Patients presenting with allergic conditions in the pharmacy is a common occurence. But pharmacists are well placed to help manage these symptoms, writes Holly Shaw
Key learning points
• The UK has one of the highest rates of allergy in the Western world
• Allergies can have a significantly negative impact on a person’s life and should not be trivialised
• Patients should start allergy treatment before symptoms begin
Identifying allergic triggers
Pharmacists are well placed to discuss suspected triggers and ask questions to elicit information on individual triggers. Allergic triggers that are inhaled are called aeroallergens and include:
•Pollen.
•Mould.
•Pet dander.
•House dust mite.
Exposure to aeroallergens may be seasonal, for example pollen, which
depends on the three main pollen seasons (tree, grass and weed) and which specific pollen the patient is sensitised to. Or the allergy may be perennial (occurring all year round), for example with house dust mite. Food allergens consumed in the diet vary from patient to patient, but the main ones are:
•Peanut.
•Tree nut.
•Cow’s milk.
•Soya.
•Wheat.
•Egg.
•Sesame.
•Shellfish.
•Fish.
Cow’s milk and egg allergy are commonly seen in infants and children. It is possible to develop an allergy to a food that has been eaten before with no previous symptoms.
Symptom recognition
This is an area that pharmacists are well placed to identify. Self-reporting of allergy is common, with some patients already having an allergy diagnosis. It is important for pharmacists to consider whether management in the pharmacy is appropriate, to acknowledge expertise limitations and know when to direct a patient to their GP.
Patients who may require specialist management include those without a definitive diagnosis or those from specific patient groups with specialised treatment pathways, for example pregnant women. Patients with a suspected food allergy should always be advised to see the GP for an allergy-focused clinical history.
Symptom recognition in food allergy is an important aspect of patient education, so the patient knows when to use an adrenaline auto-injector. This is as important as knowing how to use it.
Avoidance and minimisation strategies
These will vary according to the trigger. For patients with food allergy, strict avoidance is important to prevent accidental exposure. Even when patients report a mild reaction, there is no guarantee that subsequent exposure will follow the same pattern. With aeroallergens such as pollen or animal dander, advice and practical solutions can be provided.
Patient education is a key area where pharmacists can help improve patient outcomes. Because of short appointment times, patients seen in primary care may not have had adequate education on allergy management. Pharmacists can use their specialist knowledge to provide education on medication and device management.
Medications
The choice for treating allergic rhinitis can be confusing. Pharmacists are well placed to recommend a product that is matched to symptoms and their severity. It is beneficial to start treatment before symptoms begin. Eye symptoms are common in allergic rhinitis, with patients reporting red, watery and itchy eyes in addition to nasal symptoms. If this is the case, eye drops may be required.
Antihistamines are the first line of defence for many allergic conditions.
When helping patients choose an antihistamine, it is important to be aware of the sedative effect of first-generation drugs, as well as the short duration of action. The benefit of second-generation antihistamines is the rapid onset, which is good for compliance, as is the daily dosing and the fact that they are non-sedating. On occasion, patients may require high doses of antihistamines to manage allergic or potentially non-allergic symptoms – eg in chronic spontaneous urticaria. Although these doses should be prescribed, it is important to provide reassurance that they are safe and within national guidelines.
Potential to develop asthma
Allergic conditions commonly co-exist, specifically asthma and allergic rhinitis. Allergic rhinitis is also a known risk factor for the development of asthma, which should flag as a clinical suspicion. Poorly managed allergic rhinitis can impact on asthma, with 80% of asthmatics also suffering with allergic rhinitis.[2]
Adherence
This is influenced by perceived benefits, duration of the medication or treatment regime and cost. Patients commonly report that their medication was not effective and subsequently stop using it. This might be linked to poor device technique, for example if a nasal spray is used incorrectly, the patient may conclude that the medication is not beneficial.
Device technique
This aspect of allergy management is often overlooked. Incorrect use of a device has the potential to result in poor outcomes.
This is particularly important for food allergy and the treatment of anaphylaxis, where adrenaline is the first stage of management. Devices are used to deliver medication to target specific symptoms and include nasal sprays, eye drops, adrenaline auto-injectors and inhaler devices. The ideal opportunity to educate patients on device technique is when they are dispensed. Patient education should take place using the same device as the patient’s, as they vary.
Medication reviews
These are important for patients with allergic conditions, who are often on more than one type of medication. Reviews can drive improvements, especially in management approaches that are stepped according to symptom severity. Pharmacists should also monitor the step up or down of medication and encourage patients to use expiry alert services to ensure medication is renewed before it expires.
Allergy management plans
These are a written plan for patients with allergic conditions to assist in the early recognition and treatment of symptoms. Patients who have an allergy requiring an adrenaline auto-injector or asthma should have a personalised management plan.
Patients presenting to the pharmacy seeking information on allergy testing should be signposted to their GP to discuss their symptoms and whether they are caused by allergy. Food allergy diagnosis is carried out by either a specific IgE blood test (previously known as a RAST test) or by skin prick testing, looking for the presence of IgE antibodies in the blood and skin.
Unproven testing methods that are not scientifically validated can result in an inaccurate diagnosis and lead to an unnecessarily restrictive diet that does not meet nutritional requirements. Examples of some of these include:
•Vega testing (electrodermal testing).
•Applied kinesiology.
•IgG blood tests.
•Hair analysis testing.
Conclusion
Pharmacists are in a unique position to deliver patient education at the point of care, provide support and give expert advice.
References
- Mintel (2010) – Allergy statistics - 21 million adults suffer from at least one allergy. (accessed 1 March 2017) org/allergy-statistics/allergy-statistics
- Allergic Rhinitis and its Impact on Asthma (ARIA). Management of allergic rhinitis and its impact on asthma: pocket guide 2008 (accessed on 27 February 2016). whiar.org/docs/ARIA_PG_08_View_WM.pdf
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