ctma 2 - canadian pharmacists association
TRANSCRIPT
CTMA 2
Canada’s Trusted Reference forMinor Ailments
Sample Chapters for Conference_J.indd 1 6/17/2016 2:35:16 PM
CANADIAN CURRENT COMPREHENSIVE CONVENIENT
Created by Canadian experts for Canadian healthcare practitioners
treating Canadian patients
www.pharmacists.ca
Sample Chapters for Conference_J.indd 2 6/17/2016 2:35:16 PM
Compendium of Therapeutics for Minor Ailments Copyright © Canadian Pharmacists Association. All rights reserved.
Table of ContentsEditorial Advisory Committee ................................................................................................vii
Authors ........................................................................................................................... viii
Reviewers ........................................................................................................................ ix
Editor's Message ................................................................................................................ x
Editorial Policy, Description and Limitations of Information........................................................... xi
How to Use Compendium of Therapeutics for Minor Ailments ......................................................xii
Patient Assessments ......................................................................................................... xiii
Communicating With Patients1 Effective Pharmacist-patient Interactions, Barbara J. Farrell ...................................................12 Facilitating Behaviour Change, Lisa Dolovich .................................................................... 123 Pharmacist Assessment of the Self-treating Patient, Nardine Nakhla ...................................... 21
Psychiatric Conditions4 Depression, Ric M. Procyshyn and Alasdair M. Barr............................................................ 275 Insomnia, Ric M. Procyshyn and Alasdair M. Barr............................................................... 386 Smoking Cessation, Kristine Petrasko and Manjit Bains....................................................... 52
Central Nervous System Conditions7 Fever, Yvonne M. Shevchuk .......................................................................................... 828 Headache, Irene Worthington ........................................................................................ 999 Heat-related Disorders, Dorothy Tscheng ........................................................................11710 Tinnitus, Yvonne M. Shevchuk ..................................................................................... 12811 Vertigo and Dizziness, Yvonne M. Shevchuk ................................................................... 132
Eye Care12 Assessment of Patients with Eye Conditions, Anne M. Friesen ............................................ 13913 Conjunctivitis, Anne M. Friesen .................................................................................... 14014 Contact Lens Care, David S. Wing and Ken Gellatly ......................................................... 14815 Dry Eye, Anne M. Friesen ........................................................................................... 16216 Eyelid Conditions: Hordeolum, Chalazion and Blepharitis, Anne M. Friesen ........................... 169
Ear Conditions17 Assessment of Patients with Hearing Loss, Ear Pain and Ear Drainage, Yvonne M.
Shevchuk ................................................................................................................ 18718 Complications Affecting the Ear: Ear Piercing, Foreign Bodies and Barotrauma, Yvonne M.
Shevchuk ................................................................................................................ 19319 Impacted Earwax, Yvonne M. Shevchuk......................................................................... 198
iii
Sample Chapters for Conference_J.indd 3 6/17/2016 2:35:16 PM
Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments
20 Otitis Media and Otitis Externa, Yvonne M. Shevchuk ....................................................... 206
Respiratory Conditions21 Acute Cough, Daniel J.G. Thirion .................................................................................. 21722 Allergic Rhinitis, Jennifer Kendrick ................................................................................ 22623 Assessment of Patients with Upper Respiratory Tract Symptoms, Daniel J.G. Thirion .............. 24924 Viral Rhinitis, Influenza, Rhinosinusitis and Pharyngitis, Daniel J.G. Thirion ........................... 254
Metabolic and Cardiovascular Conditions25 Diabetes Care, Lori MacCallum .................................................................................... 27326 Diabetes Care Devices, Ronald Silver ........................................................................... 29327 Lifestyle Management and Disease Prevention, L. Maria Gutschi ........................................ 302
Gastrointestinal Conditions28 Assessment of Patients with Abdominal Pain, Peter Thomson ............................................ 32329 Constipation, Jane Bowles-Jordan ................................................................................ 32730 Diarrhea, Antonietta Forrester ...................................................................................... 35331 Dyspepsia and GERD, Co Q. D. Pham .......................................................................... 37832 Gastrointestinal Gas, Co Q. D. Pham............................................................................. 39033 Hemorrhoids, Joyce Chan ........................................................................................... 39834 Infant Colic, Shelita Dattani ......................................................................................... 40735 Irritable Bowel Syndrome, Lynette Kosar ........................................................................ 42036 Nausea and Vomiting, Christine Hughes ........................................................................ 42937 Ostomy Care, Marie Berry........................................................................................... 44838 Perianal Symptom Assessment, Joyce Chan .................................................................. 46339 Pinworms, Joyce Chan ............................................................................................... 465
Nutrition40 Infant Nutrition, Joan Brennan-Donnan .......................................................................... 47241 Special Diets, Shirley Heschuk..................................................................................... 49142 Sports Nutrition, Shirley Heschuk.................................................................................. 50643 Weight Management, Shirley Heschuk........................................................................... 519
Musculoskeletal Conditions44 Drug Use and Abuse in Sports, Lily Lum......................................................................... 54745 Low Back Pain, Kelly Grindrod, Jason Kielly and Carlo Marra ............................................. 55446 Osteoarthritis, Kelly Grindrod, Jason Kielly and Carlo Marra ............................................... 56947 Osteoporosis, Lalitha Raman-Wilms and Anne Marie Whelan ............................................. 59048 Sports Injuries, Lily Lum.............................................................................................. 608
Foot Conditions
iv
Sample Chapters for Conference_J.indd 4 6/17/2016 2:35:17 PM
Compendium of Therapeutics for Minor Ailments Copyright © Canadian Pharmacists Association. All rights reserved.
49 Assessment of Foot Symptoms, Anne Mallin ................................................................... 62150 Athlete's Foot, Anne Mallin .......................................................................................... 62351 Corns, Calluses, Bunions and Ingrown Toenails, Anne Mallin.............................................. 63152 Plantar Warts, Anne Mallin .......................................................................................... 641
Dermatologic Conditions53 A Summary of Common Skin Conditions, Penny F. Miller ................................................... 64854 Acne, Debra Sibbald .................................................................................................. 65355 Atopic, Contact, and Stasis Dermatitis, Debra Sibbald ....................................................... 68256 Bacterial Skin Infections: Impetigo, Furuncles and Carbuncles, Penny F. Miller ....................... 71657 Burns, Nancy Kleiman ................................................................................................ 73058 Dandruff and Seborrheic Dermatitis, Debra Sibbald .......................................................... 74059 Diaper Dermatitis, Debra Sibbald.................................................................................. 76060 Dressings, Marie Berry ............................................................................................... 77961 Drug-induced Skin Reactions, Sandra Knowles ............................................................... 78662 Dry Skin, Nancy Kleiman ............................................................................................ 80263 Frostbite, Nancy Kleiman ............................................................................................ 80964 Fungal Nail Infections (Onychomycosis), Penny F. Miller.................................................... 81865 Fungal Skin Infections, Penny F. Miller ........................................................................... 82766 Hair Care and Hair Growth, Nancy Kleiman .................................................................... 84267 Insect Bites and Stings, Nancy Kleiman ......................................................................... 86168 Minor Cuts and Wounds, Nancy Kleiman ........................................................................ 87769 Parasitic Skin Infections: Lice and Scabies, Penny F. Miller ................................................ 88670 Perspiration and Body Odour, Nancy Kleiman ................................................................. 90471 Psoriasis, Debra Sibbald............................................................................................. 91572 Prevention and Treatment of Sun-Induced Skin Damage, Nancy Kleiman.............................. 93973 Viral Skin Infections: Common and Flat Warts, Penny F. Miller ............................................ 95674 Viral Skin Rashes, Sandra Knowles............................................................................... 968
Reproductive, Gynecologic and Genitourinary Health75 Benign Prostatic Hyperplasia and Associated Lower Urinary Tract Symptoms, Cheryl A.
Sadowski ................................................................................................................ 98576 Contraception, Anne Marie Whelan ............................................................................... 99977 Dysmenorrhea, Thomas E.R. Brown ............................................................................103178 Male Sexual Dysfunction, Tom Smiley ..........................................................................104179 Menopause and Perimenopause, Thomas E.R. Brown .....................................................105480 Pregnancy and Fertility Testing, Marie Berry...................................................................106781 Premenstrual Syndrome, Thomas E.R. Brown ................................................................107482 Prenatal and Postpartum Care, Carla Dillon ...................................................................109083 Urinary Incontinence, Cheryl A. Sadowski ..................................................................... 113284 Vaginal Symptoms, Hygiene and Infections, Laura-Lynn Pollock......................................... 1145
v
Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments
20 Otitis Media and Otitis Externa, Yvonne M. Shevchuk ....................................................... 206
Respiratory Conditions21 Acute Cough, Daniel J.G. Thirion .................................................................................. 21722 Allergic Rhinitis, Jennifer Kendrick ................................................................................ 22623 Assessment of Patients with Upper Respiratory Tract Symptoms, Daniel J.G. Thirion .............. 24924 Viral Rhinitis, Influenza, Rhinosinusitis and Pharyngitis, Daniel J.G. Thirion ........................... 254
Metabolic and Cardiovascular Conditions25 Diabetes Care, Lori MacCallum .................................................................................... 27326 Diabetes Care Devices, Ronald Silver ........................................................................... 29327 Lifestyle Management and Disease Prevention, L. Maria Gutschi ........................................ 302
Gastrointestinal Conditions28 Assessment of Patients with Abdominal Pain, Peter Thomson ............................................ 32329 Constipation, Jane Bowles-Jordan ................................................................................ 32730 Diarrhea, Antonietta Forrester ...................................................................................... 35331 Dyspepsia and GERD, Co Q. D. Pham .......................................................................... 37832 Gastrointestinal Gas, Co Q. D. Pham............................................................................. 39033 Hemorrhoids, Joyce Chan ........................................................................................... 39834 Infant Colic, Shelita Dattani ......................................................................................... 40735 Irritable Bowel Syndrome, Lynette Kosar ........................................................................ 42036 Nausea and Vomiting, Christine Hughes ........................................................................ 42937 Ostomy Care, Marie Berry........................................................................................... 44838 Perianal Symptom Assessment, Joyce Chan .................................................................. 46339 Pinworms, Joyce Chan ............................................................................................... 465
Nutrition40 Infant Nutrition, Joan Brennan-Donnan .......................................................................... 47241 Special Diets, Shirley Heschuk..................................................................................... 49142 Sports Nutrition, Shirley Heschuk.................................................................................. 50643 Weight Management, Shirley Heschuk........................................................................... 519
Musculoskeletal Conditions44 Drug Use and Abuse in Sports, Lily Lum......................................................................... 54745 Low Back Pain, Kelly Grindrod, Jason Kielly and Carlo Marra ............................................. 55446 Osteoarthritis, Kelly Grindrod, Jason Kielly and Carlo Marra ............................................... 56947 Osteoporosis, Lalitha Raman-Wilms and Anne Marie Whelan ............................................. 59048 Sports Injuries, Lily Lum.............................................................................................. 608
Foot Conditions
iv
Sample Chapters for Conference_J.indd 5 6/17/2016 2:35:17 PM
Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments
Dental Health85 Dental Conditions, Michelle Bourassa........................................................................... 116786 Oral Hygiene, Dental Plaque and Caries, Michelle Bourassa ............................................. 117687 Periodontal Conditions: Gingivitis and Periodontitis, Michelle Bourassa ............................... 118888 Teething, Michelle Bourassa .......................................................................................1201
Mouth Conditions89 Aphthous Ulcers (Canker Sores), Adeline T. Chau Markarian.............................................120990 Cold Sores (Herpes Labialis), James S. Conklin .............................................................122091 Dry Mouth, Victoria Kletas ..........................................................................................123292 Halitosis, Shirin Abadi ...............................................................................................124293 Oral Candidiasis, Karen Wlock ....................................................................................1249
General AppendicesI Complementary and Alternative Therapies, Cynthia Richard and Paul A. Spagnuolo ..............1258II Home Testing, Marie Berry .........................................................................................1278III Information for the Traveller, Mark Kearney ....................................................................1289IV Medical Devices and Aids to Daily Living, Marie Berry ......................................................1304V Pregnancy and Breastfeeding: Self-care Therapy for Common Conditions, Myla E.
Moretti ...................................................................................................................1320VI Nutritional Supplements, L. Maria Gutschi .....................................................................1329
vi
Sample Chapters for Conference_J.indd 6 6/17/2016 2:35:18 PM
Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments
Ear Conditions
Chapter 20Chapter 20Otitis Media and Otitis ExternaYvonne M. Shevchuk, BSP, PharmD, FCSHP
Otitis MediaPathophysiologyAcute otitis media (AOM) is an infection of the middle ear cavity and is one of the most commonbacterial infections in childhood.1 Seventy-five percent of children experience at least 1 episode priorto entering school.2 To diagnose AOM, 3 criteria need to be met: 1) signs and symptoms of middle earinflammation 2) the presence of middle ear effusion and 3) acute onset (often abrupt) of signs andsymptoms of middle ear inflammation and effusion.1 Symptoms include acute ear pain (oftenunilateral and developing over a few hours), fever and reduced hearing.1 Tugging or pulling on the earsis often described, but this is a very nonspecific sign.1 Children too young to complain of pain orpressure in the ears may display irritability, excessive fussiness, poor feeding and disrupted sleeppatterns. Acute otitis media is more common in the winter months. A recent history of viral upperrespiratory tract infection is often present.2 The microorganisms most commonly associated with AOMare Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis.1,2
AOM has a high spontaneous recovery rate; 80% of children experience spontaneous symptomaticrelief with placebo or no drug therapy.3,4 For this reason, the concept of “watchful waiting” isadvocated after appropriate healthcare practitioner assessment and diagnosis of AOM. Rather thanimmediate initiation of antibiotic therapy, appropriately selected children are managed with analgesictherapy for the first 24–48 hours. This includes children >6 months of age with no craniofacialabnormalities who have uncomplicated AOM (normal host, no otorrhea, no history of chronic orrecurrent AOM) without severe pain or systemic illness, and whose caregivers are able to recognizesevere illness, take the child for immediate assessment, and provide access to follow-up care.1,2
Goals of Therapy■ Relieve symptoms of fever, pain and irritability■ Eliminate bacteria from the middle ear■ Ensure appropriate therapy to reduce the risk of resistant pathogens and drug-related adverse effects
such as antibiotic-associated diarrhea■ Prevent complications, e.g., mastoiditis, intracranial infection, facial paralysis
Nonpharmacologic TherapyComfort measures, such as warmed oils, warm or cold compresses and heating pads have been used byparents and caregivers for years, although there are no studies evaluating their effectiveness. If tried,heat therapy should be used cautiously and with close supervision in children, to avoid burns. A youngchild should never sleep with a hot water bottle or heating pad. Question the caregiver about whetherthere has been any drainage from the ear prior to recommending any topical therapy. Warmed oilshould not be used if there is a chance of perforation or any suspicion of drainage. Warming of dropsor oil should be done by rolling the bottle between the palms; other methods such as placing the bottle
206 Ear Conditions
Sample Chapters for Conference_J.indd 7 6/17/2016 2:35:18 PM
Ear Conditions
Compendium of Therapeutics for Minor Ailments Copyright © Canadian Pharmacists Association. All rights reserved.
in a glass of warm water or using the microwave oven should be avoided as serious burns have beenreported.
Pharmacologic TherapyFor more information on management of acute otitis media, consult the Compendium of TherapeuticChoices: Acute Otitis Media in Childhood.■ If antibiotics are used, systemic therapy is required; topical agents are not used in AOM.■ Adequate analgesia with usual doses of acetaminophen or ibuprofen is important (see Chapter 7:
Fever, Table 5).■ Topical analgesics may provide short-term analgesia in children with AOM, but should not replace
oral analgesics.5,6 Topical analgesics may cause local hypersensitivity reactions.■ Decongestants and antihistamines, which were recommended in the past, do not speed the
resolution of effusion and can have significant adverse effects in children and therefore should notbe used.7,8
For a more complete discussion of acute otitis media, see Suggested Readings.
Otitis ExternaPathophysiologyOtitis externa is defined as inflammation of the external auditory canal (EAC) and may also involvethe pinna or tympanic membrane (TM). Otitis externa is often due to infection.9,10,11,12 The EAC iswarm, dark and prone to becoming moist. This provides an excellent environment for bacteria or fungito proliferate, particularly if the EAC is traumatized. Otitis externa can be categorized as acute diffuse,acute localized, chronic, eczematous or necrotizing.12 The main focus of this chapter is acute diffuseotitis externa.
Acute Diffuse Otitis ExternaPredisposing factors for acute diffuse otitis externa include:9,10,11,13■ Too little cerumen—cerumen provides antibacterial action by physically protecting the canal and
maintaining a low pH■ Too much cerumen, which can lead to occlusion and maceration■ Moisture (swimming, bathing, water sports, perspiration, increased humidity)—macerates
underlying skin and raises pH■ Trauma to EAC (fingernails, cotton-tipped swabs, other foreign objects, overzealous wax removal)
—abrasion and laceration allowing inoculation of organisms■ Chronic dermatologic disorders■ Hearing aids■ Narrow, hairy ear canal.
The most common etiology of acute otitis externa is bacterial infection. Fungal overgrowth occursrarely, and primarily in patients who have received prior antibiotic therapy. The 2 most commonmicroorganisms causing acute otitis externa are Pseudomonas aeruginosa (20–60%) andStaphylococcus aureus (10–70%).10,11
Bacterial otitis externa produces ear pain or discomfort (otalgia), otorrhea, pruritus and tenderness,especially on manipulation of the ear.10,11 These symptoms may be more intense than those seen withfungal otitis externa. Cellulitis of the pinna and regional lymphadenopathy may be present.10 Fungal
Chapter 20: Otitis Media and Otitis Externa 207
Sample Chapters for Conference_J.indd 8 6/17/2016 2:35:18 PM
Chapter 20: Otitis Media and Otitis Externa
Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments
otitis externa may be asymptomatic or may produce pruritus and fullness in the ear. It classicallyoccurs after prolonged treatment of bacterial otitis externa with antibiotics which alter the bacterialflora of the EAC. The EAC may contain black, grey, bluish green, yellow or white fungal elements anddebris.
Acute Localized Otitis Externa (Furunculosis)This is an acute localized “boil” (infected hair follicle) in the ear canal usually due to S. aureus. Itproduces localized pain, itching, edema, erythema and possibly a fluctuance or abscess. The painsubsides when the boil comes to a head and bursts. Topical mupirocin or fusidic acid can be used formild cases.14 Incision and drainage may be required for some patients. Patients appearing to needincision and drainage should be seen by a healthcare practitioner with appropriate training. In moresevere cases, systemic antibiotics active against S. aureus should be considered.10
Chronic Otitis ExternaChronic otitis externa is characterized as a thickening of the EAC skin secondary to low-gradeinfection and inflammation. There is usually unrelenting pruritus, mild discomfort and dry, flaky skinin the EAC with lack of cerumen. This is often due to nonbacterial causes including allergic contactdermatitis.9
Eczematous Otitis ExternaEczematous otitis externa may be due to a variety of skin conditions, including atopic, seborrheic orcontact dermatitis, psoriasis, lupus erythematosus, neurodermatitis and infantile eczema. Lesionstypically occur elsewhere on the body, especially the head and neck, as well as the auricle and EAC.Appearance may range from mild erythema and scaling with atopic dermatitis to the typical adherentscales of psoriasis (see Chapter 55: Atopic, Contact, and Stasis Dermatitis; Chapter 58: Dandruff andSeborrheic Dermatitis; and Chapter 71: Psoriasis for a more complete description of the lesions). Themost common symptom is pruritus, although erythema, edema, crusting and oozing may be present.The lesions may become secondarily infected with bacteria or fungi. Treatment is primarilymanagement of the underlying condition.15
Necrotizing (Malignant) Otitis ExternaThis is an infection that extends to the mastoid or temporal bone and is usually seen inimmunocompromised patients or those with diabetes. Urgent referral and systemic antimicrobialtherapy are required.10,11
This chapter focuses on the management of acute diffuse otitis externa.
Goals of Therapy■ Eliminate pathogenic microorganisms■ Control pain■ Restore the canal to normal health so it resists infection—return to normal acidic pH and adequate
cerumen
Patient AssessmentAcute otitis externa is characterized by otalgia (70% of cases), itching (60%) or fullness (22%) with orwithout hearing loss (32%) and discharge in or coming from the ear (otorrhea).10,16 Incidence peaks inchildren age 7–12 years and declines after the age of 50.16 It is unilateral in 90% of cases.16 Thediscomfort can range from pruritus to severe pain. The pain is often worse with motion of the ear
208 Ear Conditions
Sample Chapters for Conference_J.indd 9 6/17/2016 2:35:18 PM
Ear Conditions
Compendium of Therapeutics for Minor Ailments Copyright © Canadian Pharmacists Association. All rights reserved.
(pushing the tragus or pulling the pinna),10 including movement caused by chewing.11 Determining thetype of otitis externa (infectious vs. noninfectious) can be assisted by the description of the signs andsymptoms above and the presence of contributing factors (e.g., history of swimming or trauma to theEAC), or the presence of dermatologic conditions on areas of the body other than the EAC.
The drug must be delivered to the infected tissue if topical therapy is to be successful.10,16 Cleansingmust be done by a healthcare practitioner with appropriate training. Therefore, if there is significantedema or debris in the EAC, the patient may need to be referred so that aural toilet can be performedor for a wick to be placed.10 In mild cases, a topical product may be initiated without cleansing;recommendations for pain management are important.
Nonpharmacologic TherapyAdequate cleansing of the ear canal with removal of debris may be required frequently so that topicaltherapy can be effective.9,10 If the canal is not patent, ear wicks may be inserted by a healthcarepractitioner to reduce edema and swelling and provide a mechanism for drug delivery to the canal.10,11These may remain in place for 2–5 days.
Pharmacologic TherapyFor comparative ingredients of nonprescription products, consult the Compendium of Products forMinor Ailments—Analgesic Products: Internal Analgesics and Antipyretics; Otic Products.
Topical treatment is the mainstay of therapy, although in more severe cases, when infection has spreadbeyond the EAC, when otitis media coexists, or if the patient has a condition such as diabetes orimmunodeficiency, systemic antibiotics may be required.10 In uncomplicated cases, systemic therapydoes not improve outcomes compared with topical therapy and increases the risk of adverse effects andantibiotic resistance and time to clinical cure.17 Topical therapy options include acidifying agents,antibiotics alone or antibiotic/corticosteroid combinations (see Table 1). Comparative trials showsimilar outcomes among approaches; therefore, the choice is determined by healthcare practitioner andpatient preference, the side effect profile of the agents and cost.10,11,12,18,19 One trial demonstrated thatcorticosteroid drops (with either acetic acid or antibiotic) are more effective than acetic acid alone andrecommended that acetic acid alone not be used in adult patients.20 In patients whose symptoms lastlonger than a week, acetic acid may be less effective than an antibiotic/corticosteroid combination;efficacy at 1 week is similar.18 Advantages and disadvantages of the various products are outlined inTable 1.
Antibiotic drops are available as both otic and ophthalmic preparations. Both nonprescription andprescription products are available. Otic products are more acidic than ophthalmic preparations andmay cause burning on instillation. If a patient cannot tolerate otic preparations, ophthalmicpreparations may be more comfortable.21 Preparations for treatment of otitis externa may containcorticosteroids, which reduce inflammation and edema and may resolve symptoms more quickly;however, this has not been shown in all studies and corticosteroids may occasionally be topicalsensitizers.18
One particular concern with topical therapy of acute otitis externa is the potential ototoxicity ofaminoglycosides.22 This is a documented adverse effect of systemically administeredaminoglycosides. If the tympanic membrane is intact, the risk with topical administration is extremelysmall. Risk factors for ototoxicity include ruptured tympanic membrane, use of the product for morethan 1 week and continued use after otorrhea has subsided. Topical fluoroquinolones have not beenassociated with ototoxicity.
Enough liquid to fill the canal (3–4 drops) should be instilled 3–4 times daily (most products exceptfluoroquinolones). Symptoms will last for approximately 6 days after treatment begins; however,
Chapter 20: Otitis Media and Otitis Externa 209
Sample Chapters for Conference_J.indd 10 6/17/2016 2:35:18 PM
Chapter 20: Otitis Media and Otitis Externa
Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments
improvement in symptoms should occur within 48–72 hours.10 Patients should be treated for 1 week. Ifsymptoms are not completely gone, therapy can be continued until symptoms resolve plus a few daysbeyond (up to 2 weeks).18 In 65–90% of patients, clinical resolution occurs in 7–10 days.10 Forinformation on correct instillation of eardrops, see Eardrops—What You Need to Know.
Fungal otitis externa often responds to cleansing and acidification alone, although topical antifungalagents (clioquinol, clotrimazole, tolnaftate) may also be used.16 Some preparations may need to becompounded.
Otitis externa can be very painful. Usual doses of acetaminophen, ibuprofen or naproxen sodiumcan be used for analgesia (ASA can be used in adults).10,11 Although some otic preparations containtopical anesthetics, the efficacy of these agents has not been determined in acute otitis externa, andtopical hypersensitivity reactions can occur.10 If topical anesthetic agents are used in addition to othertopical therapy, this will dilute the acidifier or antibiotic present in the canal. Avoid their use in otitisexterna. Systemic analgesia is the preferred recommendation.
Eczematous Otitis ExternaEczematous otitis externa is managed by treating the underlying dermatologic disease (e.g., seborrhea,psoriasis, acne).9,15 Contact dermatitis commonly occurs on or in the ears, and grooming products(e.g., shampoos, hair sprays and hair dyes) are common allergens.10 Hearing aids and earplugs mayalso cause dermatitis of the EAC. Neomycin is one of the topical medications that most commonlycauses allergic contact dermatitis.10 Patients sensitive to neomycin may also react to tobramycin. Otheragents commonly placed in the ear that are reported to cause contact dermatitis include benzalkoniumchloride, benzocaine and propylene glycol.23
Management includes avoiding the offending agent, applying acetic acid solution to dry oozinglesions and re-acidify the canal, or symptomatic therapy with a topical corticosteroid.
Prevention of RecurrenceProvide information on how to prevent a recurrence to individuals who develop acute otitis externa:■ After swimming or bathing, dry the external canal with a blow dryer on low setting or by
instillation of acidifying or alcohol drops.10,11,16■ Avoid overzealous cleansing and scratching (trauma) of the ear canal.10■ Avoid cotton-tipped swabs.11,16,24■ Avoid water sports for at least 7–10 days during treatment.10■ Ear plugs and bathing caps may be used to keep the ears dry; however, there is little evidence to
guide recommendations.10 Frequent use of ear plugs may also act as a local irritant and promoteinfection.
Monitoring of TherapySymptoms should be significantly reduced by day 3 of therapy,10,11 and for most patients symptomsshould have completely resolved in a week. Occasionally up to 14 days of treatment is needed.18Follow up with the patient in 3–5 days to ensure symptoms are improving and at the end of treatmentto ensure resolution. If symptoms worsen or do not resolve, consider the following: the patient may bereacting to the medication (contact dermatitis); a superinfection may have developed; the diagnosismay be incorrect; improper or infrequent use of eardrops; inadequate penetration of topical agents dueto debris or narrowing of the canal; immunosuppression or malignant otitis externa; or the organism isnot susceptible to the topical agent selected.9,10 Assessment for further treatment will be required.
210 Ear Conditions
Sample Chapters for Conference_J.indd 11 6/17/2016 2:35:18 PM
Ear Conditions
Compendium of Therapeutics for Minor Ailments Copyright © Canadian Pharmacists Association. All rights reserved.
Advice for the PatientAdvise patients on:■ Prevention of recurrences■ Methods of pain control■ Correct use of eardrops■ Possible side effects of treatment and their management (see Table 1)■ When to see a healthcare practitioner.
Chapter 20: Otitis Media and Otitis Externa 211
Sample Chapters for Conference_J.indd 12 6/17/2016 2:35:18 PM
Chapter 20: Otitis Media and Otitis Externa
Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments
Table1:
Drugs
forO
titisEx
terna
Class
Drug
Indicatio
nsAdverse
Effects
Com
ments
Costa
AcidifyingAgents
aceticacid2%
25Preventionand
treatmentofm
ildAOE
Can
beirritatingto
inflamed
canal.
Possiblyototoxic.
Broad-spectrumantibacterial.
Restoresacidity
tocanal.
Lowercostthan
antibiotics.
Nocommercialproductavailable.May
beprepared
bydilutingwhitevinegarw
ithequalpartsisopropyl
alcoholorw
ater.10
$
Antibiotics
ciprofloxacin
Ciloxan,generics
TreatmentofA
OE
Welltolerated.
Notassociated
with
ototoxicity.
Activeagainstm
anygram
-negativeorganism
sincludingP.aeruginosa
andsomegram
-positive
(S.
aureus).
Twice-daily
dosing.
Topicalquinolonesprovidesimilarclinicalcurerates
asothertopicalantibiotics.19
Ophthalmicsolutions
canbe
used
intheears.
$
gram
icidin/polym
yxinB
OptimyxinEarDrops,
Polysporin
Eye/Ear
Drops
TreatmentofA
OE
Potentially
ototoxic.
Gramicidin—activeagainstgram-positive
organism
s.Polym
yxinB—activeagainstgram-negative
organism
s.
$$
moxifloxacin
Vigam
oxTreatmentofA
OE
See
ciprofloxacin.
See
ciprofloxacin.
Ophthalmicsolutions
canbe
used
intheears.
$$
ofloxacin
Ocuflox,generics
TreatmentofA
OE
See
ciprofloxacin.
See
ciprofloxacin.
Ophthalmicsolutions
canbe
used
intheears.
$
tobram
ycin
Tobrex,generics
TreatmentofA
OE
Potentially
ototoxic,
particularly
with
perforatedtympanic
mem
brane,
tympanostom
ytubesor
use>1
wk.
Aminoglycosidesactiveagainstgram-negative
organism
s(e.g.,Pseudom
onas)and
S.aureus.
Ophthalmicsolutions
canbe
used
intheears.
$
Corticosteroids
dexamethasone
Maxidex
Dermatologiccauses
ofAOE
May
cause
hypersensitivity
reactions.
Anti-inflammatorypropertiesreduce
swellingand
edem
a.Ifbacterialetiology
combine
with
acidifieror
antibiotic.
Ophthalmicsolutions
canbe
used
intheears.
$
(cont'd)
212 Ear Conditions
Sample Chapters for Conference_J.indd 13 6/17/2016 2:35:19 PM
Ear Conditions
Compendium of Therapeutics for Minor Ailments Copyright © Canadian Pharmacists Association. All rights reserved.
Class
Drug
Indicatio
nsAdverse
Effects
Com
ments
Costa
Antibiotic/
Corticosteroid
Com
binatio
ns
ciprofloxacin/
dexamethasone
Ciprodex
TreatmentofA
OE
See
ciprofloxacin.
See
dexamethasone.
See
ciprofloxacin.
See
dexamethasone.
$$$
clioquinol/flum
ethasone
pivalate
LocacortenVioform
Eardrops
TreatmentofA
OE
Negligiblegram
-negativeactivity.
Bacteriostatic.
See
dexamethasone.
Clioquinolactiveagainstfungiandgram
-positive
bacteria.
See
dexamethasone.
$$
framycetin/gramicidin/
dexamethasone
Sofracort
TreatmentofA
OE
See
tobram
ycin.
See
dexamethasone.
Fram
ycetinactiveagainstgram-negativeorganism
s(butnotP
seudom
onas)and
S.aureus.
Gramicidin—activeagainstgram-positive
organism
s.See
dexamethasone.
$$
Miscellaneou
santipyrine/benzocaine
Auralgan
Topicalanalgesia
Benzocainemay
producetopical
hypersensitivity
reactions.
Antipyrine—
mild
anesthetic;can
cause
burninganditching.
May
masksymptom
sof
worsening
AOE.
Donotuse
with
ruptured
tympanicmem
brane.
Oralanalgesicspreferred.
$
isopropylalcohol95%
glycerin5%
Auro-DriEarWater
PreventionofAOE
Painfulwhenused
inacuteotitisexterna.
Usefuldryingagent.
$
aCostofsmallestavailablepack
size;includesdrug
costonly.
Abb
reviations:
AOE=acuteotitisexterna
Legend:
$<$10
$$$10–20
$$$$20–30
Chapter 20: Otitis Media and Otitis Externa 213
Sample Chapters for Conference_J.indd 14 6/17/2016 2:35:19 PM
Chapter 20: Otitis Media and Otitis Externa
Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments
Suggested Readings
Otitis ExternaHui CP; Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Acute otitis
externa. Paediatr Child Health 2013;18:96-101.Rosenfeld RM, Schwartz SR, Cannon CR et al. Clinical practice guideline: acute otitis externa.Otolaryngol Head Neck Surg 2014;150:S1-S24.
Schaefer P, Baugh RF. Acute otitis externa: an update. Am Fam Physician 2012;86:1055-61.Otitis MediaLe Saux N, Robinson J. Management of acute otitis media in children six months of age and older.Paediatr Child Health 2016;21(1):39–44.
Lieberthal AS, Carroll AE, Chonmaitree T et al. Diagnosis and management of acute otitis media.Pediatrics 2013:131:e964-99.
Vergison A, Dagan R, Arguedas A et al. Otitis media and its consequences: beyond the earache.Lancet Infect Dis 2010;10:195-203.
References1. Lieberthal AS, Carroll AE, Chonmaitree T et al. Diagnosis and management of acute otitis media. Pediatrics 2013;131:e964-99.2. Le Saux N, Robinson J. Management of acute otitis media in children six months of age and older. Paediatr Child Health 2016;21(1):39–44.3. Rosenfeld RM, Vertrees JE, Carr J et al. Clinical efficacy of antimicrobial drugs for acute otitis media: metaanalysis of 5400 children from
thirty-three randomized trials. J Pediatr 1994;124:355-67.4. Venekamp RP, Sanders SL, Glasziou PP et al. Antibiotics for acute otitis media in children. Cochrane Database of Syst Rev
2015;1:CD000219.5. Carley SD. Best evidence topic reports. Towards evidence based emergency medicine: Best BETs from the Manchester Royal Infirmary.Emerg Med J 2008;25:103.
6. Foxlee R, Johansson A, Wejfalk J et al. Topical analgesia for acute otitis media. Cochrane Database Syst Rev 2006;3:CD005657.7. Mandel EM, Rockette HE, Bluestone CD et al. Efficacy of amoxicillin with and without decongestant-antihistamine for otitis media with
effusion in children. Results of a double-blind, randomized trial. N Engl J Med 1987;316:432-7.8. Cantekin EI, Mandel EM, Bluestone CD et al. Lack of efficacy of a decongestant-antihistamine combination for otitis media with effusion
(“secretory” otitis media) in children. Results of a double-blind, randomized trial. N Engl J Med 1983;308:297-301.9. Schaefer P, Baugh RF. Acute otitis externa: an update. Am Fam Physician 2012;86:1055-61.10. Rosenfeld RM, Schwartz SR, Cannon CR et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg 2014;150:S1-
S24.11. Hui CP; Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Acute otitis externa. Paediatr Child Health
2013;18:96-101.12. Hajioff D, Mackeith S. Otitis externa. Clin Evid (Online) 2008;pii:0510.13. Klein JO. Otitis externa, otitis media and mastoiditis. In: Mandell GL, Bennett JE, Dolin R, eds.Mandell, Douglas and Bennett's principles
and practice of infectious diseases. 7th ed. Philadelphia: Churchill Livingston/Elsevier; 2010. p. 831-8.14. Blondel-Hill E, Fryters S. Bugs & Drugs app. Edmonton (AB): Alberta Health Services; 2015.15. Shea CR. Dermatologic diseases of the external auditory canal. Otolaryngol Clin North Am 1996;29:783-94.16. Osguthorpe JD, Nielsen DR. Otitis externa: review and clinical update. Am Fam Physician 2006:74:1510-6.17. Pabla L, Jindal M, Latif K. The management of otitis externa in UK general practice. Eur Arch Otorhinolaryngol 2012;269:753-6.18. Kaushik V, Malik T, Saeed SR. Interventions for acute otitis externa. Cochrane Database Syst Rev 2010;1:CD004740.19. Rosenfeld RM, Singer M, Wasserman JM et al. Systematic review of topical antimicrobial therapy for acute otitis externa. Otolaryngol Head
Neck Surg 2006;134:S24-48.20. van Balen FA, Smit WM, Zuithoff NP et al. Clinical efficacy of three common treatments in acute otitis externa in primary care: randomised
controlled trial. BMJ 2003;327:1201-5.21. Ong YK, Chee G. Infections of the external ear. Ann Acad Med Singapore 2005;34:330-4.22. Haynes DS, Rutka J, Hawke M et al. Ototoxicity of ototopical drops–an update. Otolaryngol Clin North Am 2007;40:669-83.23. Fraki JE, Kalimo K, Tuohimaa P et al. Contact allergy to various components of topical preparations for treatment of external otitis. Acta
Otolaryngol 1985;100:414-8.24. Nussinovitch M, Rimon A, Volovitz B et al. Cotton-tipped applicators as a leading cause of otitis externa. Int J Pediatr Otorhinolaryngol
2004;68:433-5.25. Thorp MA, Kruger J, Oliver S et al. The antibacterial activity of acetic acid and Burow's solution as topical otological preparations. J Laryngol
Otol 1998;112:925-8.
214 Ear Conditions
Compendium of Therapeutics for Minor Ailments Copyright © Canadian Pharmacists Association. All rights reserved.
Class
Drug
Indicatio
nsAdverse
Effects
Com
ments
Costa
Antibiotic/
Corticosteroid
Com
binatio
ns
ciprofloxacin/
dexamethasone
Ciprodex
TreatmentofA
OE
See
ciprofloxacin.
See
dexamethasone.
See
ciprofloxacin.
See
dexamethasone.
$$$
clioquinol/flum
ethasone
pivalate
LocacortenVioform
Eardrops
TreatmentofA
OE
Negligiblegram
-negativeactivity.
Bacteriostatic.
See
dexamethasone.
Clioquinolactiveagainstfungiandgram
-positive
bacteria.
See
dexamethasone.
$$
framycetin/gramicidin/
dexamethasone
Sofracort
TreatmentofA
OE
See
tobram
ycin.
See
dexamethasone.
Fram
ycetinactiveagainstgram-negativeorganism
s(butnotP
seudom
onas)and
S.aureus.
Gramicidin—activeagainstgram-positive
organism
s.See
dexamethasone.
$$
Miscellaneou
santipyrine/benzocaine
Auralgan
Topicalanalgesia
Benzocainemay
producetopical
hypersensitivity
reactions.
Antipyrine—
mild
anesthetic;can
cause
burninganditching.
May
masksymptom
sof
worsening
AOE.
Donotuse
with
ruptured
tympanicmem
brane.
Oralanalgesicspreferred.
$
isopropylalcohol95%
glycerin5%
Auro-DriEarWater
PreventionofAOE
Painfulwhenused
inacuteotitisexterna.
Usefuldryingagent.
$
aCostofsmallestavailablepack
size;includesdrug
costonly.
Abb
reviations:
AOE=acuteotitisexterna
Legend:
$<$10
$$$10–20
$$$$20–30
Chapter 20: Otitis Media and Otitis Externa 213
Sample Chapters for Conference_J.indd 15 6/17/2016 2:35:19 PM
Ear Conditions
Compendium of Therapeutics for Minor Ailments Copyright © Canadian Pharmacists Association. All rights reserved.
Acute Otitis Externa (Swimmer's Ear)—What You Need toKnow
What is acute otitis externa?Acute otitis externa, or “swimmer's ear,” is an infection of the ear canal. The symptoms are itching orpain in the ear and liquid draining from it. The ear may become plugged. Your hearing may beaffected.
What causes acute otitis externa?The skin in your ears may become infected because of:■ Too much water in the ear (from bathing, swimming or water sports)■ Removing the natural earwax that protects the ear canal■ Skin conditions in the ear canal (such as eczema)■ Using cotton-tipped swabs, fingernails or other sharp objects in the ear canal■ Wax buildup due to hearing aids or other ear devices
What is the treatment for acute otitis externa?■ The usual treatment is prescription eardrops. A healthcare provider may have to clean the ear canal
for the drops to work.■ Most drops need to be used 3 or 4 times a day.■ Use the drops until 3 days after all symptoms are gone.■ Symptoms are usually much better in 3 days and should be gone in 10 days.■ While you are using eardrops:
– Keep your ears as dry as possible. Take a bath instead of a shower. Avoid swimming and watersports until the treatment is done.
– Don't poke your fingers or other objects into your ears.
What can you do to prevent acute otitis externa?■ Keep the ear canal as dry as possible:
– Dry ears with a towel after swimming or bathing. Use a blow dryer set on low to dry the earcanal. You can also use diluted vinegar or alcohol drops in the ear.
– Try using a bathing cap or ear plugs when swimming. If this makes it worse, stop using.■ Do not clean earwax out of your ears:
– Earwax protects against infection. The ears generally clean themselves. If you have pain in yourears from earwax, see your healthcare provider.
■ Do not put anything in the ear canal except eardrops. Fingernails, cotton-tipped swabs and otherobjects irritate and damage the skin. If the skin is damaged you are more likely to get an infection.
Chapter 20: Otitis Media and Otitis Externa 215
Sample Chapters for Conference_J.indd 16 6/17/2016 2:35:19 PM
Chapter 20: Otitis Media and Otitis Externa
Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments
Eardrops—What You Need to Know
Hints to help you use eardrops safely:If possible, get someone to put the drops in your ear for you.■ Warm the eardrops to body temperature by holding the bottle in your hands for a few minutes. Do
not heat the drops in hot water or the microwave because this could cause pain and dizziness orserious burns.
■ Always wash your hands with soap and water before administering the eardrops.■ The eardrops must be kept clean. Do not let the dropper touch the ear or anything else that could
have germs on it and let germs get into your eardrops.■ Shake the bottle before using if there is a “Shake Well” label on the bottle. Lie on your side so that
the ear you are treating is facing up.■ The ear canal must be straight so that the eardrops can reach the affected tissue. The direction that
you pull the top of the ear depends on the person's age.– For adults and children over 3 years, gently pull the top of the ear up and back.– For children under 3 years, gently pull the top of the ear down and back
■ Hold the dropper above the ear. Place the prescribed number of drops into the ear. Do not put thedropper into the ear canal. It could injure the ear.
■ Stay in the same position for 3–5 minutes after using the drops. This will allow the eardrops to rundown into the ear canal.
■ A gentle to-and-fro movement of the ear will sometimes help in getting the drops to their intendeddestination. You can also press with an in/out movement on the small piece of cartilage in front ofthe ear.
■ Dry the earlobe if there are any eardrops on it.■ If you have had a wick placed in your ear, do not remove it. It may fall out on its own as the
swelling and infection in the ear improves.
If you have to put drops in both ears:Wait about 5–10 minutes before putting drops in the second ear. You want to be sure that the medicinestays in the ear canal of the first ear long enough to reach the eardrum before you tilt your head to putdrops in the other ear.
These instructions may be changed by your healthcare provider depending on your medical conditionor the type of medicine in the eardrops.© 2016 Consumer Health Information Corporation (www.consumer-health.com). All rights reserved. This information is adapted from UnderstandingCanadian Prescription Drugs by Dorothy L. Smith, Pharm.D. published by Key Porter Books 1992.
216 Ear Conditions
Sample Chapters for Conference_J.indd 17 6/17/2016 2:35:19 PM
Sample Chapters for Conference_J.indd 18 6/17/2016 2:35:19 PM
Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments
Respiratory Conditions
Chapter 22Chapter 22Allergic RhinitisJennifer Kendrick, BScPharm, ACPR, PharmD
PathophysiologyAllergic rhinitis affects 10–30% of the population, and the prevalence is increasing.1,2,3 It is estimatedthat more than 500 million people worldwide are affected.3 The prevalence of allergic rhinitis isthought to be highest in school-age children; 80% of people with allergic rhinitis are diagnosed before20 years of age.1,4 Allergic rhinitis is associated with a genetic predisposition; children have a 30%chance of developing allergic rhinitis if one parent is affected and a 50% chance if both are affected.5,6
Allergic rhinitis is characterized by inflammation of the nasal mucosa following inhalation of anallergen.1,4,6,7 The allergic reaction is mediated by antigen-antibody responses and takes place in 3phases. The first phase, sensitization, occurs on first contact with the allergen. IgE is produced andbinds to receptors on the surface of mast cells and basophils. The second and third phases occur on re-exposure to an allergen in a sensitized individual. The second phase, immediate reaction, occurs withinminutes of re-exposure and lasts up to 30–90 minutes. In this phase the allergen binds to allergen-specific IgE and the mast cells release preformed mediators, histamine and tumor necrosis factor alpha(TNF-α), and newly generated mediators, leukotrienes LTC4, LTD4, LTE4, prostaglandin D2 andkinins. The third phase, late reaction, occurs 4–8 hours after exposure. It is characterized by migrationof inflammatory cells, eosinophils, monocytes, macrophages and basophils.
Allergic rhinitis was previously classified as seasonal or perennial; however, this classification wasdetermined to be inadequate for a number of reasons. For example, outdoor pollens and moulds maybe perennial in some regions and symptoms of perennial allergy may not be present year-round. TheAllergic Rhinitis and its Impact on Asthma (ARIA) guideline proposed the classifications ofintermittent allergic rhinitis (IAR) and persistent allergic rhinitis (PAR) in 2008.3 IAR is defined assymptoms of allergic rhinitis occurring <4 days/week or for <4 weeks at a time. PAR is defined assymptoms of allergic rhinitis occurring ≥4 days/week and for ≥4 weeks at a time. Allergic rhinitis isfurther classified based on severity. In mild allergic rhinitis, symptoms are present but not troublesomeand there is no impairment in daily activities, school or work and no sleep disturbance. In moderate/severe allergic rhinitis, one or more is present: troublesome symptoms, impairment in daily activities,school or work, or sleep disturbance.3,7 The ARIA classification has been validated in both adults andchildren.
Rhinitis may also be nonallergic. Conditions associated with nonallergic rhinitis are listed in Table 1.Drugs associated with rhinitis are listed in Table 2.
Goals of Therapy■ Prevent symptoms by avoiding exposure to allergen(s)■ Alleviate signs and symptoms produced by the allergic response■ Improve quality of life
226 Respiratory Conditions
Sample Chapters for Conference_J.indd 19 6/17/2016 2:35:20 PM
Respiratory Conditions
Compendium of Therapeutics for Minor Ailments Copyright © Canadian Pharmacists Association. All rights reserved.
Table 1: Possible Nonallergic Causes of Acute and Chronic Rhinitis3,4,6,7
■ Drug-induced (see )■ Hormones
– pregnancy, menstruation, hypothyroidism■ Infection
– viral, bacterial, fungal, other■ Nonallergic rhinitis with eosinophilia syndrome (NARES)■ Other
– emotions, e.g., stress, sexual arousal– vasomotor rhinitis, e.g., exercise, cold air– anatomic abnormalities, e.g., nasal septal deviation, enlarged adenoids and tonsils, nasal tumors, choanal atresiaa
– food and alcohol– nasal polyps– atrophy– foreign body
a A congenital defect where the posterior nares do not communicate with the nasopharynx.
Table 2: Drugs Associated with Rhinitis6,8
■ ACE inhibitors■ ASA and other NSAIDs■ Cocaine■ Diuretics, e.g., amiloride, hydrochlorothiazide■ Gabapentin■ Hydralazine
■ Oral contraceptives■ Phosphodiesterase-5 inhibitors, e.g., sildenafil■ Psychotropics, e.g., chlorpromazine, risperidone■ Sympatholytics, e.g., clonidine, doxazosin, methyldopa,
phentolamine, prazosin■ Topical decongestants (prolonged use)
Patient AssessmentThe sensitization phase of allergic rhinitis is asymptomatic. Symptoms of the second or immediatephase include sneezing, nasal and palatal pruritus, congestion and clear rhinorrhea.9 Symptoms of thedelayed phase are similar but nasal congestion predominates.4 Patients may also have itchy, red,watery eyes (allergic conjunctivitis), itchy throat, ear fullness and popping, and a feeling of pressureover the cheeks and forehead.4 Facial signs of allergic rhinitis are illustrated in Figure 1. The allergicsalute is a sign more commonly seen in children, where the patient wipes the nose with the palm of thehand in an upward motion.
Some patients present primarily with symptoms of sneezing and rhinorrhea, whereas others are mostlybothered by nasal blockage and have little or no itching or sneezing.6 Eye symptoms are morecommonly associated with outdoor allergens.3,7
Allergic rhinitis can have a significant impact on a patient's quality of life. Patients may haveheadache, difficulty concentrating, fatigue or sleep disturbance.6 Malaise or fatigue may be presentingcomplaints in children.9 Complications of allergic rhinitis include sinusitis, otitis media, asthma, andsleep apnea. In children, there may be dental overbite and a high-arched palate due to chronic mouthbreathing.3,6
An assessment plan for patients suffering from allergic rhinitis is illustrated in Figure 2. During theassessment, also identify precipitating factors/allergens and assess occupational exposure and responseto previous therapy.
Chapter 22: Allergic Rhinitis 227
Sample Chapters for Conference_J.indd 20 6/17/2016 2:35:20 PM
Chapter 22: Allergic Rhinitis
Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments
Figure 1: Facial Signs of Allergic Rhinitis
Morgan's Lines or Dennie's sign or folds are extra creases at the lower eyelids due to edema. Allergic shiners describe discoloured infraorbital areas due tovenous stasis resulting from nasal swelling. The transverse nasal crease is a crease seen at the junction of the bulbous portion of the nose and thenosebridge and is caused by recurrent nose rubbing (allergic salute). Conjunctival injection refers to conjunctival redness fading toward the edges.
Consider the need for prescription therapy or referral for allergy testing if the patient has already triedappropriate nonprescription therapy for 2 weeks without an adequate response, or if the allergenresponsible for symptoms cannot be readily identified.3 Also refer patients for further assessment ifthey have signs or symptoms that are unilateral or are not usually associated with allergic rhinitis (e.g.,fever, pain, loss of smell or taste, recurrent epistaxis, purulent nasal or ocular secretions, postnasal dripwith or without rhinorrhea) or symptoms suggesting complications such as asthma.3
PreventionPrevention is the first step in the management of allergic rhinitis. Although consensus is thatimprovement in symptoms should occur with allergen avoidance, little evidence supports individualmeasures.3 While some measures such as washing pets, impermeable covers for bedding, and airfiltration have been shown to reduce the allergen level, a corresponding reduction in allergic symptomshas not been shown.9 The benefits of environmental control may take weeks or months to fullymanifest. Avoidance measures for common allergens are presented below.1,3,6,7
Pollen■ Keep windows and doors closed when at home or in the car.■ If using air conditioning, keep the unit on recirculate or the indoor cycle, if the choice is available.■ Do not use window or attic fans.■ Monitor weather reports on pollen counts, if available. Decrease outdoor exposure during periods
of high pollen counts. Pollen counts tend to be highest on sunny, windy days.■ Do not dry clothing outdoors.■ Shower or bathe and wash hair after outdoor activity to remove pollen from hair and skin and
prevent contamination of bedding.
228 Respiratory Conditions
Sample Chapters for Conference_J.indd 21 6/17/2016 2:35:21 PM
Respiratory Conditions
Compendium of Therapeutics for Minor Ailments Copyright © Canadian Pharmacists Association. All rights reserved.
Outdoor Moulds■ Remain in a closed environment as much as possible.■ If using air conditioning, keep the unit on the indoor cycle, if the choice is available; note, however,
that units can be heavily contaminated with mould.■ Use of face masks for activities such as raking leaves or working with compost or dry soil may
have limited value because air seeps around the edges of the mask and the mask does not protectthe eyes.
Indoor Moulds■ Use fungicide on sinks, shower stalls, nonrefrigerated vegetable storage areas and garbage pails. A
solution of equal parts household bleach and water effectively kills mould.■ Avoid console humidifiers and cool mist vaporizers; if these must be used, keep them scrupulously
clean.■ If the home is built over a crawl space, install a plastic vapor barrier over exposed soil and keep
foundation vents open.■ If the basement is damp or tends to flood, avoid carpeting or furnishing the basement. Use a
dehumidifier at all times and empty the extracted water from the air frequently; remove anystanding water as soon as possible.
■ Remove houseplants, which are a common source of mould. Alternatively, keep soil surface dryand clean of debris to reduce mould.
House Dust Mites■ Avoid carpeting the bedroom and main living areas.■ Plastic, leather or wood furniture is best.■ Some acaricides (e.g., benzyl benzoate, tannic acid) appear to reduce the mite population if used
regularly. However, their clinical effect is not established and they are not routinely recommended.3■ If possible, clean while the allergic individual is not at home.■ Mite-sensitive persons should avoid vacuuming or making beds. Those who must do their own
cleaning should wear a facemask during cleaning and for 10–15 minutes afterward.■ Use a vacuum cleaner with an efficient double filtration system.■ Keep indoor humidity between 40% and 45%.■ Minimize use of humidifiers as excess humidity promotes mite growth.■ Encase all mattresses, box springs and pillows in the allergic individual's bedroom in zippered,
allergen-proof casings.■ Consider replacing old mattresses.■ Wash bedding in hot (>55°C) water at least every 2 weeks. Cooler water temperatures will not kill
dust mites, nor will detergents.■ Avoid stuffed toys that cannot be washed. Alternatively, put stuffed toys or pillows in a hot dryer or
in plastic bags and freeze every 2 weeks to kill dust mites.■ Do not store items under the bed.■ Use window shades instead of venetian blinds.■ Evidence suggests the best strategy is a combination of the above interventions.10
Chapter 22: Allergic Rhinitis 229
Sample Chapters for Conference_J.indd 22 6/17/2016 2:35:21 PM
Chapter 22: Allergic Rhinitis
Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments
Animal Allergens■ Permanent removal of pets from the home is the best way to control animal allergens. This should
be followed by thorough cleaning of the house, including washing carpets. “Trial” removal of petsis not helpful; it can take 20 weeks or longer for cat allergen levels to drop to levels comparable tohomes without cats.
■ If the family is unable to remove the animal from the home then:– remove carpets and replace with hard flooring– keep the animal away from the allergic individual's bedroom and other living areas where the
allergic individual spends time– a high-efficiency particulate air (HEPA) filter or electrostatic air purifier may be helpful– washing cats weekly and dogs once or twice weekly may help but evidence to support this
approach is lacking– eliminate litter boxes if possible; otherwise place them in an area unconnected to the air supply
for the rest of the house.
Occupational Allergens■ For individuals affected by occupational rhinitis, recommend minimizing or eliminating exposure.■ Common causes of occupational rhinitis include animal or vegetable proteins (e.g., mouse, rat,
wheat, grains, latex), enzymes, pharmaceuticals (e.g., antibiotics) and chemicals (e.g., resins).
Nonpharmacologic TherapyIntranasal saline spray and irrigation has been shown to reduce nasal symptoms and the need forpharmacologic therapy in children and nonpregnant adults.11 The effect of intranasal saline irrigationin pregnant women is less clear.12 Isotonic saline is preferred to hypertonic saline, as it improvesmucociliary clearance; however, the optimal dose, frequency and delivery have not been established.11
Tobacco smoke can aggravate symptoms and should be avoided by all patients with allergic rhinitis.3Other irritants that should be avoided include insect sprays, air pollution and fresh tar or paint.3
Pharmacologic TherapyWhen avoidance of allergens is ineffective or impractical, consider pharmacologic options. If it ispossible to predict the onset of symptoms (e.g., intermittent exposure), prophylactic medication shouldbe started before exposure.
For comparative ingredients of nonprescription products, consult the Compendium of Products forMinor Ailments—Cough, Cold and Allergy Products.
Table 3 summarizes the pharmacologic activity of different therapies for the treatment of allergicrhinitis.
Medications for treatment of allergic rhinitis are described in Table 5 and Table 6.
Several guidelines for the treatment of allergic rhinitis are available and each provides similartreatment recommendations.3,6,7,9 For mild symptoms, second-generation antihistamines are thedrugs of choice, although they produce only a modest improvement in nasal congestion. First-generation antihistamines are no longer recommended first-line due to their adverse effect profile.6For moderate to severe allergic rhinitis, regularly administered intranasal corticosteroids arerecommended as first-line therapy.14
230 Respiratory Conditions
Sample Chapters for Conference_J.indd 23 6/17/2016 2:35:21 PM
Respiratory Conditions
Compendium of Therapeutics for Minor Ailments Copyright © Canadian Pharmacists Association. All rights reserved.
Table 3: Comparative Symptom Relief of Allergic Rhinitis Therapies7,13
Medication Rhinorrhea Congestion Sneezing Nasal ItchEye
Symptomsa
Oral antihistamines + +/- + + +/-
Intranasal mast cell stabilizers +/- +/- +/- +/- -
Decongestants (oral and topical) - + - - -
Intranasal corticosteroids ++ ++ ++ ++ +/-
Leukotriene receptor antagonists + + +/- +/- +/-
Intranasal anticholinergics ++ - - - -
Intranasal antihistamines ++ ++ ++ ++ +/-
a See Chapter 13: Conjunctivitis.Abbreviations: (+/-) = modest or variable effect
AntihistaminesIntroduced in the 1940s, antihistamines were the first medications used for the treatment of allergicrhinitis. They act as competitive antagonists for the histamine-1 (H1) receptor found on the surface oftarget cells in the nose, lung, conjunctiva and skin.15 They also act as a reverse agonist, meaning thatthey change the three-dimensional configuration of the receptor, decreasing its affinity for histamineand down-regulating histamine-driven symptoms.15 Antihistamines decrease nasal itching, sneezing,rhinorrhea, conjunctival itching and lacrimation but generally do not relieve nasal congestion.Desloratadine, fexofenadine and cetirizine have modest effects on nasal congestion.16Antihistamines are first-line treatment in mild cases of allergic rhinitis.3,6,9
Antihistamines are divided into 2 major classes: first- and second-generation. All are similarlyeffective; however, adverse effect profiles and pharmacology differ.15,17,18,19,20,21
First-generation antihistamines have a rapid onset but relatively short duration of action due to theirshort half-life.22,23 They are poorly selective for the H1 receptor and also exert effects on cholinergicreceptors. The anticholinergic effect manifests as dry mouth and nasal passages, difficulty voidingurine, constipation and tachycardia. They are also highly lipophilic and therefore cross the blood-brainbarrier and interact with central H1 receptors. This results in CNS effects such as sedation andpsychomotor and cognitive impairment. In children, paradoxical excitation may occur.24 Performanceimpairment has been documented using various measures (e.g., reaction time, visual-motorcoordination, arithmetical exercises and memory, learning and driving tests) although more recent datasuggest that the magnitude of these effects has been overstated.25,26 CNS depression and impairmentcan be independent of any subjective complaints by the patient.27 First-generation antihistamines alsoimpair learning and academic performance in children.27 Workers taking first-generationantihistamines have lower work performance and are more likely to be involved in workplaceaccidents. Daytime performance effects are noted even when the antihistamine is taken only atbedtime.6,27
First-generation antihistamines can decrease rhinorrhea, but mucus secretion may be thickened and canbe more bothersome for some patients.15
The first-generation antihistamines should be used with caution in patients with narrow-angleglaucoma, stenosing peptic ulcer, pyloroduodenal obstruction, symptomatic prostatic hypertrophy orbladder-neck obstruction, cardiovascular disease and chronic lung disease.
Chapter 22: Allergic Rhinitis 231
Sample Chapters for Conference_J.indd 24 6/17/2016 2:35:21 PM
Chapter 22: Allergic Rhinitis
Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments
Second-generation antihistamines are more selective for H1 receptors and less lipophilic.Consequently, they do not have significant anticholinergic adverse effects and do not cross the blood-brain barrier.20 Use of cetirizine in standard doses is associated with more sedation compared withplacebo, but less than first-generation antihistamines.6 Administration of standard doses of loratadineand desloratadine results in an incidence of sedation equivalent to placebo; however, drowsiness hasbeen reported at higher than recommended doses, or rarely in susceptible individuals at recommendeddoses.6 Fexofenadine appears to be nonsedating, even at increased doses. Due to their improvedadverse effect profile, especially with regard to sedation and psychomotor performance, second-generation antihistamines represent a better choice than first-generation agents for the treatment ofallergic rhinitis.6,14 Clinical trials comparing various second-generation antihistamines demonstratesimilar reduction of symptoms.2,19,21,28 They are less effective than intranasal corticosteroids for mostsymptoms of allergic rhinitis.6 Two meta-analyses demonstrated intranasal corticosteroids were moreeffective than antihistamines for relieving congestion and sneezing; for ocular symptoms, nodifference was found.29,30
The intranasal antihistamine levocabastine is effective for sneezing, nasal pruritus and rhinorrhea. Ithas a rapid onset of action (<15 minutes), but must be used 2–4 times daily.22 The intranasalantihistamine azelastine (available only in combination with fluticasone in Canada) is clinicallysimilar to oral second-generation antihistamines for the relief of nasal symptoms.30
Antihistamines are more effective when taken before allergen exposure. The best results are obtainedwith chronic dosing compared with intermittent dosing; therefore, patients should take theantihistamine for as long as they are in contact with the allergen.14 If one antihistamine is not effective,switching to another antihistamine may be beneficial.31
Mast Cell StabilizersSodium cromoglycate (also called cromolyn sodium) modestly reduces itching, sneezing andrhinorrhea but is not effective for nasal congestion.3 Treatment should begin before exposure to theallergen and continue for the entire allergen season.22 If treatment begins after allergen exposure, reliefmay be delayed up to 4 weeks. Sodium cromoglycate is less effective than corticosteroids for allergicrhinitis and has not been adequately compared with leukotriene receptor antagonists andantihistamines.6,30
DecongestantsDecongestants are available in oral and topical formulations. Oral decongestants generally have aweaker effect on nasal obstruction than the topical formulations.22 When given orally, decongestantscan cause systemic adverse effects (see Table 5). Most available agents do not cause blood pressureelevations in normotensive persons unless the recommended dose is significantly exceeded.32Elevation of blood pressure may occur at standard doses in hypertensive patients.33
Systemic absorption from topical formulations is low, resulting in mainly local adverse effects (seeTable 6). Rhinitis medicamentosa (rebound vasodilation) can occur if topical decongestants are usedfor more than 3–5 days.34 In one study, 49% of patients reported using an intranasal decongestant dailyfor at least one year, even though 80% reported having received education about limiting the durationof use. Intranasal decongestant overuse was less common in patients who were using intranasalcorticosteroid or oral antihistamine.35 Overuse can lead to nasal congestion when the topical agent isstopped, and to permanent overgrowth of nasal tissue with chronic overuse. This condition is morelikely to occur with shorter-acting agents (phenylephrine) than with longer-acting agents(oxymetazoline and xylometazoline). Many solutions to this problem have been proposed, includingslow tapering of the decongestant, adding or switching to intranasal corticosteroids, or abruptdiscontinuation of the topical decongestant. Abrupt cessation is effective but may be uncomfortable forthe patient as nasal congestion may persist for several days or weeks.34
232 Respiratory Conditions
Sample Chapters for Conference_J.indd 25 6/17/2016 2:35:21 PM
Respiratory Conditions
Compendium of Therapeutics for Minor Ailments Copyright © Canadian Pharmacists Association. All rights reserved.
CorticosteroidsIntranasal corticosteroids are more effective against the nasal symptoms of allergic rhinitis than oraland intranasal antihistamines, nasal cromoglycate and leukotriene receptor antagonists.29,30 Intranasalcorticosteroids are the drugs of choice for moderate to severe or persistent allergic rhinitis, and formild allergic rhinitis that does not respond to antihistamines.3,6,9 Some intranasal corticosteroids(mometasone furoate and fluticasone furoate) have a modest benefit on allergic conjunctivitissymptoms.6,10,36,37,38 A meta-analysis suggests that intranasal corticosteroids as a class are effective forocular symptoms of allergic rhinitis; however the magnitude of effect has not been quantified.39 Onsetof action of intranasal corticosteroids is within 6–8 hours of first dose, although maximum effect maytake a few weeks. Short courses of oral corticosteroids may be required for severe cases of allergicrhinitis that is unresponsive to other treatment.6 Patients may prefer intranasal corticosteroids inaerosol form compared with spray form; therefore, switching to another intranasal corticosteroidformulation may be recommended if patient tolerability is affecting therapy.40 Regular use ofintranasal steroids is more effective than intermittent use.14
Leukotriene Receptor Antagonists (LTRA)Montelukast is superior to placebo but less effective than intranasal corticosteroids for nasalsymptoms of allergic rhinitis.30 Montelukast is similar in efficacy to loratadine, but patient response ismore variable than with antihistamines.30 There may be additive effects when it is used concomitantlywith antihistamines. Montelukast is more effective than oral antihistamines and comparable tointranasal corticosteroids for reduction of asthma symptoms and use of rescue asthma medication.30 Asa result, montelukast may be a reasonable option for allergic rhinitis coexisting with asthma.6,7,9Otherwise, montelukast is not recommended as first-line therapy for allergic rhinitis.9
ImmunotherapyAccording to clinical practice guidelines, allergen immunotherapy should be considered for patientswho continue to have moderate to severe symptoms despite treatment or those who require systemiccorticosteroids.2,9 Immunotherapy may be indicated when the exposure to allergens is significant andunavoidable (e.g., grass pollen), and when the symptom complex is severe enough to warrant the time,expense and small risk of anaphylaxis.6 Allergen immunotherapy is the only treatment that can modifythe natural history of allergic rhinitis and potentially induce long-term disease remission after cessationof treatment. It may also prevent the development of new allergies and reduce the risk of developmentof asthma in children. Therefore, allergen immunotherapy may be considered even in milder cases ofallergic rhinitis. Immunotherapy is administered by subcutaneous injection, although sublingualimmunotherapy seems to be somewhat effective as well.6,41,42
AnticholinergicsIntranasal ipratropium bromide is effective for rhinorrhea secondary to allergic rhinitis but not forother symptoms.22
Combination TherapiesCombination therapy is recommended by some guidelines when patients have inadequate response tomonotherapy.9 Some combinations have been shown to be more effective than monotherapy whileothers have not.
First- and Second-generation AntihistaminesSome experts suggest a second-generation antihistamine during the day and a first-generationantihistamine at bedtime to promote sleep. Evidence to support this practice is lacking and next-day
Chapter 22: Allergic Rhinitis 233
Sample Chapters for Conference_J.indd 26 6/17/2016 2:35:22 PM
Chapter 22: Allergic Rhinitis
Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments
sedation is possible.2 If sleep is disturbed due to allergies, symptom relief itself can be expected toimprove sleep.
Antihistamine plus DecongestantBecause antihistamines may have only a modest effect on nasal congestion, antihistamines anddecongestants are often combined. Some patients may respond to this combination whencorticosteroids have failed or when either medication alone does not provide adequate relief of nasalsymptoms.2,30
Antihistamine plus CorticosteroidIntranasal corticosteroids are often combined with oral antihistamines to treat severe or resistant casesof allergic rhinitis.6 This strategy seems logical because the 2 drugs have different mechanisms ofaction. Evidence is insufficient to support the combination of intranasal corticosteroids and oralantihistamines, as it has not been consistently shown to be superior to either medication alone.2,30However, intranasal corticosteroid in combination with intranasal antihistamine (fluticasone/azelastine) is more effective for the nasal symptoms of allergic rhinitis than either medication alone.30
Antihistamine or Intranasal Corticosteroid plus LTRAAn additive effect has been shown when LTRAs and either oral antihistamines or intranasalcorticosteroids are used concomitantly.30 The efficacy of oral antihistamines in combination with aLTRA is less than that of intranasal corticosteroids alone.6 However, antihistamine-LTRA combinationtherapy may provide an alternative for patients who are unresponsive or nonadherent to intranasalcorticosteroid therapy.
Special PopulationsChildrenThe guidelines for treatment of allergic rhinitis in children are similar to those for adults.6 Healthcarepractitioners must ensure they select the correct dosage, ensure proper administration and minimizeadverse effects.3,7,24 Most second-generation antihistamines are now available in pediatricformulations for children >6 months and are generally preferred over first-generation agents due toimproved adverse effect profiles. Table 5 and Table 6 provide dosage guidelines and age limits for oraland intranasal agents. Intranasal corticosteroids are also effective and are considered safe in children>2 years of age, depending on the formulation.24 Intranasal budesonide and mometasone furoatehave not shown growth suppression with prolonged use at recommended doses.6,43,44 Intranasalbeclomethasone dipropionate, fluticasone propionate and triamcinolone acetonide have beenshown to reduce growth velocity by 0.2–0.9 cm per year within the first year of treatment.45,46,47Longer term studies have not been conducted. If intranasal corticosteroids are used, use the lowestpossible dose, monitor growth and use other therapies (e.g., antihistamines) to minimize the dose ofcorticosteroid required for symptom control.6 Decongestants are not recommended for use in childrenunder 6 years.48,49 In those children, intranasal saline drops or spray may be used to clear nasalpassages before eating or sleeping.
PregnancyIntranasal cromoglycate and intranasal corticosteroids are both considered safe during pregnancyalthough beclomethasone, budesonide and fluticasone propionate have accumulated more safetydata than other intranasal corticosteroids.6 Neither first- nor second-generation antihistamines havebeen associated with teratogenic effects in pregnancy.50,51 First-generation antihistamines werepreviously favoured because of substantially greater experience; however, safety data for cetirizineand loratadine now indicate these are acceptable options. Chlorpheniramine has a good safety
234 Respiratory Conditions
Sample Chapters for Conference_J.indd 27 6/17/2016 2:35:22 PM
Respiratory Conditions
Compendium of Therapeutics for Minor Ailments Copyright © Canadian Pharmacists Association. All rights reserved.
record in pregnancy. Although diphenhydramine has good safety data and is still recommended andfrequently used in pregnancy, there have been isolated reports of cleft palate.51 Sedation and impairedperformance may limit the use of first-generation antihistamines. Oral decongestants should beavoided in the first trimester.51 A topical decongestant may be used; at usual doses, they do notpresent a risk to the fetus. Immunotherapy generally should not be started during pregnancy. Coursesof immunotherapy started prior to conception may be continued if beneficial and not causing systemicreactions; doses should not be increased during pregnancy.52 See Appendix V: Pregnancy andBreastfeeding: Self-care Therapy for Common Conditions.
BreastfeedingRecommendations for breastfeeding are similar to those during pregnancy. Both first- and second-generation antihistamines are considered safe while breastfeeding.53 First-generation antihistaminesmay in theory diminish milk production via their anticholinergic effect; however, this has not beenreported in practice. Infant somnolence should be monitored when a first-generation antihistamine orcetirizine is used.
The systemic absorption of topical decongestants is low and transfer into breast milk is unknown.Consequently, these agents are expected to be reasonably safe during breastfeeding.
The American Academy of Pediatrics considers pseudoephedrine to be compatible withbreastfeeding.51 Information on the use of other oral decongestants during breastfeeding is limited.
Information on the use of topical sodium cromoglycate during breastfeeding is not available, althoughthe manufacturer recommends caution.
Monitoring of TherapyTable 4 provides a monitoring plan framework that should be individualized.
Table 4: Monitoring of Therapy for Allergic Rhinitis
Symptoms Monitoring Endpoint of Therapy Actions
Allergic symptoms(sneezing, runny nose,itchy and watery eyes,congestion, rhinorrhea)
Patients: DailyHealthcare practitioner:Next visit or by telephone 1wk later
Patient able to performdaily activities.Patient able to sleep.
If nonprescription therapy is ineffectiveafter 1 wk, optimize allergen avoidanceand medication dose (if applicable). Ifsymptoms not controlled after a furtherwk of therapy, consider another agent.Refer as necessary.3
Drowsiness(antihistamine)
Patient: DailyHealthcare practitioner:Next visit or by telephonewhen checking for efficacy
Patient not drowsy duringthe day.
Switch to a less sedating antihistamine.If using cetirizine, could give dose atbedtime.
Insomnia(oral decongestant)
Patient: DailyHealthcare practitioner: 1wk
No insomnia. Change medication schedule so lastdose taken 4–6 h before bedtime ordiscontinue medication.
Elevated blood pressurein hypertensive patients(oral decongestant)
Patient: DailyHealthcare practitioner:Monitor blood pressure ofhypertensive patients twicein the first wk
No elevation in bloodpressure above baseline.
Stop decongestant if blood pressureelevated above baseline.
Chapter 22: Allergic Rhinitis 235
Sample Chapters for Conference_J.indd 28 6/17/2016 2:35:22 PM
Chapter 22: Allergic Rhinitis
Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments
Advice for the PatientAdvise all patients about allergen avoidance. In addition, patients who require drug therapy shouldreceive counselling regarding proper use of the medication, expected results and management ofadverse effects (see Table 4).
Figure 2: Assessment and Initial Treatment of Patients with Allergic Rhinitis3,4,6,7
236 Respiratory Conditions
Sample Chapters for Conference_J.indd 29 6/17/2016 2:35:24 PM
Respiratory Conditions
Compendium of Therapeutics for Minor Ailments Copyright © Canadian Pharmacists Association. All rights reserved.
Table5:
OralA
gentsforA
llergicRhinitis
Class
Drug
Dosage
Adverse
Effects
DrugInteractions
Com
ments
Costa
Antihistamines,
First-g
eneration
chlorpheniramine
Chlor-Tripolon,
generics
Adu
lts:4
mgQ4–6H
po;
maximum
24mg/day
Children:0.35
mg/kg/day
dividedQ4–6H
poor 2–5y:1mgQ4–6H
po;
maximum
6mg/day
6–11
y:2mgQ4–6H
po;
maximum
12mg/day
CNS:S
edation,fatigue,
dizziness,impairm
ent
ofcognition
and
performance.
Anticholinergic:Dry
mouthandeyes,
constipation,urinary
retention.
IncreasedCNSdepression
whencombined:Alcohol,
sedatives,tranquilizers,
barbiturates.
Increasedanticholinergic
side
effectswhencombined
with:TCAs,scopolam
ine.
Increase
chlorpheniramine
levelsresulting
inincreased
adverseeffectswhen
combinedwith
moderate
CYP2D
6inhibitors,e.g.,
amiodarone,celecoxib.
Avoidcombinationwith
strong
CYP2D
6inhibitors,
e.g.,bupropion,paroxetine.
$
diphenhydram
ine
Benadryl
Preparations,
generics
Adu
lts:25–50
mgQ6–8H
po;m
aximum
300mg/day
Children:5mg/kg/day
given
in3or4divideddosespo
2–5y:Maximum
37.5mg/day
6–11
y:Maximum
150mg/day
See
chlorpheniramine.
IncreasedCNSdepression:
Alcohol,sedatives,
tranquilizers,barbiturates.
Increasedanticholinergic
side
effectswhencombined
with:TCAs,scopolam
ine.
May
increase
levelsof
CYP2D
6substrates,e.g.,
metoprolol,venlafaxine.
Availableinpediatric
liquid
formulation.
$
Antihistamines,
Second
-generatio
n
cetirizine
Reactine,generics
Adu
lts:5–10mgQ24Hpo;
maximum
20mgQ24Hpo
Children:
6–12
months:2.5mgQ24H
po 12–23months:2.5mgQ24H
po;m
aximum
2.5mgQ12H
2–5y:2.5mgQ24Hpo;
maximum
5mg/dayin1or2
doses
≥6y:Adultdosage
Minimaltono
anticholinergiceffects.
May
causedrow
siness
insomeindividuals
especiallyathigher
doses.
Headache.
IncreasedCNSdepression:
Alcohol,sedatives,
tranquilizers,barbiturates.
Increasedanticholinergic
side
effects:TC
As,
scopolam
ine.
Activemetabolite
ofhydroxyzine.
Availableinpediatric
5mg
rapid-dissolve
tablet.
Availableas
5mg/5mL
syrup.
$
Chapter 22: Allergic Rhinitis 237
Sample Chapters for Conference_J.indd 30 6/17/2016 2:35:24 PM
Chapter 22: Allergic Rhinitis
Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments
Class
Drug
Dosage
Adverse
Effects
DrugInteractions
Com
ments
Costa
desloratadine
Aerius,generics
Adu
lts:5
mgQ24Hpo
Children:
6–11
months:1mgQ24Hpo
1–5y:1.25
mgQ24Hpo
6–11
y:2.5mgQ24Hpo
Minimaltono
anticholinergiceffects.
Headache.
P-gpinhibitors(e.g.,
erythrom
ycin,ketoconazole)
may
increase
loratadine
levelswhileP-gpinducers
(e.g.,carbam
azepine,
dexamethasone)m
aydecrease
loratadine
levels;
clinicaleffectprobably
minimal.
Activemetabolite
ofloratadine.
Availableinpediatric
liquid
formulation.
$
fexofenadine
Allegra
Adu
lts:60mgQ12Hpo
Sustained-release:120
mg
Q24Hpo
Children:
2–11
y:30
mgQ12Hpo
See
desloratadine.
Decreased
fexofenadine
level:Aluminum
-and
magnesium
-containing
antacids.
Ingestionoffruitjuices
such
asapple,grapefruitor
orange
may
decrease
bioavailability.
Activemetabolite
ofterfenadine.O
nly5%
ofa
dose
ismetabolized.
$
loratadine
Claritin,C
laritin
LiquidCapsules,
generics
Adu
lts:10mgQ24Hpo
Children:
2–5y:5mgQ24Hpo
≥5y:10
mgQ24Hpo
See
desloratadine.
QT cprolongationreported
with
concom
itantuseof
loratadine
andam
iodarone.
Cautionisadvised.
P-gpinhibitors(e.g.,
erythrom
ycin,ketoconazole)
may
increase
loratadine
levelswhileP-gpinducers
(e.g.,carbam
azepine,
dexamethasone)m
aydecrease
loratadine
levels;
clinicaleffectprobably
minimal.
Availableinpediatric
liquid
formulationandrapid-
dissolve
tablets.
$ (cont'd)
Table5:
OralA
gentsforA
llergicRhinitis
(cont'd)
238 Respiratory Conditions
Sample Chapters for Conference_J.indd 31 6/17/2016 2:35:24 PM
Respiratory Conditions
Compendium of Therapeutics for Minor Ailments Copyright © Canadian Pharmacists Association. All rights reserved.
Class
Drug
Dosage
Adverse
Effects
DrugInteractions
Com
ments
Costa
Decon
gestants
pseudoephedrine
Eltor120,
Sudafed,generics
Adu
lts:60mgQ4–6H
po;
maximum
240mg/day
Sustained-release:120
mg
Q12Hpo;m
aximum
240mg/
day
Children:
6–11
y:30
mgQ4–6H
poMaximum
120mg/day
≥12y:adultdose
Mild
CNSstimulation
(nervousness,
excitability,
restlessness,dizziness,
weakness,insomnia).
Peripheral
vasoconstriction.
Tachycardiaor
palpitationmay
occur.
Blood
pressuremay
beincreasedin
hypertensivesubjects.
May
adverselyaffect
bloodsugarcontrolin
diabetics.
Beta-blockers:
Antihypertensiveeffectsmay
bereduced.
Contraindicatedwith
MAOIs
andergotderivatives.
Avoidusewith
phenothiazines
andselective
serotoninreuptake
inhibitors.
Cautioninpatientswith
heartdisease,highblood
pressure,hyperthyroidism
,diabetes,angleclosure
glaucomaandprostatic
enlargem
ent.
Concurrentuse
with
oruse
within2weeks
ofMAOIs
may
causehypertensive
crisis.
$$
Antihistamine,
Second
-generatio
n/Decon
gestant
Com
binatio
ns
cetirizine/
pseudoephedrine
Reactine
Com
plete
Adu
lts:1
tab(5mg/120mg)
Q12Hpo
Children:
≥12y:Giveadultdose
See
cetirizine.
See
pseudoephedrine.
See
cetirizine.
See
pseudoephedrine.
See
cetirizine.
See
pseudoephedrine.
$$
desloratadine/
pseudoephedrine
AeriusDualAction
12Hour
Adu
lts:1
tab(2.5
mg/120mg)Q12Hpo
Children:
≥12y:Giveadultdose
See
desloratadine.
See
pseudoephedrine.
See
desloratadine.
See
pseudoephedrine.
See
desloratadine.
See
pseudoephedrine.
$$
fexofenadine/
pseudoephedrine
Allegra-D
Adu
lts:1
tab(60mg/
120mg)Q12Hpo
Children:
≥12y:Giveadultdose
See
desloratadine.
See
pseudoephedrine.
See
fexofenadine.
See
pseudoephedrine.
See
fexofenadine.
See
pseudoephedrine.
$$
loratadine/
pseudoephedrine
ClaritinAllergy+
Sinus,C
laritin
Allergy+Sinus
ExtraStrength
Adu
lts:1
tab(5mg/120mg)
Q12Hpo
or 1tab(10mg/240mg)Q24H
po Children:
≥12y:Giveadultdose
See
desloratadine.
See
pseudoephedrine.
See
loratadine.
See
pseudoephedrine.
See
loratadine.
See
pseudoephedrine.
$$ (cont'd)
Chapter 22: Allergic Rhinitis 239
Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments
Class
Drug
Dosage
Adverse
Effects
DrugInteractions
Com
ments
Costa
Leukotrie
neReceptor
Antagon
ists
montelukast
Singulair,
Montelukast,other
generics
Adu
ltsandchildren≥15y:
10mgQHS
Children:
6–14
y:5mgQHS
2–5y:4mgQHS
Headache,abdominal
pain,flu-like
symptom
s.Strong
CYP2C
9and3A
4inducers(e.g.,
carbam
azepine,
phenobarbital,phenytoin,
rifam
pin)may
decrease
montelukastlevelswhereas,
strong
CYP2C
9inhibitors
(e.g.,sulfadiazine)may
increase
montelukastlevels;
clinicalsignificanceis
uncertain;how
ever,m
onitor
forreduced
efficacyor
adverseeffects.
Strong
CYP2C
9and3A
4inducers(e.g.,
carbam
azepine,
phenobarbital,phenytoin,
rifam
pin)may
decrease
montelukastlevels
whereas,strong
CYP2C
9inhibitors(e.g.,fluconazole)
may
increase
montelukast
levels;clinicalsignificance
isuncertain;how
ever,
monitorforreduced
efficacyoradverseeffects
$$
aCostof10daysupply;includesdrug
costonly
Dosageadjustmentm
aybe
requiredinrenalimpairm
ent.
Abb
reviations:
CNS=centralnervous
system
;MAOI=
monoamineoxidaseinhibitor;SR=sustainedrelease
Legend:
$<$10
$$$10–20
Table5:
OralA
gentsforA
llergicRhinitis
(cont'd)
240 Respiratory Conditions
Sample Chapters for Conference_J.indd 32 6/17/2016 2:35:25 PM
Chapter 22: Allergic Rhinitis
Copyright © . All rights reserved. Compendium of Therapeutics for Minor Ailments
Class
Drug
Dosage
Adverse
Effects
DrugInteractions
Com
ments
Costa
Leukotrie
neReceptor
Antagon
ists
montelukast
Singulair,
Montelukast,other
generics
Adu
ltsandchildren≥15y:
10mgQHS
Children:
6–14
y:5mgQHS
2–5y:4mgQHS
Headache,abdominal
pain,flu-like
symptom
s.Strong
CYP2C
9and3A
4inducers(e.g.,
carbam
azepine,
phenobarbital,phenytoin,
rifam
pin)may
decrease
montelukastlevelswhereas,
strong
CYP2C
9inhibitors
(e.g.,sulfadiazine)may
increase
montelukastlevels;
clinicalsignificanceis
uncertain;how
ever,m
onitor
forreduced
efficacyor
adverseeffects.
Strong
CYP2C
9and3A
4inducers(e.g.,
carbam
azepine,
phenobarbital,phenytoin,
rifam
pin)may
decrease
montelukastlevels
whereas,strong
CYP2C
9inhibitors(e.g.,fluconazole)
may
increase
montelukast
levels;clinicalsignificance
isuncertain;how
ever,
monitorforreduced
efficacyoradverseeffects
$$
aCostof10-daysupply;includesdrug
costonly
Dosageadjustmentm
aybe
requiredinrenalimpairm
ent.
Abb
reviations:
CNS=centralnervous
system
;MAOI=
monoamineoxidaseinhibitor;SR=sustainedrelease
Legend:
$<$10
$$$10–20
Table5:
OralA
gentsforA
llergicRhinitis
(cont'd)
24 Respiratory Conditions
Sample Chapters for Conference_J.indd 33 6/17/2016 2:35:25 PM
Respiratory Conditions
Compendium of Therapeutics for Minor Ailments Copyright © . All rights reserved.
Table6:
IntranasalAgentsforA
llergicRhinitis
Class
Drug
Dosage
Adverse
Effects
Com
ments
Costa
Antihistamines
levocabastine
LivostinNasalSpray
Adu
ltsandChildren(≥12–65y):2
sprays
(50µg/spray)pernostrilBID;m
ayincrease
to2sprays
TID–Q
ID
Nasalirritation.
Shake
wellbeforeuse.
Initialprimingrequired.
Discontinue
ifno
improvem
entseen
within3days.
$$$
Antihistamine/
Corticosteroid
Com
binatio
ns
azelastine/fluticasone
Dym
ista
Adu
ltsandchildren≥12y:1spray
(137
µg/50µg)ineach
nostrilBID
Burning
orstinging,
nosebleeds.
Dysgeusiamay
occurif
patienttiltshead
back
too
farduringadministration.
Avoidusewith
ritonavirdueto
potentialforsystem
iccorticosteroid
effects.
Rarelycauses
drow
siness.
$100
Corticosteroids
beclom
ethasone
generics
Adu
ltsandchildren≥6
y:2sprays
(50µg/spray)ineach
nostrilBID
Adults:M
aximum
12sprays/day
Children:Maximum
8sprays/day
Use
lowesteffectivedose
form
aintenance
therapy
Burning
orstinging,
nosebleed.
May
causemild
grow
thsuppressionwith
prolongeduse.
45,46,47
Use
atregularintervals.S
lowonset
(7–14days
form
aximaleffect).
Drugmay
failtoreachthesiteof
actionifexcessivenasalm
ucus
secretionoredem
aofthenasal
mucosaispresent.May
usea
vasoconstrictor(intranasal
decongestant)2–3
days
priortothe
suspension.
Aim
sprayup
towards
turbinates
and
away
fromseptum
.Liquidformsmay
bemoreeffectivethan
metered-dose
inhalers.
$$
Chapter 22: Allergic Rhinitis 25
Sample Chapters for Conference_J.indd 34 6/17/2016 2:35:25 PM
Chapter 22: Allergic Rhinitis
Copyright © . All rights reserved. Compendium of Therapeutics for Minor Ailments
Class
Drug
Dosage
Adverse
Effects
Com
ments
Costa
budesonide
RhinocortAqua,
RhinocortTurbuhaler
Nasalsuspension
:Adu
ltsandchildren≥6
y(64µg
/metered
dose):Initialdose
2sprays
ineach
nostril
daily
or 1sprayineach
nostrilBID;m
aydecrease
maintenance
dose
to1sprayineach
nostril
daily
Nasalpo
wder:
Adu
ltsandchildren≥6
y(100
µg/dose):
Initialdose
2applications
ineach
nostrilin
themorning
or 1applicationineach
nostrilBID;m
aydecrease
maintenance
dose
to1sprayin
each
nostrildaily
Maximum
400µg/day
See
beclom
ethasone.
See
beclom
ethasone.
Forthe
nasalsuspension,initial
primingneeded.R
e-primeifnotused
≥4days.
$$-$$$
ciclesonide
Omnaris
Adu
ltsandchildren≥12y:2sprays
(50µg/spray)ineach
nostrildaily;
maximum
200µg/day
Burning
orstinging,
nosebleeds.
See
beclom
ethasone.
Initialprimingneeded.
$$$
flunisolide
generics
Adu
lts:2
sprays
(25µg/metered
spray)in
each
nostrilBID,m
ayincrease
toTIDif
needed;m
aximum
300µg/day
Children6–14
y:1sprayineach
nostril
TID;m
aximum
150µg/day
See
ciclesonide.
See
beclom
ethasone.
$$
Table6:
IntranasalAgentsforA
llergicRhinitis
(cont'd)
26 Respiratory Conditions
Sample Chapters for Conference_J.indd 35 6/17/2016 2:35:25 PM
Respiratory Conditions
Compendium of Therapeutics for Minor Ailments Copyright © . All rights reserved.
Class
Drug
Dosage
Adverse
Effects
Com
ments
Costa
fluticasonepropionate
Flonase,generics
Adu
ltsandchildren≥12y:2sprays
(50µg/spray)ineach
nostrildaily,m
ayincrease
toBID
inseveresituations;
maximum
400µg/day
Children4–11
y:1–2sprays
ineach
nostril
daily;m
aximum
200µg/day
See
beclom
ethasone.
See
beclom
ethasone.
$$$
fluticasonefuroate
Avamys
Adu
ltsandchildren≥12y:2sprays
(27.5µg/spray)ineach
nostrilonce
daily;
maximum
110µg/day
Children≥2
yto
<12y:1sprayineach
nostrilonce
daily,m
ayincrease
to2sprays
ineach
nostrilonce
daily
ifneeded.
Decreaseto1sprayineach
nostrildaily
for
maintenance;m
aximum
110µg/day
See
ciclesonide.
See
beclom
ethasone.
Initialprimingneeded.R
e-primeif
notused≥30days
orifcapleftofffor
≥5days.
$$$
mom
etasone
Nasonex
Adu
ltsandchildren≥12y:2sprays
(50μg/spray)ineach
nostrildaily,m
aydecrease
to1sprayineach
nostrildaily
for
maintenance;m
ayincrease
toBID
inseveresituations.
Children3–11
y:1sprayineach
nostril
daily
See
ciclesonide.
See
beclom
ethasone.
$$$
triam
cinolone
NasacortA
QAdu
ltsandchildren≥12y:2sprays
(55µg/spray)ineach
nostrilonce
daily,m
aydecrease
to1sprayineach
nostrilonce
daily
Children4–11
y:1spray(55µg/spray)in
each
nostrilonce
daily,m
ayincrease
to2
sprays
ineach
nostrilonce
daily
ifneeded.
Decreaseto1sprayineach
nostrildaily
for
maintenance;m
aximum
110µg/day
See
ciclesonide.
See
beclom
ethasone.
$$$ (cont'd)
Chapter 22: Allergic Rhinitis 27
Sample Chapters for Conference_J.indd 36 6/17/2016 2:35:25 PM
Chapter 22: Allergic Rhinitis
Copyright © . All rights reserved. Compendium of Therapeutics for Minor Ailments
Class
Drug
Dosage
Adverse
Effects
Com
ments
Costa
Decon
gestants
oxym
etazoline
ClaritinAllergy
Decongestant,Dristan
Long
LastingNasal
Mist,DristanLong
LastingMentholated
NasalSpray
Adu
ltsandchildren≥6
y:0.05%solution
2–3dropsorsprays/nostrilQ
12H
Burning,stinging,
sneezing,dryness
ofthe
nasalm
ucosa.
Bradycardia,tachycardia,
hypotensionand
hypertensionhave
been
reported.
Onsetofaction:5–10
min.
Long
durationofactionlastingup
to12
h.Donotuse
longerthan
3–5days.
$
phenylephrine
DristanNasalMist
Adu
ltsandchildren≥6
y:0.25%or0.5%
solution2–3dropsorsprays/nostrilQ
4HSee
oxym
etazoline.
See
oxym
etazoline.
$
xylometazoline
Otrivin,BalminilNasal
Decongestant
Adu
ltsandchildren≥6
y:0.05%or0.1%
solution2–3dropsor1–2sprays/nostril
Q8-10H
See
oxym
etazoline.
See
oxym
etazoline.
$
MastC
ell
Stabilizers
sodium
crom
oglycate
Rhinaris
CSAnti-
allergic
Adu
ltsandchildren>2
y:1spray/nostril
3–6tim
esdaily
Local:Sneezing,nasal
stinging
orirritation,bad
tasteinthemouth,
epistaxis.
Less
effectivethan
otheragents.
Onsetofactiondelayedup
to4wk.
$$
aCostof1
unit(spray
pump);includesdrug
costonly.
Legend:
$<$10
$$$10–20
$$-$$$
$10–30
$$$$20–30
Table6:
IntranasalAgentsforA
llergicRhinitis
(cont'd)
28 Respiratory Conditions
Sample Chapters for Conference_J.indd 37 6/17/2016 2:35:25 PM
Respiratory Conditions
Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments
Suggested Readings
Brozek JL, Bousquet J, Baena-Cagnani CE et al. Allergic Rhinitis and its Impact on Asthma (ARIA)guidelines: 2010 revision. J Allergy Clin Immunol 2010;126:466-76.
Seidman MD, Gurgel RK, Lin SYet al. Clinical practice guideline: Allergic rhinitis. Otolaryngol HeadNeck Surg 2015;152:S1-43.
Wallace DV, Dykewicz MS, Bernstein DI et al. The diagnosis and management of rhinitis: an updatedpractice parameter. J Allergy Clin Immunol 2008;122:S1-84.
Wheatley LM, Togias A. Clinical practice. Allergic rhinitis. N Engl J Med 2015;372:456-63.
References1. Mucci T, Govindaraj S, Tversky J. Allergic rhinitis.Mt Sinai J Med 2011;78:634-44.2. Plaut M, Valentine MD. Clinical practice. Allergic rhinitis. N Engl J Med 2005;353:1934-44.3. Brozek JL, Bousquet J, Baena-Cagnani CE et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision. J Allergy ClinImmunol 2010;126:466-76.
4. Greiner A, Hellings PW, Rotiroti G et al. Allergic rhinitis. Lancet 2011;378:2112-22.5. Kay AB. Allergy and allergic diseases. First of two parts. N Engl J Med 2001;344:30-7.6. Wallace DV, Dykewicz MS, Bernstein DI et al. The diagnosis and management of rhinitis: an updated practice parameter.J Allergy Clin Immunol 2008;122:S1-84.
7. Scadding GK, Durham SR, Mirakian R et al. BSACI guidelines for the management of allergic and non-allergic rhinitis. Clin Exp Allergy2008;38:19-42.
8. Varghese M, Glaum MC, Lockey RF. Drug-induced rhinitis. Clin Exp Allergy 2010;40:381-4.9. Seidman MD, Gurgel RK, Lin SY et al. Clinical practice guideline: Allergic rhinitis. Otolaryngol Head Neck Surg 2015;152:S1-43.10. Nurmatov U, van Schayck CP, Hurwitz B et al. House dust mite avoidance measures for perennial allergic rhinitis: an updated Cochrane
systematic review. Allergy 2012;67:158-65.11. Hermelingmeier KE, Weber RK, Hellmich M et al. Nasal irrigation as an adjunctive treatment in allergic rhinitis: a systematic review and
meta-analysis. Am J Rhinol Allergy 2012;26:e119-25.12. Garavello W, Somigliana E, Acaia B et al. Nasal lavage in pregnant women with seasonal allergic rhinitis: a randomized study. Int Arch
Allergy Immunol 2010;151:137-41.13. Wilson AM, O'Byrne PM, Parameswaran K. Leukotriene receptor antagonists for allergic rhinitis: a systematic review and meta-analysis. Am
J Med 2004;116:338-44.14. Laekeman G, Simoens S, Buffels J et al. Continuous versus on-demand pharmacotherapy of allergic rhinitis: evidence and practice. Respir
Med 2010;104:615-25.15. Krouse JH. Allergic rhinitis–current pharmacotherapy. Otolaryngol Clin North Am 2008;41:347-58.16. Bachert C. A review of the efficacy of desloratadine, fexofenadine, and levocetirizine in the treatment of nasal congestion in patients with
allergic rhinitis. Clin Ther 2009;31:921-44.17. Lehman JM, Blaiss MS. Selecting the optimal oral antihistamine for patients with allergic rhinitis. Drugs 2006;66:2309-19.18. Simons FE. Advances in H1-antihistamines N Engl J Med 2004;351:2203-17.19. Slater JW, Zechnich AD, Haxby DG. Second-generation antihistamines: a comparative review. Drugs 1999;57:31-47.20. Horak F, Stubner UP. Comparative tolerability of second generation antihistamines. Drug Saf 1999;20:385-401.21. Simons FE. H1-receptor antagonists. Comparative tolerability and safety. Drug Saf 1994;10:350-80.22. Melvin TA, Patel AA. Pharmacotherapy for allergic rhinitis. Otolaryngol Clin North Am 2011;44:727-39.23. Sur DK, Scandale S. Treatment of allergic rhinitis. Am Fam Physician 2010;81:1440-6.24. Turner PJ, Kemp AS. Allergic rhinitis in children. J Paediatr Child Health 2012;48:302-10.25. Bender BG, Berning S, Dudden R et al. Sedation and performance impairment of diphenhydramine and second-generation antihistamines: a
meta-analysis. J Allergy Clin Immunol 2003;111:770-6.26. Weiler JM, Bloomfield JR, Woodworth GG et al. Effects of fexofenadine, diphenhydramine and alcohol on driving performance. A
randomized, placebo-controlled trial in the Iowa driving simulator. Ann Intern Med 2000;132:354-63.27. Church MK, Maurer M, Simons FE et al. Risk of first-generation H(1)-antihistamines: a GA(2)LEN position paper. Allergy 2010;65:459-66.28. Walsh GM, Annunziato L, Frossard N et al. New insights into the second generation antihistamines. Drugs 2001;61:207-36.29. Weiner JM, Abramson MJ, Puy RM. Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of
randomised controlled trials. BMJ 1998;317:1624-9.30. Glacy J, Putnam K, Godfrey S et al. Treatments for seasonal allergic rhinitis. Rockville: Agency for Healthcare Research and Quality; 2013.
(Comparative Effectiveness Reviews, No. 120.) Available from: www.ncbi.nlm.nih.gov/books/NBK153714.31. Golightly LK, Greos LS. Second-generation antihistamines: actions and efficacy in the management of allergic disorders. Drugs 2005;65:341-
84.32. Johnson DA, Hricik JG. The pharmacology of alpha-adrenergic decongestants. Pharmacotherapy 1993;13:110S-15S.33. Chua SS, Benrimoj SI, Gordon RD et al. A controlled clinical trial on the cardiovascular effects of single doses of pseudoephedrine in
hypertensive patients. Br J Clin Pharmacol 1989;28:369-72.34. Graf P. Rhinitis medicamentosa: aspects of pathophysiology and treatment. Allergy 1997;52:28-34.35. Mehuys E, Gevaert P, Brusselle G et al. Self-medication in persistent rhinitis: overuse of decongestants in half of the patients. J Allergy Clin
Immunol Pract 2014;2:313-9.36. Ratner P, Van Bavel JV, Mohar D et al. Efficacy of daily intranasal fluticasone propionate on ocular symptoms associated with seasonal
allergic rhinitis. Ann Allergy Asthma Immunol 2015;114:141-7.37. van Drunen C, Meltzer EO, Bachert C et al. Nasal allergies and beyond: a clinical review of the pharmacology, efficacy, and safety of
mometasone furoate. Allergy 2005;60:5-19.
244 Respiratory Conditions
Sample Chapters for Conference_J.indd 38 6/17/2016 2:35:26 PM
Chapter 22: Allergic Rhinitis
Compendium of Therapeutics for Minor Ailments Copyright © Canadian Pharmacists Association. All rights reserved.
38. Kaiser HB, Naclerio RM, Given J et al. Fluticasone furoate nasal spray: a single treatment option for the symptoms of seasonal allergicrhinitis. J Allergy Clin Immunol 2007;119:1430-7.
39. Hong J, Bielory B, Rosenberg JL. Efficacy of intranasal corticosteroids for the ocular symptoms of allergic rhinitis: a systematic review.Allergy Asthma Proc 2011;32:22-35.
40. Berger WE, Prenner B, Turner R et al. A patient preference and satisfaction study of ciclesonide nasal aerosol and mometasone furoateaqueous nasal spray in patients with perennial allergic rhinitis. Allergy Asthma Proc 2013;34:542-50.
41. Kowalski ML. Systemic and specific treatment for a global disease: allergen immunotherapy revisited. Allergy 2006;61:791-5.42. Jacobsen L, Niggemann B, Dreborg S et al. Specific immunotherapy has long term preventive effect of seasonal and perennial asthma: 10-year
follow-up on the PAT study. Allergy 2007;62:943-8.43. Allen DB. Systemic effects of intranasal steroids: an endocrinologist's perspective. J Allergy Clin Immunol 2000;106:S179-90.44. Skoner DP, Gentile DA, Doyle WJ. Effect on growth of long-term treatment with intranasal triamcinolone acetonide aqueous in children with
allergic rhinitis. Ann Allergy Asthma Immunol 2008;101:431-6.45. Skoner DP, Rachelefsky GS, Meltzer EO et al. Detection of growth suppression in children during treatment with intranasal beclomethasone
dipropionate. Pediatrics 2000;105:E23.46. Lee LA, Sterling R, Maspero J et al. Growth velocity reduced with once-daily fluticasone furoate nasal spray in prepubescent children with
perennial allergic rhinitits. J Allergy Clin Immunol Pract 2014;2:421-7.47. Skoner DP, Berger WE, Gawchik SM et al. Intranasal triamcinolone and growth velocity. Pediatrics 2015;135:e348-56.48. Healthy Canadians. Health Canada releases decision on the labelling of cough and cold products for children. Available from:
www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2008/13267a-eng.php. Accessed November 30, 2009.49. Peterson RG, Cran B, Knoppert D et al. Scientific Advisory Panel on Nonprescription Paediatric Cough and Cold Medications (SAP-
NPCCM). Record of proceedings. Ottawa: Health Canada; March 20, 2008.50. Mazzotta P, Loebstein R, Koren G. Treating allergic rhinitis in pregnancy. Safety considerations. Drug Saf 1999;20:361-75.51. Briggs GG, Freeman RK. Drugs in pregnancy and lactation: a reference guide to fetal and neonatal risk. 10th ed. Baltimore: Lippincott
Williams & Wilkins; 2015.52. Oykhman P, Kim HL, Ellis AK. Allergen immunotherapy in pregnancy. Allergy Asthma Clin Immunol 2015;11:31.53. Hale TW. Medications and mothers' milk: a manual of lactational pharmacology. 15th ed. Amarillo: Hale Publishing; 2012.
Chapter 22: Allergic Rhinitis 245
Sample Chapters for Conference_J.indd 39 6/17/2016 2:35:26 PM
Respiratory Conditions
Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments
Allergic Rhinitis—What You Need to Know
Allergic rhinitis is a condition caused by allergens in the air. Allergens are things that cause allergies.Some of the symptoms of allergic rhinitis are sneezing, coughing, runny nose, and itchy or wateryeyes. The most important thing you can do to feel better is to avoid the things that cause your allergies.Also avoid exposure to cigarette smoke and strong smells. If you do not know what causes yourallergies, see your doctor.
Helpful Hints for People Who Have AllergiesIf you are allergic to pollen:■ Keep the windows and doors of your house closed.■ If you need to use air conditioning, set the unit to the indoor cycle.■ Do not use window or attic fans.■ Check the weather report to find out about the pollen count. The pollen count tells you what kind of
pollen is in the air and how much. Avoid spending time outdoors when the pollen count is high. Thepollen count is highest on sunny, windy days and in the morning.
■ Do not dry your clothing outdoors.■ Shower or take a bath and wash your hair after outdoor activity. This will remove pollen from your
hair and skin. You want to avoid getting pollen into your bedding.
If you are allergic to outdoor moulds:■ Stay indoors as much as possible.■ If you need to use air conditioning, set the unit to the indoor cycle. Have your air conditioner
cleaned regularly. Air conditioners can be heavily contaminated with mould.■ Use a facemask if you rake leaves or work with compost or dry soil.
If you are allergic to indoor moulds:■ Kill mould with a solution of equal parts household bleach and water. Wash sinks, shower stalls,
nonrefrigerated vegetable storage areas and garbage pails with this solution.■ Avoid using a humidifier or cool mist vaporizer. Moulds grow easily where it is damp. If you must
use a humidifier or vaporizer, clean it often with a solution of equal parts bleach and water.■ If your home is built over a crawl space, install a plastic vapor barrier over exposed soil and keep
the foundation vents open.■ If your basement is damp or tends to flood, do not put carpet or furniture there. For a damp
basement, run a dehumidifier at all times. Empty water from the machine often and clean itregularly. For a flooded basement, drain the water as quickly as possible.
■ Fix any leaky faucets or pipes promptly.■ Do not keep houseplants.
If you are allergic to dust mites:■ Do not put carpet in your bedroom or main living areas.■ Plastic, leather or wood furniture is best.■ If possible, have someone else clean the house while you are not at home.■ If you must do your own cleaning, wear a facemask while you clean and for 10–15 minutes
afterward.
246 Respiratory Conditions
Sample Chapters for Conference_J.indd 40 6/17/2016 2:35:26 PM
Chapter 22: Allergic Rhinitis
Compendium of Therapeutics for Minor Ailments Copyright © Canadian Pharmacists Association. All rights reserved.
■ Use a vacuum cleaner with an efficient double-filtration system.■ Keep indoor humidity between 40% and 45%. You can buy a hygrometer to measure the humidity
in your house at a hardware store or home centre.■ Avoid using a humidifier or cool mist vaporizer.■ Use zippered, allergen-proof casings on all mattresses, box springs and pillows.■ Consider replacing old mattresses.■ Wash your bedding in hot (>55°C) water at least every 2 weeks. Cooler water will not kill dust
mites.■ Do not keep stuffed toys that cannot be washed.■ Do not store items under your bed.■ Use window shades instead of venetian blinds.
If you are allergic to a pet:■ The best choice is to find another home for the animal. It can take several months before the
allergen levels return to normal.■ If you are not able to give up your pet, then:
– You may find it helps to install a HEPA or electrostatic air purifier in your home.– Keep animals out of your bedroom at all times.– Keep animals out of rooms that have carpets.– Try to keep animals off furniture.– Washing cats weekly and dogs twice weekly may help, though this has not been proven.– Get rid of litter boxes if possible. If not, put them in an area that is not connected to the air
supply for the rest of your home.– If the animal lives in a cage, keep it in a room without carpet, far away from your bedroom.
Medication to Help with Allergy SymptomsYou may want to try medication if:■ You don't feel better even when you avoid the things that cause your allergies.■ Your allergies are interfering with your sleep or your daily activities.
Your pharmacist can help you pick the best medication for you and show you how to use it. SeeTable 1. You can choose between pills or a nasal spray.
Table 1: How to Use a Nasal Spray or Drops
Nasal Spray (Adults only)
1. Gently blow your nose.2. Gently shake bottle and remove cap or lid.3. With your head upright but not tilted backward, press your finger against one side of your nose to close the nostril. Spray the
medication into the open nostril, with the tip directed away from the middle of the nose and back towards the nasal cavity.Squeeze the bottle quickly and breathe in slowly through the nose.
4. Remove tip of nasal spray from your nostril and breathe out through your mouth.5. Do the same thing on the other side.6. Blow your nose in 3–5 minutes.
(cont'd)
Chapter 22: Allergic Rhinitis 247
Sample Chapters for Conference_J.indd 41 6/17/2016 2:35:26 PM
Respiratory Conditions
Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutics for Minor Ailments
Table 1: How to Use a Nasal Spray or Drops (cont'd)
7. Rinse the tip of the spray bottle with hot water, but try not to get water in the bottle. Replace lid.8. Do not use more nose spray than the recommended amount.
Nose Drops (Adult or child)
1. Gently blow your nose.2. Lie on your back on a bed with your head hanging slightly over the side.3. Gently shake bottle. Fill the dropper with the recommended amount of medication. Put the dropper just inside one nostril
(about 0.8 cm or one-third inch). If possible, don't let the dropper touch the skin.4. Apply the recommended number of drops. Apply the medication to the other nostril in the same way.5. Stay in the same position for about 5 minutes. Tilt head from side to side.6. Blow the nose 3–5 minutes later.7. You can also take nose drops by tilting your head back (instead of lying down). Use the recommended number of drops for
each nostril. Then bend over at the waist and hold that position for a few seconds before coming up straight again.8. Rinse the dropper with hot water and return it to the bottle.9. Do not use nose drops more than is recommended on the package.
248 Respiratory Conditions
Sample Chapters for Conference_J.indd 42 6/17/2016 2:35:26 PM
CANADIAN CURRENT EVIDENCE-BASED CONVENIENT
CPSCompendium of
Pharmaceuticalsand Specialties
CTCCompendium of
TherapeuticChoices
CPMACompendium of
Products
Minor Ailments
CTMACompendium ofTherapeutics for
Minor Ailments
Compendium of Pharmaceuticals and SpecialtiesThe Canadian standard for drug information
Published in English and
French
Compendium of Therapeutic ChoicesEvidence-based treatment options for primary care
French version available
online
Compendium of Products for Minor AilmentsThe Canadian reference for nonprescription products
French version available
online
Compendium of Therapeutics for Minor AilmentsEvidence-based treatment options for minor ailments
French version available
online
www.pharmacists.ca | 1-800-917-9489
Drug & Therapeutic Information Resources
for
Sample Chapters for Conference_J.indd 43 6/17/2016 2:35:26 PM
Sample Chapters for Conference_J.indd 44 6/17/2016 2:35:27 PM