Decreasing the burden of allergic rhinitis in the community and establish a new evidence-based pathway for care in the community

allergic rhinitis

Allergic Rhinitis (AR) is a chronic respiratory condition that currently affects 30% of the world’s population [1] and 19% of Australians [2]. AR often coexists with asthma [3-5]; 30% of people with AR have asthma while 80% of people with asthma have AR [6-8]. AR can negatively impact on health-related quality of life (QOL) - sleep, mental and voluntary motor function and participation in social activities [1, 8, 9]. AR can also create a significant economic burden, direct costs to patients i.e. $9.4 billion in Australia [1] and indirect costs caused by absenteeism and presenteeism (decreased productivity at work/school) [10].

AR is rarely present in isolation. The classical symptoms of AR include nasal congestion, nasal itching, sneezing and rhinorrhea. Some patients also experience ocular symptoms (rhinoconjunctivitis) such as tears, itching and redness of the eyes.

The management of AR is articulated in a series of international evidence-based guidelines, including the Allergic Rhinitis and its impact on Asthma (ARIA) [8]. Unfortunately, the translation of these guidelines into practice over time has been slow and requires evidence-based strategies. Currently, a majority of people with AR in the community are experiencing moderate-severe symptoms and only 15% are selecting appropriate medication.

There are clinical interventions for AR articulated/promoted and passively disseminated through a multitude of professional organisations. None of these clinical interventions are evidence based with no evaluation of implementation, efficacy or impact.

Hence, the following issues relating to AR management/implementing guidelines and their implementation remain:

Medication in the community pharmacy

  • Different AR medications are available in different countries
  • Prices of AR medications vary in different healthcare settings and global guidelines try and cover all these differences
  • AR medication scheduling and arrangements different globally
  • In Australia, AR medication scheduling differs in different states e.g. AR medications, which are available behind the counter (S3) in Queensland but available on the shelf (S2) in the supermarket (limited supply pack) in NSW.

Traditional management

  • AR has historically been managed with oral antihistamine, currently considered an “old” drug. While new drugs such as intranasal corticosteroids have been introduced and are currently the most effective treatment for AR.
  • People with AR predominantly self-medicate their AR through self-selecting treatment in the community pharmacy.

Healthcare Professionals role in AR management

  • AR Guidelines are difficult to translate into practice.
  • High self-management by AR patients’ results in limited engagement with HCPs.
  • The differential diagnosis of AR can be difficult as AR may appear with different combinations of symptoms.

Patients’ management belief and perception

  • 35% - 55% of AR patients self-diagnosing their condition [11-13].
  • Patients often underreport and underestimate the severity of their AR symptoms [14-17].
  • Patients treat their AR sub-optimally often lacking knowledge themselves while underutilizing their HCP [12, 15, 18-20].
  • This suboptimal medication management leads to poor control of symptoms [21-23].

Patients develop treatment fatigue; a sense of having explored all available options with regards to treating their AR and having exhausted any desire to pursue further investigations or treatment options[24].

This study will evaluate the impact of an AR Clinical Management Pathway”, a clinical pathway/process based on Allergic Rhinitis and its Impact on Asthma (ARIA) 2017 evidence and the framework, on the medication management of AR.

This will provide the first global evidence for a translatable process to be implemented by pharmacists into the community pharmacy.

Note: This clinical pathway would be the first evidence-based clinical pathway. While there are many recommendations available in Australian healthcare organisations, currently there is no evidence-based clinical pathway which guides the recommendations and has been shown to not only change the behavior of pharmacist management, but can also be implemented in pharmacy.

Program Type: Honours, Masters of Philosophy, Doctor of Philosophy programs.

Research Group: Quality Use of Respiratory Medicines Group

Supervisors: Professor Sinthia Bosnic-Anticevich and the Quality Use of Respiratory Medicines Group in collaboration with international collaborators will supervise the candidate.

Synopsis and Research Plan: This research will be conducted in 2 phases:

  • Phase 1: will take the form of a cross-sectional, pre-post intervention study in which the feasibility of implementing the AR Clinical Management Pathway (AR-CMaP) will be tested.
  • Phase 2 will involved the implementation of the AR-CMaP in the community pharmacy setting and the evaluation of it in terms of clinical, humanistic and economic impact on the patient, healthcare system and society.

Significance: As a result of this research, we expect to achieve an evidence-based clinical pathway to implement in the community pharmacy which will:

  • Improve AR management by increasing the proportion of AR patients who select optimal AR medication.
  • Provide evidence on the effective of this clinical pathway to change the current AR management in the community pharmacy setting.
  • Provide a framework for pharmacy practice and a pathway for integrated care of AR globally.
  • Improve health outcomes for people with AR in the community.

This clinical pathway will be incorporated into future national and international AR guidelines; ARIA, PSA, Pharmacy Guilds, National Asthma Council Australia etc.

Funding: Funding is available for Phase 1 of this research. Funding for Phase 2 will be sought in the future.

Candidate: A healthcare professional background is favourable but not essential.

Contact: Professor Sinthia Bosnic-Anticevich, Sinthia.bosnic-anticevich@sydney.edu.au, 9114 0145 or 0414 015 614. 


References

  1. Pawankar, R., et al., World Allergy Organisation (WAO): White book on allergy. Wisconsin: World Allergy Organisation. Available online at: http://www.worldallergy.org/UserFiles/file/WAO-White-Book-on-Allergy web.pdf, 2011.
  2. AIHW, Australia’s health 2016, A.I.o.H.a. Welfare, Editor. 2016: Canberra, Australia.
  3. Oka, A., et al., Ongoing allergic rhinitis impairs asthma control by enhancing the lower airway inflammation. The Journal of Allergy and Clinical Immunology: In Practice, 2014. 2(2): p. 172-178. e1.
  4. Omachi, T.A., et al., Allergic Status Is Associated With Increased Number Of Asthma Exacerbations, in C38. NEW DEVELOPMENTS IN ASTHMA CARE, METHODS, AND OUTCOMES. 2016, Am Thoracic Soc. p. A4970-A4970.
  5. Feng, C.H., M.D. Miller, and R.A. Simon, The united allergic airway: connections between allergic rhinitis, asthma, and chronic sinusitis. American journal of rhinology & allergy, 2012. 26(3): p. 187.
  6. Van Der Leeuw, S., et al., The minimal clinically important difference of the control of allergic rhinitis and asthma test (CARAT): cross-cultural validation and relation with pollen counts. NPJ primary care respiratory medicine, 2015. 25: p. 14107.
  7. Brozek, J.L., et al., Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 Revision. Journal of Allergy and Clinical Immunology, 2010. 126(3): p. 466-476.
  8. Brożek, J., et al., Allergic Rhinitis and its Impact on Asthma (ARIA) Guidelines – 2016 Revision. Journal of Allergy and Clinical Immunology, 2017. S0091-6749(17): p. 30919-3.
  9. Keith, P.K., et al., The burden of allergic rhinitis (AR) in Canada: perspectives of physicians and patients. Allergy Asthma Clin Immunol, 2012. 8(1): p. 7.
  10. Pawankar, R., et al., World Allergy Organisation (WAO) White Book on Allergy: update 2013. Milwaukee: World Allergy Organization, 2013.
  11. Bauchau, V. and S. Durham, Prevalence and rate of diagnosis of allergic rhinitis in Europe. European Respiratory Journal, 2004. 24(5): p. 758-764.
  12. Tan, R., et al., Identifying the hidden burden of allergic rhinitis (AR) in community pharmacy: a global phenomenon. Asthma Research and Practice, 2017. 3(1).
  13. Canonica, G.W., M. Triggiani, and G. Senna, 360 degree perspective on allergic rhinitis management in Italy: a survey of GPs, pharmacists and patients. Clin Mol Allergy, 2015. 13: p. 25.
  14. Nolte, H., S. Nepper-Christensen, and V. Backer, Unawareness and undertreatment of asthma and allergic rhinitis in a general population. Respir Med, 2006. 100(2): p. 354-62.
  15. Fromer, L.M., et al., Current Allergic Rhinitis Experiences Survey (CARES): Consumers' awareness, attitudes and practices. Allergy Asthma Proc, 2014. 35(4): p. 307-15.
  16. Williams, A. and G. Scadding, Is reliance on self-medication and pharmacy care adequate for rhinitis patients? International Journal of Clinical Practice, 2009. 63(1): p. 98-104.
  17. Peroni, D., et al., Rhinitis in preschool children: prevalence, association with allergic diseases and risk factors. Clinical & Experimental Allergy, 2003. 33(10): p. 1349-1354.
  18. Bousquet, J., P. van Cauwenberge, and N. Khaltaev, ARIA in the pharmacy: management of allergic rhinitis symptoms in the pharmacy - Allergic rhinitis and its impact on asthma. Allergy, 2004. 59(4): p. 373-387.
  19. Tan, R., et al., The Burden of Rhinitis and the Impact of Medication Management within the Community Pharmacy Setting. The Journal of Allergy and Clinical Immunology: In Practice, 2018.
  20. Small, P. and H. Kim, Allergic rhinitis. Allergy Asthma Clin Immunol, 2011. 7(suppl 1): p. S3.
  21. Lourenco, O., et al., Evaluation of Allergic Rhinitis and Asthma Control in a Portuguese Community Pharmacy Setting. Journal of Managed Care Pharmacy, 2014. 20(5): p. 513-522.
  22. Tan, R., et al., The burden of Rhinits adn the Impact of Medication Management within the Community Pharmacy Setting. Journal of Allergy and Clinical Immunology: In Practice, inpress.
  23.  Bosnic-Anticevich, S., et al., Lack of asthma and rhinitis control in general practitioner-managed patients prescribed fixed-dose combination therapy in Australia. J Asthma, 2017: p. 1-11.