Activity Transcript

Charles P. Vega, MD: Hello, I'm Dr Chuck Vega, health sciences clinical professor in the Department of Family Medicine at the University of California at Irvine School of Medicine. Welcome to this program titled, “Intranasal Sprays for Allergy Relief: Clearing the Air.” I'm delighted to be joined today by Dr Jonathan Corren, who is clinical faculty at the David Geffen School of Medicine at UCLA, and a specialist in allergy and clinical immunology. Welcome, Jonathan.

Jonathan Corren, MD: Thanks very much, Chuck.

Dr Vega: We're going to do something really fun for the next 15 minutes or so. It's going to be a quick-fire program where we've each got a countdown timer and just 60 to 90 seconds to answer each question. We're going to see if we can get out the key information regarding the use of over-the-counter (OTC) intranasal sprays for the management of people with perennial allergic rhinitis. Let's go ahead and get started. Jonathan, today we're talking about perennial allergic rhinitis. How is this different from seasonal allergic rhinitis and how should clinicians use patient history to make treatment recommendations?

Dr Corren: First of all, Chuck, perennial allergic rhinitis really is a disease that lasts throughout the entire year. Generally, it's due to indoor allergens like dust mites, animal dander, and potentially, indoor molds. It's something that may not occur on a daily basis, but often does. Some of the classic symptoms are congestion, postnasal drip, discharge, and maybe some sneezing and itching as well. Seasonal rhinitis is something that occurs really discreetly in the Spring, typically, or the Fall, or both. It starts and it finishes. People with perennial rhinitis have to deal with a lot more.

Dr Vega: It sounds a lot more difficult. Beyond the temporality of it, are there other clues that can help us make a diagnosis of perennial versus allergic?

Dr Corren: The key thing is temporal, but oftentimes people will complain about that when they're in a certain location, perhaps indoors. When they wake up in the morning, that's the classic time for mites to affect people. Typically, with seasonal allergic rhinitis, it's more of an outdoor thing. Physical findings may be very similar between the 2. You'll see a boggy membrane, maybe a little bit of clear discharge, maybe a little bit of pharyngeal discharge, but other than that, not a whole lot.

Dr Vega: Can you give us a sense of the clinical burden of perennial allergic rhinitis? Sounds pretty serious.

Dr Corren: Because it's a year-round thing and it can come and go, sometimes being unpredictable, it can really affect people, not only at home but at work as well. There have been some really great pharmacoeconomic studies looking at this and what they've discovered is that people actually miss a lot of work because of this problem. Not only that, when they are at work, there's a phenomenon called presenteeism where people may be there but they're not really doing the job properly and not getting it done. They're not productive, they don't feel good, they don't interact well with coworkers. The sum total of this is that there's billions of dollars lost economically, and an impact on quality of life that really affects how people do day to day and how they interact with their families. There's a lot here, I think, to be concerned about.

Dr Vega: I imagine during the COVID-19 pandemic that it's pretty serious to come to work or to go to school and have clear congestion, coughing and sneezing. These are things that society does not look upon kindly over the past couple years. Has that been affecting your patients quite a lot?

Dr Corren: Not only affecting our established patients, but it really drove a lot of people to the allergist. People would go to a restaurant and start to sneeze, and people would sort of retract away from them. People would be afraid to go out in public because of that cough that comes from postnasal drip. I think that particularly now with the pandemic and with the upcoming flu season and respiratory syncytial virus (RSV), there are so many other things that can imitate allergies that people really want to get a handle on this because of the way it affects interactions.

Dr Vega: Can you talk a little bit about guidelines that are available to help clinicians manage patients with perennial allergies? What do they say?

Dr Corren: In the last 10 years, there's been a lot of attention devoted to this area. As we know, we're trying to standardize the way we treat patients, the way we diagnose them. I would say there are at least 3 to 4 guidelines that were established since about 2014, some from the family practice organizations, some from the otolaryngologists, and some from my own group of allergists. What they've tried to tell us is that there are some first line therapies we should use in people who have persistent, daily, perennial allergic rhinitis. What comes to mind first are intranasal steroids. They take care of the congestion. They get rid of some of the other symptoms as well. In people who have intermittent symptoms however, steroid is not the best choice. Many of the people may have symptoms 1 week and not the next. In that situation, we've found that intranasal antihistamines actually are a very good choice. They start to work within a few minutes. They take care of most of the symptoms, as well. There may be a place for intermittent use of oral antihistamines as well, but typically for symptoms of sneezing and itching, the oral drugs, with the exception of pseudoephedrine, the oral drugs really don't take care of anything but sneezing and itching. They don't address the congestion very well.

Dr Vega: In your practice, I'd imagine you're using more of an all the above option because you're seeing more severe patients than we might see in primary care. Is that right?

Dr Corren: Absolutely. Sometimes it's everything but the kitchen sink, which then the guidelines set us up for that. If people don't respond to the above regimen that we've been talking about, then environmental control measures become very important. Finally, immunotherapy, which is sort of the gold standard for people that don't respond to anything. All the guidelines do emphasize the role of that, but that's really a much bigger task to undertake. There are some things I'd like to ask you. First of all, let's talk about some of these different OTC products available for these patients with perennial allergic rhinitis. I think it would be helpful for the audience to really hear about some of the different intranasal corticosteroids.

Dr Vega: Yes, I'd love to share. It's interesting because I think a lot of us prescribe these agents. We're not necessarily thinking about the agent we're prescribing. We just happen to know that's the agent we've always used and therefore it's going to be effective or not effective to what we know, and we're not necessarily individualizing treatment.

The good news about corticosteroids intranasally is that they have a broad range of indications. We know they're effective for both allergic and non-allergic rhinitis, acute rhinosinusitis, and chronic rhinitis with nasal polyposis. But there is a difference. There is a first-generation intranasal corticosteroid group; these have a higher bioavailability than the second-generation corticosteroids.

One thing that I think is a lot more important to patients is whether you have a very wet nose or if you have a dry nose, you can have different forms of rhinitis, and it changes in patients from moment to moment, year to year. For wet nose, mometasone furoate and budesonide, they have a drying effect on the nose, whereas a dry nose might respond better to a drug like ciclesonide. In addition, there are 2 preparations of fluticasone available, fluticasone furoate and fluticasone propionate. The furoate has a greater receptor affinity, so you might see a difference in terms of efficacy. I'm not sure I've really seen that in clinical practice too much. It does vary more individual to individual. Find something that patients like.

Then, I'm very concerned with safety of these agents as well, and particularly among kids. You treat kids in your practice. One of the biggest questions we get is what about growth velocity? Will these corticosteroids which have some very modest systemic absorption, reduced growth velocity? There have been studies that have tied beclomethasone to reduce the pediatric growth velocity. It's questionable whether that's really significant in terms of the total loss of that velocity, but in other studies, mometasone, fluticasone, triamcinolone and ciclesonide, they really haven't been demonstrated to impair growth to any significant degree. Another concern is, could we potentially be suppressing the adrenal system and the hypothalamic pituitary axis? There's really no correlation between these inhaled corticosteroids and an impairment of that axis. Finally, could there be an association between systemic steroids? We know that systemic steroids promote higher intraocular pressure. Is that something we need to be concerned with these intranasal steroids? Doesn't seem to be the case either overall. So overall, a very well tolerated cohort of drugs which we know are very effective.

Dr Corren: The one thing I would add is that in many patients, particularly older adults where there's already some natural dry taking place in the nasal membranes, patients may complain of stinging. One thing we can do to avoid that is to use an intranasal saline spray. Another problem can be nose bleeds. Usually, it's very mild epistaxis. They blow their nose. They get a little blood in a tissue. It's very rare to get frank epistaxis with a huge nosebleed where they have to go to the emergency room. Certainly, when patients complain about that, we may think about either cutting down the frequency of the drug or even maybe looking for an alternative agent.

That kind of leads us into the next question, which is what about other classes of drugs like intranasal antihistamines? Can you talk about those and review for us some of the differences?

Dr Vega: Yes, for sure, because these are great agents as well. They can be used in children. When I think about azelastine, there are 2 formulations. The second preparation has a different vehicle, it's reduced the amount of bitter taste. It has to be dosed very frequently to be effective, but you can use it more as needed. You can use up to 2 sprays per nostril twice daily for more perennial rhinitis. These are the folks, as you mentioned, that are really suffering every day with their symptoms and don't get a lot of off time, unfortunately.

The big difference with azelastine versus the corticosteroids is its onset of action. We're talking about an onset of action with azelastine of just 15 minutes or so, whereas with intranasal corticosteroids you can expect the effects won't start for 3 to 12 hours, and you don't achieve maximal effects for 2 weeks. It's not a good start and stop kind of drug. It's a nice steady drug to take over time with the intranasal corticosteroids, but not every patient's going to want that and fit that profile. And honestly, in my practice, the younger they are, the less they're going to want to use an intranasal product every day.

We know that azelastine particularly, compares well with when we think about using oral antihistamines. Folks who are failing loratadine that have been given azelastine, they do better in terms of their symptom scores. Adding in oral antihistamine to azelastine doesn't really seem to improve patients' symptom profile much at all.

The nice thing about these intranasal preparations, is that it can reduce the overall medication burden. For patients don't want to take a lot of drugs, using an intranasal corticosteroid, using an intranasal antihistamine can really cut down on the overall number of pills and sprays that they're taking on a routine basis.

Dr Corren: I would add to that, there are some of our patients who, particularly during certain times of the year -- it might be, let's say in the fall when there's a lot of mold exposure, which is again one of the other big perennial allergens -- they may get some itching. We don't know why exactly, occasionally even some hives. That might be one particular situation where we combine something like azelastine maybe with an oral long-acting antihistamine to cover some of those more systemic symptoms.

Dr Vega: I mentioned that we are going to go to the big guns. That's what you're here for. What do you think about intranasal corticosteroids and antihistamines in a combination product? When do we use those and how effective are they?

Dr Corren: Very frequently people have been taking an oral antihistamine on an as needed basis and they're not doing well. They don't feel very good. One of the first things we'll do is put them on an intranasal steroid. Most of these drugs, as you mentioned Chuck, are available OTC. I don't feel strongly about which one they choose, typically. We'll give that a good 2 to 4 weeks because there is a cumulative effect as they continue to take the drug on a daily basis. There's a good percentage of patients with moderate to severe perennial allergic rhinitis that are not controlled with the intranasal steroid alone. In that situation, we immediately add an OTC intranasal antihistamine. We give it twice daily and we give that another few weeks. A significant portion of people that didn't respond to the intranasal steroid alone, or in some cases the azelastine alone, which is far less common, will do very well in this combination.

It's something we really try to educate the patients about. It's important to keep taking it consistently. There are commercial products that you can buy in combination, combining both the steroid fluticasone typically with azelastine. In some situations, a patient's insurance will not cover this, so we'll pair those 2 things together separately, and patients typically do very well with that.

Dr Vega: Is there clinical trial data that supports the use of the combination as being better than either alone?

Dr Corren: Yes, it's a very good question, and absolutely much more so than combining an intranasal steroid with an oral antihistamine, which has been looked at extensively.

Dr Vega: The data is pretty weak.

Dr Corren: Yes, it’s very weak. It doesn't seem like it adds significantly to the efficacy, but in this case, there's a significant difference with intranasal antihistamines. You get less nasal congestion, less discharge, less of the overall syndrome that the patients typically have to experience on a daily basis.

Dr Vega: Jonathan, when should a clinician consider using, alone or in combination, an oral OTC antihistamine?

Dr Corren: There are some people that still don't like to take intranasal medications, and if their primary symptoms are sneezing and itching maybe with a little discharge and they have intermittent symptoms, we'll certainly give them the benefit of that and allow them to try something that's not sedating, like a loratadine or a fexofenadine, where they're not going to be affected in their daily functioning. But very often they come back to us within a week or a couple weeks or a month, suggesting to us that this really isn't fixing the problem.

When we talk about combining an oral antihistamine with an intranasal steroid, we've talked about that a bit, there really isn't any real advantage. Some people have a prominent component of congestion, so they may want to take something like an oral antihistamine with an oral decongestant. The problem with that is there's a lot of side effects. There may be insomnia, people will feel palpitations, tachycardia, some dryness of the mouth. In older people, more serious things like urinary retention or constipation. Typically, I draw away from those drugs.

Chuck, I'd like to ask you, we know that some of these drugs have to be taken on a regular daily basis. Tell us how important you think medication adherence is to the management of this disease.

Dr Vega: I think especially when you're thinking about perennial rhinitis, it's critically important because it's not just this on again, off again phenomenon. It also makes me think about avoiding allergens in the first place. It is a challenge, but you really have to be dedicated to this lifestyle of avoiding allergens and mitigating the effects of allergens. I think it is very important they go through testing so that we can incorporate not just the right medications, but relatively simple measures like bedding covers and lowering humidity in the home for mites. For pollen and outdoor mold, you want to keep your windows closed, use screen filters in the windows, using the air conditioner, and then you might even need to limit the amount of time you spend outdoors. High efficiency particulate air (HEPA) filters, a lot of folks have questions of whether HEPA filters can work, and they are effective. They help with animal dander, with mold and dust.

Dr Corren: I was just going to say, we know how near and dear our pets are in many of the families that we treat. The one advice I would give to some of our audience members would be, before making any recommendations about getting rid of the animal, get a radioallergosorbent (RAST) test. What we used to call RAST is actually an amino acid, an IgE, test for whatever animal they have in the home, and dust mites. They don't have to do the entire panel because if there's a seasonal component, you'll pick up on that from the history. I think before we make major environmental control measure recommendations, we're going to want to get an idea, are they really allergic or not? Sometimes it's hard to tell from the history alone.

Dr Vega: I might send a patient over to you who's having trouble with their dog or cat because that's a huge issue, but I also send patients who are just suffering, and even going through the steps we've already described, they're still having a lot of symptoms and it's affecting their quality of life. When should we be referring to a specialist?

Dr Corren: I think you hit the first one, which is if they have uncontrolled symptoms on everything you've tried, which may be a combination of medications, both oral and intranasal, and some basic environmental control measures. What we'll typically do in that situation is a complete panel of testing. We're going to be looking at animal danders, everything and anything that they have contact with, including horses if they happen to ride on weekends, dust mites, cockroaches, which we often don't think about, but may be more of an industrial allergen exposure. All of the molds both indoor and out, and then all the pollens. The trees, the grasses, the weeds, and try to get an idea of what their level of sensitivity is. Now interestingly, Chuck, about half the time they come back being negative. About half the people with perennial rhinitis will be allergic. The other have something maybe related to other irritants like air pollution.

Dr Vega: Vasomotor.

Dr Corren: Exactly. In that situation, we then address whether we've done everything we can do environmentally and then consider allergy immunotherapy, which really as I said, is a very efficacious form of treatment, but it's not for everybody. There may be certain situations for dust mites, for instance, where you can use sublingual immunotherapy. You should also consider referring to an allergist if patients have complications of allergic rhinitis, recurring sinusitis or chronic sinusitis, in children recurring ear disease, although they may have already seen an otolaryngologist as well. Also, if they have concomitant asthma that's difficult to control. All of these things, I think, point the way to maybe getting a different opinion about what's going on.

Dr Vega: I'm going to give you a space to have the final word, but what I'm hearing today, and I think my conclusion is that we should definitely be thinking about using these intranasal preparations because they are highly effective, but you have to take them regularly. Use your environmental control measures, think about the fact that the intranasal antihistamines work much faster than intranasal corticosteroids, but you have folks with perennial symptoms who might need both therapies. Because these are so well tolerated and safe, I think that they should be used in primary care and that way the referrals we're making to you are the referrals that truly need to go to you. What's your take home?

Dr Corren: Chuck, I agree completely. I think right now we're in a really good place for patients and for primary care physicians. Patients have access to these medications. They may not try them, but it's very easy for you and your colleagues to tell the patient there's something you can get OTC. That really reinforces a safety issue. It's so safe that it's now been made OTC, both the intranasal steroids and intranasal antihistamines. That combination of the 2 will take care of the bulk of patients. The vast majority will do really well. For that last group, always remember that you have colleagues like myself who are very eager to help identify what allergens they are and how we can get rid of them.

Dr Vega: Jonathan, thank you for this great discussion. I know we're out of time. Thank you as well for participating in this activity. We know that you're busy, so it means a lot that you took the time to watch this. Please continue on to answer the questions that follow and complete the evaluation. Be well.

This transcript has not been copyedited.