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Technician
CE
Lesson
ce
PHARMACIST
ce
PHARM TECH
By Nancy Lyons, BS Pharm MBA
CDE, clinical pharmacist training and
management consultant
Author Disclosures: Nancy Lyons
and the DSN editorial and continuing
education staff do not have any actual or
potential conflicts of interest in relation
to this lesson.
Universal program number: 0401-0000-14-201-H01-T
Activity type: Knowledge-based
Initial release date: April 4, 2014
Planned expiration date: April 4, 2017
This program is worth one contact hours (0.1 CEUs).
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Target Audience
Pharmacy
C L I Ntechnicians
I C I A N in community-based practice.
Program Goal
To improve the technician’s ability to refer patients with symptoms
of allergic rhinitis in need of consultation to the pharmacist.
Learning Objectives
Upon completion of this program, the technician should be able to:
1.List the symptoms of allergic rhinitis.
2.Define trigger control strategies that may help prevent
allergic rhinitis.
3.Identify conditions and patient populations when non-pharmacologic options are appropriate.
4.List treatment options for allergic rhinitis with consideration to
special populations.
5.Explain when to refer a patient with potential allergic rhinitis
symptoms to the pharmacist.
To obtain credit: A minimum test score of 70% is needed to
obtain a statement of credit. Submit your answers online at www.
CEdrugstorenews.com, and receive your statement of credit in
your CE account folder immediately.
All customer service questions, including those regarding statements of credit, should be directed to (800) 933-9666.
This lesson has been developed to meet
requirements for PTCB and ICPT recertification.
Drug Store News is accredited by the
Accreditation Council for Pharmacy Education as a provider
of continuing pharmacy education.
1 • march/april 2014
This lesson is supported by an educational grant from
Understanding the
technician’s role
in assisting the patient
with allergic rhinitis
Introduction
According to the Asthma and Allergy
Foundation of America, allergy is the
fifth-leading chronic disease in the United States among all ages and the third
most common chronic disease in children
younger than 18 years of age.1,2,3 It is estimated that approximately 30 million
to 60 million Americans are affected by
allergic rhinitis. That equates to 10% to
30% of adults and up to 40% of children.4
During childhood, boys are more likely to
suffer from allergic rhinitis than girls, but
the tendency reverses in puberty, leading
to near equilibrium of incidence in adulthood.5 The incidence has been rapidly
increasing in all ethnic groups over the
past three decades and continues to rise
quickly limiting the ability to accurately
report incidence statistics. Additionally,
researchers advise that allergic rhinitis
is often ignored, underreported and undiagnosed.4 This missed or delayed opportunity to adequately treat and control
the patient with allergic rhinitis also may
contribute to the development of asthma,
as the conditions have been linked.1 The
community pharmacy technician is in a
perfect position to adequately screen and
refer patients suffering from allergic rhinitis who downplay the importance or
proper evaluation and treatment.
Recent estimates of the costs of allergies
also vary greatly for the reasons described
previously. However, research has estimated that all types of allergies have a price tag
of $14.5 billion.1,2 That is divided into $12.3
billion for direct costs, which include office
visits and all medications — prescription
and over the counter medications — and
indirect costs of $2.2 billion.1,2 Indirect costs
include lost work or school, lost productivity and death. In adults, allergic rhinitis
has been estimated to result in 4 million
lost workdays per year, or $700 million in
total lost productivity. Additionally, aller-
gic rhinitis has been linked to educational
delays in children and social difficulties in
all age groups.1,2,5
Multiple patients affected by allergic
rhinitis will present to the pharmacy in
need of relief. As a technician in a community pharmacy, and thus a key point
of entry into the pharmacy, it is important to understand the condition and assist in making the appropriate referrals
to ensure that patients in this growing
population are properly managed.
Risk factors
Allergic rhinitis was first reported by
Sir John Bostock during a report to the
Medical and Surgical Society of London
in 1819. Bostock described the condition
as a rare affliction of wealthy people.5
A great deal of research concerning the
incidence of the disease worldwide has
occurred since that first report, with continued challenges in identifying a direct
cause. Researchers with the International
Study of Asthma and Allergies in Childhood, or ISAAC, project found that approximately 80% of individuals with allergic rhinitis develop symptoms before
20 years of age.5 A German study that included 467 children showed a genetic link
to the development of allergies. Other
risk factors for allergic rhinitis as reported by the ISAAC project include ethnic
origin other than white European, high
socioeconomic status, environmental pollution, birth during a pollen season, no
older siblings, late entry into preschool,
heavy maternal smoking during the first
year of life and exposure to indoor allergens.5 A recent study published in the Pediatric Journal of the American Medical Association points to an increased incidence
of childhood allergic diseases within the
United States as compared with children
living outside the United States, suggesting a link to increased incidence of allergy
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Technician CE Lesson
Table 1
Common symptoms of allergic rhinitis7
affected area
symptom
Nose
Watery nasal discharge
Nasal blockage
Rapid sneezing
Nasal itching
Post-nasal drip
Loss of taste
Sinus pressure
Sinus pain
Eyes
Itching
Redness
Gritty secretions
Swelling
Blue tint — “Allergic shiners”
Throat
Soreness
Hoarseness
Itching
Ears
Soreness
Pressure
Congestions
Popping/sound distortion
Itching
Sleep cycle
Mouth breathing
Frequent awakening
Daytime fatigue
Difficulty performing work
in more industrialized or indoor-centric environments. Some evidence is available that links
decreased incidence of allergy in children who
grew up on farms.5 Still, other studies indicate
that early exposure to foods and other substances previously thought to increase allergic
predisposition may actually provide protection
for children. While exact causal relationships
are not known, researchers indicate that more
scholarship is needed to confirm links to excessive hygiene as compared with early or frequent exposure to bacteria and other antigens.6
Experts continue to dispute the hygiene-related
theories. In all, the exact cause of allergic exacerbation is not clearly understood.
Symptoms
The classic symptoms of allergic rhinitis, also
known as hay fever, begin with the nose — as
the term rhinitis suggests — and often also include the eyes, throat and ears. The symptoms
can cause interruption of sleep and can lead to
general irritability as well.7 See Table 1 for a list
of common symptoms of allergic rhinitis.
Patients often experience nasal symptoms that
include watery discharge, blocked nasal passages, persistent sneezing, nasal itching, postnasal
drip, loss of taste, increased facial pressure and
possibly pain across the sinus area. The eyes can
also be affected. Patients may complain of itchiness, redness, feelings of grittiness and swelling.
Depending upon the severity of the effects in
the eyes, patients may develop an intense swelling and blue tint of the skin below the eye. This
condition around the eyes is known as allergic
Patient Scenario 1
While picking up refills of metformin, enalapril and simvastatin, Jeffery, a 54-year-old male with diabetes, shares
that he has really been struggling now that the trees are beginning to bloom. He thought he was getting a spring
cold last week when he sneezed nearly 20 times an hour for three days, but now thinks it’s something more than a
cold. Jeffery is concerned that with all of his medical problems he is doomed to suffer. He is so congested now that
is literally hurts to breathe. He feels terrible and is having trouble controlling his diabetes. His blood sugar was 270
before breakfast; he just checked his blood pressure in the pharmacy machine and that was elevated, too.
He feels hopeless and really wants help so he can get back to work and complete some urgent projects. His
head is throbbing. What can the technician do to best care for this patient?
Discussion
In talking with this patient for a short period of time, the technician received a great deal of information about
a patient in significant need of assistance. The technician learned that the patient:
1. Began experiencing issues approximately one week ago when the local morning news was warning
viewers that the pollen count was the highest so far this season;
2. Has had continuing symptoms for a week and is beginning to experience the profound congestion and
swelling that are typical of a late-phase response;
3. Has a number of medical conditions, some of which are beginning to become uncontrolled; and
4. Is very motivated to feel better soon.
After gathering the info, the technician recommends that Jeffery speak with the pharmacist. The technician
should bring the pharmacist to the patient while providing introductions and a quick summary of the details
Jeffrey already shared. The technician also should ask Jeffery to confirm that everything was stated correctly.
The pharmacist then begins a conversation with the patient to probe for any additional information that is
needed in order to make a recommendation.
After the pharmacist speaks with Jeffery, she asks the technician to show him the location of the cool mist humidifiers
and the new over-the-counter steroid nasal spray. The pharmacist already reviewed proper use and dosing of the
nasal spray and advised the patient on the importance of limiting the transfer of the outdoor allergens to the indoor
environment. The patient will regularly vacuum, and may consider an air purifier for the bedroom if his symptoms
continue. The technician shows the patient the recommended products, including humidifiers with a built-in hygrometer.
Even though it appears that the patient suffers from seasonal allergies (and specifically tree pollen) the technician
discusses keeping the humidity level below 50% (30% to 40% optimally) to avoid problems with dust mites and mold.
shiners. The patient also may experience symptoms in the throat and ears, such as general soreness, itchiness, hoarse throat, ear pressure and
congestion in the ears that can lead to popping
or distortion of sound. General symptoms experienced during sleep include mouth-breathing,
frequent awakening, daytime fatigue and difficulty performing work.7,8
When patients present at the pharmacy complaining of one or more of the symptoms above,
it is important to understand that the symptoms
described above may not be caused by allergic
rhinitis. Allergic rhinitis is caused by an IgE immune response. Allergic rhinitis is either seasonal (i.e., usually in response to pollen, grass or
other geographic location or climate driven environmental factors) or perennial (i.e., dust mites,
molds, animal allergens or non-climate change
related pollen exposure) in nature. Each of these
conditions is linked to the immune response.8
Non-allergic rhinitis and other medical conditions also may cause symptoms that mimic the
presentation of allergic rhinitis. Patients may be
experiencing non-allergic rhinitis or symptoms
that are not a result of IgE processes. Uncovering the potential causes behind the symptoms
will guide the recommendation that is needed.
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Table 2
Common triggers8
seasonal triggers
perennial triggers
Pollen
Dust mites
Grasses
Insects
Weeds
Animal dander
Mold
Mold
Fungi
Fungi
As a pharmacy technician, it is important to
get some additional information before making any referrals or product recommendations.
Symptoms could be caused by foods or alcohol,
viral or bacterial infections, occupational rhinitis (irritants from the worksite that do not cause
an immune response), hormones, drugs, nasal
polyps and other conditions. Gathering some
background information to be shared with the
pharmacist will enable better patient care and
increased efficiency in the pharmacy. Learning
if the patient has previously been diagnosed
with allergic rhinitis might allow a streamlined
conversation that simply informs the patient of
the location of the product recommended by
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Technician CE Lesson
the physician. If the patient has no previous
diagnosis of allergic rhinitis, understanding the
onset of the symptoms in relation to the presence or absence of seasonal changes or changes
to the home environment is important information needed for the pharmacist’s recommendation. Additionally, learning if the patient has
experienced recent changes or has other medical conditions will add to the quality of the
pharmacist’s recommendation. Determining
the presence or absence of triggers, as well as
ruling out other medical conditions, is an important step in assisting the patient in finding
the correct treatment options. In many cases,
the pharmacist will need to refer the patient to a
physician for evaluation and treatment.8
be advised to use clothes dryers rather than
hanging clothing and bedding outside to dry.
These tactics can help avoid transferring outdoor allergens to the indoor environment.
Because completely eliminating the transfer
of the outdoor allergens to the indoor environment is often difficult, patients should also be
advised to regularly clean floors and surfaces
with HEPA equipped vacuums and using
HEPA furnace filters. If symptom improvement
isn’t seen after avoidance and thorough cleaning patients may also consider an in-room air
purifier to be placed in the sleeping area. In
cases of extreme allergic response, patients may
choose to move to a dryer climate where the
pollen, grass, mold or fungi isn’t as prevalent.
Common allergens: Triggers and
trigger control
Patients who are experiencing true allergic
rhinitis have been exposed to an allergen that
caused the immune response to initiate, leading to the cascade of processes that results in
effects on the body described earlier. The allergens that cause the immune response to begin
are referred to as triggers. As was discussed
earlier, triggers are divided into two primary
categories: seasonal triggers and perennial
triggers. A list of common seasonal and perennial triggers is found in Table 2.
Literature has documented a number of negative effects on the patient’s quality of life that
result from uncontrolled allergic rhinitis. During
the discussion with the patient, it is important to
understand the impacts that the symptoms can
have on the patient, and work with him or her to
help them understand the triggers and what can
be done to lessen the exposure to the trigger.9 All
patients affected by allergic rhinitis should begin
any treatment plan with trigger control.
Perennial triggers
Common perennial triggers include dust
mites, infestations of cockroaches and nesting
beetles, animal dander, mold and fungi. In general, perennial triggers are more difficult to avoid.
Dust mites require heat and humidity to live
and increase. Tactics to limit dust mites include
reducing indoor humidity and temperature,
encasing mattresses, pillows and other bedding in dust mite reducing covers, washing all
bedding in hot water weekly, using vacuums
with HEPA filters to thoroughly clean carpeting regularly or choosing tiled or hard wood
flooring that is regularly cleaned and dusted.
While source-control and surface-cleaning
are considered important first-line recommendations, ventilation filtration and air cleaners
may provide additional benefits. It is important to advise patients that ventilation filtration and air purifiers are not intended to take
the place of trigger control and removal that
has already been described.
When the home has insect infestations, working to remove the infestation should be the first
action taken. Because insects can be particularly
difficult to eliminate, improving conditions that
caused the infestation also is recommended.
Sealing windows and other areas that beetles
are using to enter the home is recommended,
along with using chemical barriers. Removing
standing water, exposed food and trash can improve the possibility of stopping cockroaches.
In either case, washing areas where insects have
been can remove allergens and reduce the potential for the immune response.
Animal dander also can present a difficult
issue due to the emotional attachment to the
family pet that often exists. If the animal can
be removed from the home, it is important to
advise the patient that it will take time (often
several months) for all of the animal dander
to be completely cleared from the home and
for symptom improvement to be seen. In cases
where the animal cannot be removed from the
home, limiting the pet’s access to the bedroom
of the affected individual is advised. In addition, frequent cleaning of carpeting or other
areas that attract hair and dander is advised.
Seasonal triggers
Seasonal triggers include pollen from trees
and blooming plants, grasses and weeds. These
triggers typically increase in the spring or fall
depending upon the area of the country. Additionally, spores from mold and fungi growth
also are seasonally linked. With seasonal triggers, the patient generally has little control over
the environment, though monitoring pollen
and mold spore counts in the area can assist the
patient in planning outdoor events. In fact, a
study was conducted that monitored national
pollen-count fluctuations and online allergy
queries. It can be expected that pharmacies also
will experience greater demand for education
and recommendations about allergic rhinitis
during increased pollen-count seasons. 10
Trigger-control tactics for seasonal triggers
include avoiding prolonged periods outside
during periods of high-contact risk triggers,
wearing clothing that presents a barrier to the
allergen when outside, keeping windows in
the home and automobiles closed and using air
conditioning instead of fans. Patients also can
3 • march/april 2014
There is some evidence that the use of an air
cleaner may reduce airborne pet dander and
may provide additional relief when added to
thorough cleaning regimens.
With mold and fungi issues within the home,
it is important to work to remove the offending allergen. In some cases, it may be necessary
to enlist professional cleaning companies that
specialize in mold and fungal removal. In addition, limiting the relative humidity of the home
also can improve the internal environment and
make mold and fungal growth less optimal.
Perennial trigger-control tactics focus on
continuing efforts by the patient. Source control and surface cleaning are considered important first-line recommendations. Ventilation filtration and air cleaners may provide
additional benefits as adjuncts and extensions
to the primary methods of perennial trigger
control that have been described.
Treatment options
When trigger control is not possible or not
effective in reducing the patient’s exposure,
treatment is needed. Options available for the
patient include symptom relief and intervention within the various steps of the immune
process. The treatment options can be further
divided into complementary or alternative
medicine/treatment, non-drug treatment and
over-the-counter or prescription medications.
It is important for the technician to be familiar
with the different types of treatments available
and the evidence supporting the treatments. In
addition, it is important to be aware of the special populations of patients who may require
modifications to the treatment recommendations.11 In general, all patient populations will
benefit from non-drug options that provide
relief as the risk-to-benefit is positive. With all
patients, a careful evaluation of benefits and
risks should guide the therapies chosen.
Special populations
As is common with any medical treatment,
individual factors will guide therapy recommendations that are made. As the pharmacist
formulates a plan for the patient, some basic
information will be needed. Age, the presence
of other physical or medical conditions, and
the use of other drugs or substances, including
herbal products and recreational drugs, are all
important pieces of information to gather.
It is well documented that safety and effectiveness data is lacking for many over-thecounter and prescription medications used for
relief of the traditional symptoms related to allergic rhinitis in infants and children. Current
recommendations suggest that most products
be avoided in children younger than 6 years
old.12 A few antihistamines have safety and
effectiveness data in infants and children and
have dosing data available. Additionally, intranasal corticosteroids are considered first line
therapy options, although side effect must be
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Technician CE Lesson
taken into consideration. Complete symptom
identification is needed in order for the pharmacist to make a proper recommendation.
In addition to special considerations made for
the very young, modifications to recommendations also are needed in the elderly. As the body
ages, organ systems begin to process medications differently, and basic biomechanical functions change. Changes seen in the liver, kidneys,
total body fat percentages, consistency of the
nasal mucosa, mechanics of swallowing, and
visual and general motor functioning all contribute to different responses to therapy. Dizziness
and drowsiness caused by antihistamines can be
enhanced in this population and lead to falls, potential of broken bones and other issues.13
Recommendations for proper treatment of allergic rhinitis also are affected by the presence of
other medical conditions. The pharmacist must
be aware of all conditions and treatments used
in order to properly screen for drug interactions and potential for exacerbating other medical conditions. Hypertension, asthma, diabetes,
heart conditions, enlarged prostate and other
chronic illnesses will potentially modify treatment recommendations. Of special consideration is pregnancy or lactation, as many medications can have harmful effects on the baby,
particularly during the first trimester as organ
development occurs. The focus for relief for
pregnant and lactating patients will be on trigger control, non-drug remedies and a balance
of risks-to-benefit for medications that may be
used. The pharmacist can recommend appropriate treatment focusing on medications that have
acceptable pregnancy category ratings. In many
cases these patients will be advised to visit the
doctor if symptoms are severe and trigger control isn’t effective.11,14
Complementary alternative therapies
A number of complementary alternative
medicine, or CAM, therapies have been introduced that include claims of condition improvement and symptom relief in patients suffering
from allergic rhinitis. In order to investigate the
claims made by the service and product providers, research was conducted to review and score
any clinical trials supporting the alternative
therapy. Researchers investigated a large number of physical, phytotherapy, systemic medication, behavioral and other therapies and scored
the available evidence. In general, the available
studies did not provide enough evidence to recommend any of the complementary alternative
medicines available.15 A few studies did show
negative or harmful potential effects. If a patient arrives at the pharmacy with questions
about an allergy alternative therapy, a referral
to the pharmacist should be made to weigh the
risks and benefits.
drug therapy that has been proven effective
in providing patients with relief. Nasal irrigation with sterile saline solutions or the use of
a saline nasal spray can be of help to a number of patients. Nasal irrigation works to treat
post-nasal drip, or drainage down the back of
the throat; sneezing; nasal dryness; and congestion. Saline helps to rinse allergens and irritants
from the nose and also can be used before the
administration of other intranasal medications
to remove excess mucous and allow the active
medication better access to the nasal mucosa.
When saline irrigation solutions are used, the
patient should be advised to purchase commercially available sterile products or to use
distilled or boiled water (not tap water) when
mixing a homemade solution for nasal lavage.11
Several different types of products can be
used for nasal irrigation. The basic process involves a bulb syringe, squeeze bottle or neti pot
to allow the user to manually pour or spray a
mixture of saline into one nostril. The fluid
flows through the nasal cavity and into the other nostril, rinsing the allergens away. Kits are
available that allow users to control the pressure of the flow and to conveniently prepare
the solution with pre-measured saline packets.
Humidifiers
When allergic rhinitis symptoms are at the
peak for a patient, a dry, itchy throat and nasal passages can be particularly bothersome.
Humidifiers can offer needed relief by adding
moisture back into the air. This often is more
important in the wintertime and in dryer areas.
The benefits of adding a humidifier are clear.
However, special considerations are necessary
for perennial allergy sufferers. As was discussed
earlier, the majority of perennial allergies are
caused by dust mites, mold and fungi. These
allergens thrive in high-humidity and higher
temperature areas. Methods to control dust
mite proliferation include keeping the humidity levels below 50%.16 Thirty to forty percent
Patient Scenario 2
While the technician is in the OTC section, she notices a mother with a child in an infant carrier searching
through the cough-cold products and comforting the obviously sick infant. Knowing that many OTC products
are not available for children that young, the technician approaches the mother and asks if she can help her
find anything. The frantic mother turns and explains that she does need help as her son is ill. The technician
suggests that the mother come back to the pharmacy to speak with the pharmacist.
Discussion
The technician did the right thing in intervening with the patient wandering the OTC aisles. Many parents
aren’t aware of the issues with dosing and safety. More importantly, if the infant is having a true allergyrelated issue, it may be advisable to get the child in to see a physician to get adequate control medications to
prevent any issues that may lead to asthma, since allergic rhinitis is linked to asthma. The pharmacist should
gather more information from the patient and make a recommendation.
Table 3
Non-drug therapies11
type of non-drug therapy
key counseling points
Nasal irrigation and saline spray
• Effective in providing relief with minimal side effects.
• Can be used in multiple patient populations.
• Advise patients to use commercially available products or to mix solutions using
distilled water.
• Multiple delivery devices are available for patient comfort/preferences.
Humidifiers
•
•
•
•
Cool compresses
• May be used for symptom relief alone or prior to nasal sprays to allow better
penetration of medication.
• Monitor use in young children or the elderly carefully to avoid shifting and blocking
of the nose or mouth.
Forced-air whole-house filters
• Recommend panel filters made of non-woven substances.
• Recommend filters with MERV ratings of 11 or higher.
• Change filters every three months.
Portable room air cleaners/purifiers
•
•
•
•
•
Non-drug therapies
Nasal irrigation and saline spray
Besides the CAM therapies, there is a non-
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Choose only cool mist to avoid formation of dust mites.
Purchase units that monitor humidity to allow maintenance below 50%.
Use distilled water to avoid mineral build-up.
Clean units thoroughly to avoid bacteria build-up.
Use after thorough surface cleaning and trigger control/reductions.
Review cost of unit and filters when assessing device.
Avoid ozone-producing units.
Choose HEPA models
Choose devices with CADR ratings appropriate to room size where the device will
be placed and those that have been Energy Star ® qualified
march/april 2014 •
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Technician CE Lesson
humidity is optimal. When recommending a
humidifier for symptom relief, be sure to advise
the patient to use only cool-mist (not steam) devices and distilled water to avoid the build-up
of minerals, to clean and filter the device regularly to avoid the development of mold, and to
moderate the use to achieve a humidity level of
30% to 40%. The best humidifiers for this purpose will have a built in hygrometer to allow
the desired humidity level to be programmed,
monitored and maintained.16
Cool compresses
If patients are suffering from pain and irritation around the eyes and sinus cavity due to
allergic rhinitis, reduction of swelling can provide some relief. Applying a cool compress or
gel pack on the affected area can reduce blood
flow and pressure. A cool compress applied
across the bridge of the nose before the administration of a nasal spray may add to the effectiveness of the therapy by allowing the drug
better access to the nasal passage. Advise parents to supervise young children when using
cool compresses and to remove the compress if
the child falls asleep to avoid any airway obstruction that could occur if the compress shifts.
Forced-air, whole-house filters
An often overlooked method of controlling
perennial allergies is a forced-air, wholehouse filter, also called a furnace filter or WHF.
In homes with forced-air heating and airconditioning systems, these filters provide a
number of benefits, including odor removal,
protection of the mechanical parts of the forced
air system, reduction of fire hazards by trapping
flammable materials, protection of decor and
a reduction in circulating particulate matter.
There are five primary types of furnace filters
available on the market. Those are panel filters;
high efficiency; particulate air, or HEPA, filters;
washable/reusable filters; electronic air cleaner
filters; and hybrid combinations.17 While the
American Society of Heating, Refrigeration
and Air-Conditioning Engineers, or ASHRAE,
recommends that any system that supplies air
to ductwork longer than 10 feet must have a
minimum efficiency reporting value, or MERV, of
six or more, the American Lung Association, or
ALA, provides more specific recommendations.
The ALA recommends a non-woven panel filter
with 1-in. pleats. The guidance also recommends
that consumers choose a filter with a MERV
value of 11 or higher and that the filter is changed
every three months.
Portable room air cleaners/purifiers
When patients have practiced thorough trigger control and cleaning without symptom relief,
a portable room air cleaner/purifier may provide
additional relief. Although researchers disagree
about the clinical effectiveness of the use of air
purifiers, reductions in some airborne allergens
and irritants have been seen. Researchers stress
5 • March/april 2014
Patient Scenario 3
The technician is working diligently in the prescription drop-off area, attempting to get caught up after a recent
rush. A 20-year-old female patient, Genna, arrives at the pharmacy with obvious nasal allergy symptoms. She
volunteers that the pharmacist spoke with her last month about trigger control for her perennial allergies, and
she has gone to great lengths to control the dust mites and pet dander in her bedroom. She has even taken
the initiative to replace the carpeting in her room with hardwood floors and has encased all of her pillows in
dust mite-reducing coverings. Despite damp dusting all of her walls and furniture, she still is struggling and
needs more advice, as she’s considering purchasing an in-room air purifier.
Discussion
Because this patient has practiced thorough trigger control and reduction by cleaning surfaces, encasing
bedding and removing the carpeting, she may receive additional benefits if she chooses to purchase an air
purifier. As the technician waits for the pharmacist to be available, she quickly reviews some of the items to
target when choosing an air purifier. Her recommendations include:
• Reviewing the cost of unit and filters when comparing units;
• Avoiding ozone-producing units and choosing a HEPA unit;
• Accessing the CADR.org website to choose a device with an appropriate CADR and Energy Star® rating; and
• Discussing the potential for white noise with the use of the air purifier. This may or may not be desirable
depending on the patient’s preference. Recommend testing the product for acceptable noise level in the
room it will be used in.
When the pharmacist arrives, he supports the decision to consider an air purifier and agrees with the
recommendations the technician provided. He also advises the patient that she may be able to get some
relief by using the new over-the-counter steroid nasal spray that has just become available. He then provides
counseling on the proper use of the spray.
that air cleaners/purifiers are not intended to replace trigger-control and surface cleaning efforts,
as these devices only remove particles in the air
and do not affect allergens that may have settled
on surfaces.
While air cleaners are not able to remove triggers that have already settled on surfaces, studies are emerging demonstrating improvements
in trigger exposure, particularly if the room
air cleaner/purifier was placed in the sleeping
areas. In general, more study still is needed as
researchers are urged to focus on studies that
are of longer duration and demonstrate links to
medication use and other objective findings to
demonstrate efficacy.
For patients who are ready to invest in portable room air cleaners or purifiers, careful consideration is needed. Experts recommend looking for units that balance cost — of the unit and
filter replacements — with air cleaning and energy efficiency, unit maintenance needs and reporting, and noise. It also is recommended that
users select units that do not generate ozone,
as ozone may irritate allergies and asthma directly. Advise patients to choose only HEPA air
purifiers and to reject units that have ionizers or
ozone generators.
The Environmental Protection Agency (EPA)
recommends a standard developed by the Association of Home Appliance Manufacturers
(AHAM) to independently rate the effectiveness
of portable air cleaner devices. That standard
evaluates the Clean Air Delivery Rate (CADR)
of an air cleaner to assign a numeric AHAM
Verifiede rating. The CADR rating indicates the
device’s ability to deliver contaminant –free air
within a standard test chamber. A CADR is de-
Table 4
Common oral antihistamines
product
generation
Prescription
status
Brompheniramine
First
OTC
Chlorpheniramine
First
OTC
Cetirizine
Second
OTC
Clemastine
First
OTC
Desloratidine
Second
Rx
Diphenhydramine
First
OTC
Fexofenadine
Second
OTC
Levocetirizine
Second
Rx
Loratidine
Second
OTC
termined for dust, tobacco smoke, and pollen
separately. Higher CADR ratings are desirable.
Because room settings vary, it is unlikely that
the device will achieve the exact CADR value
as published, however the independent system does allow consumers to compare devices
consistently. A website is available to allow consumers to input room dimensions and desired
CADR ratings. The website is www.CADR.org.
Additionally, consumers should be advised
to look for the Energy Star ® insignia to choose
energy efficient products. Additionally, patients
should have a good understanding of the filter
replacement or cleaning procedures and costs.17
To maximize the effectiveness of a portable
air purifier, placement of the unit is critical.
Use the unit in a closed room, keeping doors
and windows shut as much as possible. Advise patients to place the unit in an unobstruct-
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Technician CE Lesson
ed area to allow free airflow into and out of
the unit. When know allergens are present the
air cleaner should be placed near the source.
When a specific allergen source is unknown,
position the unit so that the clean air flow is
directed toward the center of the room.
Drug therapies
A number of medications are available to
relieve symptoms of allergic rhinitis and to
stop progression of the allergic response. All
medications must be selected carefully, taking
a number of factors into consideration. This
section will review the categories of medication
available and provide an overview of the
actions of the medications. The pharmacist
always is the best source for the patient in
making therapy decisions, and the technician
always must refer the patient to the pharmacist.
Nasal glucocorticoids
Nasal glucocorticoids, also known as steroid
nasal sprays, often are considered first-line
therapy in treating the symptoms of allergic
rhinitis. These agents work by reducing
inflammation caused by the inflammatory
process. Drugs in this category have been
highly studied and have been proven to be
more effective than other treatments, including
oral antihistamines. Safety and effectiveness
have been established for children ages 2
years and older for most of the products.
Glucocorticoids may provide some relief at
the beginning of treatment, but maximum
effectiveness usually is seen after a few days
to weeks. When patients use the nasal spray,
they first must clear the nose by blowing or
wiping away mucous. In most cases, the head
should be tilted downward to prevent the
medication from dripping from the back of
the nasal cavity. After administering the spray,
rinsing the throat with water is recommended
in case any medication is present. This also
will help to remove any bad taste that may
result. Because the nasal steroids are not taken
by mouth, many of the common symptoms
seen with oral steroid use are not reported.
A recent study does indicate that the use of
nasal steroids can decrease growth velocity in
children with allergic rhinitis, and pediatric
patients should be monitored closely.18
Drugs in this category include beclomethasone, budesonide, ciclesonide, flunisolide,
fluticasone, fluticasone furoate, mometasone
and triamcinolone. Drugs in this category are
currently available by prescription. Triamcinolone received FDA approval in fall 2013 that
allows triamcinolone acetonide (Nasacort
AQ®) to be sold over the counter. This product
now is available without a prescription. This
change in status presents a number of opportunities to educate patients about the proper
use of the product. The pharmacy technician
should be ready to screen and refer patients to
the pharmacist proactively when the product
is selected from the over-the-counter shelf. 19
Oral antihistamines
Antihistamines have been available for a
number of years and work within a step in the
body’s allergic response to block the formation
of histamine. This function works to relieve itching, sneezing, runny nose and watery eyes. Early
antihistamines, also known as first generation,
are linked to side effects that include sedation
and the potential to cause excessive dryness that
can lead to dry mouth, dry eyes, urinary retention and constipation. These medications should
not be used before driving or operating heavy
machinery. Newer, second generation antihistamines are available that selectively bind the H1
receptor and have fewer adverse side effects,
especially related to sedation. These products
can have a direct effect on the heart and are used
with caution in cardiac patients. Newer antihistamines also have longer dosing intervals that
can increase compliance and control.
Multiple oral antihistamine products are
available, many in combination with decongestants and pain relievers, to provide multisymptom relief for patients. Table 4 reviews
the common oral antihistamine products.
Intranasal antihistamines
Two prescription nasal antihistamine sprays
are available to allow topical application of the
medication directly to the affected area. Since
the medications are applied directly to the nasal mucosa, relief begins within minutes, and
side effects seen from the oral formulations are
minimized. Azelastine and olopatadine are the
drugs currently available within this class. Azelastine also is available in combination with
fluticasone with the resulting product showing
better results than either drug when used alone.
Oral decongestants
There are two common oral decongestants
available that have been marketed in multiple
combinations. Those drugs are pseudoephedrine
and phenylephrine. Oral decongestants work by
constricting the blood vessels to relieve pressure
and congestion in the nose. Because of the mechanism of action, a number of contraindications
exist that require screening and evaluation by
the pharmacist. Additionally, although pseudoephedrine is highly regulated due to the potential to convert the product into an illicit drug, the
product is preferred in the management of allergic rhinitis in patients without contraindications.
Intranasal decongestants
Decongestant preparations also are available
over the counter to be sprayed directly on the
nasal passage. The two most common ingredients are available in multiple formulations. The
drugs are oxymetazoline and phenylephrine.
These products are very potent and effective at
providing immediate relief. Use of the product
should be limited to two to three days, as prolonged use can cause rebound congestion that
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also is known as rhinitis medicamentosa. When
interviewing a patient who is complaining of
excessive nasal congestion, the pharmacist will
need to assess for extended use of decongestant
nasal sprays to avoid worsening the problem.
Mast cell stabilizers
Within the allergic response, mast cells contribute to the immune response. Cromolyn is
available over the counter and is used in advance of the expected allergen to stabilize mast
cells and prevent the ensuing reaction. The medication must be used four times daily for several
weeks prior to the expected allergen. Side effects
are mild. Many patients do not adhere to therapy
for the recommended loading period and do not
see the maximum effects of the drug. Providing
encouragement and support for the patients can
result in better outcomes.
Leukotriene receptor antagonists
Montelukast is a leukotriene receptor antagonist that works to reduce allergy symptoms
and inflammation by blocking the leukotriene
receptor in the allergic response cascade. This
product is available by prescription only and
has the possibility of causing headaches and
upper respiratory tract infections.
Ipratropium
Ipratropium is an anticholinergic medication
that is available as a nasal spray to treat allergic
rhinitis. It is available by prescription and can
cause nosebleeds and nasal and oral dryness.
The medication can be absorbed systemically
and can cause problems with patients who have
glaucoma or prostate and/or bladder issues.
Immunotherapy
As was discussed in the introduction of
this lesson, allergic rhinitis is a condition that
is increasing both in the numbers of patients
suffering from the symptoms and in the severity of the body’s response. Allergic rhinitis has
been linked to the development of asthma in
patients who were previously not diagnosed.
Uncontrolled allergic rhinitis also contributes
to the worsening of asthma symptoms.
While additional research still is needed, a
growing number of patients may be candidates
for immunotherapy, also known as allergy
shots. Allergy shots are administered by a specially trained allergist who identifies specific
known allergens for the patient and administers gradually increasing amounts of the allergen over time. An allergist is a pediatrician or
internist who completed at least two additional
years of specialized training related to the diagnosis and treatment of allergies, asthma and
other immunologic diseases. Immunotherapy
usually is administered weekly for several
weeks, then monthly for a minimum of three to
five years. The therapy is costly and does have
a number of risks that must be weighed with
the trained allergist. However, a recent study
March/april 2014 •
6
Technician CE Lesson
in the Journal of Allergy and Clinical Immunology demonstrated an overall cost savings when
immunotherapy was used to prevent allergic
rhinitis.20 Additionally, researchers also have
published promising initial results in a study
investigating the effectiveness of an oral dust
mite immunotherapy.21 Continued work in the
field will undoubtedly result in new and more
available treatment options for patients.
Conclusion and call to action
With the ever-increasing number of patients
suffering from allergy-related symptoms, the
community pharmacy technician is in a prime
position to proactively advocate and refer patients
into discussions with the pharmacist that will
lead to better care. With the knowledge learned
in this lesson, it is important for the technician
to actively search out patients who need
additional information and recommendations.
As patients age and experience new healthrelated conditions, many may not realize the true
harm that can come to them for continuing to use
a tried-and-true over-the-counter remedy now
that they are living with hypertension, glaucoma,
diabetes or even a pregnancy. Being a primary
point-of-contact for many patients, the pharmacy
technician can act as a safety mechanism for the
patient. Rather than just asking if the patient has
any questions for the pharmacist, knowledgeable
technicians can recommend and direct patients
to the pharmacist with the information that
is needed. Ideally the pharmacist/patient
interaction will begin with a quick introduction
and sharing of information already collected from
the patient so that the patient and pharmacist can
interact efficiently.
Another opportunity for the community
pharmacy technician exists in intervening
with non-pharmacy patients who may be selftreating and potentially not properly controlling
their allergic rhinitis. Many living with allergic
rhinitis have accepted the condition and simply
endure the symptoms. As a member of the
patient’s healthcare team, the technician can
step up and let them know they have more
options than simply enduring the symptoms. As
more medications move to an over-the-counter
status, it will be more important than ever
for all community pharmacy technicians and
pharmacists to be more involved in ensuring
positive outcomes. Step up with the information
learned to assist your patients in living better
with allergic rhinitis.
1 “Allergy Facts and Figures”. Asthma and Allergy Foundation of America. http://www.aafa.org/display.cfm?id=9&sub=30#prev Accessed January 5, 2014. 2 Schiller JS, Lucas JW, Peregoy JA. Summary
health statistics for U.S. adults: National Health Interview Survey, 2011. National Center for Health Statistics. Vital Health Stat 10(256). 2012. 3 Bloom B, Cohen RA, Freeman G. Summary health statistics
for U.S. children: National Health Interview Survey, 2011. National Center for Health Statistics. Vital Health Stat 10(254). 2012. 4 Wallace, DV, Dykewicz, M S et al. The diagnosis and management of
rhinitis: An updated practice parameter. Journal Allergy and Clinical Immunology 2008; 122:S1-84. 5 Greiner, A, Hellings, P W, et al. Allergic Rhinitis. The Lancet (2012); 378(9809): 2112-2122. 6 Silverberg
JI, Simpson EL, Durkin HG, Joks R. Prevalence of Allergic Disease in Foreign-Born American Children. JAMA Pediatrics. (2013); 167(6):554-560. 7 Brozek, J L, Bousquet, J E, Baena-Cagnani, C.E,
Bonini, S, Canonica, GW, Casale, T D et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision J Allergy Clin Immunol, 126 (2010), pp. 466–476. 8 Mandhane, S N, Shah, J H,
Thennati, R. Allergic rhinitis: An update on disease, present treatments and future prospects. International Immunopharmacology. (2011) 11-11:1646-1662. 9 Meltzer, E O, Gross, G N, et al. Allergic rhinitis
substantially impacts patient quality of life: Findings from the Nasal Allergy Survey Assessing Limitations. The Journal of Family Practice (2012). 61-2:S5-S10. 10 Kern, J M, Bielory, L, et al. Targeting
Patient Education: Correlating Fluctuating Pollen Counts with Patient Online Inquires Into Asthma and Allergic Rhinitis. Journal of Allergy and Clinical Immunology. (2014) 133-2:AB256. 11 Greiner, A N,
Meltzer, E O, Pharmacologic rationale for treating allergic and nonallergic rhinitis. Journal of Allergy and Clinical Immunology. (2006). 118-5:985-996. 12 Baena-Cagnani, C E. Safety and tolerability of
treatments for allergic rhinitis in children. Drug Saf. 2004; 27(12):883-98. 13 Slavin, R G. Special Considerations in treatment of allergic rhinitis in the elderly: role of intranasal corticosteroids. Allergy and
Asthma Proceedings. (2010); 31(3): 179-84. 14 Consultation and Referral Guidelines Citing the Evidence: How the Allergist/ Immunologist Can Help. Practice Resources. American Academy of Allergy
Asthma and Immunology. http://www.aaaai.org/practice-resources/consultation-and-referral-guidelines.aspx Accessed January 10, 2014. 15 G. Passalacqua, P.J. Bousquet, K.H. Carlsen, J. Kemp, R.F.
Lockey, B. Niggemann et al. ARIA update: I—systematic review of complementary and alternative medicine for rhinitis and asthma J Allergy Clin Immunol, 117 (2006), pp. 1054–106. 16 “Humidifiers
and Indoor Allergies”. Conditions and Treatments. American Academy of Allergy, Asthma and Immunology. https://www.aaaai.org/conditions-and-treatments/library/allergy-library/humidifiers-and-indoorallergies.aspx. Accessed January 5, 2014. 17 Sublett, J.L., Seltzer, J., et al Air filters and air cleaners: Rostrum by the American Academy of Allergy, Asthma & Immunology Indoor Allergen Committee.
American Academy of Allergy, Asthma & Immunology. 125-1 (2010), pp. 37-38. 18 Skoner, D P FDA Guidance-Design Study of the Effect of Intranasal Triamcinolone Acetonide Aqueous (TAA_AQ) on
Growth Velocity (GV) of Children with Perennial Allergic Rhinitis (PAR). Journal of Allergy and Clinical Immunology. 2014; 133-2:AB3. 19 Phend, C “Nasacort Allergy Spray Going OTC” Med Page Today.
10 Oct 13. http://www.medpagetoday.com/allergyimmunology/allergy/42235. Accessed November 30, 2013. 20 Hankin, C S, Cox, L, Bronstone, A, Wang, Z, Allergy immunotherapy: Reduced health
care costs in adults and children with allergic rhinitis. Journal of Allergy and Clinical Immunology. (2013) 131-4:1084-1091. 21 Bergmann, K.C, Demoly, P. et al. Efficacy and safety of sublingual tablets
of house dust mite allergen extracts in adults with allergic rhinitis. J Allergy and Clinical Immunology (2013) doi 10.1016.
Learning Assessment
Successful completion of “Understanding the
technician’s role in assisting the patient with
allergic rhinitis” (0401-0000-14-201-H01-T)
is worth one contact hour of credit. To
submit answers, visit our website at www.
CEdrugstorenews.com.
1.Common symptoms of allergic rhinitis
include:
a. Stiffness in the joints, pain in the
extremities and visual disturbances
b.Runny nose, watery eyes, persistent
sneezing and congestion
c. Nasal dryness, general malaise and
dizziness upon standing
d.Excitability, abdominal distress,
constipation and urinary hesitancy
7 • march/april 2014
2.Patients with allergic rhinitis can suffer
with sleep disturbances. Sleep disturbance symptoms include:
a. Mouth-breathing
b.Difficulty performing work
c. Daytime awakening
d.All of the above
3.Patients who arrive at the pharmacy with
swelling and a blue tint in the skin below
the eyes have a condition called:
a. Azure halos
b.Rhinitis medicamentosa
c. Nasal polyps
d.Allergic shiners
4.Researchers advise that allergic rhinitis:
a. Is present in 10% to 30% of adults
b.Affects up to 40% of children
c. Is more common in male children than
female children
d.All of the above
5.Allergic rhinitis has been directly linked
to which of the following conditions:
a. Delayed progression to puberty
b.Urinary retention
c.Asthma
d.Hypertension
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Technician CE Lesson
Learning Assessment
6.Trigger control is important for patients
suffering from allergies. For patients with
seasonal allergies, which of the following
actions are recommended to control
triggers?
a. Accessing pollen and mold reports
before planning outdoor activities
b.Avoiding prolonged periods outside
when pollen counts are high
c. Using air-conditioning
d.All of the above
7.Which of the following triggers could
need to be controlled by a person suffering from seasonal or perennial allergies?
a.Mold
b.Ragweed
c. Dust mites
d.Tree pollen
8.Nasal irrigation, humidifiers and room air
purifiers are examples of non-drug therapies that could be recommended for:
a. Young children
b.Lactating mothers
c. Elderly men
d.All of the above
9.Which of the following special patient
populations requires extra evaluation by
the pharmacist due to changes in nasal
mucosa and the mechanics of swallowing?
a. Lactating mothers
b.Children younger than 2 years of age
c. The elderly
d.Pregnant women
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10.A patient picking up his regular refill of
hypertension medication is exhibiting
a number of classic allergic rhinitis
symptoms (e.g., runny nose, sneezing,
watery eyes and swollen nasal passages).
Choose the best interaction that the
technician can make from the list below:
a. The technician should quickly ask if he has
any questions for the pharmacist, quickly
complete the transaction and send him on
his way before he starts sneezing again.
b.The technician should ask if he has any
questions about his medication for the
pharmacist and tell him where to find
the cough and cold remedies in aisle 7.
c. The technician should spend a few minutes learning about his symptoms and
recommend that he speak with the pharmacist to get some treatment that will
work with his blood pressure medicine.
d.The technician should send him to the
front cash register to pay in an effort to
control infection at the pharmacy counter.
March/april 2014 •
8