Treating allergic rhinitis through better patient management

The Asthma and Allergy Foundation of America estimates that 50 million Americans suffer from allergic rhinitis, which includes hay fever and seasonal or perennial indoor/outdoor nasal allergies. These conditions are thought to affect up to 30% of adults and 40% of children, according to reports from the American College of Asthma Allergy & Immunology. This represents a marked increase over past decades; in the 1940s, hay fever was estimated to affect only 1% of the U. S. population.

Hay fever is the fifth-leading chronic disease for adults and a significant cause of work absenteeism, resulting in nearly four million missed workdays each year at a cost of over $700 million in lost productivity. In addition, hay fever results in significant presenteeism, with poor performance while at work due either to the symptoms of the condition itself or the effects of medication used to treat those symptoms.

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Overall, allergies are responsible for nearly $14.5 billion in medical costs each year. More than 11 million outpatient office visits occur annually to address allergy, primarily in the spring and fall. What these statistics fail to show is the significant effect allergies can have on many patients’ quality of life, given that allergy symptoms can have a greater impact even than diseases such as asthma.

Despite the burden associated with allergic symptoms, studies have shown that only a small percentage of patients actually seek medical advice regarding treatment. A review of data from the National Medical Expenditure Survey found that only 12.4% of patients with allergic rhinitis visited their physician to manage the condition, while others used home remedies or over-the-counter medications. Even with these attempts at treatment, about 50% of patients with allergic rhinitis report symptoms lasting more than four months per year, and 20% have symptoms lasting at least nine months.

Clinicians play an important role in helping patients alleviate their allergy symptoms. “While there is no cure for grass pollen allergies, they can be managed through treatment and avoiding exposure to the pollen,” says Karen Midthun, MD, director of the U.S. Food and Drug Administration’s Center for Biologics Evaluation and Research. Thus, effective, efficient patient counseling on management and medication is key to managing patients’ seasonal symptoms.

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Patient Management Tips

Evaluate effectively. A complete history will help clarify the patient’s chief concerns and symptoms, including symptom triggers, seasonality, and chronicity; environmental, home, and occupational exposure; and current coexisting conditions and medications. Specifically, asking patients about pollen and animal exposure can have positive predictive value for diagnosing allergic rhinitis.

It is also important to establish how symptoms affect a patient’s quality of life. Nasal examination, while important to supporting a diagnosis of allergic rhinitis, is not necessarily sufficient by itself to defining the condition. Perform a physical examination of all organ systems that may be affected by allergies, especially the lower respiratory tract.

It is also important to ask about the presence of comorbidities and other related conditions during the patient examination. Patient issues commonly associated with allergic rhinitis can include asthma, sleep disturbances, sinusitis, otitis media, ocular symptoms, abnormal breathing patterns that can alter facial growth in children, and effects on cognitive function that can manifest as falling school grades during allergy season.

Define allergy triggers. Identifying a patient’s allergy triggers provides crucial information for successful management. Common triggers of allergic rhinitis include animals, dust mites, fungi, insect emanations, and pollens.

Pollen types can vary widely based on climate and locale, and fungi are ubiquitous organisms that can produce clinically significant allergens. Therefore, patient education regarding avoidance of established allergic triggers is essential.

Individualize a treatment plan and educate accordingly. Successful management of allergic rhinitis typically requires a combination of allergen avoidance, patient education, pharmacotherapy, and possibly immunotherapy. Patient management and monitoring should be individualized based on reported symptoms, physical examination, comorbidities, and patient age and preferences.

A strong physician/patient/family partnership will provide the most effective framework for treatment success, and education is a key element in facilitating adherence and optimizing treatment outcomes. Patients should understand how to avoid environmental triggers, as well as the appropriate use of over-the-counter or prescription medications. Pharmacological management often requires a step-up approach when therapy is inadequate for symptom control, or a step-down approach when symptom relief is achieved.

Therefore, clinicians and families should agree as to when escalation or de-escalation of therapy is appropriate. Targeted immunotherapy may be necessary for symptom control in patients with moderate or severe persistent allergic rhinitis that does not respond to other forms of treatment.

Optimize allergen and self-management techniques. Patients with allergic rhinitis should avoid known allergic triggers such as pets, as well as general respiratory irritants such as cigarette smoke, perfumes, and paint fumes. Nasal irrigation with saline can be a beneficial self-management technique for alleviating symptoms, and may be used alone or as adjuvant therapy.

Some suggestions for controlling exposure to specific allergens include:

• Animals: avoid contact

• Dust mites: use dust covers for bedding, control humidity, vacuum carpets frequently, use high efficiency particulate (HEPA) filters.

• Indoor fungi: remove sources of moisture, replace contaminated materials, use diluted bleach solution to clean nonporous surfaces

• Pollen: limit time outdoors when pollen counts are high

• Tobacco smoke and other irritants: minimize exposure

Establish regular follow-up appointments. Consistent follow-up can allow for timely recognition of complications, increase therapeutic success, and improve compliance. Follow-up visits also facilitate regular review of a patient’s treatment plan so that it can be modified as necessary based on symptom control and quality of life.

Know when to refer. Referral to an allergist/immunologist can be helpful when there is a need to identify more specifically the allergens affecting a patient so that stricter environmental control can be achieved.

Additionally, specialist consultation may be necessary when patients with allergic rhinitis have inadequately controlled symptoms, report a decrease in quality of life, or experience reduced ability to function. Additional reasons to refer include adverse reactions to medications, the presence of comorbid conditions such as asthma or recurrent sinusitis, or when immunotherapy is being considered as a treatment option.