Improving Outcomes in Allergic Rhinitis: A Patient-Centered Approach

Course Director

Michael S. Blaiss, MD

Michael S. Blaiss, MD
University of Tennessee
Health Science Center
Memphis, Tennessee

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Dr. Blaiss provides expert feedback to the questions submitted by your peers during a recent survey on this topic.


Patients with allergic rhinitis, a ubiquitous IgE-mediated hypersensitivity reaction to specific allergens, may endure the congestion, rhinorrhea, sneezing, and nasal itching that are hallmarks of this disorder and have a significant impact on patient quality of life. If left untreated, these symptoms may result in sinusitis, serous otitis media, sleep-related complaints, decreased productivity, and even learning problems. Patients may assume that over-the-counter antihistamines are the only solution to these symptoms, but unfortunately they don’t work well enough for many allergy sufferers. Therefore it is important that clinicians are able to establish an accurate diagnosis of allergic rhinitis and formulate treatment plans that are consistent with evidence-based guidelines. Further, clinicians should be able to develop individualized treatment plans from available therapeutic options, thereby improving adherence and clinical outcomes.

In this activity, Michael S. Blaiss, MD, answers questions submitted by US primary care physicians regarding current practice for optimal allergic rhinitis management.

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How can physicians help their patients with allergic rhinitis understand that they may need to take their medication every day?

Dr. Blaiss: Adherence to medication is a real problem for allergic rhinitis—the main reason is that patients don't understand that this is a chronic condition; that they need to take the medication not just when they're having symptoms, but in fact to prevent them from having symptoms.

Now, physicians sometimes contribute to the patients' poor adherence in allergic rhinitis, because many times we may be prescribing complex regimens, where we have patients taking two or three different medications for their allergic rhinitis. Another problem we have is failing to explain to our patients the benefits of taking the medication, and therefore we get poor adherence. We have to make sure that patients understand that it doesn't matter how great a medication is—in fact, if they don't use it, the patient is not going to get relief. Some other problems I think we have to deal with is not understanding the patient's lifestyle, and working with the patient so that in fact they can be more adherent to their treatment. And we always have to be cognizant of the cost of medications.

I do think one of the major problems we have with adherence with allergy treatments are in fact the side effects associated with them, and especially the formulation of the medications.

Narrator: Under current guidelines, intranasal corticosteroids are considered the most effective first-line therapy to improve allergic rhinitis symptoms and burden of disease.1 Although the various approved intranasal corticosteroids appear to be equivalent in terms of reducing disease burden, the method in which these agents are delivered to a patient has significant impact on the treatment’s overall success.2

Dr. Blaiss: Now, in allergic rhinitis, we commonly use nasal sprays because they're so effective, but many patients just don't like the taste or the smell [of the nasal spray]; they don't like the drip of the spray out of their nose or down the back of their throat. And in fact in the Allergies in America survey, we found that the spray dripping down the back of the throat was one of the major problems that stopped patients from using their spray on a daily basis.3 And the Nasal Allergy Survey Assessing Limitations reported that one-third of patients with allergic rhinitis named dripping down the throat as a bothersome side effect that was associated with the use of aqueous intranasal corticosteroid formulations.4

So how do we improve adherence—and therefore improve outcomes—in our patients with allergic rhinitis? I think the first thing we have to do is educate the patient about their condition, that it is a chronic condition, and understand the benefits of the treatments that we're using.

Now, no one dies from allergic rhinitis, but in fact there is significant morbidity, with decreased productivity at work or at school. We also know patients have a very poor quality of life and poor sleep associated with their condition. As I mentioned previously, we have to gear the treatment to the patient's lifestyle. So what may work for a middle-aged female, as far as their allergic rhinitis, may be quite different than if we were treating a teenage boy. [I should note] very importantly is once-a-day dosing works the best, and to use as few medications as possible. And if we're using nasal sprays, to minimize the side effects associated with taste, smell, and volume.

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You have a 30-year-old, otherwise-healthy male patient who suffers from allergic rhinitis (particularly in the spring) and does not experience any relief with antihistamines. He is resistant to use intranasal steroids long term. What can you tell him?

Dr. Blaiss: Well, I think it's very important that we stress with the patient that intranasal corticosteroids are the gold standard in the treatment of patients with allergic rhinitis. In fact, the Joint Task Force on Practice Parameters on Allergic Rhinitis by the American Academy and the American College of Allergy, Asthma, and Immunology state that intranasal corticosteroids are the most effective medication class for controlling all symptoms of allergic rhinitis, and in almost all studies published, intranasal corticosteroids have been shown to be more effective than oral antihistamines.1 And in other studies, it's been shown that adding an oral antihistamine to an intranasal steroid adds no increased improvement over just using the intranasal steroid alone.1

So why is this? Well, intranasal steroids treat all the major symptoms of allergic rhinitis, so we need to explain to the patient that it controls the sneezing, the nasal itching, the runny nose, and the nasal congestion. And controlling the nasal congestion is so very important because it is due to the underlying nasal inflammation that is seen in allergic rhinitis. Now, oral antihistamines only block one mediator in allergic rhinitis, which is histamine, and they have virtually no effect on nasal congestion—and we know that nasal congestion from the Allergies in America survey is the most bothersome symptom that patients have with allergic rhinitis.3

So what can we tell that patient, then, who is hesitant to use intranasal corticosteroids? Well, one of the problems that I see in my patients is a steroid phobia; it's important to explain to the patient that these are not anabolic steroids that can be abused, these are [gluco]corticosteroids. And because they are sprayed into the nose, there is minimal systemic absorption. So side effects are extremely rare with the use of these medications.5 In fact, we know they're safe: They're approved by the FDA for long-term use in our patients with nasal allergies.

Narrator: A review of the published literature indicates that the side-effect profiles of inhaled corticosteroids consist primarily of a low incidence of mostly mild and often transient local adverse events, such as nasal irritation and epistaxis.5

Dr. Blaiss: Another problem that may be the reason [why] the patient does not want to use the [intranasal] spray is that some patients think that all nasal sprays are addicting. Now, nasal decongestant sprays like oxymetazoline, which you can buy over the counter, can cause a rebound effect, or what we call rhinitis medicamentosa. And this is definitely not seen with the use of intranasal steroids, so they are not habit-forming or addicting.6

As I mentioned, another major problem that our patients complain about is the dislike of nasal sprays because of problems with taste and smell and dripping out the nose and down the back of the throat. The good news now is that the FDA in 2012 approved intranasal corticosteroids that are in a dry-gas [formulation] that we call hydrofluoroalkane, or HFA.7 And these agents are just as effective as the older liquid steroid nasal sprays, but for our patients, they do not have the problem as far as taste or smell or drip, because they're in a gas. So this is a great option to use in our patients to improve adherence if they do not like using a liquid nasal spray.

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Are there validated and/or easy-to-use tools that can help physicians monitor their patients with allergic rhinitis in terms of symptoms and quality of life?

Dr. Blaiss: Well, in caring for your patient with allergic rhinitis, it's important to understand that not only are they having significant upper respiratory symptoms, but that allergic rhinitis does have a major effect on their quality of life. So we see problems as far as fatigue and sleep disturbances; we see problems in the child as far as learning and attention problems; and both for children and adults, we see absenteeism from school or work or presenteeism. What we mean by presenteeism is that the patient is at work, or the child's at school, but because of symptoms of their allergic rhinitis, they have impaired functioning. We also know that allergic rhinitis can lead to a lot of psychological problems in the patient, and studies have shown that patients with allergic rhinitis could have low self-esteem. We see shyness, depression and, in fact, even anxiety associated with the condition.8 So it's very important to try to monitor the patient's quality of life.

Now, what's been used to monitor quality of life have been different questionnaires. We have the generic quality-of-life questionnaires, which in fact can be used not only for allergic rhinitis, but any other chronic condition. And several studies have shown in using these questionnaires, that patients with allergic rhinitis have poorer quality of life than patients who have asthma.8

We also have what are called disease-specific quality-of-life questionnaires. And for allergic rhinitis, the main one that's been used in clinical studies is the Rhinoconjunctivitis Quality of Life Questionnaire.9 There's seven different domains associated with quality of life in allergic rhinitis, both for children and adults. And these include nasal symptoms; eye symptoms; non-eye nasal symptoms, so that includes things like itchy throat or itchy ears; practical problems associated with allergic rhinitis, such as having to rub your eyes and nose in public or having to carry a handkerchief; activities that can be depressed with allergic rhinitis; emotional function, such as anxiety, depression; and the last very important domain, in fact, is sleep.

Now, this questionnaire is used a lot in clinical studies, but unfortunately is not easy to use in a practice situation. And the good news just recently has been the validation of a new instrument that is very user-friendly and can be done easily in any office situation, and that is the Rhinitis Control Assessment Test, abbreviated RCAT.10 It's a patient-completed, validated instrument to evaluate their symptom control. It has six questions, and the patient answers these on a five-point Likert scale. These questions ask: During the past week, how often did you have nasal congestion? During the past week, how often did you sneeze? During the past week, how often did you have watery eyes? The fourth question, a very important question related to quality of life: During the past week, to what extent did your nasal or your allergy symptoms interfere with your sleep? Number 5, also an important quality-of-life question: During the past week, how often did you avoid any activities—for example, visiting a house with a cat or dog, gardening—because of your nasal or other allergy symptoms? And the last question, During the past week, how well did your nasal or allergy symptoms control? So this can be quickly done in an office setting [and] can give you and your patient an understanding of how well their nasal allergies are under control.

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  1. Wallace DV et al. J Allergy Clin Immunol. 2008;122(2 suppl):S1-S84. doi:10.1016/j.jaci.2008.06.003.
  2. Carr WW. [published online ahead of print June 20, 2013]. Am J Rhinol Allergy.
  3. Meltzer EO et al. Allergy Asthma Proc. 2012;33(suppl 1):S113-S141.
  4. Meltzer EO et al. J Fam Pract. 2012;61(2 suppl):S5-S10.
  5. Sastre J, Mosges R. J Investig Allergol Clin Immunol. 2012;22:1-12.
  6. Varghese M et al. Clin Exp Allergy. 2010;40:381-384.
  7. Med Lett Drugs Ther. 2012;54:84. Available at:
  8. Xi L et al. J Investig Allergol Clin Immunol. 2012;22:264-269.
  9. Juniper EF et al. J Allergy Clin Immunol. 1996;98:843-845.
  10. Meltzer EO et al. J Allergy Clin Immunol. 2013;131:379-386.

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This activity is supported by an educational grant from Teva Respiratory.

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