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In collaboration with the World Health Organization
A Pocket Guide for Pharmacists
• Allergic rhinitis is clinically defined as a symptomatic disorder of the nose
induced, after allergen exposure, by an IgE-mediated inflammation of the • Allergic rhinitis represents a global health problem affecting at least 10%
to 40% of the population. Although it is not usually a severe disease, it alters the social life of patients and affects school performance and work • Asthma and rhinitis are common co-morbidities suggesting the concept
• New knowledge on the mechanisms underlying allergic inflammation of the airways has resulted in better therapeutic strategies. • The ARIA initiative has been developed in collaboration with WHO to be state-of-the-art for physicians and health-care workers. A special guide has been developed for the pharmacist.
• As trusted healthcare professionals, pharmacists are in an excellent position to identify symptoms of allergic rhinitis and recommend any appropriate treatment. This guide provides a practical, step-by-step approach to • in recognising allergic rhinitis and assessing its severity, • in understanding the effect of treatment on rhinitis and co-morbidities, • in determining whether management in the pharmacy is appropriate, • on the initiation of an appropriate treatment and monitoring plan, • by proposing appropriate preventive measures.
• increase collaboration between pharmacists, physicians and other • reduce the burden incurred by allergic rhinitis and its co-morbidities, • aid in the identification of undiagnosed or uncontrolled asthma, • improve cost-effectiveness in the management of allergic rhinitis.
This document is a guide. It is not intended to be a mandatory standard of care document for individual countries. It is provided as a basis for pharmacists and their staff to develop relevant local standards of care for their patients. Recognising
allergic rhinitis
in the pharmacy

1- Recognising allergic rhinitis and differentiating
allergy from other causes including infection
• Some patients who consult the pharmacist will have had allergic rhinitis previously diagnosed by a physician, others will have made an appropriate self-diagnosis, some will not have received any diagnosis of rhinitis or may even have an incorrect diagnosis (e.g. a viral infection or a cold). • Allergic rhinitis has symptoms similar to those of a number of other con- ditions and may be confused with a viral infection such as the common • The presence of nasal itching, rhinorrhea, sneezing and eye symptoms are usually consistent with allergic rhinitis.
Symptoms suggestive
Symptoms usually NOT associated
of allergic rhinitis
with allergic rhinitis
– unilateral symptoms
2 or more of the following symptoms for
– nasal obstruction without other symptoms
> 1 hr on most days:
– mucopurulent rhinorrhea
– watery anterior rhinorrhea
– posterior rhinorrhea (post nasal drip)
– sneezing, especially paroxysmal
–with thick mucous
– nasal obstruction
–and/or no anterior rhinorrhea
– nasal pruritis
± conjunctivitis
– recurrent epistaxis
– anosmia

Classify and assess severity
Refer the patient rapidly to a physician
2- Assessing the severity of allergic rhinitis
A recent classification of allergic rhinitis (intermittent or persistent) has replaced the previous classification of seasonal and perennial forms.
4 days per week
• > 4 days per week
• or 4 weeks
• and > 4 weeks
• normal sleep
one or more items
• no impairment of daily
• abnormal sleep
activities, sport, leisure
• impairment of daily
• normal work and school
activities, sport, leisure
• no troublesome symptoms
• impairment of work and
school activities
• troublesome symptoms
3- Management by pharmacists or referral
to physician
• Referral to a physician should be considered in cases where: • persistent, moderate to severe symptoms of rhinitis are present (although initial treatment might be provided by a pharmacist whilst • symptoms are suggestive of undiagnosed asthma or uncontrolled asthma in patients with a diagnosis of asthma (e.g. wheezing or • symptoms of infection (mucopurulent discharge, sore throat, myalgia, • symptoms do not respond to initial pharmacy management within • bothersome side effects are experienced. • Referral to a physician is also advisable during pregnancy, because some medications should be administered with caution. • Management by a physician is also appropriate for children under 12, taking into account the difficulties in establishing the diagnosis, in selecting the proper medications to avoid side effects and the frequent off-label use of medicines in this young age group.
4- Asthma co-morbidity
• Allergic rhinitis and asthma often coexist. Allergic rhinitis is regarded as a risk factor for the development of asthma. • In patients with asthma, rhinitis may be associated with a poor control of • Patients with persistent rhinitis should be questioned for symptoms of • Patients with asthma should be questioned for symptoms of rhinitis. 5- Conjunctivitis
• Eye symptoms are common in patients suffering from allergic rhinitis.
However, they do not exist in all patients with rhinitis. • The presence of conjunctivitis should always be considered. • On the other hand, conjunctivitis is not always induced by allergic triggers.
• Photophobia (light sensitivity) is an important symptom to be noted, and, if present, needs a physician evaluation. Eye itching is common in allergic conjunctivitis. In contrast, eye burning is rarely a sign of allergic Symptoms suggestive of allergic conjunctivitis
Symptoms NOT suggestive of allergic conjunctivitis
1 or more of the following symptoms for > 1 hr on most days:
1 or more of the following symptoms:
– symptoms associated with rhinitis
– symptoms NOT associated with rhinitis
– bilateral eye symptoms
– unilateral conjunctivitis
– eye itching
– NO eye itching
– watery eyes
– BUT eye burning
– red eyes
– dry eyes
– NO photophobia
– photophobia
Do the symptoms concern
Refer the patient to a doctor
the patient or the pharmacist?
oral H1-blocker*/$
If after 7-15 days
or ocular H1-blocker*/£
No Improvement
or ocular chromone*/£
*: depending on drug availability not in prefered order
$: non-sedating H1-blockers are prefered
£: formulations without preservatives are better tolerated

Management of
allergic rhinitis

The management of allergic rhinitis is evidence-based and includes: • Allergen avoidance:
• Most allergen avoidance studies have dealt with asthma symptoms and very few have studied rhinitis symptoms. A single intervention may be insufficient to control symptoms of rhinitis or asthma. • However, allergen avoidance, including house mites, should be an • More data are needed to fully appreciate the value of allergen avoidance. • Medications (pharmacological treatment):
• Pharmacological treatment should take into account the efficacy, safety and cost-effectiveness of medications, the patient's preference as well as the objective of treatment, severity of the disease and the presence • Medications used for rhinitis are most commonly administered • The efficacy of medications may differ between patients.
• Many medications used in the treatment of allergic rhinitis are available without a medical prescription although there is a large • Non-sedating H1 oral antihistamines are preferred to sedative ones because of their considerably lower incidence of side effects compared to sedating antihistamines. Patients may not always perceive sedation • Intranasal corticosteroids are the most effective treatment of allergic rhinitis, in particular in severe disease or when nasal obstruction predominates. They are safe but some patients prefer oral drugs. • Common treatments currently available for allergic rhinitis (including prescription-only medicines) are listed below and pharmacists are able to advise patients on both prescribed and OTC medications.
• Specific immunotherapy:
• Allergen specific vaccination is the practice of administering gradually increasing quantities of an allergen extract to an allergic subject to ameliorate the symptoms associated with the subsequent exposure to the causative allergen. The efficacy of injection and sublingual immunotherapy using inhalant allergens to treat allergic rhinitis and asthma is evidence-based when optimally administered. Standardised therapeutic vaccines which are available for the most common • Education:
when possible
specialist prescription
may alter the natural
easily administered
course of the disease
always indicated
Responses to commonly asked questions
• Medications are for the relief of symptoms and have no long-lasting effect when stopped. Therefore, in persistent disease, maintenance • Tachyphylaxis does not usually occur with prolonged treatment except for intranasal decongestants. Continuous treatment with other • Most medications recommended in this guideline do not have significant long-term side effects and can be administered for prolonged periods.
Alternative and complementary medicine (e.g. homeopathy, herbal
medicines, acupuncture) is increasingly used for the treatment of rhinitis, although the definite proof of their efficacy is not evidence-based. Herbal medicine can induce pharmacological interactions with medications used in the treatment of allergic rhinitis or other illnesses. • Surgery may be used as an adjunctive intervention in a few highly
• It is recommended to propose a strategy combining the treatment of both the upper and lower airway disease in terms of efficacy and safety.
• Follow-up is required in patients with persistent rhinitis and severe TREAT IN A STEPWISE APPROACH
(adolescents and adults)
(history ± skin prick tests or serum specific IgE)
Allergen avoidance
Intermittent symptoms
Persistent symptoms
• oral H1 -blocker
• oral H1 -blocker
1 -blocker
• intranasal H1 -blocker
add H1 -blocker
If conjunctivitis add:
• oral H1 -blocker
• or intra-ocular H1 -blocker
consider specific immunotherapy
Medications available for the treatment of allergic rhinitis
(including prescription-only medicines):

Generic names
Mechanism of
Side effects
2nd generation
2nd generation
induce sedation and has - rapidly effective (less 1st generation
1st generation
- minor local side effects - rapidly effective antihistamines
- minor local side effects - the most effective glucocorticosteroids Budesonide
Local chromones
- minor local side effects - intraocular chromones (intranasal, ocular) Nedocromil
Generic names
Mechanism of
Side effects
— same side effects
as oral deconges-
tants but less intense oral decongestants
occurring with prolonged to avoid rhinitis Intranasal
- minor local side effects - effective in anticholinergics
Oral/IM gluco-
A pharmacy protocol for treating allergic rhinitis
With recent changes in the regulatory status of some medications for
allergic rhinitis symptoms, pharmacists may recommend more therapies which are available without prescription. The use of these medications is likely to result in cost savings for both the patient and health care profes- sional. The involvement of the pharmacist in the overall management of the patient is also likely to reduce risks of overdosing and drug interactions. Based on the above considerations, a recommended pharmacy protocol for Symptoms of allergic rhinitis
Mild persistent
Mild intermittent
Moderate-severe intermittent
Oral H1-blocker*/$
Oral H1-blocker*/$
or nasal H1-blocker*
Refer to physician
or nasal H1-blocker*
or decongestant*
and/or decongestant*
or nasal chromone*
or nasal steroid*/£
or nasal chromone*

or nasal saline
*: depending on drug availability and not in prefered order
$: non-sedating H1-blockers should be preferred

If after 7-15 days
£: if nasal obstruction predominates, intranasal steroids are the
first line treatment
No improvement
Allergic rhinitis, like other chronic diseases, requires monitoring for: • improvement of symptoms and quality of life,• assessment of safety of OTC and prescribed medications,• need for referral to a physician,• need to discontinue or reinstate medications.
A pharmacy protocol for treating ocular symptoms
• With the exception of nasal decongestants and anticholinergics, all the major treatments discussed above are effective against the ocular symptoms of allergic rhinitis. Sodium cromoglycate, nedocromil sodium, NAAGA and H1-antihistamines (azelastine, levocabastine, ketotifen, olopatadine) are also available as eye drops. Intranasal glucocortico- steroids have shown some effect in eye symptoms associated with allergic • Intraocular glucocorticosteroids are effective, but because of known side effects should only be prescribed and monitored by eye-care Symptoms suggestive of
allergic conjunctivitis
1 or more of the following symptoms
for > 1 hr on most days
– symptoms associated with rhinitis
– bilateral eye symptoms
– eye itching
– watery eyes
– red eyes
– NO photophobia

Do eye symptoms concern
Refer the patient
the patient or the pharmacist?
to a physician
If after 7-15 days
or ocular H1-blocker*
No improvement
or ocular chromone*$
*: depending on drug availability
*: not in preferred order
$: formulations without preservatives are better tolerated

The management of allergic rhinitis and
asthma in the pharmacy

• Asthma may be severe and even life-threatening. • When pharmacists identify patients with undiagnosed or untreated asthma, or asthma which is not optimally controlled, they should encourage these individuals to obtain appropriate medical care.
The patient does not know if he
Patient with a diagnosis
(she) is asthmatic
of asthma
4 simple questions:
1 or more of the following:*
– Has your asthma interfered with usual activities (e.g. housework, work/school)? – Do you need your reliever inhaler (blue) If YES to any of these questions
If YES to any of these questions
your patient may be asthmatic
your patient has uncontrolled asthmatic
Refer the patient to a physician
*from the National Asthma Campaign, “conquering asthma” • The treatment of asthma should follow the recently published GINA • It is important to manage co-morbidity of allergic rhinitis and asthma.
Treatment of allergic rhinitis has been associated with improved outcomes Distribution of this Pharmacist’s Pocket Guide has been made possible ARIA has received educational grants from:


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