The topical nasal steroid is the pure anti-inflammatory product. We use this to treat the inflammatory state of the patient, recognizing that allergic rhinitis is an inflammatory problem. Antihistamines can reduce some of the symptoms but not as effectively as some of the topical nasal steroids. Added to that patients obviously have a preference to use a single product that they can use once per day, for most Americans this would ideally mean taking a pill, but unfortunately that’s not the best product for them. Our challenge is to change their attitudes and beliefs about appropriate treatment of these problems.
Dr. Meltzer: As an allergist I tend to think about allergic disease not only in terms of what is, but how did it get there. It is important to understand allergic rhinitis as an inflammatory process that involves numerous mediators, cytokines, and inflammatory cells. Oral antihistamines block only one of the mediators; they have no effect on cytokines or inflammatory cells or any of the other mediators. As such, while they can help with itchy noses, sneezing and runny noses, they do not help with congestion— which is the most bothersome and the most frequent symptom. Likewise, anticholinergics only help with runny nose, and are not effective against nasal itch, sneeze or congestion. Most people with allergic rhinitis have chronic disease, and topical decongestants should not be used for prolonged periods of time. Oral decongestants have dose-related side effects and the doses required to effectively reduce congestion increase the risks of irritability, diffculty sleeping and nervousness. Leukotriene modifiers are at best minimal to modest improvers of symptoms. Thus, the intranasal corticosteroids (because of their broad based mechanisms of action) are currently considered to be the best monotherapies.
However, when prescribing intranasal corticosteroids, there are a number of important considerations. First, we should ensure the patient is administering the spray properly in terms of the technique. In addition, there may be some patient preference in terms of whether an individual prefers an aerosol formulation or an aqueous formulation. There may also be issues in regard to cost and related to the availability of different agents on a formulary. Indeed, managed care limitations have been problematic for many of us who take care of patients. Furthermore, we certainly need to monitor that patients adhere to their regimen. I find in my practice that most people do not start taking their medication prior to a season; they wait until they’re in the midst of the worst time of their symptomatology and then expect an immediate treatment effect. I try to explain to them, that allergic rhinitis is an ongoing process, a fire, and if effective therapy is established and maintained early on, then the fire can be kept under control and the outcome will be far better than trying to deal with it when there is a flare-up of the major symptoms. This is a communication issue. Every person may have a different view and we need to come to an understanding of each individuals’ viewpoint (what their goals of treatment are). We are not going to be able to force a patient to stick with a particular treatment. It’s about educating them and encouraging them to take responsibility. I tell them “when you leave my office, you’re the one who has allergic rhinitis and I recommend you take the medication. However, you make the decisions.”
Dr. Hadley: We also must not forget that inappropriate patient comprehension and knowledge can also be problematic. Some patients take their medication too late, or perhaps too long, and they have side effects. Side effects can increase the burden of their disease and impact on their ability to perform well at work or school or play.
Dr. Stoloff: Yes, in primary care, especially when treating the older population who have hypertension, one often sees patients take decongestants, and one realizes the multitude of side effects associated with them. And, as Dr. Hadley says, very few patients are aware that their medications are causing these problems.
There are basically three key aspects related to patient communication. Firstly, patient education; we need to ensure our patients are aware of what they have, why they have it and what they can do about it. Secondly, there needs to be ongoing communication between the patient and the clinician to ensure availability of questions and availability of goal setting. Thirdly, patients should have realistic expectations, because when patients revisit we can assess if we have met their expectations or if adjustments in management are needed.