Overcoming barriers to intranasal corticosteroid use in patients with uncontrolled allergic rhinitis

Mary Barna Bridgeman, Mary Barna Bridgeman

Abstract

Patients suffering from allergic rhinitis often attempt to self-manage their symptoms and may seek advice from pharmacists about nonprescription product choices. Several drug classes, both prescription and over-the-counter (OTC), are available, including intranasal corticosteroids (INCSs); oral, intranasal, and ocular antihistamines; leukotriene antagonists; and topical and systemic decongestants, as well as immunotherapies. Selection of the optimal treatment approach depends on the temporal pattern, frequency, and severity of symptoms as well as the patient's age. 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.

Keywords: allergy; nasal sprays; over-the-counter medications; patient counseling; pharmacy practice.

Conflict of interest statement

Disclosure The author reports no conflicts of interest in this work.

Figures

Figure 1
Figure 1
Pathophysiological steps leading to allergic rhinitis symptoms. Note: Based on Figure 2 of Pathophysiology of allergic and nonallergic rhinitis. Sin B, Togias A. 2011. Proc Am Thorac Soc. 2011;8(1):106–114. Abbreviations: EOS, eosinophil; GM-CSF, granulocyte-macrophage colony-stimulating factor; IgE, immunoglobulin E; IL, interleukin; Th2, helper T-cell type 2.
Figure 2
Figure 2
Treatment recommendations for the self-care of allergic rhinitis. Note: Posted with permission of the American Pharmacists Association from Krinsky DL, Ferreri SP, Hemstreet BA, et al. Handbook of Nonprescription Drugs. 18th ed. Washington, DC: American Pharmacists Association; 2015:174. Abbreviations: ADR, adverse drug reactions; AH, antihistamine; AR, allergic rhinitis; HCP, healthcare provider; INCS, intranasal corticosteroid; Rx, prescription.
Figure 3
Figure 3
General instructions for the use of intranasal corticosteroid sprays. Note: Posted with permission of the American Pharmacists Association from Krinsky DL, Ferreri SP, Hemstreet BA, et al. Handbook of Nonprescription Drugs. 18th ed. Washington, DC: American Pharmacists Association; 2015;187.

References

    1. Seidman MD, Gurgel RK, Lin SY, et al. Guideline Otolaryngology Development Group AAO-HNSF. Clinical practice guideline: allergic rhinitis. Otolaryngol Head Neck Surg. 2015;152(1 suppl):S1–S43.
    1. Members of the Workshops ARIA in the pharmacy: management of allergic rhinitis symptoms in the pharmacy. Allergic rhinitis and its impact on asthma. Allergy. 2004;59(4):373–387.
    1. Nathan RA, Meltzer EO, Derebery J, et al. The prevalence of nasal symptoms attributed to allergies in the United States: findings from the burden of rhinitis in an America survey. Allergy Asthma Proc. 2008;29(6):600–608.
    1. Bielory L, Skoner DP, Blaiss MS, et al. Ocular and nasal allergy symptom burden in America: the allergies, immunotherapy, and rhinoconjunctivitis (AIRS) surveys. Allergy Asthma Proc. 2014;35(3):211–218.
    1. Allergies in America: a landmark survey of nasal allergy sufferers. Executive summary. HealthSTAR Communications, Inc, in partnership with Schulman, Ronca & Bucuvalas, Inc; [Accessed March 30, 2017]. pp. 1–45. Available from: .
    1. Meltzer EO, Blaiss MS, Jennifer DM, et al. Burden of allergic rhinitis: results from the pediatric allergies in America survey. J Allergy Clin Immunol. 2009;124(suppl 3):S43–S70.
    1. Shedden A. Impact of nasal congestion on quality of life and work productivity in allergic rhinitis: findings from a large online survey. Treat Respir Med. 2005;4(6):439–446.
    1. Blaiss MS, Meltzer EO, Derebery MJ, Boyle JM. Patient and healthcare-provider perspectives on the burden of allergic rhinitis. Allergy Asthma Proc. 2007;28(suppl 1):S4–S10.
    1. Canonica GW, Mullol J, Pradalier A, Didier A. Patient perceptions of allergic rhinitis and quality of life: findings from a survey conducted in Europe and the United States. World Allergy Organ J. 2008;1(9):138–144.
    1. Blaiss MS. Allergic rhinitis: direct and indirect costs. Allergy Asthma Proc. 2010;31(5):375–380.
    1. Greiner AN, Hellings PW, Rotiroti G, Scadding GK. Allergic rhinitis. Lancet. 2011;378(9809):2112–2122.
    1. Thompson A, Sardana N, Craig TJ. Sleep impairment and daytime sleepiness in patients with allergic rhinitis: the role of congestion and inflammation. Ann Allergy Asthma Immunol. 2013;111(6):446–451.
    1. Fromer LM, Blaiss MS, Jacob-Nara JA, Long RM, Mannion KM, Lauersen LA. Current allergic rhinitis experiences survey (CARES): consumers’ awareness, attitudes and practices. Allergy Asthma Proc. 2014;35(4):307–315.
    1. Sin B, Togias A. Pathophysiology of allergic and nonallergic rhinitis. Proc Am Thorac Soc. 2011;8(1):106–114.
    1. Bernstein DI, Schwartz G, Bernstein JA. Allergic rhinitis: mechanisms and treatment. Immunol Allergy Clin North Am. 2016;36(2):261–278.
    1. Wheatley LM, Togias A. Clinical practice. Allergic rhinitis. N Engl J Med. 2015;372(5):456–463.
    1. Brozek JL, Bousquet J, Baena-Cagnani CE, et al. Global Allergy and Asthma European Network. Grading of Recommendations Assessment, Development and Evaluation Working Group Allergic rhinitis and its impact on asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol. 2010;126(3):466–476.
    1. Wallace DV, Dykewicz MS, Bernstein DI, et al. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008;122(2 suppl):S1–S84.
    1. Beconase AQ [package insert] Research Triangle Park, NC: Glaxo-SmithKline; 2015.
    1. Nasonex [package insert] Whitehouse Station, NJ: Merck & Co, Inc.; 2013.
    1. Rhinocort Aqua [package insert] Wilmington, DE: AstraZeneca; 2010.
    1. Flixonase [summary of product characteristics France] Cedex, France: GlaxoSmithKline Laboratory; 2013.
    1. Nasacort [summary of product characteristics France] Gentilly, France: Sanofi Aventis France; 2016.
    1. Sastre J, Mosges R. Local and systemic safety of intranasal corticosteroids. J Investig Allergol Clin Immunol. 2012;22(1):1–12.
    1. Skoner DP. The tall and the short: repainting the landscape about the growth effects of inhaled and intranasal corticosteroids. Allergy Asthma Proc. 2016;37(3):180–191.
    1. Yanez A, Rodrigo GJ. Intranasal corticosteroids versus topical H1 receptor antagonists for the treatment of allergic rhinitis: a systematic review with meta-analysis. Ann Allergy Asthma Immunol. 2002;89(5):479–484.
    1. Mounsey AL, Gray RE. Topical antihistamines and mast cell stabilizers for treating allergic conjunctivitis. Am Fam Physician. 2016;93(11):915–916.
    1. QNASL [package insert] Horsham, PA: Teva Respiratory, LLC; 2014.
    1. FDA Rhinocort Allergy (OTC Product) Approved Label. [Accessed May 25, 2016]. 2016. Available from: .
    1. Omnaris [package insert] Marlborough, MA: Sunovion Pharmaceuticals Inc; 2013.
    1. Zetonna [package insert] Marlborough, MA: Sunovion Pharmaceuticals Inc; 2014.
    1. Veramyst [package insert] Research Triangle Park, NC: GlaxoSmithKline; 2015.
    1. FDA Nasacort Allergy 24HR (OTC product) Approved Label. 2013. [Accessed May 25, 2016]. Available from: .
    1. Hellings PW, Dobbels F, Denhaerynck K, Piessens M, Ceuppens JL, De Geest S. Explorative study on patient’s perceived knowledge level, expectations, preferences and fear of side effects for treatment for allergic rhinitis. Clin Transl Allergy. 2012;2(1):9.
    1. Valovirta E, Ryan D. Patient adherence to allergic rhinitis treatment: results from patient surveys. Medscape J Med. 2008;10(10):247.
    1. Mahadevia PJ, Shah S, Leibman C, Kleinman L, O’Dowd L. Patient preferences for sensory attributes of intranasal corticosteroids and willingness to adhere to prescribed therapy for allergic rhinitis: a conjoint analysis. Ann Allergy Asthma Immunol. 2004;93(4):345–350.
    1. Mahadevia P, Shah S, Mannix S, et al. Willingness to pay for sensory attributes of intranasal corticosteroids among patients with allergic rhinitis. J Manag Care Pharm. 2006;12(2):143–151.
    1. Yonezaki M, Akiyama K, Karaki M, et al. Preference evaluation and perceived sensory comparison of fluticasone furoate and mometasone furoate intranasal sprays in allergic rhinitis. Auris Nasus Larynx. 2016;43(3):292–297.
    1. Meltzer EO, Andrews C, Journeay GE, et al. Comparison of patient preference for sensory attributes of fluticasone furoate or fluticasone propionate in adults with seasonal allergic rhinitis: a randomized, placebo-controlled, double-blind study. Ann Allergy Asthma Immunol. 2010;104(4):331–338.
    1. Khanna P, Shah A. Assessment of sensory perceptions and patient preference for intranasal corticosteroid sprays in allergic rhinitis. Am J Rhinol. 2005;19(3):316–321.
    1. Meltzer EO, Bardelas J, Goldsobel A, Kaiser H. A preference evaluation study comparing the sensory attributes of mometasone furoate and fluticasone propionate nasal sprays by patients with allergic rhinitis. Treat Respir Med. 2005;4(4):289–296.
    1. Stokes M, Amorosi SL, Thompson D, Dupclay L, Garcia J, Georges G. Evaluation of patients’ preferences for triamcinolone acetonide aqueous, fluticasone propionate, and mometasone furoate nasal sprays in patients with allergic rhinitis. Otolaryngol Head Neck Surg. 2004;131(3):225–231.
    1. Shah SR, Miller C, Pethick N, Uryniak T, Jones MK, O’Dowd L. Two multicenter, randomized, single-blind, single-dose, crossover studies of specific sensory attributes of budesonide aqueous nasal spray and fluticasone propionate nasal spray. Clin Ther. 2003;25(8):2198–2214.
    1. Lumry W, Hampel F, LaForce C, Kiechel F, el-Akkad T, Murray JJ. A comparison of once-daily triamcinolone acetonide aqueous and twice-daily beclomethasone dipropionate aqueous nasal sprays in the treatment of seasonal allergic rhinitis. Allergy Asthma Proc. 2003;24(3):203–210.
    1. Bunnag C, Suprihati D, Wang DY. Patient preference and sensory perception of three intranasal corticosteroids for allergic rhinitis. Clin Drug Investig. 2003;23(1):39–44.
    1. Bachert C, El-Akkad T. Patient preferences and sensory comparisons of three intranasal corticosteroids for the treatment of allergic rhinitis. Ann Allergy Asthma Immunol. 2002;89(3):292–297.
    1. Bousquet J, Khaltaev N, Cruz AA, et al. Allergic rhinitis and its impact on asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen) Allergy. 2008;63(suppl 86):8–160.
    1. Scolaro KL. Colds and allergy. In: Krinsky DL, Ferrari SP, Hemstreet B, et al., editors. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 18th ed. Washington, DC: American Pharmacists Association; 2015. pp. 171–196.
    1. Kuehl BL, Abdulnour S, O’Dell M, Kyle TK. Understanding the role of the healthcare professional in patient self-management of allergic rhinitis. SAGE Open Med. 2015;3 2050312115595822.
    1. FDA Flonase Allergy Relief (OTC Product) Approved Label. 2014. [Accessed May 25, 2016]. Available from: .
    1. Benninger MS, Hadley JA, Osguthorpe JD, et al. Techniques of intranasal steroid use. Otolaryngol Head Neck Surg. 2004;130(1):5–24.
    1. GSK FDA Approves Flonase ® Sensimist™ Allergy Relief [press release] 2016. [Accessed: September 8, 2016]. Available at:

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera