Allergic Rhinitis: Workplace Productivity & Treatment

• Nasal congestion may cause reduced airflow, fullness, stuffiness, or obstruction.
• Mucosal inflammation is the primary cause of nasal congestion in allergic rhinitis and rhinosinusitis.
• Nasal congestion frequently accompanies allergic rhinitis, rhinosinusitis, and nasal polyposis due to mucosal inflammation.
• Nasal congestion can worsen or remain unaffected by continuous positive airway pressure (CPAP) in individuals with obstructive sleep apnea and allergic rhinitis.

Allergic Rhinitis

• Allergic rhinitis, impacting 14% to 60% of the U.S. population, is the most prevalent atopic condition in the United States.
• Approximately 60% of individuals reporting allergic rhinitis symptoms experience nasal congestion on a daily or near-daily basis.
• The total direct medical cost of allergic rhinitis in the U.S. was $3.4 billion in 2003.
• Allergic rhinitis symptoms led to an average productivity loss of $518 per employee.
• 80% of allergic rhinitis patients reported nasal congestion as bothersome, and face fatigue, mood changes, depression, anxiety, and impaired cognitive function, affecting life quality.
• Effective relief is reported when allergic rhinitis patients use nonsedating antihistamines and intranasal corticosteroids.
• Nasal congestion in allergic rhinitis results from early- and late-phase allergic inflammatory responses.
• An antigen encounter in nasal mucosa of allergic rhinitis patients triggers mast cell crosslinking of immunoglobulin E (IgE) receptors.
• Mast cell degranulation releases histamine and proteases, which causes swelling, edema, fluid secretion, and congestion

Late-Phase Inflammation

• Continued swelling and edema from inflammatory cells in the late-phase worsen nasal congestion by eosinophils, neutrophils, basophils, mast cells, and lymphocytes.
• Eosinophil infiltration negatively affects nasal airflow in allergic rhinitis patients.
• Symptoms worsen with continued antigen exposure as cellular infiltration primes mucosa.
• Actions of TNF-a, cell adhesion molecules, proinflammatory interleukins, IgE synthesis, and eosinophil-basophil priming cause inflammation, venous engorgement, nasal hyperreactivity, and congestion.
• Nonallergic rhinitis forms (infectious, vasomotor, eosinophilia syndrome, hormonal) are not IgE mediated.
• Nasal congestion is a symptom particularly in pregnancy-related rhinitis.

Rhinosinusitis

• Rhinosinusitis is the inflammation of mucosa in the nasal passages and paranasal sinuses.
• Causes of rhinosinusitis include infectious and noninfectious factors, as well as immunologic and nonimmunologic inflammation.
• Viral infection, or the common cold, is the most common cause of it.
• Research indicates viral infection stimulates inflammatory pathways, prolonging symptoms even when viral replication stops.
• Microorganisms are largely responsible for acute rhinosinusitis, lasting fewer than 4 weeks.
• Proinflammatory cytokines and elevated kinin levels cause vascular leakage, engorgement, afferent nerve stimulation, and congestion.
• Viral upper respiratory infections elevate TNF-a and proinflammatory cytokines, increasing neutrophil and T cell infiltration, leading to congestion.
• The common cold is a frequent cause of acute rhinosinusitis, with 1 billion cases annually in the U.S.
• Total spending on cold medications reached $11.4 billion in 2022.
• Adults average 2-3 colds per year, and children experience 6 or more.
• Rhinosinusitis is among the top 10 most costly conditions, with substantial costs related to medical expenditures and work absence.
• Chronic rhinosinusitis (CRS) is characterized by nasal blockage, obstruction, congestion, nasal discharge, facial pain, and reduced smell.
• CRS, which lasts 12 weeks or longer, may have non-infectious causes.

Nasal Polyposis

• Nasal polyposis is a chronic inflammatory disease in the upper airway that affects roughly 4% of the population.
• Chronic infection, aspirin intolerance, trapped pollutants, epithelial destruction, cell defects, and inhalant or food allergies may contribute to nasal polyposis.
• Chronic inflammatory rhinosinusitis commonly results in nasal polyps, which are small sacs filled with cellular fluid, in the middle meatus originating from the nasal mucous membrane.
• Nasal passages become blocked by polyps, causing nasal obstruction, discharge, and impaired smell.
• Similar to allergic rhinitis and rhinosinusitis, inflammation and edema cause nasal congestion in nasal polyposis.
• Eosinophils and mediators are highly present in allergic and nonallergic nasal polyposis.
• T-cell response patterns differentiate between chronic rhinosinusitis and nasal polyposis, and Staphylococcus aureus enterotoxins play a role in nasal polyposis.
• An estimated 30 million Americans living with chronic rhinosinusitis, one-third of these patients may have nasal polyposis.
• Data shows of 529 patients with chronic congestion experience congestion every day (25%), regularly experience headaches, (over half); almost half impacts the ability to smell or taste food.
• Congestion significantly impacts nighttime sleep (60%), resulting in fatigue (one-third), and it negatively impacts daily activities (85%).

Treating Nasal Congestion

• Nasal congestion is commonly treated using decongestants.
• Decongestants are sympathomimetics, stimulating alpha receptors to constrict blood vessels, reducing vessel engorgement and mucosal edema.
• Direct-acting decongestants bind directly to adrenergic receptors; indirect-acting decongestants (ephedrine) displace norepinephrine from storage vesicles, potentially causing tachyphylaxis.
• Mixed decongestants have both direct and indirect activity.
• Decongestants effectively treat short- and medium-term congestion, but cardiovascular and central nervous system adverse effects can limit their broader use.
• Oral decongestants can lead to elevated blood pressure, tachycardia, palpitations, arrhythmia, restlessness, insomnia, anxiety, tremors, fear, and hallucinations through sympathomimetic activity.
• Adrenergic stimulation from decongestants can exacerbate hypertension, coronary heart disease, ischemic heart disease, diabetes mellitus, hyperthyroidism, and elevated intraocular pressure.
• Alpha-adrenergic agonists in these drugs may worsen urinary flow or cause urinary retention in patients with prostate disease.
• Topical intranasal decongestants, when used properly, have few systemic adverse effects and commonly show adverse effects as a result of vehicle.
• Oxymetazoline, a long-acting decongestant, is widely available over-the-counter which works in 25 seconds to reduce edema and inflammation by stimulating nasal mucosa a-adrenergic receptors, causing vasoconstriction.
• Administering oxymetazoline 0.05% nasal spray efficiently relieved congestions symptoms.
• Patients with certain comorbidities should avoid decongestants due to sympathomimetic activity.

Intranasal Systemic Absorption

• Intranasal oxymetazoline is poorly absorbed and therefore poorly distributed systemically caution is advised in patients with cardiovascular disease, diabetes, thyroid disease, and prostate disease.
• Patients with concurrent disease states should be stable and consult their provider before starting intranasal decongestants.
• Intranasal oxymetazoline may cause temporary reactions: burning, increased nasal discharge, and dryness of the nasal mucosa, but the incidence of serious adverse effects are low when at therapeutic dose and label.
• Systemic sympathomimetic effects such as hypertension, nervousness, nausea, dizziness, headache, insomnia, palpitations, or reflex tachycardia can infrequently happen when using oxymetazoline intranasally,
• Oxymetazoline is lacking systemic drug-drug interactions but it is advisable to avoid patients taking monoamine oxidase inhibitors using concurrent decongestants.
• Formulations made include; no-drip formula, moisturizers, menthol.
• Oxymetazoline is preferred for long-acting congestion, since it lasts through the night. This helps children get a full night's rest.

FDA communication

• The FDA published a safety communication regarding the adverse effects of accidental ingestion of decongestant eye drops and intranasal sprays that contained tetrahydrozoline, oxymetazoline, and naphazoline.
• Adverse effects of accidental ingestion caused: coma, decreased heart rate, and sedation.
• Amounts of 1 to 2 milliliters resulted in adverse effects: nausea, vomiting, drooling, hypotension, hyperthermia, and lethargy,.
• Patients should be reminded to keep these products away from children and to call the Poison Help Line (800-222- 1222) in case of accidental ingestion even though intranasal decongestants and eye drops come in child-resistant packaging.

Rhinitis Medicamentosa

• Nasla spray usage needs to be limited to prevent rhinitis medicamentosa.
• Rhinitis medicamentosa causes severe nasal blockage that can create oral breathing, a dry and sore throat, and insomnia, snoring, and disturbed sleep.
• Intranasal decongestants are either: B-phenylethylamine and imidazoline derivatives.
• B-Phenylethylamine derivative decongestants produce vasoconstriction by activating a1-adrenoreceptors which stimulate the sympathetic nervous system.
• B-adrenoreceptors could cause rebound vasodilation and therefore rebound congestion.
• Drugs from intranasal decongestants that classify as B-phenylethylamine derivatives consist of phenylephrine and can show symptoms anywhere from 3 days to 6 week of use.
• Imidazole derivatives, like oxymetazoline, are a2 agonists. Also this has a high effectiveness for decreasing blood flow, and are less likely to cause congestion.
• A study followed 30 subjects using oxymetazoline (0.05%) twice daily of a four week period. During this time frame they did not develop rebound congestion or diminished responsiveness of the drug.
• A Swedish study investigated if benzalkonium chloride had an effect on nasal mucosa, this study found that benzalkonium chloride did not show any effects on nasal mucosa.
• Patients should be instructed to only use intranasal decongestants for virus illnesses for 3 to 5 days.
• A study showed there were randomized doses of oxymetazoline for two weeks, subjects did not report worsening congestion as time went on.
• Researches showed that using intranasal congestion with oxymetazoline can be used for beyond 3 days.
• Treatment starts with immediate discombobulation of the decongestants.
• Then receiving nasal corticosteroids can helps with easing the nasal decongestion.
• Some patients use oral corticosteroids for a specified amount of time to help reduce their side effects.
• Preventative measure of intranasal congestion when using intranasal decongestant.
• Oxymetazoline with fluticasone furoate 1 sprays each, all used daily shows better relief rather than using steroid alone.
• Intranasal shows the corticosteroid oxymetazoline prevented rhinitis medicamentosa and this combination might be useful in with a nonallergic nasal congestion.

Systematic Review for Rhinitis

• A study was done comparing 2 groups, where medication was withdrawn it was shown that the patients did not undergo rhinitis medicamentosa.
• Studies show that combined corticosteroid may be effective at treating nasal congestion and reduce rhinitis symptoms in patients than either drug alone, without inducing rhinitis medicamentosa.
• Longer term users should talk with their provider.
• The potential usage and recommendation of inhaled corticosteroid with a nasal decongestant without have rhinitis medicamentosa, but patient should seek medical treatment on the subject.
• Gathering information from the patient regarding their symptoms, their symptoms, history, onset, location, aggravating factors, remitting factors, current medications, allergies, chronic conditions, and social history follows the SCHOLAR-MAC method, a well-documented method for patient assessment. Pharmacy technicians can assist by gathering this information.

Patient Assessment

• Patients are assessed by pharmacists to see if they can be treated in house or need medical attention.
• A patient with cat allergies the use of an inhalant can cause allergies. Symptoms from this the medications need to be reviewed.
• Patients are able to receive medical treatment or medications that may need them, but cannot be solved with the tool at hand.
• When medical assistance is need due to their concurrent chronic diseases (cardiovascular disease, diabetes, thyroid disease, or prostate disease), symptoms of nonallergic rhinitis and/or infections .
• Patients must be sure there is a correct product to ensure patient safety.

Plan & Safe Usage & Measures

• Use medication for the best result.
• When congestion is involved there should be ways to treat for a secure use.
• The proper use of nasal decongestants
• The proper use of nasal decongestants includes not only how to use the devices that deliver the medication, but also the importance of adhering to the recommended dosing. Read recommended dosing on the package and discuss that sprays
• If using for the first time by spraying in the air, away from the face, until users see mist.
• Aim the tip of the device away from nasal septum.

Explore the economic burden of allergic rhinitis, considering direct medical costs and indirect productivity losses. Investigate therapeutic interventions for nasal congestion in allergic rhinitis and comorbid rhinosinusitis. Understand the impact on sleep and cognitive function.