Best Practices in Primary Care

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(No Transcript)
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Faculty

• Sandra M. Gawchik, DO
• Co-Director, Division of Allergy and Immunology
• Crozer-Chester Medical Center
• Chester, Pennsylvania
• Clinical Associate Professor of Pediatrics
• Department of Pediatrics
• Division of Allergy and Immunology
• Thomas Jefferson University
• Philadelphia, Pennsylvania

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Disclosure Statement

• The Network for Continuing Medical Education
  requires that CME faculty disclose, during the
  planning of an activity, the existence of any
  personal financial or other relationships they or
  their spouses/partners have with the commercial
  supporter of the activity or with the
  manufacturer of any commercial product or service
  discussed in the activity.

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Faculty Disclosure

• Sandra M. Gawchik, DO, is on the advisory board
  of and has served as a consultant to
  Schering-Plough Corporation and Sepracor Inc. is
  on the speakers' bureau of AstraZeneca
  Pharmaceuticals LP, Dey, L.P., GlaxoSmithKline,
  Schering-Plough Corporation, and Sepracor Inc.
  has received research support from Abbott
  Laboratories, AstraZeneca Pharmaceuticals LP,
  Bristol-Myers Squibb Company, Dey, L.P., Forest
  Laboratories, Inc., Genentech, Inc.,
  GlaxoSmithKline, Johnson Johnson, Merck Co.,
  Inc., Novartis Pharmaceuticals Corporation,
  Pfizer Inc, Roche Laboratories, sanofi-aventis,
  Schering-Plough Corporation, Sepracor Inc., and
  Wyeth Pharmaceuticals and has indicated
  ownership interests in Abbott Laboratories and
  Barr Pharmaceuticals, Inc.

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Learning Objectives

• Identify the clinical characteristics of allergic
  rhinitis, including key symptoms and symptoms
  that patients rate most bothersome, and assess
  their impact on the management of allergic
  rhinitis
• Evaluate the effects that allergic rhinitis can
  have on physical and psychosocial functioning in
  patients, including its impact on work in adults
  and on school in children
• Formulate evidence- and guideline-based
  strategies for the aggressive management of
  allergic rhinitis
• Analyze barriers to treatment success and
  adequate control of symptoms, and develop
  strategies for removing those barriers
• Assess evidence for current and emerging
  treatment strategies for allergic rhinitis with
  respect to patient outcomes and safety

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US Classification of Allergic Rhinitis(AR )

• Immunoglobulin E (IgE)-mediated reaction to
  allergens
• Seasonal allergic rhinitis (SAR)
• Symptoms periodic and correlate with seasonal
  variations in airborne allergens
• Typical allergens grass, tree, and weed pollens
  fungal (mold) spores in certain climates
• Perennial allergic rhinitis (PAR)
• Symptoms persistent, the result of exposure to
  perennial environmental allergens
• Typical allergens dust mites, molds, animal
  allergens, certain occupational allergens,
  pollen prevalent perennially
• Patients can have both SAR and PAR

Ragweed
Dust mite
Wallace DV, et al. J Allergy Clin Immunol.
2008122(2 suppl)S1-S84.
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Characteristic Symptoms of AR

• Watery rhinorrhea
• Nasal congestion
• Repetitive sneezing
• Itching of eyes, nose, ears, throat
• Watery eyes
• Nasal airflow obstruction
• Conjunctiva, eustachian tubes, middle ear, and
  paranasal sinuses may be involved

Wallace DV, et al. J Allergy Clin Immunol.
2008122(2 suppl)S1-S84.
8
Case Study Presentation

• 42-year-old female
• History of SAR since early adolescence with
  symptoms every spring
• Usually takes OTC antihistamines, but this year
  says they are not working
• Sought appointment because in addition to her
  usual spring sneezing, she is also suffering a
  constant stuffed nose
• Husband complains that lately she has been
  snoring at night
• Tired in the morning
• Has a red nose and rubs her eyes and nose
  frequently during the examination
• Dark circles under her eyes
• Mouth breathing
• All other signs normal

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AR Differential Diagnoses

• Rhinitis medicamentosa (medication-induced
  rhinitis)
• Infectious rhinitis
• Anatomic obstruction
• Hormonal rhinitis
• Nonallergic eosinophilic rhinitis
• Idiopathic nonallergic rhinitis

Wallace DV, et al. J Allergy Clin Immunol.
2008122(2 suppl)S1-S84.
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AR Can Affect Many Aspects of a Patients Life
AR may have a negative effect on

• Attention and reaction times1
• Cognitive functions1
• Motivation and energy level2
• Sleep3,4
• Productivity at work/school5
• Mood2
• Economic impact nationwide6
• Cost or treating AR increased from 6.1 billion
  in 2000 (2005 dollars) to 11.2 billion in 2005
• More than half of that was on prescription
  medications

1. Wilken JA, et al. Ann Allergy Asthma Immunol.
200289(4)372-380 2. Marshall PS, et al.
Psychosom Med. 200264(4)684-691 3. Bousquet J,
et al. J Allergy Clin Immunol. 2006117(1)158-162
4. Léger D, et al. Arch Intern Med.
2006166(16)1744-1748 5. Lamb CE, et al. Curr
Med Res Opin. 200622(6)1203-1210 6. American
Academy of Allergy Asthma Immunology Allergy
Statistics. Available at http//aaaai.org/media/s
tatistics/allergy-statistics.aspallergicrhinitis.
Accessed March 3, 2009.
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Feelings of Nasal Allergy Sufferers During
Allergy Season
Embarrassed
8
15
Depressed
Frequently
13
23
or Blue
Sometimes
Irritable
26
38
Miserable
29
36
N2500
Tired
44
36
0
20
40
60
80
100
Percentage of Patients ()
Allergies in America a landmark survey of nasal
allergy sufferers executive summary. Available
at www.mmcpub.com/scsaia/AdultSummary.pdf.
Accessed February 27, 2009.
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AR and Comorbid Disorders
EustachianTubeDysfunction
Conjunctivitis
AllergicRhinitis
SleepApnea
NasalPolyposis
Asthma
Sinusitis
Adapted with permission from Spector SL. J
Allergy Clin Immunol. 199799(2 suppl)S773-S780.
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Impact of Nasal Congestion in AR

• Nasal congestion often rated as most bothersome
  AR symptom1
• One of the main reasons patients seek medical
  advice
• Often insufficiently controlled by
  pharmacotherapy1
• Complex pathophysiology involving neural,
  vascular, inflammatory elements2
• Pathophysiology may pose treatment challenges,
  leading to patient dissatisfaction with treatments

1. Shedden A. Treat Respir Med.
20054439-446. 2. Rosenwasser L. Allergy Asthma
Proc. 20072810-15.
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Nasal Congestion Impact on Sleep

• An estimated 57 of adults and up to 88 of
  children with AR may have sleep problems1
• Nasal congestion and mouth breathing are a
  consequence of AR2
• Results in sleep-disordered breathing1
• ? sleep fragmentation2
• ? microarousals (10-fold greater than controls)
  and sleep fragmentation1
• ? airway blockage, which may lead to sleep apnea2
• Loss of sleep results in daytime fatigue1

1. Nathan RA. Allergy Asthma Proc.
200728(1)3-9. 2. Blaiss MS. Allergy Asthma
Proc. 200324(4)231-238.
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Allergies in America SurveyBothersome Symptoms
During Nasal Allergy Attacks
90
80
Moderately
38
70
Extremely
60
36
33
50
of Sufferers
30
31
31
26
28
40
27
40
30
19
28
26
20
25
23
20
20
18
16
10
11
0
Itching
Ear Pain
Headache
Facial Pain
Runny Nose
Watering Eyes
Postnasal Drip
Stuffed-up Nose
Red, Itching Eyes
Repeated Sneezing
N2500
Allergies in America a landmark survey of nasal
allergy sufferers executive summary. Available
at www.mmcpub.com/scsaia/AdultSummary.pdf.
Accessed February 27, 2009.
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Impact of AR on Daily Life
60
85 of Respondents
50
40
of Sufferers
30
26
25
19
20
15
14
10
1
0
Little
Some
Moderate
A Lot
Symptoms Did Not Impact Daily Life
Not Sure
Extent of Interference With Daily Life
N2500
Allergies in America a landmark survey of nasal
allergy sufferers executive summary. Available
at www.mmcpub.com/scsaia/AdultSummary.pdf.
Accessed February 27, 2009.
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Treatment ofAllergic Rhinitis
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Physical Examination

• Nose
• External deformity, nasal polyps, nasal crease
• Eyes
• Conjunctivitis, allergic shiners
• Ears
• Abnormalities of tympanic membranes, eustachian
  tube dysfunction
• Mouth
• Mouth breathing, malocclusion
• Chest
• Bilateral and expiratory wheezing
• Skin
• Eczema, skin dryness

Wallace DV, et al. J Allergy Clin Immunol.
2008122(2 suppl)S1-S84.
19
Case Study Diagnosis

• Patient history and physical exam
• Symptoms are continuous throughout year but worse
  in the spring
• Allergic shiners
• Allergic crease
• Prominent and severe nasal blockage/congestion
  with boggy pale turbinates
• Postnasal drainage

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Case Study Diagnosis

• Since patient appears to have SAR, could go
  straight to treatment or to tests to determine
  sensitivity to specific allergens
• Laboratory Evaluation
• Skin prick tests most cost effective, but need
  to be performed by trained specialist
• In vitro specific-IgE tests (eg, RAST) for
  specific allergens

Wallace DV, et al. J Allergy Clin Immunol.
2008122(2 suppl)S1-S84.
21
Case Study Diagnosis

• Positive RAST to tree and grass pollens and dust
  mites
• Seasonal pollen sensitivity plus sensitivity to
  indoor allergens
• Diagnosis PAR and SARpersistent, moderate
  disease

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Treatment of Allergic Rhinitis
Allergen Avoidance
Pharmacotherapy
Immunotherapy
Patient Education
Bousquet J, et al. J Allergy Clin Immunol.
2001108(suppl)S147-S334.
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Allergen Avoidance Environmental Controls

• Allergens
• Pollens
• Dust mites
• Animal dander
• Mold spores
• Cockroach droppings
• Irritants
• Smoke
• Fumes environmental and occupational
• Perfumes
• Strong odors

Wallace DV, et al. J Allergy Clin Immunol.
2008122(2 suppl)S1-S84.
24
Case StudyPatient Treatment Plan

• Environmental Controls
• Seasonal allergens
• Avoid outdoor activities during times of high
  pollen counts
• Use air conditioning keep windows closed
• Wear a face mask during outdoor activities (eg,
  lawn mowing)
• Perennial allergens
• Reduce exposure to indoor mold by reducing
  humidity to lt50 if possible
• Washing bedding weekly in hot water to help
  control dust mites use allergen-impermeable
  covers on pillow, mattress, box spring
• Remove pets from home if possible, or keep out of
  patients bedroom
• HEPA vacuuming of carpeting
• Wear face mask when house cleaning
• Pharmacotherapy
• Options for this patient will be discussed next

Wallace DV, et al. J Allergy Clin Immunol.
2008122(2 suppl)S1-S84.
25
Pharmacotherapy Antihistamines1,2

• First generation
• Short acting
• Cause drowsiness, cognitive/motor impairment, dry
  mouth, urine retention
• Unfavorable risk/benefit ratio resulting from
  side effects
• Second generation
• As efficacious as first-generation
  antihistamines, less sedation
• Long acting
• Can be used intermittently, but continuous use
  most effective for SAR and PAR

1. Wallace DV, et al. J Allergy Clin Immunol.
2008122(2 suppl)S1-S84. 2. Bousquet J, et al. J
Allergy Clin Immunol. 2001108(suppl)S147-S334.
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Oral Antihistamines

• Commonly used oral antihistamines
• First generation brompheniramine (Dimetapp),
  chlorpheniramine (Chlor-Trimeton), clemastine
  (Tavist), diphenhydramine (Benadryl)
• Second generation cetirizine (Zyrtec),
  desloratadine (Clarinex), fexofenadine (Allegra),
  loratadine (Claritin), levocetirizine (Xyzal)

Wallace DV, et al. J Allergy Clin Immunol.
2008122(2 suppl)S1-S84.
27
Intranasal Antihistamines

• May be used as first-line treatment in AR1
• Equivalent to or superior to oral 2nd generation
  antihistamines for treatment of SAR1
• Associated with clinically significant effect on
  nasal congestion1
• May have some anti-inflammatory effect2
• Generally less effective than intranasal
  corticosteroids in treatment of AR1 but
• Quicker onset of action than intranasal
  corticosteroids (ICS)3
• Adding intranasal antihistamines to ICS may be of
  benefit in some patients3
• Side effects bitter taste, sedation2
• Newer agents (eg, olapatadine hydrochloride
  Patanase4, azelastine HCl Astepro)5 are
  better tolerated fewer reports of bitter taste

1. Wallace DV, et al. J Allergy Clin Immunol.
2008122(2 suppl)S1-S84 2. Corren J, et al.
Clin Ther. 200527543-553 3. Kaliner M. Ann
Allergy Asthma Immunol. 20075383-391 4.
Alcons Patanse nasal spray approved by FDA for
treatment of nasal allergy symptoms.
http//www.news-medical.net/?id37409. Accessed
February 26, 2009 5. FDA approves Astepro.
http//www.medicalnewstoday.com/articles/125898.ph
p. Accessed February 26, 2009.
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Intranasal Antihistamines

• Intranasal antihistamines available in the US
• Azelastine (Astelin or Astepro) nasal spray1
• Olopatadine (Patanase) nasal spray1
• Astelin2 is approved for age 5 years and up for
  allergic rhinitis Patanase3 and Astepro4 are
  only approved for age 12 years and up

• Wallace DV, et al. J Allergy Clin Immunol.
  2008122(2 suppl)S1-S84.
• Astelin package insert. Somerset, NJ MedPointe
  Pharamceuticals2006.
• Patanase package insert. Fort Worth, TX Alcon
  Laboratories, Inc. 2008.
• Astepro package insert. Somerset, NJ MEDA
  Pharmaceuticals 2008.

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Decongestants

• Relieve obstructive nasal symptoms, but not other
  AR symptoms1
• Indicated for relief of nasal and eustachian tube
  congestion2
• Side effects1
• Oral nervousness, irritability, palpitations
• Topical Local irritation, rhinitis medicamentosa
  (rebound)
• Point of sale restrictions on oral decongestants3

• Nash D. Pediatr Ann. 199827799-808.
• Pseudoephedrine. http//www.drugs.com/ppa/pseudoep
  hedrine-d-isoephedrine.html. Accessed February
  27, 2009.
• 3. DEA Final Regulation Ephedrine,
  pseudoephedrine, and phenylpropanolamine
  requirements. American Pharmacists Association
  Web site. http//www.pswi.org/government/Pseudoeph
  edrine093006.pdf. Accessed February 27, 2009.

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Commonly Used Oral and Topical Decongestants

• Topical
• Phenylephrine (Neo-Synephrine)
• Oxymetazoline (Afrin)
• Oral
• Pseudoephedrine (Sudafed)
• Phenylephrine (Sudafed PE)

Drugs_at_FDA. US Food and Drug Administration Web
site. http//www.accessdata.fda.gov/scripts/cder/d
rugsatfda/index.cfm. Accessed February 27, 2009.
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Oral Antihistamine-Decongestant Combinations

• Acrivastine/pseudoephedrine (Semprex-D)
• Cetirizine/pseudoephedrine (Zyrtec-D)
• Fexofenadine/pseudoephedrine (Allegra-D)
• Loratadine/pseudoephedrine (Claritin-D)

Wallace DV, et al. J Allergy Clin Immunol.
2008122(2 suppl)S1-S84.
32
Intranasal Corticosteroids

• Most effective medications for treating AR1
• Reduce sneezing, itching, rhinorrhea, and
  congestion1
• Patient preference in intranasal steroids greatly
  affects compliance with treatment2
• Local side effects, which are generally minimal,
  include stinging, burning, dryness, sneezing,
  epistaxis1
• Patient education about proper administration can
  help avert rare nasal septal perforations2

1. Wallace DV, et al. J Allergy Clin Immunol.
2008122(2 suppl)S1-S84. 2. Brunton SA, Fromer
LM. South Med J. 2007100(7)701-708.
33
Intranasal Corticosteroids

• Commonly used intranasal corticosteroids
• Beclomethasone dipropionate (Beconase AQ)
• Budesonide (Rhinocort Aqua)
• Flunisolide (Nasarel)
• Fluticasone furoate (Veramyst)
• Fluticasone propionate (Flonase)
• Mometasone furoate monohydrate (Nasonex)
• Triamcinolone acetonide (Nasacort AQ)
• Ciclesonide (Omnaris)

Drugs_at_FDA. US Food and Drug Administration.
http//www.accessdata.fda.gov/scripts/cder/drugsat
fda/index.cfm. Accessed February 27, 2009.
34
Intranasal CorticosteroidsProper Technique for
Use

• Clear the nose1
• Shake the spray bottle
• Tilt head 30 forward
• Use correct axis of insertion
• Direct spray away from the septum tominimize
  risk of septal perforation2
• Fully depress spray nozzle1
• Alternate nostrils with each puff

1. Loh CY, et al. Allergy. 200459(11)1168-1172.
2. Brunton SA, Fromer LM. South Med J.
2007100(7)701-708.
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Systemic Glucocorticoids

• Rarely a first-line therapy1,2
• Usually reserved for the most severe cases of AR
  not responsive to other treatments1,2
• Especially cases involving nasal polyposis
• Generally prescribed for short bursts (3-7 days)
  followed by taper1,2
• Avoid long-acting IM preparations2
• Risk of systemic side effects with longer
  duration of treatment (HPA axis suppression,
  Cushings syndrome)2
• Commonly used systemic glucocorticoids include
  prednisone, prednisolone, methylprednisolone3

HPA Hypothalamic-pituitary-adrenal. 1. van
Cauwenberge P, et al. Immunol Allergy Clin North
Am. 200525489-509. 2. Wallace DV, et al. J
Allergy Clin Immunol. 2008122(2
suppl)S1-S84. 3. Drugs_at_FDA. US Food and Drug
Administration Web site. http//www.accessdata.fd
a.gov/scripts/cder/drugsatfda/index.cfm. Accessed
February 27, 2009.
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Other Pharmacotherapies

• Mast cell stabilizers1
• Not as effective as intranasal corticosteroids
• Prevent and relieve AR symptoms
• Side effects include sneezing, burning
• Leukotriene-receptor antagonists2
• No significant difference in efficacy with
  antihistamines
• Less effective than intranasal corticosteroids
• Intranasal anticholinergics1
• Provide relief from excessive rhinorrhea not
  controlled by other medications
• Side effects include nasal dryness, bloody nasal
  discharge

1. Wallace DV, et al. J Allergy Clin Immunol.
2008122(2 suppl)S1-S84. 2. Nathan RA. Ann
Allergy Asthma Immunol. 200390(2)182-191.
37
Other PharmacotherapiesExamples

• Mast cell stabilizers
• Cromolyn sodium (Nasalcrom)
• Leukotriene-receptor antagonists
• Montelukast (Singulair)
• Intranasal anticholinergics
• Ipratropium bromide (Atrovent)

Drugs_at_FDA. US Food and Drug Administration Web
site. http//www.accessdata.fda.gov/scripts/cder/d
rugsatfda/index.cfm. Accessed February 27, 2009.
38
Immunotherapy

• Subcutaneous immunotherapy Multiple mechanisms
  of action (may shift immune response from TH2- to
  TH1-response to allergen)
• Efficacy
• Demonstrated in AR, asthma, insect allergies
• Only disease-modifying therapy for AR
• Side effects local reactions, anaphylaxis
• Sublingual immunotherapy is not FDA-approved

Wallace DV, et al. J Allergy Clin Immunol.
2008122(2 suppl)S1-S84.
39
Factors in the Consideration of Immunotherapy1,2

• Severity and duration of symptoms
• Responsiveness to other forms of therapy
• Unacceptable adverse effects of medications
• Patients desire to avoid long-term
  pharmacotherapy
• Reduction of the risk of future asthma
• Presence of comorbid conditions such as sinusitis
  or asthma

1. Wallace DV, et al. J Allergy Clin Immunol.
2008122(2 suppl)S1-S84.2. Bousquet J, et al.
Ann Allergy Asthma Immunol. 199881(5)401-405.
40
Patient Education Adherence
Symptom Improvement With 50 WMC
100
100
N63
78
78
70
67
65
50
50
Symptom Improvement
Patients
11
n49
n7
0
0
Rhinorrhea
NasalObstruction
Sneezing
Forgot Medication(1-5 times)
lt50 Compliance(WMC)
Nasal Itch
WMC weight of medication consumed.
Loh CY, et al. Allergy. 200459(11)1168-1172.
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Increasing Adherence to Treatment

• Keep it simple
• Deliver it effectively
• Avoid its problems
• Call it medicine
• Provide it readily

• Review its usage
• Link it with lifestyle
• Put it in writing
• Support it psychosocially
• Minimize the cost

Meltzer EO. J Allergy Clin Immunol.
1995951097-1110.
42
Allergies in America SurveyMany Nasal Allergy
Sufferers Are Dissatisfied With Their Current
Allergy Medication
Reasons for dissatisfaction with allergy medicine
2
Not Sure
4
Other
1
Hard to Administer
1
Cost/Co-pay
1
Not Covered
10
Did Not Provide 24-Hour Relief
12
Effectiveness Wore Off
21
Bothersome Side Effects
66
Was Not Effective
0
20
40
60
80
100
N860
Percentage of Patients ()
Allergies in America a landmark survey of nasal
allergy sufferers executive summary. Available
at www.mmcpub.com/scsaia/AdultSummary.pdf.
Accessed February 27, 2009.
43
When to Consider Referral

• Question as to etiology of the rhinitis
• Symptoms not adequately managed
• Multiple complications or comorbidities
• Management of immunotherapy, if indicated

Wallace DV, et al. J Allergy Clin Immunol.
2008122(2 suppl)S1-S84.
44
AR Management 2008 Practice Parameters

• Individualize management of AR, considering
• Symptom spectrum, duration, severity
• Physical exam findings
• Comorbidities
• Patient age
• Patient preferences
• Use step-up and step-down approaches
• Step-up when therapy is inadequate
• Step-down after symptom relief achieved or
  maximized

Wallace DV, et al. J Allergy Clin Immunol.
2008122(2 suppl)S1-S84.
45
Case StudyPatient Treatment Plan
Pharmacotherapy regimen

• Intranasal corticosteroid
• AND
• Second-generation antihistamine as needed
• Return in 4 weeks to review treatment
• If no improvement, refer to allergy specialist

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Conclusions

• AR is not a trivial condition
• It can lead to significant comorbidities and poor
  quality of life for the patient
• Proper management starts with a good history and
  physical examination
• Education, avoidance procedures, proper
  medication, and possibly allergen immunotherapy
  are the pillars of treatment
• The bottom line is no person with AR should
  suffer with their condition

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Questions and Answers