Symptoms in the Pharmacy :Respiratory Problems (14)

Treatment timescale  (Allergic rhinitis)

Improvement in symptoms should occur within a few days. If no improvement is noted after 5 days, the patient might be referred to the doctor for other therapy.

Management

Management is based on whether symptoms are intermittent or persistent and mild or moderate. Options include antihistamines, nasal steroids and sodium cromoglicate (sodium cromoglycate) in formulations for the nose and eyes. OTC antihistamines and steroid nasal sprays are effective in the treatment of allergic rhinitis. The choice of treatment should be rational and based on the patient’s symptoms and
previous history where relevant.

Many cases of hay fever can be managed with OTC treatment and it is reasonable for the pharmacist to recommend treatment. Patients with symptoms that do not respond to OTC products can be referred to the doctor at a later stage. Pharmacists also have an important role
in ensuring that patients know how to use any prescribed medicines correctly (e.g. steroid nasal sprays, which must be used continuously for the patient to benefit).

Antihistamines

Many pharmacists would consider these drugs to be the first-line treatment for mild to moderate and intermittent symptoms of allergic rhinitis. They are effective in reducing sneezing and rhinorrhoea,
less so in reducing nasal congestion. Non-sedating antihistamines available OTC include acrivastine, cetirizine and loratadine. All are effective in reducing the troublesome symptoms of hay fever and have the advantage of causing less sedation than some of the older antihistamines.

Cetirizine and loratadine are taken once daily while acrivastine is taken three times daily. Recommended doses should not be exceeded.


For sale OTC, acrivastine, cetirizine and loratadine can be recommended for children over 12 years.
While drowsiness is an extremely unlikely side-effect of any of the three drugs, patients might be well advised to try the treatment for a day before driving or operating machinery. Recent evidence suggests that loratidine is less likely to have any sedative effect than the other two, but the incidence of drowsiness is extremely small.

Acrivastine, cetirizine and loratadine may be used for other allergic skin disorders such as perennial rhinitis and urticaria.
Older antihistamines, such as promethazine and diphenhydramine, have a greater tendency to produce sedative effects. Indeed, both drugs are available in the UK in OTC products promoted for the management of temporary sleep disorders . The shorter half-life of diphenhydramine (5–8 h compared with 8–12 h of promethazine)
should mean less likelihood of a morning hangover/drowsiness effect.
Other older antihistamines are relatively less sedative, such as chlorphenamine (chlorpheniramine) and clemastine. Patients may develop tolerance to their sedation effects. 

Anticholinergic activity is very much lower among the newer drugs compared  to the older drugs. 

Interactions. The potential sedative effects of older antihistamines are increased by alcohol, hypnotics, sedatives and anxiolytics. The alcohol content of some OTC medicines should be remembered.
The plasma concentration of non-sedating antihistamines may be increased by ritonavir; plasma concentration of loratadine may be increased by amprenavir and cimetidine. There is a theoretical possibility that antihistamines can antagonise the effects of betahistine.

Side-effects. The major side-effect of the older antihistamines is their potential to cause drowsiness. Their anticholinergic activity may result in a dry mouth, blurred vision, constipation and urinary retention.
These effects will be increased if the patient is already taking another drug with anticholinergic effects (e.g. tricyclic antidepressants, neuroleptics).

At very high doses, antihistamines have CNS excitatory rather than depressive effects. Such effects seem to be more likely to occur in children. At toxic levels, there have been reports of fits being induced.
As a result, it has been suggested that antihistamines should be used with care in epileptic patients. However, this appears to be a largely theoretical risk.

Antihistamines are best avoided by patients with narrow- (closed-) angle glaucoma, since the anticholinergic effects produced can cause an increase in intraocular pressure. They should be used with caution in patients with liver disease or prostatic hypertrophy.


Decongestants

Oral or topical decongestants may be used to reduce nasal congestion alone or in combination with an antihistamine. They can be useful in patients starting to use a preventer such as a nasal corticosteroid (e.g. beclometasone) or sodium cromoglicate where congestion can prevent
the drug from reaching the nasal mucosa. Topical decongestants can cause rebound congestion, especially with prolonged use. They should not be used for more than 1 week. Oral decongestants are occasionally included such as pseudoephedrine. Their use, interactions and adverse
effects are considered in the section on ‘Colds and flu’ .
Eye drops containing an antihistamine and sympathomimetic
combination are available and may be of value in troublesome eye symptoms, particularly when symptoms are intermittent. The sympathomimetic acts as a vasoconstrictor, reducing irritation and redness. Some patients find that the vasoconstrictor causes painful stinging when first applied. Eye drops that contain a vasoconstrictor should not be used in patients who have glaucoma or who wear soft contact lenses.

Steroid nasal sprays
Beclometasone nasal spray (aqueous pump rather than aerosol version), fluticasone metered nasal spray and triamcinolone aqueous nasal spray can be used for the treatment of seasonal allergic rhinitis.

     A steroid nasal spray is the treatment of choice for moderate to severe nasal symptoms that are continuous. The steroid acts to reduce inflammation that has occurred as a result of the allergen’s action.
Regular use is essential for full benefit to be obtained and treatment should be continued throughout the hay fever season. If symptoms of hay fever are already present, the patient needs to know that it is likely to take several days before the full treatment effect is reached.

     Dryness and irritation of the nose and throat, and nosebleeds have occasionally been reported; otherwise side-effects are rare. Beclometasone, fluticasone and triamcinolone nasal sprays can be used in
patients over 18 years of age for up to 3 months. They should not be recommended for pregnant women or for anyone with glaucoma.
Patients are sometimes alarmed by the term ‘steroid’, associating it with potent oral steroids and possible side-effects. Therefore the pharmacist needs to take account of these concerns in explanations about the drug and how it works.

Sodium cromoglicate
Sodium cromoglicate is availableOTCas nasal drops or spray and as eye drops. An OTC nasal spray product containing sodium cromoglicate with a small  amount of decongestant is available. The amount of decongestant is said to be too small to produce rebound congestion.

Cromoglicate can be effective as a prophylactic if used correctly. It should be started at least 1 week before the hay fever season is likely to begin and then used continuously. There seem to be no significant side-effects, although nasal irritation may occasionally occur.

Cromoglicate eye drops are effective for the treatment of eye symptoms that are not controlled by antihistamines. Cromoglicate should be used continuously to obtain full benefit. The eye drops should be used four times a day. The eye drops contain the preservative benzalkonium
chloride and should not be used by wearers of soft contact
lenses.

Topical antihistamines
Nasal treatments
Azelastine and levocabastine are used in allergic rhinitis. The BNF suggests that treatment should begin 2–3 weeks before the start of the hay fever season. Azelastine and levocabastine are available as aqueous nasal sprays. Their place in treatment is likely to be for mild and intermittent symptoms. Azelastine can be used in adults and children over 5 years of age; levocabastine can be used in adults
and children over 12 years of age. Advise the patient to keep the head upright during use to prevent the liquid trickling into the throat and causing an unpleasant taste.

Eye treatments

Levocabastine eye drops can be used in children over 12 years of age and adults for the treatment of seasonal allergic conjunctivitis.

Further advice

1- Car windows and air vents should be kept closed while driving.
Otherwise a high pollen concentration inside the car can result.

2- Where house dust mite is identified as a problem, regular cleaning of the house to maintain dust levels at a minimum can help. Special vacuum cleaners are now on sale that are claimed to be particularly effective.