The patient with rhinitis in the pharmacy. A cross-sectional study in real life
© Lombardi; licensee BioMed Central. 2016
Received: 17 April 2014
Accepted: 5 May 2015
Published: 4 June 2015
In the practical management of allergic rhinitis (AR), pharmacists are usually the first-line contact, also because some medications are available as over the counter. Therefore, pharmacists may represent an important resource, in mediating the interaction between patients and physicians. We evaluated the clinical/demographic characteristics of patients with respiratory allergies who consulted their pharmacists as first-line contact. A patient-oriented questionnaire was developed by a scientific committee including pharmacists, GPs, allergists, pulmonologists and ENT specialists.
The questionnaire consisted of items covering the general aspects of AR. Allergic Rhinitis and its Impact on Asthma guidelines were assumed as reference for diagnosis and therapy. The questionnaire was distributed to pharmacies, and pharmacists were asked to deliver the questionnaire to all patients referring for nasal symptoms.
30 pharmacies were involved during the pollen season 2011, and 410 patients (55 % male) participated. The most frequent complaints were 20 rhinitis (49 %) and conjunctivitis (29 %), followed by lower respiratory symptoms (cough and/or dyspnea). Isolated conjunctival symptoms were present in only 22 % of patients. Among patients with lower respiratory symptoms, cough was the most frequent, variously associated with upper respiratory symptoms or overt dyspnea. Dyspnea alone was present in 16 % of patients. 39 % of patients had no physician-based diagnosis. Oral antihistamines were the most used self-medication, followed by intranasal decongestants. 30 % of respondents had used alternative medicines.
According to these data, AR is still considered a trivial disease, frequently self-managed, with over the counter medications, not in line with guidelines. A physician-based diagnosis is present in about 60 % of patients.
Respiratory allergic diseases (asthma/rhinitis) probably represent in absolute the most frequent immune-mediated disorders , and their prevalence is still increasing worldwide, as recently underlined in the GEIRD (Gene Environment Interactions in Respiratory Diseases) epidemiological study . The impact of respiratory allergy is of particular relevance when considering the costs, either direct (expenditure for drugs, hospitalizations, access to medical care) or indirect (absenteeism, presenteism, decreased school/work performance). Allergic Rhinitis (AR) is defined as a symptomatic disorder of the nasal mucosa, due to an IgE-mediated inflammation that follows the contact with an offending allergen. Cardinal symptoms of AR are nasal itching, sneezing, rhinorrhea and obstruction, and they are spontaneously reversible or controlled by adequate treatment [3–5]. AR can be frequently associated with other comorbidities, such as rhinosinusitis which is present in about 20–30 % patients , asthma (10–35 %) , and conjunctivitis. Also polyposis and sleep disturbances [8,9], are not rare, occurring in not less than 10 % of subjects. This aspects make the diagnostic approach sometimes particularly complex . Nonetheless, AR is still considered as a “trivial” disease, that can be easily managed by the patient himself or by healthcare providers other than physicians. In this context, pharmacists are usually the first-line contact for AR patients [3,11], also because, several medications (namely, oral/local antihistamines and decongestants) are available as “over the counter” . Therefore, pharmacists with an adequate preparation may represent an important healthcare resource, in mediating the contact between patients and physicians. This is especially true when a more detailed diagnostic approach is needed. Based on these considerations, we aimed at evaluating the clinical/demographic characteristics of patients suffering with respiratory allergies who consulted pharmacists as first-line contact. This was done by a questionnaire-based survey.
Template of the questionnaire used
• South American
Which symptom mainly prompted you to go to the pharmacy?
• Rhinitis (sneezing, runny nose, itchy nose, stuffy nose)
• Conjunctivitis (burning eyes, itchy eyes, photophobia)
• Dyspnea (short breath)
How long before your visit to the pharmacy did the symptom appear?
• < 5 days
• 5-10 days
• 11-30 days
• > 30 days
The problem was already diagnosed by a physician?
Did you received a physician prescription for your symptoms?
Which medications do you usually take?
(multiple answers allowed)
• Topical nasal decongestants
• Systemic antihistamines
• Topical antihistamines
• Topical steroids
• Systemic steroids
• Topical anticholinergics
• Topical Cromones
• If you can not specify the class, indicate commercial names
Do you use or have used complementary/alternative medicines (e.g. homeopathy, acupuncture, herbs) for your rhinitis/asthma?
Do you use or have used allergy vaccines?
• Sublingual route
• Subcutaneous route
If for this problem you usually care alone, why do you?
• It is a trivial problem
• It’s not worth to talk to the doctor
• The doctor underestimates
• Just consult the pharmacist
Do your symptoms affect your everyday life?
• Not at all
The Allergic Rhinitis and its Impact on Asthma (ARIA) document was assumed as guideline for diagnostic and therapeutic approaches [3,10]. The questionnaire, as a paper sheet, was distributed to pharmacies of the Brescia province and pharmacists were asked to deliver the questionnaire to all patients referring for nasal symptoms during the 2011 pollen season (February –May). The participation into this survey was on a voluntary basis and all the personal/demographic data were kept strictly anonymous. The observational study was notified to the Conjunct Commission of Brescia Phisicians & Pharmacists Orders, according to the Italian legislation.
AR is a common and frequent healthcare problem, affecting almost 25 % of the general population [1,2]. The epidemiological impact lead to the search for a better diagnostic definition and for an evidence-based approach to its therapy, as done with the ARIA guidelines , also considering that patients’ profile is becoming more and more complex . Nonetheless, AR still remains considered a trivial disease, since it is not life-threatening and easy to manage . For those reasons AR is frequently self-managed by patients, and the pharmacist, therefore, represent the first-line contact. Guidelines dedicated to pharmacists have been already published , but their real impact on everydays’ practice have been not been specifically addressed so far. Thus, we attempted to evaluate the characteristics, diagnosis, treatment profile and perception of AR in a pharmacy setting. As expected, a vast majority of patients still retain the use of “over the counter” medicines as the primary resource, being rhinitis a self-manageable disease. Also, in line with the internationally increasing use of Complementary-Alternative Medicines , according to Italian data about one third of patients approached these therapies for their diseases or symptoms . In general it is known that the reasons for the choice of the use of complementary medicines are multiple, among which prevails the conviction of the lower level of toxicity compared to conventional treatments .
According to our data, collected by pharmacists, a large percentage of patients still consider AR as a trivial disease , and recur to self-administered drugs (oral/nasal antihistamines and/or nasal vasoconstrictors), whereas an appropriate diagnosis is made only in few cases. In particular, the use of intranasal decongestants testifies for a non-optimal management of AR, as well as the poor referral to physicians. This is in line with elsewhere reported data based on pharmacists’ experience [20–22]. Finally, the use and knowledge of allergen-specific immunotherapy seems to need improvement. Based on the present results, a more strict and bi-directional collaboration between pharmacists and physicians would be auspicable.
We are grateful to Nadia Marcobruni MD (Unit of Pneumology, Spedali Civili Hospital, Brescia, Italy) and Davide Tomenzoli MD (Unit of Otolaryngology, Spedali Civili Hospital, Brescia, Italy), who participated in the preliminary phase of the study.
- Bousquet J, Van Cauwenberge P, Khaltaev N. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol. 2001;108(5 Suppl):S147–334.View ArticlePubMedGoogle Scholar
- De Marco R, Cappa V, Accordini S, Rava M, Antonicelli L, Bortolami O, et al. Trends in the prevalence of asthma and allergic rhinitis in Italy between 1991 and 2010. Eur Respir J. 2012;39:883–92.View ArticlePubMedGoogle Scholar
- Bousquet J, Van Cauwenberge P, Khaltaev N. ARIA in the pharmacy: management of allergic rhinitis symptoms in the pharmacy. Allergy. 2004;59:373–87.View ArticleGoogle Scholar
- International Consensus Report on Diagnosis and Management of Rhinitis. International Rhinitis Management Working Group. Allergy. 1994;49(19 Suppl):1–34.Google Scholar
- van Cauwenberge P, Bachert C, Passalacqua G, Bousquet J, Canonica GW, Durham SR, et al. Consensus statement on the treatment of allergic rhinitis. European Academy of Allergology and Clinical Immunology. Allergy. 2000;55:116–34.View ArticlePubMedGoogle Scholar
- Georgalas C, Vlastos I, Picavet V, van Drunen C, Garas G. Prokopakis Is chronic rhinosinusitis related to allergic rhinitis in adults and children? Applying epidemiological guidelines for causation. Allergy. 2014;69:828–33.View ArticlePubMedGoogle Scholar
- Bousquet J, Annesi-Maesano I, Carat F, Léger D, Rugina M, Pribil C, et al. Characteristics of intermittent and persistent allergic rhinitis: DREAMS study group. Clin Exp Allergy. 2005;35:728–32.View ArticlePubMedGoogle Scholar
- Soose RJ. Role of allergy in sleep-disordered breathing. Otolaryngol Clin North Am. 2011;44:625–35.View ArticlePubMedGoogle Scholar
- Ahmadiafshar A, Farjd HR, Moezzi F, Mousavinasab N. Nasal polyposis in patients with asthma and allergic rhinitis. J Laryngol Otol. 2012;126:780–3.View ArticlePubMedGoogle Scholar
- Bousquet J, Khaltaev N, Cruz AA, Denburg J, Fokkens WJ, Togias A, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen). Allergy. 2008;63 Suppl 86:8–160.View ArticlePubMedGoogle Scholar
- Smith L, Nguyen T, Seeto C, Saini B, Brown L. The role of non-clinicians in a goal setting model for the management of allergic rhinitis in community pharmacy settings. Patient Educ Couns. 2011;85(2):e26–32.View ArticlePubMedGoogle Scholar
- Baiardini I, Braido F, Tarantini F, Porcu A, Bonini S, Bousquet PJ, et al. GA2LEN ARIA-suggested drugs for allergic rhinitis: what impact on quality of life? A GA2LEN review Allergy. 2008;63(6):660–9.View ArticlePubMedGoogle Scholar
- Lombardi C, Canonica GW, Passalacqua G. IGRAM, Italian Group on Respiratory Allergy in Migrants. The possible influence of the environment on respiratory allergy: a survey on immigrants to Italy. Ann Allergy Asthma Immunol. 2011;106(5):407–11.View ArticlePubMedGoogle Scholar
- Mösges R, Klimek L. Today’s allergic rhinitis patients are different: new factors that may play a role. Allergy. 2007;62:969–75.View ArticlePubMedGoogle Scholar
- Valovirta E, Myrseth SE, Palkonen S. The voice of the patients: allergic rhinitis is not a trivial disease Curr Opin Allergy Clin Immunol.2008; 8: 1-9Google Scholar
- Ernst E. The role of complementary and alternative medicine. Br Med J. 2000;321:1133.View ArticleGoogle Scholar
- Senna G, Passalacqua G, Crivellaro M, Bonadonna P, Gani F, Dorizzi R, et al. Unconventional medicine: a risk of undertreatment of allergic patients. Allergy. 1999;54(10):1117–9.View ArticlePubMedGoogle Scholar
- Anonimous. Allergic rhinitis: common, costly and neglected. The Lancet. 2009;371:2057.Google Scholar
- Smith L, Nguyen T, Seeto C, Saini B, Brown L. The role of non-clinicians in a goal setting model for the management of allergic rhinitis in community pharmacy settings Patient Educ Couns. 2011; 85: e26-32Google Scholar
- Williams A, Scadding G. Is reliance on self-medication and pharmacy care adequate for rhinitis patients? Int J Clin Pract. 2009;63:98–104.View ArticlePubMedGoogle Scholar
- Porteous T, Wyke S, Smith S, Bond C, Francis J, Lee AJ, et al. ‘Help for Hay Fever’, a goal-focused intervention for people with intermittent allergic rhinitis, delivered in Scottish community pharmacies: study protocol for a pilot cluster randomized controlled trial. Trials. 2013;14:217.View ArticlePubMedPubMed CentralGoogle Scholar
- Canonica GW, Baena-Cagnani CE, Compalati E, Bohle B, Bonini S, Bousquet J, et al. 100 years of immunotherapy: the Monaco charter. under the high patronage of His Serene Highness Prince Albert II of Monao. Int Arch Allergy Immunol. 2013;160:346–9.View ArticlePubMedGoogle Scholar
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