Reacting to allergy
In a survey earlier this year, GPs said that up to 90 per cent of their appointments with summer pollen sufferers were unnecessary and could be dealt with in the local pharmacy. They are absolutely right
After reading this feature you should be able to:
- Differentiate between cold and allergy symptoms
- Explain the first-line approach to allergy management
- Support anaphylaxis patients
- Offer general advice on food allergies
Last year, almost 50,000 hayfever sufferers visited their GP in June for a consultation lasting, on average, seven minutes – the equivalent of 6,000 hours of surgery time across the country in just one month. In an Asda Pharmacy survey (undertaken in April), 99 per cent of the GPs taking part said more people should be made aware that pharmacists are able to advise and treat patients with minor ailments, including allergies such as hayfever.
“There is no reason for people to see their GP about hayfever unless the diagnosis is unclear,” says Allergy UK nurse adviser Holly Shaw. “This may also apply if their hayfever symptoms are not being managed with pharmacy products or they are impacting on their daily life, such as leading to poor sleep or affecting their sinuses or asthma.”
One reason why so many GP consultations are about hayfeveris because the UK has some of the highest allergy rates in theworld. According to Allergy UK, 44 per cent of British adults nowsuffer from at least one allergy and the number of sufferers is on the rise.
Hayfever (seasonal allergic rhinitis) affects one in five people in the UK, flaring up at certain times of the year, depending on which pollen(s) trigger the allergy. However, for others, allergies are a year-round problem, causing nasal symptoms, allergic conjunctivitis, skin rashes and even potentially life-threatening anaphylaxis or asthma attacks.
Allergies can be treated in various ways, depending on the trigger and the severity of the symptoms. It is essential to ensure that all allergies are being managed effectively. According to Anaphylaxis UK, there are various reasons why allergy symptoms may not be treated correctly. “There can be a lack of education surrounding allergic symptoms or a lack of access to allergy diagnosis,” says a charity spokesperson.
“Community pharmacists need to explain how and when to take/use allergy medication, including prescribed adrenaline auto-injectors. There is also evidence that patients can underestimate the risks of not managing their own symptoms.”
Spotting key signs
For many everyday allergies, diagnosis is made from the symptoms alone. According to Dr Adam Fox, consultant paediatric allergist at Evelina London Children’s Hospital, pharmacists need to differentiate between allergic and non-allergic symptoms. “First, what is the individual’s risk of having allergies?” he says. “Do they have a family or personal history of asthma and/or hayfever or a personal history of eczema?
“Secondly, do their symptoms fit the profile? For example, hayfever will classically cause nasal congestion, itching, a runny nose and eye symptoms. Thirdly, what about the timing? Are the symptoms seasonal or perennial? What happens if the patient goes on holiday – away from the family pet, for example? This can be more difficult to assess with an allergy to house dust mites, as hotel rooms or second homes are notoriously dusty.”
Dr Fox says that food allergies should be easier to identify. “Symptoms such as itching, urticaria (hives) and swelling are likely to be immediate and therefore obvious, occurring very quickly,” he says. “Typically, food allergies first appear in early childhood, although some adults may develop symptoms for the first time, most likely to fish or shellfish.
“If a food allergy is suspected, customers should be advised to undergo allergy testing. With environmental allergies, it is usually possible to make a clinical diagnosis without allergy testing, but people may wish to be tested if there are any diagnostic doubts or if they will be having desensitisation treatment.”
Patients can underestimate the risks of not managing their own symptoms
Some pharmacies stock allergy testing kits. Dr Adrian Morris, an allergy consultant in London and Surrey, says careful thought should be given to which products to stock. On its website, the British Society for Allergy and Clinical Immunology (BSACI) says that it doesn’t recommend allergy testing for IgE at a distance or by untrained individuals and would not advise using unproven tests such as kinesiology, Vega tests or hair analysis, for example.
“Most over-the-counter allergy testing kits are not reliable or accurate, so it is important that pharmacists make sure they only stock validated tests recommended by the BSACI,” says Dr Morris. “Allergy testing through a consultant can be difficult to obtain on the NHS as there are not many allergy specialists in the UK, but GPs can arrange allergy testing themselves.”
According to Anaphylaxis UK, patients should be referred for allergy testing when they have had a suspected allergic or anaphylactic reaction. “Community pharmacists should be able to recognise the symptoms of an allergic reaction and advise those patients to go to their GP,” says the charity’s spokesperson.
“Confirm that the patient is not having an acute anaphylaxis. reaction and manage accordingly. If a patient presents with an allergic reaction, then the GP should refer them to an allergy clinic. This process is the same for adults and children but we understand there are geographical differences in terms of the number of allergy clinics in a region.”
Allergic rhinitis - spotting the signs
Community pharmacists are well-placed to recognise some of the key signs of allergic rhinitis (seasonal and perennial). Farah Ali, pharmacist at Perrigo’s Warman-Freed Learning Pharmacy, has the following advice on helping to determine the difference between the signs of a cold and hayfever:
- A runny nose and clear, watery discharge could be due to hayfever. If coloured green or yellow, it could indicate a cold
- Itchy eyes are a common hayfever symptom but not for a cold
- Unexplained aches and pains indicate a cold rather than hayfever
- Sudden bouts of sneezing may be related to pollen exposure, as opposed to occasional sneezes typically experienced with colds
- If symptoms develop within a minute to a few hours, it could be hayfever; symptoms of a cold tend to form gradually (in two to three days)
- If symptoms are persistent over several weeks, it could be a sign of hayfever, whereas a cold typically lasts between three to seven days and rarely for more than a couple of weeks.
Asthma patients should be tested for allergies if their asthma is poorly controlled. Pharmacists may notice that patients keep returning for more inhalers, for example. A recent study conducted on behalf of the BSACI revealed that over 3 million asthmatics have not been tested for the allergic triggers that could cause a fatal attack. NICE guidance recommends specific IgE testing to identify allergens as soon as a formal asthma diagnosis has been made.
“We know that triggers can be identified for many people with asthma. The attacks don’t come out of the blue,” says Dr Shuaib Nasser, consultant in the department of allergy and asthma at Cambridge University Hospitals NHS Foundation Trust. “If someone has urticaria, eczema or rhinitis, the management is likely to be the same whether or not the cause is allergic or non-allergic,” he points out.
“Working out whether a person is allergic to something in particular means they can then avoid exposure as much as possible. We can’t test everyone for allergies, but we can test those people whose symptoms are not responding to simple medicines or those who will need to modify their behaviour.”
- Avoidance strategies are the first-line approach in allergy management alongside suitable medication
- Patient education is essential to ensure allergies are being managed effectively
- Many people don’t use nasal sprays appropriately or effectively. Pharmacists should advise on the correct technique
Allergic rhinitis is one of the commonest forms of allergy treated in the pharmacy setting. Avoidance strategies are the first-line approach alongside suitable medicines. “Customers should check the pollen count daily and stay indoors when it is high. Pollen levels can remain high in the early evenings as the air cools and pollen drops to the ground,” says pharmacist Farah Ali.
“Keep windows closed when indoors and vacuum regularly. Limit time spent in rural, grassy areas and avoid cutting the grass, wear wrap-around sunglasses and avoid drying clothes outside when pollen counts are high – pollen clings to clothes, which brings it into the home. Try allergen barriers to help prevent pollen from attaching to the lining of the nose, such as a dedicated nasal spray, and use a diary or log to track symptoms, especially when severe.”
Community pharmacists play an important role in advising allergic rhinitis sufferers how to take a stepped treatment approach. “Long-acting non-sedating antihistamines are the main first-line treatment for rhinitis,” says Dr Fox. “It is important to check that customers aren’t taking short-acting sedating antihistamines such as chlorphenamine.
“Antihistamines can be used alongside sensible avoidance measures as well as saline nasal sprays for a blocked nose. If this isn’t effective, customers can use corticosteroid nasal sprays, including those bought over the counter. Compliance is a key issue, however, as many people don’t use nasal sprays appropriately or effectively. They are very safe to use in the longterm, although parents may be nervous due to previous bad press. Pharmacists can stress, however, that the newer nasal sprays have less bioavailability than the older versions, so there is little effect on children’s growth.”
Dr Nasser believes that community pharmacists need to play a more prominent role in other areas of allergy management as well – and will do so in the future. “We need to deflect pressures away from GPs and ensure that as much support as possible is in place,” he says. “Pharmacists can play a key role in asthma and allergy, particularly in the use of inhalers, asthma medicines and adrenaline auto-injectors. They can also play a key role in drug allergies, asking patients if they have any allergies before they dispense any medicines.”
Adrenaline auto-injectors are prescribed to anyone considered to be at high risk of anaphylaxis. Many patients carry autoinjectors with them at all times as a precaution, but they may forget how to use these if they haven’t needed to do so.
“Pharmacists can keep some trainer pens in-store to show patients how to use them whenever they collect a repeat prescription,” says Dr Morris. “Although patients can watch videos online, a direct approach by a pharmacist may be more appropriate, showing them how hard to ‘whack’ the auto-injector and how long to hold it in place. It is important to stress that, if in doubt, patients should use their auto-injector rather than wait too long if a reaction occurs – people are often too scared to use them.”
Over three million asthmatics have not been tested for the allergic triggers that could cause a fatal attack
Dr Fox recommends that anyone prescribed an auto-injector arranges an appointment with a specialist allergy clinic every two or three years. “Some patients may develop tolerance to their allergen and therefore outgrow their allergies – wheat, egg or soya being good examples,” he says.
“Patients with nut allergy are less likely to develop tolerance but are at a 75 per cent risk of also developing asthma. If they have asthma and a nut allergy, they have an increased risk of having an anaphylactic reaction on exposure to that nut. If patients were diagnosed several years ago, they may need a new risk assessment, including allergy tests – some may be avoiding more nuts than they need to – and re-education on carrying and using adrenaline auto-injectors.”
If customers have tried all other primary care treatment approaches and are still experiencing severe symptoms, they may be referred to secondary care for desensitisation (immunotherapy). “Immunotherapy is available for those with venom allergy to wasps and bees,” says Dr Nasser.
“It can also be used for people with very severe hayfever in whom treatments are not effective. There is no immunotherapy on the NHS for peanut allergy, however, although programmes are in development. Most people with peanut allergy have other nut allergies as well, but it is not yet known whether patients would need to take the treatment daily for the rest of their lives or whether two years’ use would provide enough protection.”
Supporting anaphylaxis patients
Anaphylaxis UK recommends that pharmacists:
- Keep up to date on how to use the three brands of adrenaline auto-injectors available in the UK
- Encourage customers to sign up for the expiry alert service
- Remind patients of the impact that heat and cold temperatures can have on their adrenaline auto-injector device
- Remind patients to regularly check the window of their device to ensure the liquid is clear and colourless
- Be aware that 16 to 25-year-olds are most vulnerable in terms of managing their allergies and remind them to carry their adrenaline auto-injectors with them at all times
- Reinforce the above information with all repeat prescriptions.
Food reactions in children
According to Allergy UK, almost one in 12 young children suffers from a food allergy, with peanut allergy cases continuing to rise. Other common food allergens include eggs, milk, fish, tree nuts, shellfish and soya. A food intolerance doesn’t involve an allergic reaction but may be caused by a problem digesting certain food substances (e.g. lactose or gluten) and may cause diarrhoea, bloating and stomach cramps.
According to Allergy UK, parents should take three steps if they suspect their child has a food allergy or intolerance:
- Identify the trigger or triggers through allergy testing so they can be avoided
- Recognise the symptoms of an allergic reaction
- Know what to do if a reaction occurs. Parents will need to work with their child’s consultant to ensure that an allergy action plan is in place.
Pharmacists are well-placed to offer general advice on food allergies. However, any advice given must be appropriate to the level of knowledge of that healthcare professional, says James Gardner, children’s allergy nurse consultant at Great North Children’s Hospital, Newcastle.
“If pharmacists don’t have enough knowledge to give advice on food avoidance, they should signpost customers to an allergy clinic,” he says. “Children who have been diagnosed with a food allergy should then be referred to a dietitian so that they can be given the correct dietary and nutritional advice.”
The main symptoms of a food allergy include an itchy mouth or throat, rhinitis, a flushed face, raised itchy red rash (hives or urticaria), swelling of the face, and digestive symptoms (nausea, vomiting, stomach cramps). Hives can last from a few minutes to a few days. There will be red raised patches or spots on the skin (sometimes with white welts) alongside itching, stinging or burning. Oral antihistamines are the mainstay first-line treatment. Some children may also benefit from anti-itch creams/lotions and cold compresses.
“If a child experiences a mild reaction, such as hives, itching or some swelling, they should be given a nonsedating antihistamine such as cetirizine,” says James Gardner. “Historically, allergy patients were advised to take a sedating antihistamine, such as chlorphenamine, but this made it difficult to assess whether any sedation was due to the medication or the allergy mechanism. Non-sedating antihistamines work just as quickly and as effectively as the sedating antihistamines.”
Anaphylaxis requires urgent medical attention. It can cause wheezing or chest tightness, swelling of the tongue and throat, and noisy breathing (especially when breathing in). As the reaction progresses, it can lead to a sudden drop in blood pressure, dizziness, confusion and collapse. Children who are at risk of anaphylaxis should be prescribed two adrenaline autoinjectors. As soon as they are old enough, they should be taught how to self-administer the devices, as well as the importance of carrying these with them at all times.
Sometimes allergies can cause delayed symptoms, including atopic eczema, reflux, constipation and diarrhoea, and may lead to poor growth. “In children under two years, around 60-80 per cent of eczema cases are driven by food allergies,” says Gardner, “but once children are beyond that age, food is less likely to play a role and airborne allergens are more likely to be triggering a reaction.”
Atopic eczema can be treated with liberal amounts of topical emollients. When a flare-up occurs, topical corticosteroids can be prescribed (OTC versions should not be used on children without a doctor’s advice).