Author	Reviewer
Christine Palmay, MD, CCFP, FCFP Midtown Health and Wellness Clinic Toronto, ON	Nina Jindal, FRCPC, Internal Medicine, Clinical Immunology & Allergy Lecturer, Department of Medicine Division of Clinical Immunology and Allergy University of Toronto Toronto, ON

 

‘Tis the season of sneezing, runny noses, and allergies.  Generally perceived as an inconvenience due to the non-life-threatening nature of symptoms, we forget that approximately 20-25% of Canadians suffer from allergies.  These numbers continue to increase.  Furthermore, allergic rhinitis may be related to other conditions such as allergic conjunctivitis, asthma and even food allergies.  It is a lion cloaked as a lamb.  Our approach and treatment need re-framing.

Do not underestimate the burden of allergic rhinitis

Midst the fever and fury of catching up post COVID, we must pause and recognize that allergic rhinitis, whether seasonal or perennial, have a significant impact on quality of life.  Research has shown that allergy suffers experience sleep disturbances/poor sleep quality, cognitive impairment, and mental health issues such as anxiety and depression.  Allergies can be a leading cause for work absenteeism and can negatively affect workplace and academic performance.  Older anti-allergy medications (more to come about this) also pose a challenge as they themselves may lead to drowsiness and brain fog.  Allergic rhinitis is more than just a runny nose and as such, we need to be proactive in asking our patients how allergies affect them.

Missed clinical opportunities

Allergic rhinitis is often underrecognized by sufferers themselves.  Firstly, patients may not correlate their symptoms with other adverse health outcomes such as cognitive changes or sleep disturbances.  Afterall, it’s just a sneeze, right?  Access to medical care continues to be limited and anti-allergy over the counter options are limitless and readily available.  Just pass through a drugstore and see what lies on the shelves.  Patients can access over-the-counter medication and often undertreat, overtreat or mistreat.  I have had so many conversations with patients, whom out of desperation fill their medication cabinets with first generation antihistamines (good reliable diphenhydramine, Benadryl) or use the sedating power of other medications such as dimenhydrinate (Gravol).  These medications come with a myriad of side effects such as drowsiness, poor cognition, reduced reflex time and general brain fog.  Think of the implications for fall risk or driving errors. Furthermore, interaction with other medications are of equal concern.   When assessing a patient with allergic rhinitis, we must take time to record a detailed drug history, including what they are accessing over-the-counter.  You don’t know what you don’t know until you ask (and then know!).

So where do I start?

Let’s start by reviewing what we should NOT do – namely prescribing first-generation anti-histamines. There should be a war cry unified front to ban first generation antihistamines such as diphenhydramine) from the shelves due to their ability to cross the blood brain barrier thus invoking sedation and drowsiness. Other options such as decongestants in all forms can lead to worsening symptoms due to rebound vasodilation.  Safer options exist (again, more to come). 

Guidelines emphasize that first line options include lifestyle modifications:  avoiding carpets/drapes if possible, cleaning sheets regularly, investing in a high-efficiency air filters, avoiding outdoor activates during peak pollen season….and……having a difficult conversation about that new family pet that may be the allergen source. While these measures seem basic, they are often overlooked.  Intranasal steroids may also be a viable first line option, but from a clinical perspective, I do not find that they address the full burden of symptoms in many patients.  We need to follow-up and not just “treat and street.”

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Friend our second generation anti-histamines – more than just cetirizine!

Current guidelines steer us AWAY from first generation anti-histamines and focus on the benefits of our second generation anti-histamine class. The real benefit of these newer second generation antihistamines is reduction in concerning side effects compared to older first generation agents. Side effects such as reduced drowsiness and cognitive impairment, not to mention the potential for drug interactions.  Our medication options within this class have only recently been updated with two new options and quite frankly, game changers: bilastine (Blexten) and rupatadine (Rupall). These new kids on the block have less side effects such as drowsiness and cognitive impairment. Equally as important, they have less interaction potential with other medications.  Conveniently, pediatric formulations exist for both options and truly make them safer selections for a wide age range (because we know now how much daycares revel in runny noses!).  From a clinical perspective, patient feedback has been excellent, and my use of these newer options has replaced my old practice patterns of simply renewing a longstanding cetirizine prescription.

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When to refer?

Failure of treatment or lack of tolerability to medications warrant a comprehensive assessment as patients may be eligible for consideration of higher level treatment options such as immunotherapy (subcutaneous or sublingual) if appropriate. As well, if any red flags exist (complicated medical history, severe symptoms, severe quality of life impairment), it may be important initiate a referral.  Additionally, patients who want to know what they are allergic to or have multiple allergic co-morbidities will benefit from specialist consultation .

In summary, allergic rhinitis does not get the air time it deserves, but when treated comprehensively, results in a measurable improvement in patient’s quality of life. “NOSE” your options (cue unified groan..).

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The development of this blog was overseen by the Canadian Collaborative Research Network and was supported through an educational grant from Aralez Pharmaceuticals Canada Inc.