EVIDENCE BASED

PHARMACY PRACTICE

Evidence
R
10

RHINITIS
The Pharmacist’s Role
Stuart Jones, BPharm, MSc and Roxane Jones, BPharm, MSc

hinitis incorporates a group of disorders that may have diverse pathophysiologic mechanisms. These usually, but do not always involve an inflammatory component or mechanism. The typical symptoms experienced are rhinorrhoea, sneezing, nasal itching and/ or nasal congestion. The underlying causes may include allergic, non-allergic or infective components, either alone or in combination. The essential element in making the diagnosis, is taking an appropriate and comprehensive history, including the patient’s main symptoms, so that treatment can to be tailored to the individual patient’s symptom complex.1

Allergic rhinitis has been classified by the Allergic Rhinitis and Its Impact on Asthma Work Group (ARIA) into two categories, namely intermittent and persistent. This replaces the previously known entities of seasonal and perennial allergic rhinitis respectively. Symptoms are termed intermittent if they occur for fewer than four days per week, or for less than four consecutive weeks. Persistent symptoms are present for more than four days per week, and for a period exceeding four weeks. Once the designation of intermittent or persistent allergic rhinitis has been made, severity must be gauged as either mild or moderate to severe as follows: Mild: Normal sleep No impairment of daily activities, sports and leisure Normal work and school functioning Absence of troublesome symptoms Moderate-severe: Abnormal sleep Impairment of daily activities, sports and leisure Impairment of work and school functioning Presence of troublesome symptoms2 It is advisable for pharmacists to refer certain patients to a physician before commencing treatment for allergic rhinitis. These instances include: Children under the age of twelve years Pregnant or breast-feeding women Unilateral obstruction Anosmia (loss of smell) Nasal obstruction without rhinorrhoea Thick green or yellow mucous secretions Posterior rhinorrhoea Recurrent epistaxis Symptoms of undiagnosed or uncontrolled asthma Rhinorrhoea commencing after head trauma (possibility of CSF leak) (See Box 1 for treatment of allergic rhinitis)

ALLERGIC RHINITIS

Allergic rhinitis is a common condition, affecting between 10 and 40% of the world’s population. Its prevalence is increasing in both adults and children, and this together with its impact on quality of life has lead to it being classified as a major chronic respiratory condition.2 It is also listed as one of the top ten causes for contact with the health profession.3 Quality of life is reduced by impairing sleep, adversely affecting leisure activities, social life, school performance and work productivity. Systemic manifestations such as fatigue, headaches and impaired cognitive function add to the distress. Both the direct and indirect financial cost of sick leave, school and work absenteeism, and loss of productivity make allergic rhinitis an important health burden.3 The pathogenesis of allergic rhinitis is an allergic response mediated by a type I hypersensitivity reaction, involving excessive production of IgE antibodies in response to allergen exposure. It is also referred to as an atopic reaction. Degranulation of the mast cell follows the IgE-mediated reaction, leading to the release of inflammatory mediators. In the early phase, histamine is released, causing the characteristic symptoms of sneezing, rhinorrhoea, nasal itching and ocular symptoms of tearing and pruritus. The release of cytokines and leukotrienes leads to the manifestation of the late phase, which can begin up to six hours after initial allergen exposure. It can continue for up to forty-eight hours and is characterised by nasal congestion and post nasal drip.4

SA Pharmaceutical Journal – March 2008

SA Pharmaceutical Journal – March 2008 11 .

with anosmia also being apparent on occasion.EVIDENCE BASED PHARMACY PRACTICE NON-ALLERGIC RHINITIS There are numerous causes or types of non-allergic rhinitis. who exhibit nasal obstruction. or drug-induced rhinitis. more common in middle age Nasal blockage Autonomic (vasomotor) Medication Prolonged use of nasal deconges. surgery or ra. nasal pruritus and sneezing paroxysms are common symptoms. patients with non-allergic non-infectious rhinitis are typically symptomatic year round. temperature or barometric changes. hyposdiation mia.10 Rhinitis medicamentosa. nasal blockage Nasal septum deviation Unilateral nasal obstruction Animal proteins – laboratory research and animal breeding Vegetable proteins – baking and food processing Enzymes – food processing and detergent manufacture Pharmaceuticals – manufacturing and dispensing Chemicals – plastics and paint manufacture ing topical decongestant as well as treatment of the underlying rhinitis disorder. This condition is completely avoidable and preventable by the pharmacist who should counsel individuals purchasing these agents on their safe and effective use. contraceptive pill Spicy foods.Foul-smelling odour. The onset is typically later in life with the patients generally presenting with persistent nasal congestion and/or rhinorrhoea. crusty. or strong odours such as perfumes.5 No response in five to seven days Box 1: Selection of allergic rhinitis treatment by pharmacists2 Mild intermittent Oral H1 antagonists OR Nasal H1 antagonists OR Oral decongestants OR Topical decongestants OR Nasal Chromones OR Nasal Saline Oral H1 antagonists OR Nasal H 1 antagonists AND / OR Decongestants OR Nasal Chromones OR Nasal corticosteroids Evidence 12 Mild persistent Moderate-severe intermittent Non allergic rhinitis with eosinophilia syndrome (NARES) tends to produce symptoms that are more intense than vasomotor rhinitis. Patients with vasomotor rhinitis are further divided into two subgroups: “runners”. infection. Topical corticosteroids form the mainstay of treatment. This rebound congestion phenomenon typically occurs in patients who have selfmedicated their underlying problem of rhinitis. puberty. each with its own unique triggers and identifying symptoms. However. Hyperactivity of the nasal mucosa leads to an increase in symptoms with exposure to non-specific stimuli. cigarette smoke.Rhinitis medicamentosa with chronic nasal blockage tants Aspirin/NSAIDS Hormonal Food (gustatory) Atrophic Structural abnormalities Occupational Acute rhinitis +/. Impaired mucociliary clearance may predispose the individual to secondary infections. Little is known regarding its pathogenesis apart from the fact that non-specific nasal hyper-reactivity occurs on exposure to non-immunological stimuli including environmental factors such as relative humidity. paint fumes and inks.10 Hormonal-associated rhinitis can occur with pregnancy and oral contraceptive usage.Nasal blockage and/or rhinorrhoea placement therapy. as well as cocaine. alcohol Rhinorrhoea.6. is associated with the prolonged and indiscriminate use of topical vasoconstrictive agents such as xyloand oxymetazoline. 50% have hyper-rewith asthma and nasal polyposis active airways Physical and chemical agents α-adrenergic blockers. provided that there is a component of inflammatory rhinitis present. systemic disease or drug abuse. ACE inhibitors Clear rhinorrhoea especially in the morning. Treatment of rhinitis medicamentosa requires withdrawal from the offend- Moderate-severe persistent Refer to physician Table I: Types and possible triggers of non-allergic rhinitis5 Type NARES Triggers Symptoms Aspirin sensitivity in 50% of patients Perennial symptoms with paroxysmal episodes. which lead to increased nasal congestion and nasal SA Pharmaceutical Journal – March 2008 . facial flushing Secondary to trauma. structural lesions. The treatment of choice for vasomotor rhinitis includes the use of topical antihistamines and topical corticosteroids.10 Vasomotor rhinitis is unrelated to allergy. who demonstrate “wet” or secretory rhinorrhoea.1 See Table I for types and possible triggers of non-allergic rhinitis.asthma Pregnancy. with exacerbations during winter months. Profuse watery rhinorrhoea. hormone re. congestion and airflow resistance with minimal rhinorrhoea. peppers. and “dry” patients. The physiological changes associated with pregnancy.

SA Pharmaceutical Journal – March 2008 13 .

This clearly necessitates referral to a physician. and stuffiness are associated with a foul or fetid odour and Klebsiella colonisation. as well as secondary to trauma and radiation therapy. Should insufficient relief be obtained from these modalities. desloratadine. requiring increased dosing frequency. Both of these agents have been approved for seasonal allergic rhinitis. topical medical therapy is preferred to systemic agents.10 Atrophic rhinitis can occur as a rare complication of radical nasal tissue removal by surgery aimed to relieve obstruction. Symptoms involved are nasal congestion and obstruction occasionally leading to occlusion of the sinus ostia. Azelastine also appears to work by inhibiting the release of inflammatory mediators from mast cells. topical decongestants and analgesics.6 Bacterial rhinitis usually has Streptococcus pneumonia. coronavirus or respiratory syncitial virus with symptoms of rhinorrhoea. From this it can be seen that referral is therefore required. Due to their mechanism of action. In addition to this. Side effects of topical corticosteroids include local nasal irritation. therefore.6. Haemophilus influenzae or mycobacteria as its causative organism. but are less effective against nasal congestion. local irritation and burning. but some symptoms are highly predictive of one condition versus the other as can be seen from the approach of the rhinitis diagnostic worksheet. cognitive impairment and anticholinergic side effects including dry mouth.7 Nasal saline Nasal saline can reduce symptoms in both children and adults with intermittent allergic rhinitis and is thus a safe and 14 SA Pharmaceutical Journal – March 2008 . The dosage of azelastine is one spray (140 µg) into each nostril twice daily while that of levocabastine is two sprays (100 µg) into each nostril twice daily. The management of rhinitis in pregnancy should include therapies such as steam inhalation and nasal saline sprays. It must be emphasised that regular use is more effective than as needed usage in persistent rhinitis.temperature changes . and may occur with or without viral rhinitis as a precursor. The standard approach to management includes aggressive nasal saline irrigation and eradication of bacterial overgrowth with the use of antibiotics. as well as Eustachian tube dysfunction. first generation antihistamines have a shorter duration of action. Moraxella catarrhalis. They have been shown to alleviate other allergic symptoms at sites such as the conjunctiva. Treatment includes antibiotics. cetirizine. skin and lower airways and have additional anti-inflammatory capacity to ameliorate the nasal eosinophilia characteristic of allergic rhinitis.3 Widely used intranasal corticosteroids include beclomethasone dipropionate. momethasone fuorate. Viral rhinitis is most commonly caused by the rhinovirus.1 Features suggestive of allergic rhinitis • Sneezing • Itchy nose • Seasonal symptoms • Itchy eyes / eye rubbing • Clear rhinorrhoea • Family history of allergic rhinitis • Eczema • Food allergy Features suggestive of non-allergic rhinitis • Persistent congestion and/or rhinorrhoea without itch/sneeze • Poor response to oral antihistamines • Symptoms exacerbated by: . They are thus indicated as first-line therapy for mild to moderate intermittent and mild persistent rhinitis. nasal obstruction and sneezing being accompanied by pharyngitis. Examples of first generation antihistamines include chlorpheniramine and diphenhydramine. nasal itching and ocular symptoms.9 Topical antihistamines The available topical antihistamines are azelastine and levocabastine. Symptoms of epistaxis.5. cough and malaise. Fungal infections are more common in immunocompromised individuals.foods .10 Non-allergic and allergic rhinitis can present similarly.5.6 cholinergic side effects. levocetirizine. with subsequent development of a purulent nasal discharge. palate. Both of these antihistamines are H1-antagonists. dry eyes and difficulty in urinating. Treatment is usually symptomatic and supportive with patients recovering spontaneously within 7–10 days. sneezing. bacterial.smoke/fumes • Late age of onset • Absence of cat/dog/pet trigger5 INFECTIOUS RHINITIS This entity is caused by an infectious microorganism that can be viral. as well as nasal mucous gland hyperactivity under the influence of pregnancy-associated hormones. they are most effective against the symptoms caused by histamine release namely. progesterone-induced vascular smooth muscle relaxation. Side effects reported include a bitter taste. rhinorrhoea. The first generation oral antihistamines can cause sedation. sore throat and epistaxis affecting up to 10% of users. severe crusting. irrigation.weather changes .EVIDENCE BASED PHARMACY PRACTICE obstruction.perfumes/odours . however. triamcinolone acetonide. ebastine and mizolastine have longer durations of action thus allowing once daily dosing. The second generation antihistamines including loratidine. fluticasone propionate. Atrophic rhinitis appears to be resistant to treatment. These newer antihistamines cause less sedation and anti- Topical corticosteroids Intranasal corticosteroids are potent antiinflammatory agents that have been proven to be highly effective as a first line treatment for individuals suffering from both allergic and non-allergic rhinitis with symptoms ranging from moderate in intensity to severe or persistent. fexofenadine. include an increase in circulating blood volume resulting in nasal vascular pooling. facial pain and nasal crusting.5 MANAGEMENT – THE TOOLS IN THE PHARMACIST’S ARSENAL Oral antihistamines Oral antihistamines are effective H1-antagonists and are available without prescription. Only beclomethasone is available without a prescription in South Africa and thus can be used as an effective first-line management by pharmacists. azelastine has also gained Food and Drug Administration (FDA) approval for the treatment of non-allergic vasomotor rhinitis. or fungal in nature. The key issue connected to the use of intranasal steroids is that of compliance. budesonide.

Leech SC. 38: 19 – 42. Ryan D. i. 22 (12): 2541 – 2548. Update on Nonallergic Rhinitis. Pseudoephedrine is the most common agent available in South Africa. ed. Jooma O. 86: 494 – 508. Friedman R. www. Settipane RA.5 H1-antihistamines Oral Intranasal Eye drops Corticosteroids Intranasal Decongestants Intranasal Oral ++ ++ 0 ++ ++ 0 + + 0 +++ ++ 0 ++ 0 +++ +++ +++ +++ ++ ++ 0 0 0 0 ++++ + 0 0 0 0 suggested that intranasal corticosteroids are the mainstay of treatment and the remaining therapies should be used as adjuncts. Clinicaln and Experimantal Allergy. ed. Nasser SM. May 2006.3. Jeena P. 2006. nasal irritation and an increase in rhinorrhoea. Allergy. Lee KJ. 2008. Loh CY. Current Diagnosis and Treatment in Otolaryngology – Head and Neck Surgery.5 NS. 2004. Identifying and Managing Rhinitis and its Subtypes: Allergic and Non-allergic Components . 2004. Scadding GK. 5. Mirakian R. however their use is far below that which would be expected for a condition with such a high prevalence. Gravet C. McGraw Hill. Thus a brief period of use is indicated i. References: 1. Many forms of therapies exist. Ossip M. SAMJ. Dixon TA. placing the nozzle of the spray into the nostril in an upward and lateral position towards the inferior turbinates and not towards the nasal septum as often occurs. Manjra A. American Family Physician. but according to evidence it is SA Pharmaceutical Journal – March 2008 15 . Quillen DM. Patients should be instructed on the correct use of nasal sprays.5 See Table II for the effects of different therapies on the syptoms of rhinitis. Wang DY. Chao SS. 8. Acta Oto-Laryngologica. Mygind N. Steer J.org 3. 6. Side effects range from insomnia and agitation to an increase in blood pressure. 2. New York. 8 th ed. Jones Compliance Topical nasal corticosteroids have been shown to be superior in the treatment of nasal symptoms in both allergic and nonallergic rhinitis.e. Andersson M. CONCLUSION Rhinitis is an extremely common condition that pharmacists are faced with. Jolles SRA. Shapiro G. Wolff L. 9. Green R. 2006. Current Medical Research and Opinion.5 Table II: Effects of different therapies on the symptoms of rhinitis5 Sneezing Rhinorrhoea Nasal obstruction Nasal itch Eye symptoms Decongestants Xylometazoline and oxymetazoline are both intranasal decongestants that cause nasal vasoconstriction and are thus effective in relieving nasal congestion in both allergic and non-allergic rhinitis. Annals of Allergy. Side effects that may occur include rhinitis medicamentosa. Davis G. Joyce G.EVIDENCE BASED PHARMACY PRACTICE effective adjunct to standard therapy. 2006. 126: 1022 – 1029. Clinical Management of Allergic Rhinitis – the Allergy Society of South Africa Consensus update. Potter PC. McGraw-Hill. Essential Otolaryngology. Clark AT. 7. Siddique N. 2003. Asthma and Immunology. Walker SM. Feller DB. Lalwani AK. 59: 1168 – 1172. 73 (9): 1583 – 1590. Diagnosing Rhinitis: Allergic Versus Non-allergic. Groenewald M. Hockman M. Nassef M. Howarth PH. Topical Glucocorticosteroids in Rhinitis: Clinical Aspects. Connecticut. Carte G. Desmarais P. Casale TB. Durham SR. and in order to choose the most appropriate therapy for the individual patient. A Clinical Survey on Compliance in the Treatment of Rhinitis Using Nasal Steroids. Farooque S. Seedat R. Cullinan P. It is also effective in reducing sneezing. Gill M.a Consensus Report and Materials from the Respiratory and Allergic Disease Foundation. Lieberman P. Oral decongestants are weakly effective in reducing nasal congestion but do not cause a rebound effect. Vidjakk D. BSACI Guidelines for the Management of Allergic and Nonallergic Rhinitis.whiar. congestion and postnasal drip in patients with vasomotor rhinitis. 2001. it is best to have an understanding of the various subtypes of rhinitis. less than ten days. 9 (12): 1269 – 1272.e. Chan YH. 4. 10.

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