blenkinsopp A, Paxton P, Blenkinsopp J. Symptoms in the
Pharmacy: A Guide to the Management of Common Illness.
6th ed. West sussex: Wiley-Blackwell; 2009.
Bousquet J. Khaltev N, Cruz AA, et.al. Allergic rhinitis and its
impact on asthma (ARIA) 2008. Allergy 2008: 63 (Suppl. 86): 8
160
Min. The Pathophysiology, Diagnosis and Treatment of Allergic
Rhinitis. Allergy Asthma Immunol Res. 2010 April;2(2):65-76.
Scolaro KL. Disorders related to colds and allergics. In Berardi
RR, Ferreri SP, Hume AL, et al. Handbook of nonprescription
drugs: An interactive approach to self care. 16th ed. Washington
DC: American Pharmacists Association; 2009: 177-201
Sheikh J, Najib U. Rhinitis. Available from
http://emedicine.medscape.com/article/134825-overview#a5.
Accessed Sept 1, 2016.
Tietze KJ. Clinical skills for pharmacists: A patinet-focused
approach. 3rd ed. Missouri: Elsevier Mosby; 2012.

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