recommendations for the pharmacologic management of allergic rhinitis

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Recommendations for the pharmacologic managementof allergic rhinitis

Flavia C. L. Hoyte, M.D.,1 Eli O. Meltzer, M.D.,2 Nancy K. Ostrom, M.D., C.P.I.,2

Harold S. Nelson, M.D.,1 Greg W. Bensch, M.D.,3,4 Dennis L. Spangler, M.D.,5

William W. Storms, M.D.,6 Steven F. Weinstein, M.D.,7 and Rohit K. Katial, M.D.1

ABSTRACT

Allergic rhinitis (AR) affects at least 60 million people in the United States each year, resulting in a major impact on patientquality of life, productivity, and direct and indirect costs. As new therapies, data, and literature emerge in the management ofAR, there is a need to communicate and disseminate important information to health care professionals to advance the practiceof medicine and lessen the disease burden from AR. Treatment recommendations for AR have not been updated since the 2012Food and Drug Administration approval of nonaqueous intranasal aerosol agents using hydrofluoroalkane propellants and thefirst aqueous intranasal combination product. Here, we present an updated algorithm for the pharmacologic treatment of ARthat includes these new treatment options. Treatment recommendations are categorized by disease severity (mild versusmoderate/severe) and duration of symptoms (episodic versus nonepisodic, with episodic defined as �3 days/wk or for �3 weeks).Preferred treatments are suggested, as well as alternative options for consideration by clinicians in the context of individualpatient needs. This recommendation article also outlines the importance of treatment monitoring, which can be conducted usingthe recently developed Rhinitis Control Assessment Test. Successful therapeutic outcomes depend on multiple factors,including use of the most effective pharmacologic agents as well as patient adherence to therapy. Therefore, it is imperative thatrhinitis patients not only receive the most effective therapeutic options, but that they also understand and are able to adhereto the comprehensive treatment regimen. Successful treatment, with all of these considerations in mind, results in better diseaseoutcomes, improved quality of life for patients, and greater economic productivity in the home and workplace.

(Allergy Asthma Proc 35:S20–S27, 2014; doi: 10.2500/aap.2014.35.3761)

Allergic rhinitis (AR) is one of the most commonmedical conditions among Americans. The Aller-

gies in America survey of 61,655 adults reported anoverall prevalence of 14% of adults in the United States

of physician-diagnosed AR, while the Pediatric Aller-gies in America survey of 35,757 households found a13% prevalence of health-care professional–diagnosedAR in children 4–17 years of age.1,2 The actual preva-lence is likely to be greater than these figures.2 Thistranslates to up to 60 million affected persons in theUnited States annually.2

Even when correctly diagnosed, treatment for AR isoften ineffective.3 The U.S. Nasal Allergy Survey As-sessing Limitations has shown that almost one-half ofAR patients perceive that their disease is not optimallycontrolled, regardless of disease severity.4 This equatesto a massive burden of disease, with correspondingsocial and economic consequences. AR patients reportthat their symptoms, particularly nasal congestion,runny nose, and postnasal drip, are bothersome andadversely impact their lives, often including sleep dis-turbance. In a U.S. survey, 22% of respondents re-ported that their nasal allergy symptoms negativelyimpacted their sleep every day or most days.2 Whenallergy symptoms are at their worst, adult patients are10 times more likely to experience microarousals while

From the 1Division of Allergy and Immunology, National Jewish Health, Denver,Colorado, 2Allergy and Asthma Medical Group and Research Center, San Diego,California, 3San Joaquin General Hospital, French Camp, California, 4Allergy, Im-munology, and Asthma Medical Group, Bensch Clinical Research, Stockton, Califor-nia, 5Atlanta Allergy & Asthma Clinic, Atlanta, Georgia, 6William Storms AllergyClinic Colorado, Springs, Colorado, and 7Allergy and Asthma Specialists MedicalGroup & Research, Huntington Beach, CaliforniaSponsored by National Jewish Health and supported by an unrestricted educationalgrant from TevaGW Bensch has served as an advisor and investigator for Teva and as a speaker for AstraZenecaand Teva. FCL Hoyte has served as an advisor for Teva. RK Katial has served as an advisor forTeva. EO Meltzer has served as a consultant for Alcon, Alexza, AstraZeneca, Bausch & Lomb,Boehringer Ingelheim, Forest, Ista, Johnson & Johnson, Kalypsys, Meda, Merck, Mylan,OptiNose, Procter & Gamble, Rigel, Sanofi-Aventis, Sunovion and Teva; as a speaker forAlcon, Meda, Merck, Mylan, Sunovion, and Teva; and has received grants from Alcon,Amgen, Apotex, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, HRA, Kalypsys,MedImmune, Merck, Novartis, Ono, Procter & Gamble, Rigel, Shinonogi, Sunovion, andTeva. HS Nelson has served as a consultant for Merck, Pearl, and Shionogi and as aninvestigator for Circassia, Lincoln Diagnostics, and Rigel. N Ostrom has served as a consultantfor Ista, Meda, Merck, and Teva; as a speaker for AstraZeneca, GlaxoSmithKline, Meda, Merck,Novartis, Sunovion, and Teva; and has received grants from Apotex, AstraZeneca, BoehringerIngelheim, Cephalon, ElectroCore, GlaxoSmithKline, MedImmune, Merck, Nestle, Novartis,Rigel, Schering-Plough, Sunovion, Teva, and Watson. DL Spangler has served as an advisorfor Meda and Teva. WW Storms has served as an advisor for Alcon Labs, Amgen, AstraZeneca,Bausch & Lomb, Ista, Merck, Sunovion, Strategic Pharmaceutical Advisors, Teva, and TREATFoundation; as a speaker for Alcon Labs, AstraZeneca, Genentech/Novartis, Bausch & Lomb,Ista, Merck, Sunovion, and Teva; and has received grants from Amgen, Genentech/Novartis,GlaxoSmithKline, Ista, Meda, Sunovion, and Teva. SF Weinstein has served as an advisor forTeva and as a speaker and investigator for Merck and Teva.

Address correspondence to Flavia Hoyte, M.D., National Jewish Health, 1400 JacksonStreet, Denver, CO 80206E-mail address: [email protected] © 2014, OceanSide Publications, Inc., U.S.A.

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sleeping.5 The burden of AR is compounded by the factthat patients have a high rate of comorbidities, including,asthma, sinusitis, and allergic conjunctivitis.6 Asthma is afrequently reported comorbidity, with more than one-third of AR patients in the United States having concom-itant asthma.7 Conversely, nearly all patients with allergicasthma also have nasal allergies.8 In the Allergies inAmerica survey, nearly one-half of adults with AR alsoreport chronic sinus issues. Respondents also fre-quently reported having earaches and migraines. Gas-trointestinal reflux disease and heartburn were alsocommonly described. The quality of life of AR patientsis also negatively impacted, specifically by fatigue anddaytime somnolence, reduced cognitive function in-cluding memory and learning performance, and emo-tional and behavioral difficulties.4,9 Furthermore, ARhas a significant economic impact because of the com-bination of high prevalence of disease and its associ-ated disease burden. Absenteeism is very common forboth workers and students with AR, resulting in majordirect and indirect costs annually.10 The economic im-pact reaches beyond absenteeism, although 85% of pa-tients surveyed in the Allergies in America surveyreported that nasal allergy symptoms adversely com-promise their daily life, which can lead to substantialcosts through reduced work productivity and poorerperformance, often termed presenteeism.2

Unfortunately, despite many treatment options forAR patients, the health status of these patients has notimproved over time. As stated in the Journal of theAmerican Medical Association in 1948, “Allergic rhinitisof long standing produces profound emotional changes:appetite is impaired; losses in weight occur; sleep isdisturbed; work and efficiency are interfered with, andthe patient is not well.”11 All of this remains truetoday—65 years later. Given the significant quality oflife and economic burden of AR, effective managementof these patients is of major importance.

THE BURDEN BEYOND SYMPTOMSConsidering the extensive impact of AR on quality of

life and comorbidities, it is important to assess treatmentin the context of the patient’s overall health and well-being. Furthermore, with the current state of health caredelivery, pharmacoeconomic considerations are often in-corporated into treatment decisions. Annual overall ARcosts in 1990 were estimated to be $2.7 billion ($4.3 billionin 2003 dollars) in the United States, with costs approx-imately equal between clinical care and drug costs.12,13

By 2005, spending to treat AR was estimated to be$11.2 billion.14 Using data from a U.S. health plan of�15 million members, Dalal and colleagues reportedaverage AR costs of $657/patient per year for 2003–2004.15 Related comorbidities further increase the costof caring for these patients, magnifying the importance

of treating AR to reduce its impact on these associatedconditions.

Allergies have also been found to be a major contrib-utor to the total cost of health-related absenteeism andpresenteeism, further highlighting the potential impactof improved AR management.10 In the Allergies inAmerica survey, 7 of 10 patients said that they hadmissed work because of allergies. When at work, al-most 50% reported that allergies limited their work“some” or “a lot,” and 28% reported that their produc-tivity was impacted when symptoms were at theirworst. As considered using a visual analog scale, ARpatients reported a 23% reduction in their productivitywhen symptoms worsened.2 This leads to high indirectcosts associated with symptoms. Notably, the indirectcosts associated with AR are estimated to be larger thanthe direct health care costs for AR care.12 In one study,�75% of indirect costs associated with AR were causedby decreased productivity.16 Other indirect costs includeexpenditures for antibiotics, x rays, emergency depart-ment visits for complicating sinusitis, surgical correctionof nasal polyposis and sinusitis, medical and surgicaltherapy of otitis media with effusion, and the costs ofworsening asthma and frequent upper respiratory in-fections. Comparatively, the indirect costs per em-ployee in the United States for AR is roughly doublethat for high stress, migraine, depression, arthritis, oranxiety. It is �5 times greater than diabetes and 10times greater than coronary heart disease.10

The XPERT (XYZAL in Persistent Rhinitis Trial)Study Group has shown that compared with placebo,the oral antihistamine levocetirizine can significantlyreduce the cost of AR and its associated comorbidi-ties.17,18 However, few other studies have assessedcost-effectiveness between pharmacotherapies, andadditional studies are needed to fully assess differencesbetween treatment options in this respect. Based on2004–2005 data, costs for oral antihistamines and intra-nasal corticosteroids are approximately equal.15 Newertreatment options may offer clinical advantages, whichwill need to be balanced with cost-effectiveness. Forexample, a study of subcutaneous immunotherapy(SCIT) among 354 Florida Medicaid-enrolled childrenwith newly diagnosed AR showed a total cost-weighted savings of $401/patient over 6 months. Com-pared with the 6 months preceding SCIT initiation, thestudy found significant reductions in the use of outpa-tient (p � 0.001), pharmacy (p � 0.001), and inpatient(p � 0.02) services in the 6 months after termination ofSCIT.19 Cost-effectiveness is only one of several impor-tant treatment considerations. AR participants in clin-ical trials have reported that they were willing to payfor pharmacologic options that have preferable sensoryattributes.20 Regardless of pharmacoeconomic data, thetreatment option that best incorporates individual pa-

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tient preference promotes adherence and likely leads togreater satisfaction.

UPDATED AR TREATMENT ALGORITHMThe 2008 Allergic Rhinitis and Its Impact on Asthma

recommendations and the 2008 U.S. Joint Task ForcePractice Parameter recommendations have served asthe foundations for the contemporary development ofAR treatment algorithms.21,22 There have been recentadditions to the AR pharmacotherapy landscape, re-sulting in the need for an updated set of recommenda-tions including these new treatment options. Specifi-cally, three new drug products have been approved bythe U.S. Food and Drug Administration (FDA): twononaqueous aerosol intranasal corticosteroids usinghydrofluoroalkane propellants and a unique aqueousintranasal combination product containing both a cor-ticosteroid and an antihistamine. New treatments havethe potential to significantly alter the standard ofcare23; therefore, current AR treatment algorithmswere revisited. Of note, there have been no head-to-head trials comparing aqueous and aerosol nasal ste-roid formulations with regard to efficacy or adherence;therefore, these two options are grouped as “intranasalsteroids” in the treatment algorithm, with the option touse either type of spray depending on patient andclinician preference.

The last iteration of treatment recommendations cat-egorized AR by frequency (“intermittent” and “persis-tent”) and severity of symptoms (“mild” and “moder-ate/severe”). In the United States, �40% of adultsdiagnosed with AR have perennial AR (PAR) withseasonal exacerbations.24 Of adults with AR, �50%experience AR symptoms for �4 mo/yr, while 20%experience AR symptoms for 9 or more months peryear.25 Accordingly, the updated algorithm presented

here has moved from “intermittent” and “persistent”symptoms to “episodic” and “nonepisodic” symptoms.Symptoms that occur daily, as occurs in PAR, or areexpected to occur daily during a prolonged period, asis the case in seasonal AR (SAR), are classified asnonepisodic. Acute events or symptoms that occur lessfrequently, as defined later, are classified as episodic.This will ensure that patients with SAR are appropri-ately managed during prolonged periods (�3 weeks orlonger) of AR symptoms. We have empirically catego-rized episodic AR as �3 days/wk, or �3 weeks totalduration, but these guidelines should be modifiedbased on clinical judgment. This categorization shouldbenefit primary care providers, because these provid-ers treat the majority of AR patients. It is of greatimportance that this and future treatment algorithmsare clearly translatable to primary care practice.26

In this updated algorithm, as introduced in the 2001Allergic Rhinitis and Its Impact on Asthma recommen-dations, disease severity is classified as “mild” or“moderate/severe.”6 Mild rhinitis is defined as rhinitisin the absence of sleep disturbance, daily activity im-pairment (including leisure, school, or work), or othertroublesome symptoms. Moderate/severe rhinitis isdefined as rhinitis accompanied by other troublesomesymptoms and/or that affects quality of life.

The updated treatment algorithm is presented in Fig. 1.Briefly, for all patients, minimization of exposure totriggers is recommended and nasal saline irrigationmay be considered.27 Intranasal delivery systems formedications are preferred for all AR phenotypes. Forall patients, adherence should be addressed in theevent of nonresponse to therapy.

For patients with mild episodic AR, the preferredtreatment is an antihistamine used on an as-neededbasis. Although intranasal antihistamines have only

Therapeu�c Op�ons Episodic (≤3 days/week or <3 weeks at a �me) Non-episodic (>3 days/week)Mild Moderate/Severe Mild Moderate/Severe

Preferred pharmacotherapy

Intranasal an�histamine (prn) or oral an�histamine (prn)*

Intranasal steroid** orintranasal an�histamine

Intranasal steroid** orintranasal an�histamine

Intranasal steroid + intranasal an�histamine†

Alternate agent • Oral an�histamine (prn)• Oral decongestant (prn)• Leukotriene receptor

antagonist• Mast cell stabilizer

• Oral an�histamine ± decongestant (prn) • Oral an�histamine ± decongestant• Leukotriene receptor antagonist

• Regular use of oral an�histamine ±decongestant

• Intranasal steroid** orintranasal an�histamine, if monotherapy is sufficient

If unsuccessful, consider

• Regular use of intranasal an�histamine • Regular use of intranasal

steroid

• Intranasal steroid + intranasal an�histamine†• Oral steroid (3-5 days) followed by

intranasal steroid** and/or intranasal an�histamine

• Intranasal steroid + intranasal an�histamine†

• Oral steroid (3-5 days) followed by intranasal steroid + intranasal an�histamine†

Disease modifica�on Immunotherapy Consider immunotherapy ImmunotherapyProphylaxis Allergen and irritant avoidance, as possibleNon-pharmacotherapy Nasal saline irriga�on

* For pa�ents without prominent conges�on** Aqueous or aerosol† Either as two individual drug aqueous products or as a combina�on drug product in a single spray unit

Figure 1. Consensus panel recommendation for the treatment of allergic rhinitis.

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been rigorously studied for daily use on a regularbasis, they have been shown to be effective within15–30 minutes of application and are therefore fre-quently used on an as-needed basis for these patients.Furthermore, for patients suffering prominently fromnasal congestion, given the greater benefit of antihis-tamines in the intranasal form over their oral counter-parts in treating congestion, our recommendation is forthe use of as-needed intranasal antihistamines as thefirst-line therapy for these patients, recognizing it is anoff-label application. Alternative approaches includeas-needed oral antihistamines, leukotriene receptor an-tagonists, or as-needed oral decongestants. Over-the-counter oral antihistamines may be a more attractiveoption for patients without prominent congestion as asymptom. Furthermore, additional factors that shouldbe weighed include the over-the-counter availability ofmost oral antihistamines, their less expensive cost, andthe higher degree of adherence, which may beachieved with oral administration. Prophylaxis using amast cell stabilizer is also acceptable management, al-though this class of medication is limited by the needfor use at least three times daily to be effective. Immu-notherapy is generally considered unnecessary forthese patients.

For patients with moderate/severe episodic AR, reg-ular use of either intranasal antihistamines or intrana-sal corticosteroids are the preferred managementchoices. Although head-to-head comparison studies of2 weeks duration have suggested equivalent efficacy,longer term trials have shown greater efficacy withintranasal corticosteroids. The approval by the FDA oftwo new aerosol intranasal corticosteroid sprays ex-pands the options available to practitioners and pa-tients in this regard and may serve to increase satisfac-tion and adherence for some patients, as discussedlater. If the patient does not respond to an agent fromone of these classes, providers could attempt an agentfrom the other class. Alternative agents include the useof an oral antihistamine with or without an as-neededdecongestant, understanding the potential side effectsof these systemic medications. If preferred or alterna-tive agents are not successful, combination treatmentwith both an intranasal steroid and an intranasal anti-histamine, either by delivering both types of spraysconcurrently or by providing the newly formulatedcombination spray, is appropriate. Patients with mod-erate/severe episodic AR or with mild nonepisodic ARshould consider immunotherapy.

For patients with mild nonepisodic AR, regular useof either intranasal antihistamines or intranasal corti-costeroids are the preferred management choices. Al-ternative agents include an oral antihistamine with orwithout an as-needed decongestant. Leukotriene re-ceptor antagonists are also an acceptable alternativetherapy. If therapy is unsuccessful, combination ther-

apy with an intranasal antihistamine and an intranasalsteroid may be considered, either by delivering bothtypes of sprays concurrently or by providing the newlyformulated combination spray.

For patients with moderate/severe nonepisodic AR,combination therapy with an intranasal steroid and anintranasal antihistamine is preferred. Alternative ther-apy includes the regular use of either intranasal anti-histamines or intranasal corticosteroids and/or theregular use of an oral antihistamine with or withoutthe use of an as-needed decongestant. Immunotherapyshould be offered to these patients. For all moderate/severe patients, if symptoms are particularly severe ortreatment is unsuccessful in controlling symptoms, ashort course of oral steroids (3–5 days) may be consid-ered at the initiation of preferred therapy. This treat-ment should reduce obstruction of the nasal passages,potentially increasing drug delivery and the effective-ness of nasal saline irrigation and intranasal medica-tion.

Leukotriene receptor antagonists are FDA approvedfor the treatment of AR, and montelukast should there-fore be considered a potential option. However, be-cause of concerns about the limitations of its efficacy,the recommendation panel felt that this agent is bestconsidered an alternative option mainly for patientswith mild rhinitis because efficacy has been shown tobe equivalent to the oral antihistamine loratadine andbecause of the evidence that montelukast added to anasal steroid provided no additional benefit.28–30

Potential pharmacologic treatment options are listedin Table 1. Two other medications not included in thetreatment algorithm but used to target specific symp-toms of rhinitis are intranasal anticholinergics and in-tranasal decongestants. Ipratropium bromide nasalspray, an intranasal anticholinergic, may be appropri-ate for improving rhinorrhea, particularly in combina-tion with intranasal corticosteroids.21,31,32 However,this medication has not been shown to reduce the othersymptoms of AR. Similarly, although intranasal decon-gestants will selectively improve nasal congestion, theydo not impact the other symptoms of rhinitis. In addi-tion, they carry a significant risk of rhinitis medica-mentosa if used for more than a few days in the settingof acute symptoms.

There has been some additional focus on “naturalremedies” for AR, but data, to date, on the effective-ness of these has been inconclusive. Few large well-controlled studies have been conducted for nonphar-macologic alternatives. In 2013, the Annals of InternalMedicine published a randomized clinical trial of 422subjects, investigating acupuncture as a potential SARtreatment with marginal results. Although the Rhino-conjunctivitis Quality of Life Questionnaire (RQLQ)score was significantly improved at 8 weeks in theacupuncture plus rescue medication arm compared


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with the sham acupuncture and rescue medicationalone arms, the clinical impact of these small improve-ments are not clear. Additionally, there were severalflaws in study design, including the potential for re-cruitment bias, skewed baseline characteristics, and thelack of comparison with standard of care therapiessuch as intranasal steroids or intranasal antihistaminesused on a regular basis, rather than the less effectiverescue use of cetirizine on an as-needed basis only.33,34

Regardless, patients may show interest in nonpharma-cologic and alternative options, an important consid-eration when addressing patient adherence.

MONITORING AR TREATMENTAs with any chronic condition, adequate AR man-

agement requires methods to assess disease control.Assessment for effectiveness should include subjectivepatient assessment of AR control, including naso-ocu-lar symptoms, sleep disturbance, comorbities, adverseevents, and tolerability of medications. However, sim-ple clinical tools to accurately evaluate AR control havebeen lacking. The Rhinitis Control Assessment Test,developed in 2010, is designed to assist providers andpatients in assessing and monitoring this outcome.35,36

This patient-completed instrument contains six briefquestions, measured on a five-point Likert-type scalethat assesses matters of rhinitis control with a 1-weekrecall time. The instrument was validated against thetotal nasal symptoms score instrument, which mea-sures nasal symptoms, and a patient‘s global rating ofseverity.37 Combined with clinical evaluation andother tools, such as symptom scores (total nasal symp-

toms score and total ocular symptom score), a quality-of-life evaluation (RQLQ), and physiological measure-ments (e.g., peak nasal inspiratory flow), the RhinitisControl Assessment Test can help patients and provid-ers determine if patients are adequately controlled.38

The RQLQ, designed to assess quality-of-life issuesspecific to rhinoconjunctivitis, has been tested in bothSAR and PAR.39 The RQLQ contains 28 questions withthe domains of activity limitations, sleep problems,nose symptoms, eye symptoms, non–nose/eye symp-toms, practical problems, and emotional function. Pro-viders may also consider measuring nasal patency bypeak nasal inspiratory flow, acoustic rhinometry, orrhinomanometry, although these measures are oftennot routinely available outside of the research setting.40

ADHERENCEMaintaining adequate adherence to pharmacother-

apy is an essential component of AR management. Astudy of a large cohort of commercially insured pa-tients aged 4–64 years found that one-half of all pa-tients with a medical claim for AR between 2004 and2006 did not receive or fill a prescription for AR med-ications.41 Of those patients receiving prescriptions,most are nonadherent at some point during therapy.42

Adherence to AR therapy can be complicated by thenatural variability in symptom frequency and sever-ity.43 According to the 2007 National Health and Well-ness survey, 38% of AR patients stopped taking theirAR medication when they were feeling better.42 Toincrease adherence, it is important that providers coun-sel their patients with nonepisodic disease regarding

Table 1 Selected pharmacologic options for the treatment of AR

Intranasal Options Oral Options

Intranasal steroids Oral antihistamines (first generation)Beclomethasone dipropionate (aerosol) ChlorpheniramineBudesonide (aqueous) DiphenhydramineCiclesonide (aqueous or aerosol) HydroxyzineFlunisolide (aqueous) Oral antihistamines (second generation)Fluticasone furoate (aqueous) CetirizineFluticasone propionate (aqueous) DesloratadineMometasone (aqueous) FexofenadineTriamcinolone (aqueous) Levocetirizine

Intranasal antihistamines LoratadineAzelastine Oral decongestantsOlopatadine Pseudoephedrine

Combination intranasal formulations PhenylephrineAzelastine/fluticasone propionate Mast cell stabilizers

Intranasal decongestants CromolynPhenylephrine Leukotriene receptor antagonistsOxymetazoline Montelukast

AR � allergic rhinitis.

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the benefit of prophylactic therapy used on a regularbasis rather than merely as-needed and that providersexplain the impact of AR on other aspects of healthylife including quality of life, sleep, work, or schoolperformance and comorbid conditions.44

Some of the common adherence barriers for patientswith AR include lack of perceived benefit, fear of sideeffects, forgetfulness, tolerability, and cost. A cross-sectional survey found that asthma patients want to usethe least amount of controller medication necessary, pos-sibly because of fear of potential side effects or concernsabout cost or convenience.45 Patients with AR also reportstopping therapy for a variety of reasons, the most com-mon being perceived lack of efficacy. Others include di-minishing effectiveness, lack of 24-hour relief, and sideeffects.46 Dissatisfaction with therapy leads to decreasedadherence and encourages patients to try using multi-ple agents or to supplement therapy with over-the-counter products.44 In the Asthma and Allergy Foun-dation of America survey, 60% of patients respondedthat they are “very interested” in finding a new med-ication. Twenty-five percent reported “constantly” try-ing different medications to find one that “works.”44

Failure of clinicians to adequately consider patient fac-tors, such as adverse local and systemic effects of ther-apy or the impact of rhinitis on daily life, may nega-tively impact adherence.47 Therefore, providers shoulddiscuss patient goals and concerns before treatmentinitiation and analyze what might interfere with adher-ence to therapy.

Delivery device preferences can also potentially im-pact adherence, because patients may experience aver-sion to aqueous or aerosol nasal spray devices.48 Sen-sory attributes that may influence the frequency ofpatients’ use of nasal sprays and their willingness toadhere to therapy include smell, taste, aftertaste, thefeel of the spray fluid in one’s nose and/or throat, andthe amount of spray fluid that runs down the throat orout of the front of the nose.49 Reports suggest thatnonaqueous aerosol formulations may reduce some ofthe unpleasant sensory effects currently associatedwith intranasal steroids and thus have the potential toincrease medication adherence.43,48,50 In a retrospectivereview of Florida Medicaid claims using propensitymatching for AR patients receiving intranasal steroidsdelivered by either pressurized metered-dose inhalersor aqueous devices, patients using chlorofluorocarbonaerosol pressurized metered-dose inhalers had signifi-cantly higher median medication possession ratios andfewer median days between refills at 18 months.51 In asurvey of 120 AR patients, patient preference decreasedwith increasing intensity of taste, smell, aftertaste, throatrundown, nose runout, or the feel of the spray in thenose.49 Furthermore, patients may prefer agents that pro-duce an immediate sensory effect, such as a deconges-tant, or may avoid agents that have a disagreeable taste or

sensation.52 Thus, an early onset of action may enhancepatient adherence. Some patients, such as those witharthritis, may have physical difficulty with certain nasalspray devices. Therefore, providers can help maximizepatient adherence to prescribed regimens by selectingtherapies that incorporate some of these factors and byregularly reviewing treatment plans with the patient.21,43

For example, patients who are nonadherence because offorgetfulness may benefit from regimens that link theirdosing to a usual behavior such as tooth brushing orusing a dose indicator that helps the patient account fordosing and need for refills. Those who have difficultyadministering a consistent dose because of physical lim-itations or to trouble coordinating the timing of their sniffmay benefit from the more consistent dosing with one ofthe newer metered-dose aerosol intranasal steroidsprays.53 Ultimately, delivery of therapy depends notsolely on the medication itself, but also on the patientadministering it correctly. Therefore, it is imperative thatproviders not only prescribe the most appropriate thera-peutic option, but also that the patient has the informa-tion and ability needed to use treatments appropriatelyand consistently.

Nonadherence issues may be proactively addressedthrough patient education, where the value of the treat-ment plan and adherence should be stressed. Patientsshould understand what AR control means in the over-all impact on their quality of life. In that regard, pro-viders should stress that AR control includes not onlynaso-ocular symptoms, but quality-of-life components,including sleep and daily function. Continued patienteducation can overcome common nonadherence barri-ers such as sensory perception or lack of practice withnasal sprays. Potential misuse of intranasal devicesmay be proactively addressed by educating patients onproper administration of delivery devices,52 includingpointing nasal sprays away from the nasal septum toavoid septal irritation and to decrease the risk of septalperforation and epistaxis.

CONCLUSIONSThere are essential issues in the management of AR,

including individualization of therapy and optimalregimen design. Ensuring patient adherence to thetreatment choices is also a primary concern; improve-ments in symptom and adverse effect management, aswell as bidirectional and repeated patient–providercommunication, will help address this need. Consider-ations and practices will continue to evolve as addi-tional agents and devices enter the market. Changes inthe health-care marketplace also have the potential tosubstantially alter treatment practices. In all cases, pro-viders should be aware of the health-related quality-of-life issues for their patients, focusing not only onphysical symptom improvement but also on functional


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components adversely impacted by AR symptoms.Continued patient–provider communication and regu-lar monitoring of efficacy, adherence, and control willhelp alleviate the burden of AR for patients, health-care providers, and payers.

ACKNOWLEDGMENTSThe authors thank Andrea Harshman and Mandy Comeau from

the National Jewish Health Office of Professional Education for theirwork in coordinating this article. They also thank Teva Pharmaceu-ticals for providing the funding for this program. Medical editorMichael Linde assisted in the preparation of this article.

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